Michael Starnbach, a professor of microbiology at Harvard Medical School and member of the DRCLAS Executive Committee, works on the very timely subject of infectious diseases. He has fostered medical collaborations with Latin America and the Caribbean, particularly with Cuba and Argentina.
June Carolyn Erlick:
Michael Starnbach is a Professor of Microbiology at Harvard Medical School. He is also a member of the Doctor Class Executive Committee. Welcome Michael.
Michael Starnbach:
Thanks for having me for this exciting group of discussions.
June Carolyn Erlick:
To our Listeners, dr. Starnbach works on the very timely subject of infectious diseases. But before we delve into the fascinating subject of his research, let's explore his links with Latin America and the Caribbean. Michael, for the past 15 years, you've recruited Harvard scientists to teach microbiology and immunology courses in Cuba. How did that come about?
Michael Starnbach:
It's really a two way street also. It began with really earlier in the days of Doctor Class, before I was even involved, there were lots of discussions between John Cosworth, the director at the time, and David Rockefeller about what they wanted the center to be and what they wanted the center to focus on. And this intellectual engagement between Latin American academics and Harvard academics was to be at the core of it, but David Rockefeller always told John Cosworth specifically in each of those discussions, that Cuba was not to be excluded and that was a challenge that John rose to. He tried a number of things that had to do with political science and economics and those were difficult interactions. It was difficult for the academics on either side to come to common ground where they really could do work together and that the insight that he had was that he should try science, and in particular infectious diseases, because he believed rightly so that it was a common language and that it would be more likely that we would agree on more than we would disagree if we focused on infectious diseases and how to combat them.
Michael Starnbach:
That was the genesis of how the center really became involved with it. And John Cosworth had a colleague that he had known over the years, John David, who's now an emeritus professor at the Harvard School of Public Health who had been working in Brazil, had been working on tropical diseases in Brazil and was quite a charismatic member of our faculty. John Cosworth believed that John David would be an ideal emissary. He had worked with Cuban physicians in Brazil, where most of John David's work had been done in, but Cuban physicians are everywhere in Latin America and so John had had opportunities to go to Cuba and meet Cuban scientists in his field. John was a much more senior member of the faculty at the time and told John Cosworth he was willing to go and initiate these discussions with the scientists in Cuba, but he asked John Cosworth whether this new young faculty member, Michael Starnbach, could come along with him because he wasn't sure how long he wanted to do it.
June Carolyn Erlick:
Was that your first trip to Latin America or the Caribbean?
Michael Starnbach:
That was my first trip to Latin America and the Caribbean and I had been as a tourist to Mexico being interested in the Yucatan Peninsula and the history of the Mayan civilizations there, but simply as a tourist earlier in my life. But other than that, this was my first intellectual engagement as a faculty member with colleagues in Latin America.
June Carolyn Erlick:
So tell us have been about that trip.
Michael Starnbach:
John had organized a group of individuals to go and present a symposium at the Institute Pedro Kourí, which is Cuba's Center for Tropical Diseases, which serves in some ways as Cuba's Centers for Disease Control, where they do epidemiology, but also serves as a research hospital like the NIH would serve in the United States. It really is one of the centers for infectious disease work. It is the reference hospital for infectious diseases that aren't obviously able to be taken care of at the regional hospitals. Those patients are brought to Havana and are hospitalized actually at the institute for treatment. And that was fascinating to see a facility like that, fascinating to see the diversity of research, the kinds of epidemiology that was being done, the kinds of data that were being collected, the richness of the data that we're being collected. But probably more importantly, was the engagement of the people, the scientists that were there, both at the senior level, the director of the Institute and the assistant director of the Institute, the medical director of the Institute, Jorge Pérez, who is a physician and personality.
