A Career in Global Cardiovascular Health with Mark Huffman, MD

• Huffman was drawn to medicine and global health work at a young age after reading Promises to Keep: The Life of Dr. Thomas A. Dooley, a book gifted to him by his mother. Like Dooley, Huffman attended the University of Notre Dame and then went to medical school.
• When he applied to cardiology fellowships, Northwestern University supported his interest in global health and Huffman became the first NIH Fogarty International Research Fellow from Northwestern. He encourages students to take risks such as this early on in their career.
• His wife moved with him to India where Huffman spent his fellowship time. The country interested him for several reasons. One, there's the largest burden of heart attacks in India, there seems to be this disproportionate risk that South Asians bear but no one knows why. Two, English is an official language in India and Huffman only had rudimentary Spanish as far as other language abilities. Third, he has a cultural interest in the country. 
• In India he partnered with the Cardiology Society of India Kerala chapter, who had collected data from more than 25,000 patients from 125 hospitals from the southern state of Kerala. Huffman analyzed the data and published results in the European Heart Journal. It was described as the largest registry of its kind in India.
• Throughout his career, Huffman says he has had flexibility to work with people around the world on research and global health. Aside from India, Huffman has established research partnerships in Nigeria to collaborate on work related to hypertension. A few years ago he also took a sabbatical with his family to work at the George Institute for Global Health in Sydney.
• Huffman is a champion of polypills for cardiovascular health, a strategy he thinks could save lives in many countries, as it allows patients to take one pill with several low-doses of medications they need to prevent heart failure.
• Huffman left Northwestern at the end of 2021 to take on a new role at the Washington University in St. Louis, a move that brings him closer to his family. He says it is important for students to be strategic about their career moves but to also prioritize what is important to them, such as being in closer proximity to family.

• Find out more about the Global Health Center at Washington University in St. Louis.
• An overview of the Fogerty Fellows program.
• Read Huffman’s editorial in the New England Journal of Medicine about polypills.

Rob Murphy, MD [00:00:06] Welcome to the Explore Global Health podcast. I'm Dr Rob Murphy, executive director of the Harvey Institute for Global Health here at Northwestern University Feinberg School of Medicine. Today's guest has built a fulfilling and sustainable career in global health as a preventive cardiologist, leading studies and initiatives related to cardiovascular disease and health around the world. Mark Huffman spent 10 years here at Northwestern doing this work and has recently taken on a new role as professor of medicine and co-director of the Global Health Center at Washington University in St. Louis. He joins us today to talk about his career and different affordable strategies for cardiovascular disease prevention and low to middle income countries. So Marc, you've been at your new job for 10 days now. You just left. I was just at your going away party in December. Now you're in St. Louis, so how are things going?

Mark Huffman, MD, MPH [00:01:00] Things are great in St. Louis. Thanks for having me on. At Washington University. I'm really excited to be working with Dr. Victor Davila- Roman Dr. Lisa de la Fuentes and others in the Global Health Center who are really looking to expand the strategies, research, training and action to improve global health. Not too dissimilar from maybe some of the things that are happening at the Havey Institute for Global Health at Northwestern. My wife and I are both from St. Louis, so this is a homecoming for us, which is great. There's also some really exciting things happening here at Washington University in St. Louis, so the provost has really tried to emphasize Washington University in St. Louis for St. Louis. And so as we think about the mission and vision of the Global Health Center moving forward, we do need to think about how some of the lessons that we learn internationally can be brought back to St. Louis. But also, how can we prepare students, residents, fellows and faculty to go out into the world more broadly as representatives from St. Louis or people who have, you know, spent time in St. Louis.

Rob Murphy, MD [00:02:00] So you've said your interest in global health stems from being inspired early on in life by the missionary work of Dr. Tom Dooley in Southeast Asia, who also was from St. Louis and like you, went to the University of Notre Dame. Tell me about that connection.