Michael Starnbach:
This was an opportunity to see folks that were deeply engaged in work that was really on the very patient centered, public health centered focus of what I was working on as a very, very basic scientist, looking at very specific mechanisms of how molecules in these pathogens work against the immune system or are recognized by the immune system. That was my expertise. These were folks who really had knowledge on the ground of how these diseases affected people and the pathogenesis of those diseases in humans. So it was a symposium, it was presentations on both sides and truly enjoyed it. It became apparent to both John David and myself that this was a rich opportunity to work with the center and the center's funders to try to get some of these folks to Boston and to Cambridge to be able to work in our labs and to share with our students the kinds of insights that we were getting by spending even a short amount of time there.
June Carolyn Erlick:
Remind us what the political situation with Cuba was at that time.
Michael Starnbach:
The first visit that I made was early in the year, 2000, so it was a time when Cuba was just pulling out of what they called the Special Period, the intense economic deprivations that had occurred after the fall of the Soviet Union. And that through some small openings and being able to diversify the economy, allowing very small numbers of private restaurants and things like that, the economy had begun to improve. There was trade that was occurring between Cuba and other European and Asian countries at a limited level, but things were looking up for Cuba at that time, having come out of a very difficult period.
June Carolyn Erlick:
And was it difficult to get visas for these scientists that you wanted to bring to the states?
Michael Starnbach:
Yes. Going to Cuba has never been difficult for us in a professional capacity. We've always had the support of the university and the center in terms of very clearly documenting that we're there for professional research and getting permission from the Cuban side has not been difficult. Getting permission for the Cuban scientists to come to the US is always challenging. It was challenging at that time. We had an intrasection, we didn't have an embassy at the time in Cuba and there was an extensive set of interviews that were necessary for the scientists that we had identified as ones that we would really like to have in our labs, but that did progress and there were dedicated members of the center's staff that were on the ground there that were familiar with the intrasection staff and really facilitated being able to make it a reality.
Michael Starnbach:
Over that following year, we had three scientists begin in the labs in Boston, my lab and Eric Rubin's lab. Eric is a Professor at the Harvard School of Public Health and he has been on all the subsequent visits that I've made. He's been my sidekick in the recruitment of Cuban scientists. And in addition to learning a lot, we've had a lot of fun in Cuba doing many kinds of work, not just scientists and getting to know people at the University of Havana who are in different fields, other scholars that have come to the Rockefeller Center that I have grown close to and now visit if I'm in Cuba. That's fun.
June Carolyn Erlick:
That's great. Could you tell us a bit about what these three scientists did, what kind of collaborative work they did? And please remember that our listeners aren't scientists.
Michael Starnbach:
Correct. The scientists that came were all from the Institute Pedro Kourí, so the Tropical Diseases Institute. One of them was a younger scientist who was pursuing the problem of a viral disease, dengue fever. Dengue is still a problem in much of Latin America. And it's a problem where during the first infection with dengue, one can have a flu-like disease. On the second infection with dengue, there is an immune response that is very dangerous and can cause a hemorrhagic fee fever, much like one sees with Ebola, where people can get in very serious circumstances and people with dengue hemorrhagic fever often die of the disease. And that mechanism of how during the second infection the immune system is so dysfunctional that it allows this hemorrhagic fever to occur is terrible, but is also fascinating in terms of what prompts that on the viral side and what is it that the virus is doing that disregulates the immune system in that horrific kind of way?
Michael Starnbach:
In Cuba, this had been working extensively on the elements of the viral side that were important in that process and what we were investigating in Boston with them. The scientists that came were very interested in using the tools that we have to study the immune system to try to get a better handle on how those secondary complications play out.
June Carolyn Erlick:
So the tools you have here in Boston would be different from what they would have access to in Cuba?