Mark Huffman, MD, MPH [00:02:14] My mom gave me a book called Promises to Keep, which was a collection of letters from Tom to his mother when he was traveling. I read this when I was 12 years old, and this led to my initial interest in practicing medicine. I didn't really know what a career could look like, but I sort of thought working internationally in health would be really interesting. I later learned, you know, during that time, there were political operatives in Southeast Asia, including those funded by the CIA, for example, or who were members of the CIA. That changed my childhood thoughts of what working internationally as a physician might be. But, you know, that came later in life. But as a kid, I thought this would be a way to contribute to the greater good of the world. At Notre Dame, there is a statue by the grotto of Tom Dooley, and he died at a pretty young age of a rare form of cancer, kind of held up as this tragic hero at the university. So then I went to medical school at Tulane and pursue my master's in public health. Same time, thinking that maybe this could be a way to merge some of this interests in health and working internationally. But I didn't really know what I was going to do or how I was all going to work. I sort of consider myself initially interested in what we would call now disaster medicine. I thought, Am I doing anesthesiology for a long time because of a mentor that I had? But it wasn't until my fourth year of medical school that I really got excited about internal medicine and really decided to pursue a career in internal medicine. I went to the University of Michigan, where I had great support and but didn't really know again how I might bring these interests together. But I remember reading Tom Friedman's book The World is Flat and thinking there's all kinds of amazing ideas out there, and we in medicine and biomedical research don't always have these pathways to tap into that. That world of multidirectional, network based science and certainly the people that I was hanging out with, we weren't sort of quite talking in those ways. And I remember not really knowing how to bring these ideas together, but was at a cardiology grand rounds where Paul Ricker was visiting and he had previously lived in Uganda. I believe if it's been a while since college interaction, but he strongly encouraged me to pursue this. I was OK. Great now I fell in Bolton as a cardiology fellow applicant and I went around to nice programs and most heads of cardiology or program director said This is a terrible decision. I should definitely not do this. And it was really Northwestern and only one other program that expressed interest. And so Bob Bono was the head of cardiology at Northwestern at the time and was really supportive of my idea. But even then, when I arrived on campus, I didn't know what I was going to do. In the year that I arrived was when the Fogarty International Center expanded. It's global health fellows and scholars program to cardiology felt so at the time, Aaron Pramac was the program officer. I had reached out to him about my interest in the program and that's led me to be able to work internationally is that is that program.

Rob Murphy, MD [00:05:15] Yeah, that's great. Yeah. So what's that? That goes back to around 2009 I think. You were in that NIH Fogarty International Research Fellow program. You were the first person at Northwestern that actually went through that. Can you get a little more deeper into how that started because it obviously changed your trajectory?

Mark Huffman, MD, MPH [00:05:35] Sure, no it changed my life. When I reached out to Aaron Pramac. This was in 2007. I had just gotten married, just moved to Chicago, just started cardiology fellowship. And he said, Hey, can you do this next year? And I said, Well, I just I don't, I don't think I can. You know, I got to my wife about this. I have clinical responsibilities I have to complete. But the subsequent year, I would be interested, but I didn't really know again. Like, what was I even going to do where I was I going to work? I was interested in working in India for several reasons. One, there's the largest burden of heart attacks is in India, in large part because it's a large population. But also there seems to be this disproportionate risk that South Asians bear, that we still don't really understand why that is. And I still think that there are some important answers for all of us there. I don't have great language skills. I have pretty rudimentary Spanish, and I thought that a place like India that has English as an official language, I might be able to get by more so than, say, if I went to China and then I had cultural interests and working in India. So Mihai Georgiadis was a cardiologist who passed away a few years ago at Northwestern, who connected me with some of the cardiologists at the All India Institute for Medical Sciences. And so I had applied through that program to study heart failure and to really describe the conditions of heart failure in acute heart failure in this tertiary national hospital. My wife and I took a site visit in 2008, right after the 26 11 bombings in Mumbai. So it was kind of an unsettling time to be traveling to India for the first time. And we were a little uncertain about just what our travel plans were going to be. My wife and I were doing a site visit just to try and prepare. How did we want to live abroad in India? And Bob Bono was there helping us. Jyoti Put-- was there one of the cardiologists, and I specifically remember being at the Marriott in Chennai at the Cardiology Society of India, meeting and feeling not sure if we should really do this or not. And I said to my wife, What do you think? You know, I could be at T32 kind of a general postdoctoral research fellow in the Department of Preventive Medicine at Northwestern, which is a great, you know, opportunity in and of itself. And she said, Come on, you know, you want to do it, you're going to kick yourself if you don't. And I said, OK, let's do it. And I mean that decision by my wife who has stood beside me and behind me for all these years was critical for us to be able to live in India, which was awesome. We had a great time and then completely give me new career opportunities that I definitely wouldn't have had if I stayed back in Chicago. After all the students or trainees listening out there and take risks early on, right? I mean, if if you fail early, well, you're still like for me, I was still going to be a cardiologist, like, that's a pretty good gig. So by taking risks, maybe it can be even better.