Michael Starnbach:
Yes, and the amount of time that we have on those tools is greater. There are scientific resources that exist in Cuba, and this is true of much of Latin America, but where the amount of things, like flow cytometers that isolate cells and can characterize those cells at high speed with many different colors of lasers, these are million dollar machines. In order to book time on those in Cuba was a big deal for the scientists. Whereas, we have one in our hallway at the medical school. It just allows progress at a rate that the individual institutes in Cuba are often not able to do and also sharing a laboratory workbench with students in post docs in my lab who use these machines every day, know how to tweak them to get even more interesting results from them was really valuable to the Cuban scientists. For them, it's also just learning what's possible when one has, in their mind, unlimited access to some of the reagents and tools.
Michael Starnbach:
The embargo has been very difficult for Cuban science. Things that we order and arrive overnight have to be purchased through a central state ordering system. If they're embargoed, they have to be acquired through third party negotiations with other countries. And if they order something, it could take months and months and months for those to arrive. For them to get on the computer within the Harvard ordering system, order something and have it delivered, in some cases, the reagents they were ordering from Beverly, Massachusetts would come an hour later. It just blew their mind that that was possible. It's been one of the challenges, even... The embargo has been a significant challenge for us compared to other places in Latin America where we do research, where it's easy for us to send a FedEx package or a UPS package to anywhere else in Latin America and have it delivered basically overnight, that's not possible in Cuba. Even the exchange of reagents, things that are just tools that we're using, not even infectious disease agents, often had to be couriered by our friends from the Rockefeller Center to us or back to the scientists in Cuba.
Michael Starnbach:
Reassuring the journalist from Havana that what he was bringing was not going to get him in trouble from the US or from Cuba. "No, it's just protein." The embargo's been a challenge.
June Carolyn Erlick:
So did things become impossible during the Trump administration? What happened?
Michael Starnbach:
So I started out with this really negotiating with the Clinton administration and the ends of the Clinton administration. We could talk about this a little more. It's been interesting also to be part of groups that have gone to Washington DC under the auspices of the center to make the case that interactions with Cuba were a benefit to the United States and that those interactions were not violating the spirit of the embargo and that they were a clear benefit to the US, not only a benefit to Cuba. That's always been a hard case to make. It turns out that it's less about Republican and Democrat disagreements, it really is a very localized set of politics in certain areas of the US where there are very strong feelings about Cuba and maintaining restrictions in our ability to work with Cuba. And whether it's been a democratic or Republican administration, all of those executive branch officials have been very wary of crossing the congressional delegations from those areas where these issues are sensitive.
Michael Starnbach:
And in fact, the Democratic administrations have perhaps even been more wary of that. During the George W. Bush administration, I'd say perhaps we had the easiest time, that the reality then was is that the executives and the groups in Congress were at least of the same party and weren't worried about making riffs that were unsolvable. It has always been difficult. I don't perceive that difficulty really being political in the Democratic/Republican way that some other issues are. The Trump administration was difficult. We weren't able to do work there. Part of that though was during the Obama administration, there was a great hope that things would radically change. We now had an embassy. That embassy for some period of time really did serve as a conduit that allowed us to do work more easily. Cuban scientists were really speaking to a full fledged embassy in Havana.
Michael Starnbach:
What occurred then was there was hope that there would be a dropping of the embargo, which never occurred, but also these health concerns that emerged at the Havana Embassy and ultimately the virtual closing of that embassy down to bare bones staff because of health concerns during the Trump administration, which also were not directly political. That became and has continued as the biggest impediment that we have had in getting scientists back to Harvard since the latter parts of the Obama administration. There is no accessible diplomatic facility in Cuba anymore and the route to getting visas, which we have tried unsuccessfully, has really been even to provide transportation for scientists to Merida and the Yucatan or to Mexico City, to try to engage with the embassies there, we've tried and that has not worked out either.
Michael Starnbach:
Hopefully, the word is that we may have a reopening and a refunctioning of the embassy in Havana in the coming months or in the coming year and that would be the specific best circumstance in terms of being able to have scientists there go and speak to normal diplomats in a normal circumstance to obtain consular services for getting visas to come here and that's what we've been missing.