Rob Murphy, MD [00:08:14] That's the time in your life. You want to take some risks. You really don't have really too much to lose. And also, I remember that year you had made some very big structural changes in your program.

Mark Huffman, MD, MPH [00:08:26] So the research opportunities that were fabulous because I worked with Dr. Dorairaj Prabhakaran, who is the executive director and is the executive director of the Center for Chronic Disease Control. He was also a leader within the Public Health Foundation of India, which was at that time a newly created public private partnership between the Government of India, the Gates Foundation and other organizations. They had so much data that were available internally, but also these relationships with other groups. And so I partnered with the Cardiology Society of India Kerala chapter, who had collected data from more than 25000 patients from 125 hospitals from the southern state of Kerala, which means more than 30 million people live there. So it's a state and it's the size of a country. But these cardiologists didn't have anybody who could actually analyze the data, and I could do that. I had statistical experience, not a lot, but some they were concerned about Who is this guy from Chicago coming here? Is you going to steal our data or what? Well, you know, what's what's his motivation? And so it took me going up and down this coastal state, going on trains, going in cardiac catheterization labs, looking at angiograms of fellow cardiologists and just bonding with people to build that trust and for us to map out a plan of how would we not just analyze but disseminate, report the results and and get the word out there? And so we had a pretty high profile publication, the European Heart Journal, published about 11 years ago that described this was the largest registry of its kind in India. And then that led to us saying, Well, we've described the problem. Is there something we can do about it? So again, thinking about. Students are trainees who might be listening, don't just constantly think that your job is to describe how terrible things might be or, you know, but what are you going to do to help to contribute? And that led to submitting a grant to the National Heart, Lung and Blood Institute. Now I was at in India at an opportune time when the NHL, RBI and UnitedHealth had had funded the Centers of Excellence around the World, including one in Delhi where Prabhakar was one of the co-PIs with Vinkat Ryan at Emory. So because of that investment, not only Fogarty was coming, you know Roger Glass was coming to visit while I was there, but Betsy Nabel, at the time, Dr. Elizabeth Nabel, who was then the director of the NHLBI. My I was a cardiology fellow, you know, so I was invited to have tea with her at this, you know, luxurious hotel, which was lovely. And I remember her asking me what I would do after my fellowship, and I said, Well, you know, I'll also apply for a K award like a K 23. And she said, Well, do you think you really need more training? Why not a K99, which is a larger award with more money and kind of faster acceleration independence. And I said, well, I thought that those were four basic scientists, and she kind of slammed the table who told you that I nobody, please don't hurt me. And she just really encouraged me to go for it again. Take this risk. Like, go for it. Just again. Being in a different part of the world interacted a lot with Shah Ibrahim and George Davey Smith, who were two really prominent epidemiologists and were editors coeditors and chief of the International Journal of Epidemiology. And George and I, George would beat me in squash on a weekly basis, and we'd go after and talk about how badly he beat me. And then I would ask him scientific questions, and I was telling him about my interest in doing a quality improvement study. And he said, Why don't you do a stepped wedge trial? And I said, What's a step wedge design? I've never heard of that. He's like, you, cardiologists are the worst. I send my worst papers to cardiology journals. And so it was really this encouragement from that's Betsy Nabel, George Davey Smith to pursue this larger grant and this more complicated study design that ultimately was funded to work with the Cardiology Society of India Kerala chapter. And we subsequently led the largest cardiovascular randomized trial ever performed in India the ACS QUICK acute coronary syndrome quality improvement in Kerala trial.