June Carolyn Erlick:
If I understand you correctly, there haven't been any collaborations with the Cuban scientists since 2018.
Michael Starnbach:
That's correct. Anselmo Otero, the last Cuban scientist that was here, was here in that era. It was difficult, but it happened. Professor Otero is at the University of Havana. He works on antibiotics that he has developed from marine sponges. He has a collaborator who's a scuba diver who goes and collects samples of native sponges from the areas around the Havana. Professor Otero isolates these small antibiotic molecules, small pieces of proteins, peptides that have remarkable antibiotic characteristic. We didn't talk about the other scientists who came even initially. One was on dengue, which we talked about. We've had scientists that have come to work on tuberculosis. Tuberculosis isn't more of a problem in Cuba than it is in the United States, but Cuba serves as physicians for places where tuberculosis is a problem. They have an active research component on how the immune system could better be trained to get at rid of tuberculosis.
Michael Starnbach:
We had a scientist who also was working on histoplasma. Histoplasma is a fungal infection and this fungus is prevalent in the United States in the Ohio river valley, but is distributed in Cuba. It thrives in areas where it can live in bat quano or bird quano. There's a remarkable team of scientists in Cuba that have collected more different samples of histoplasma than we have ever dreamed just collecting in the small region of the United States where there's histoplasma. What the scientists came to Harvard to work on were some diagnostics. We wouldn't be able to develop a diagnostic with only a limited number of strains. We have to have a huge diversity of strains to make sure the diagnostic would work against all the different strains.
June Carolyn Erlick:
So not only is it collaborations, it's actually producing new knowledge?
Michael Starnbach:
That's correct. But again, this has been difficult since 2018. It has been Professor Otero at the University of Havana that we have wanted to come back. Harvard has had an outstanding visa request in his name. He wants to come to Harvard Medical School in the Dana-Farber Cancer Institute where they can, with very fine precision, determine the structures of these antibiotic molecules, which would help us understand how they work.
June Carolyn Erlick:
Well, I hope he's successful.
Michael Starnbach:
I do too. He's wonderful to have around. He's a faculty member that when he was here was just such an active part of the center as well. No matter what the topic, I remember him going with another visiting fellow in the history of art and they went several times to the museum together to look at something that she had wanted him to see that was an example of the work that she was doing here. It was fun to watch.
June Carolyn Erlick:
Great we've and living for two years in this very strange situation where not only can't Cubans be in the labs, but sometimes even regular US people can't be in the labs. I'm wondering if this strange situation has developed any other forms of collaboration with your Cuban counterparts?
Michael Starnbach:
Certainly, there has been Zoom conferences at very high levels between US scientists and Cuban scientists about the pandemic, about ideas about the pandemic. At some level, the questions early on were fairly clear that a vaccine needed to be developed, that there were approaches that Cuba was going to take there were approaches that US academics were taking and there were approaches that pharmaceutical companies throughout the world were going to take to try to solve the problem. And those were very interesting discussions, but I never saw a great deal of coordination of effort, which probably at the higher, the level of the discussions and the more ministers are there, makes it difficult to come to some agreement. Even if the scientists could come to agreement about how to do the experiments, there were other aspects of it that were very difficult to resolve with things like intellectual property. Even among the pharmaceutical companies, there's difficulties.
June Carolyn Erlick:
I don't want our listeners to think that you only work with Cubans. I understand that you are now involved in a very interesting collaboration with scientists in Mendoza, Argentina. Why Argentina, why Mendoza and what are you doing?
Michael Starnbach:
It turns out it's a project that's close to my own research interests. A number of folks in my lab work on chlamydomonas, used to cause infection of the eyes throughout the world, the disease blinding trachoma, which has been solved in Latin America and in much of the world, but we still have the disease chlamydia as a sexually transmitted infection throughout the world. We're interested not only because it's a public health problem causing infertility and ectopic pregnancy, but also because it's a fascinating example of a chronic infection. So unlike things like COVID or influenza where someone gets infected and it becomes a race between the replication of the pathogen and the ability of the immune system to clear the pathogen, and from this microbiologist's eyes, one side's going to win or the other side's going to win and it's all going to take place in a week or two. Either the pathogen is going to win and the host I going to die or the host is going to win and the pathogen's going to die.
Michael Starnbach:
But with diseases like chlamydia or HIV or tuberculosis or malaria, these are all examples of chronic diseases where a balance gets established between the replication of the pathogen and the clearance by the immune system and sometimes those infections can last for the lifetime of the host. My interest is in that evolution of the interaction between the pathogen and its host over millions of years that allows the pathogen to manipulate the immune system in such a way that it doesn't get such an advantage that it kills the host, but it has enough of advantage that it can stay infecting the host for a much longer period of time in order to spread to new hosts. For that's all the pathogen really wants to do is become more pathogen. It's not a very complex life for a pathogen, it just wants to reproduce. And the longer it can stay replicating in the host, the better.
Michael Starnbach:
There are people throughout the world who are interested in these. There's a group headed by Maria Teresa Dani at the University of Cuyo in Mendoza, who has been a colleague of mine. I've met her at meetings. And there's one specific aspect of how that manipulation might be occurring that she has had a student in her lab investigating, a PhD student in her lab, Diego DelBalso, and she asked me whether there was any way that Diego could come to my lab to use some of the tools and technologies that we had to further his PhD dissertation. There was only upside to that and so worked with Diego. The pandemic didn't make it easy in terms of having it occur as fast as we would like, but it occurred. It involved a lot of travel of Diego between Buenos Aires and Mendoza to visit an embassy that was technically closed. But we not only got approval for Diego to come, we wrote a fellowship together to the International Union of Biochemistry and Molecular Biology. The International Union paid for Diego to have come.
Michael Starnbach:
They're very interested, as the Rockefeller Center is ,interested in fostering particularly young academics, young scientists to come to Boston. And not only did Diego have a great deal of success scientifically, even in the short period of time that he was with us, but he's now coming to... Our lab meetings now include some people who come by Zoom. Diego comes every week to our weekly lab meeting by Zoom. He contributes to the lab meeting and the students in my lab, they're his friend. They're talking more regularly, I think more texting than even talking, more regularly than I am to the Diego and that's the way it should be. That's the facilitating role that the center and the university can have with Latin America.
June Carolyn Erlick:
Are there any other countries you have your eyes on for collaborations or that you would dream of having collaborations with?
Michael Starnbach:
The dream is really meeting more young scientists in places where we haven't had a lot of contact with those groups and some of that is just the amount of money that it takes for scientists in Latin America to go to international conferences. When they do go to international conferences, who were generally meeting there are the senior scientists, as opposed to some of the young scientists, which are really the targets that we would like. I had an opportunity to go twice to Brazil, talk to scientists there. My goal there has always been to talk to the younger scientists. I went to Santiago, Chile and went to the Catholic university there where they have a remarkable group studying the immunology to salmonella infections and would like to have more interactions with that group as well. But a lot of this is I don't have as much knowledge of where those opportunities are that I don't know about yet. I wish I knew more. That's my fault.
June Carolyn Erlick:
Well, you mentioned before that the public health infrastructure in Latin America has made truly amazing progress towards eliminating many diseases that were once dominant there. Could you tell our listeners a bit about that progress?
Michael Starnbach:
There are the diseases that have occurred throughout the world. Some of these diseases were the ones that even 20 to 30, 40 years ago were the ones that Harvard investigators were engaged in Latin America to try to understand and solve, which have not disappeared, but the impact of them has overwhelmingly receded. Filarial diseases, diseases of worms, onco psoriasis, river blindness that was very prevalent in Latin America, schistosomiasis, another worm that transmitted snail fever, leprosy, trachoma, this blinding disease. These are diseases of public health infrastructure, sanitation, clean water supplies and that's where making progress on those fronts, which don't directly see medical, are profoundly impactful on medicine. As conditions have improved in Latin America, at the most desperate of levels, those diseases have receded commensurate with that progress. Those are cures of economic developments, even modest development, rather than remarkable progress on the medical front.