Rob Murphy, MD [00:12:21] That's incredible. That grant is not limited to US residency, either. Right? You know, so it has a lot of potential for some of our foreign trainees. That is about the time I remember when the NIH was switching over or opening up to NCDs non-communicable diseases up and up until then, it was primary all it was all infections and you were in that first wave. So talking about cardiovascular disease deaths every year, so there's like 18 million of them, basically one out of every three people on the globe. Can you tell us your experience now training in the U.S.,  you've been at Tulane, Michigan, Northwestern,  in Wash U. You were in India. You've been. You've got a very significant grant programs in Nigeria if you want to talk about them too. So you've been around. What are the factors, the global factors that you've found are driving these morbidity and mortality?

Mark Huffman, MD, MPH [00:13:20] I think Northwestern has played a prominent role for defining cardiovascular health. Don Lloyd-Jones was the chair of the 2010 American Heart Association Committee that helped put this on the map. This was based upon decades of research led by the Department of Preventive Medicine and Jerry Stamler outlining conventional health factors and health behaviors like tobacco use, unhealthy diet or healthy diet, physical activity, body mass index. And then these health factors would be blood pressure, blood cholesterol and blood glucose. So those are things often socio-ecological model like what's happening on the individual level. There's obviously community drivers of of our health behaviors of like what's our access to food, what's our access to healthy behaviors, what's the tobacco taxation and where we live? And then there are sort of these fundamental causes of differences or fundamental cause theory of disparities. So we think about differences and access to social services, money, power, and these are some of the drivers of things like structural racism. Those tend to be the really big factors that most of which are modifiable that may be hard to modify, but they are. But a lot of the burden of cardiovascular disease is driven by non modifiable factors, such as population growth and aging. So Greg Roth at the University of Washington has done a lot of seminal work describing this proportional increase as populations get larger and older. I mean, demography is destiny, as people say. And if people are living long enough, they are quite likely to develop atherosclerosis in a modern contemporary environment. And that doesn't mean that it's inevitable. It's an eminently preventable, but it requires a change in the way in which, you know, largely we deal with diet activity and tobacco. Once people have it, then it's making sure that health services are able to meet people where they are to manage their conditions quickly and well. And that's not the other side of the coin right, the health care side of it.

Rob Murphy, MD [00:15:21] You  want to tell us a little bit about, I already alluded to your Nigeria work, which is, of course, a country I've been working in for for quite a while. Can you tell us a little bit about working in Nigeria and the programs that you have going on there?

Mark Huffman, MD, MPH [00:15:35] I'm lucky to work with Dr. Dike Ojji at the University of Abuja and his team. This began really about five years ago at Dike's invitation to collaborate on work related to hypertension. Dike was a participant in the World Heart Federation Emerging Leaders program that I co-created. He was part of the inaugural class in 2014. And so that's how we first met. We have a series of research and training grants really focused around hypertension and cardiovascular diseases. The first is an RO1 that's the largest hypertension control program in Africa. There's more than 15000 people from 60 public primary health care facilities in the Federal Capital Territory in Nigeria, and the baseline hypertension control rates were 13 percent at the start of the study, and now they're more than 50 percent. So we've been able to demonstrate that using community health extension workers within primary care is totally feasible to really have a tripling quadrupling of hypertension control. The key will be really sustaining this, and we're trying to demonstrate to the government that it's not only possible but good for Nigerians to be able to have their hypertension under control. In general, NCDs are a good investment for every $1 spent on NCD related prevention or treatment. There's an estimated $7 return on investment in terms of improved health and productivity. The second project is called the Nigeria Sodium Study, and here we're doing an evaluation of Nigeria's national sodium reduction policies. This is in collaboration again with the University of Abuja, as well as the George Institute for Global Health, which has a similar project in China with the China CDC. And through this, we use stakeholder interviews to ask people about do they even know what these activities are? And they're part of the National Multisectoral Action Plan for the Prevention and Control of non-communicable diseases. Most people don't at this point second or retail surveys to figure out what's available in grocery stores and markets in Nigeria. And you know, a lot of the products aren't labeled accurately. So it's trying to first start with improvements in labeling. And then the government is trying to decide whether or not it wants to do some form of regulation of packaged food. How much sodium or salt is in products. The third aim is around population surveys and really trying to understand where the sources of sodium come from in Nigeria. So we do very detailed dietary assessments using trained dietitians who are also certified through the University of Minnesota's Nutrition Collaborating Center and Linda Van Horn at Northwestern helps us a lot on that. This all uses these implementation science frameworks. And Lisa Hirschhorn at Northwestern has been really a tremendous partner, and a lot of this work for the earlier one in this and the last project that we have funded by Fogarty is is a training grant that Lisa Hirschhorn is now the contact PI Dike and I are the other co-Pis for cardiovascular research training related to clinical trials, Patient-Centered outcomes research and implementation research. And this is modeled after some of the work that Lisa has done, as well as with Claudia Hawkins and with partners in Tanzania at Moodily University Health and Allied Sciences. So the work in Niger has been a ton of fun and kind of feels like we're only just getting started.

Rob Murphy, MD [00:18:53] I've enjoyed working in Nigeria for all these years. You tell us a little bit about the poly pills. I know you're sort of famous for this. Like to hear more.

Mark Huffman, MD, MPH [00:19:02] Polypill is simply a term for several medicines, usually at low doses that are combined into a single pill, something people call fixed dose combination therapy. So you can think of if you have or are at risk for cardiovascular diseases, you need your blood pressure under control and you need your cholesterol under control and you may want to take an aspirin. So rather than having three separate pills or more than three separate pills, imagine just taking one pill. Hence, the term polypill. Combination therapy, I mean, I think is the bread and butter of a lot of the treatment for other conditions, like for HIV, for example. And so, I mean, many of our patients struggle to remember to take their medicines. This is a strategy that helps improve adherence to taking medicines by about 40 to 50 percent. So if you know, medicines only work if people take them. So this isn't the only strategy out there. It's just really probably the best and most scalable compared to patient centered like if you have pharmacists reminding people and those sorts of things will work too, but those are really expensive strategies. So combination therapy is something that I've been interested because of some of the initial modeling work suggests. And boy, you know, could this reduce cardiovascular disease by 80 percent? That seems to be an overstatement, but I'm part of the polypill trialists collaboration through a few trials led by folks in in Canada and Iran, showing that that reduces the risk of heart attacks by about 50 percent by putting combinations that have low doses of blood pressure lowering, cholesterol lowering and aspirin. So that's a substantial reduction in risk compared to typically it's about 20 percent for four medicines. And this isn't just model data. These are actual clinical trial data. Combination therapy can be used for other conditions increasingly used for hypertension. So we actually have a clinical trial funded by NHLBI in federally Qualified Health Centers in Chicago, part of the Access Community Health Network. Jody Cellino and are Co-PIs of that. This is a four drug combination at quarter doses. So really low doses. And what that does is it increases the likelihood that you'll get a blood pressure low response, but minimizes your side effects from that. And this is an idea that was created by Clara Chow at the University of Sydney and Anthony Rogers at the George Institute for Global Health. Now, a new Anubha Aggarwal, who is an instructor of cardiology at Northwestern, has a K99 notice of award pending for her mentor on that for heart failure ploypills. So right now, for heart failure with reduced ejection fraction, it's recommended that there are four classes of medicines are initiated simultaneously for these patients. Any time you know, we're discussing initiating a new medicine for patients in clinic, patients are often negotiating with us like, well, which one are you going to take away or how do I usually really need this? Whereas trying to use lower doses in combination also makes it easier for that patient physician discussion about what are the risks, benefits and alternatives to the medicine, their medication regimen that we're recommending. So polypill is, I think, are an idea that will likely evolve over time. You think of like polyclonal antibodies, it's the same idea. It's as it's a story. It's a story as old as like multivitamins. So it's trying to just simplify care for our patients.

Rob Murphy, MD [00:22:25] We have the same HIV, two or three relatively complicated medications put into one capsule or, you know, formulation it makes on the infectious disease side made a huge, huge impact. I imagine the same as you're seeing the same.

Mark Huffman, MD, MPH [00:22:43] Well, what has happened in HIV is that the prequalification program through the W.H.O. World Health Organization has allowed for companies to be able to de-risk poly pills, combination therapy. And so that really has not happened for cardiovascular diseases. And I don't think poly pills will take off for cardiovascular disease until they have that regulatory support because there needs to be more companies manufacturing and distributing poly pills, not fewer.

Rob Murphy, MD [00:23:13] So a lot of the medicines you're using, though, are already in the generic stage right? Right? Yeah. I mean, that's going to really also have a huge impact on the pricing, a strategy like this, right?

Mark Huffman, MD, MPH [00:23:25] I think the challenge is trying to balance a lot of companies want to be able to maximize profits. And so when they see generics, they say, Well, how are we going to make money off of this? And so that's part of that de-risking of if you have a large marketplace that is not prone to typical fluctuations, then you'll be more likely to want to enter into that. There are some newer, completely different approaches to cardiovascular preventive care that are just coming onto the market in the U.S. and are really expensive right now. But down the line may not be. Novartis has a as an injectable that silences your RNA, so it's not an M RNA like the COVID vaccines, but it is a shot that has taken once every six months to lower your cholesterol by half. And I mean, that really changes the paradigm for thinking about the strategies that we currently employ. So while I'm certainly very interested in polypill research and will continue to be, I'm also open to new ideas. And so I again, the junior people who might be listening, you know, try and think about what's going to come next, not just what's happening now.

Rob Murphy, MD [00:24:31] If it's happening in a variety of fields, even with COVID. AstraZeneca came up with Evusheld long acting monoclonal every six months, looks like it lasts. Intramuscular injection. It's actually two injections.

Mark Huffman, MD, MPH [00:24:44] Wow.

Rob Murphy, MD [00:24:44] One time every six months. And so it's really going to be a lifesaver for people with underlying immunocompromised conditions who can't respond to the vaccines, and then they don't have to just keep taking multiple infusions of the monocle. It's the same concept, but yeah, think of the future, I think that's a that's a really think out of the box. Maybe our last kind of general question here, and I'll I'll let you go back to your life in St. Louis, your new life.  Many of our students, they want to embark on a career in global health and they want to have an impact. And they want to know, how do you balance these kind of projects and seeing patients in your clinic and now in St. Louis, but also doing the international stuff and having a family life? What kind of advice do you have for them?

Mark Huffman, MD, MPH [00:25:34] I find the work that I do to be very fulfilling, both professionally but also personally. And I remember Srinath Reddy, who's the president of the Public Health Foundation of India, saying that to me when I was about to do my fellowship back in 2009, you know that he wanted to help make my time in India both personally and professionally productive. And I mean, that's the sort of integrated life that I think many people seek. Certainly, I had my own anxieties about my ability to be a loving husband and father and to be present in my family's life. And I express that to --- when I was a Fogarty fellow. I also had these conversations with Don Lloyd-Jones and Prabhakar when I was trying to think about the types of research that I would do. I knew that I wanted to live in the United States but work internationally, and how would I do that? And so I started with facility based research rather than community based research because I felt like the participants would always be safe, right? Like, there's always going to be a doctor or nurse who will be able to care for them. In the confines of our research studies versus community based research, there needs to be a greater support team around them in case you identify individuals with or at risk for serious conditions. So community based research, you could identify someone with a blood pressure of 200 over 110 and they have a headache when you have an obligation to do something for those people to get them in urgent medical care, emergent if they're symptomatic. That's what led me to do the quality improvement project in Kerala so that I could live in the U.S. but travel internationally because I think you do want to make sure your research is safe for those, you know, research is a privilege. And in terms of weaving, you know, the other parts of life, I think if you have a research based career, there's a pretty clear pathway, right? Like you do postdoc, you get a K award, you get an art award and you sort of build a skill set an area of interest. You know, people call it a niche, but I mean, you also want to have flexibility on working with different people. So you know, you, Rob, are a U.S. taxpayer. Thank you for your support for funding. You know, our teams research and you want us to share that research. And by widely sharing the research, the research products from other teams come back to us and that we get to more quickly write grants, write papers, analyze reports and these sorts of things. I actually feel like I have tons of flexibility in my life. I took a sabbatical a few years with my family to work at the George Institute for Global Health in Sydney and have a conjoined faculty position there. So I've been given a lot of opportunities because of this combination of clinical method of logic and field research. So I'd encourage young people to reach out to me. I'm happy to talk with them and work with them. You know, you think at Northwestern, we've had a whole heck of a lot of fellows after me participate in the Fogarty program. There's going to be a whole heck of a lot more. I heard just today for the first applicant and Dr. Zainab Mahmoud. She's recommended for funding for her Fogarty Fellowship here washes who are trying to do similar things here.

Rob Murphy, MD [00:28:44] If you don't mind getting a little personal. Your move back to St. Louis. You've told me some things personally that you thought it was a better fit. Could you just say just a couple of words about that? Because doing these mid-career mean most of the people listening to us podcasts are early career, but pretty soon you're in mid-career. Mid-Career comes up a lot and then you're in the old career like me. Yeah, right? But but at mid-career comes pretty quick. Can you say a couple of words about that?

Mark Huffman, MD, MPH [00:29:12] Well, I think we've all been touched by the pandemic in some way. I mean, how could we not every person on the planet as my wife and I were thinking about how we were affected, our bubble wasn't including some of our key family members, including my wife's family. And I was reading Tar Baby by Toni Morrison, and there's a scene at the end where the aunt-like figure is tired and sort of speaking with the uncle like figure about the niece who's going to go back to Europe. And the on like figure says, Well, I didn't want to ask her to stay in and help us the way that we helped her when she was younger. But it sure would have been nice. And I thought about particularly my mother in-law here in St. Louis, who's lived within the same three mile radius her entire life and has absolutely no intention of ever moving. And nor nor should she. She's got a great life here. The me thinking there's no other decision that we could make that would make those closest to us happiest. And I felt established enough in my career that I could make that transition without a major career risk. There's obviously some risk involved, but with that, there's also great opportunities here at WashU that will be different than the great opportunities that are at Northwestern. You know, our kids, we're at an age where we felt like the other 10 and six that they would be OK with such a move. Everyone tells me it's much harder once your kids get into high school or even middle school. We were taking account of the things that are most important to us and the people who are most important to us. And like, I love Northwestern, I was there for more than 14 years overall. And so it wasn't without a lot of thought and a heavy heart to leave. But also, since we've been here, we've spent so much time with our family already, even amidst the pandemic. We knew once we got here because of this very warm welcome like this is a great fit. It's been exciting for me to get started at Whatchu. People have been wonderful. There's a lot of synergies actually between some of the work that I have been doing at Northwestern and what's happening on the horizon here. So, you know, it feels like a real win win for our family. So I same thing like what you're saying before for the risks. As you get older, you're more calculated, right, like you're not going to just like go and do something you got. There's a lot more people involved. And so it takes a lot more planning. And so this took a while for us to make this happen, but it was very much a thinking about our lives and our families. You know, I'm sure the listeners will be thinking about how their decisions fit into their broader narrative about their life. I'm sitting here with my six year old son as he's trying to get on camera, as he's listening to me recording this podcast. But we spent a ton of time together during the pandemic, and so it's good to be with family.

Rob Murphy, MD [00:31:54] Great. Well, Mark, congratulations again. You made a great move. Career wise, but also personally, it sounds like I look forward to continuing to work with you. I mean, you know, the nice thing about academia works today is some of your closest colleagues are not even at the same institution that you are. I mean, that's just happening already. We work with people from around the world. It doesn't seem to limit our activities, and a lot of times it makes things, you know, even better. So good luck and congratulations, and thanks so much for joining us today.

Mark Huffman, MD, MPH [00:32:24] Thanks a lot, Rob. Thanks for having me on. I had a nice time.