June Carolyn Erlick:
What are some of the remaining neglected, as you'd say, infectious diseases?
Michael Starnbach:
The insect transmitted diseases are still a problem. We talked about dengue fever. There's a related disease called Chikungunya that is a problem throughout Latin America. Malaria is still a problem in Latin America. And vector control, controlling the insects, is the key to those diseases. We may be able to develop vaccines to protect people, but the insects are hard to control. There are certainly new approaches that are being taken through molecular biology to try to limit the capacity of these insects to grow or spread. Those experiments have to be done carefully. Because if we did eliminate species of insects, it's not necessarily clear that we know all the impacts of getting rid of those.
Michael Starnbach:
It becomes challenging and that what we realize as scientists is that the on the ground knowledge, the epidemiological knowledge of folks who are dealing with these diseases in Latin America is much greater than the experience that North American scientists and physicians have with these diseases and that we realize that it behooves us to interact with the folks that do have that on the ground knowledge to try to come up with strategies. Because as we get climate at change, as we get increased travel, as we get the capacity of insects to travel through commerce and trade to new ports, these are diseases that are beginning to show up in the United States and will continue to show up in the United States as those insects become, through climate change, able to grow in environments where they weren't normally found previously.
June Carolyn Erlick:
Can you say specifically where some of these changes are taking place, where you haven't seen these kinds of diseases before and now we're seeing them?
Michael Starnbach:
People getting these diseases on golf courses in Florida. Where that wouldn't have occurred previously, they are so far self-limiting in terms of the transmission of them from one person to another. It's usually an insect that somehow has gotten to the US, infects somebody in an environment where it's not immediately killed, but where there's not a big enough population of that particular mosquito to continue the passage from one person to another, but that there will come a time when there is a critical population of that mosquito species in a place like Florida where you will get sustained local transmission of these diseases.
June Carolyn Erlick:
That's scary.
Michael Starnbach:
Right, and it is scary. We can think of these as diseases that are found in Latin America or other tropical places, but that's a naive view of the next 20 years.
June Carolyn Erlick:
Michael, you worked on the Harvard Medical School Special Health Report on viruses and infectious diseases. The report asks whether the landscape of infectious disease changing in the 21st century. And if so, how can medical science meet the new challenges? How would you personally answer that question?
Michael Starnbach:
This is what has fascinated me about the collaborations with Latin America is that it is understanding that who's working on infectious diseases in countries where we haven't traditionally had annual meetings where we would get together with these folks, and that's whether that's in Latin America, whether that's in Asia, there is just a wealth of expertise there about diseases that we don't know normally come into contact with and surveillance for diseases that we should be aware of that we may not have the surveillance systems in place for. What has occurred, of course, is that we are a completely connected world and we can't unconnect by stopping airplanes from going back and forth or by trying to test people on airplanes. We've seen that you could have little short term progress by doing that kind of stuff, but that, in the end, these pathogens are able to cross international borders and that the way that we solve it is working internationally with collaborators to try to identify what those threats are and to try to identify counteracting materials like vaccines against those threats as early as we can identify that something might be threatening.
Michael Starnbach:
Even if it's something that doesn't yet exist as a public health problem, the more knowledge we have about how to rapidly deploy vaccine systems will help us. And we've seen that in the current pandemic, that the great success of the pandemic was the ability to rapidly deploy vaccines, that before the pandemic, there was a truth that everybody would respout that it took 10 years to make a vaccine. We now know that there are technologies that can be used to manufacture and deploy vaccines without that the time intensive workflow that we have always had for the past 60 or 70 years. As we move forward, trying to deploy those tools in advance of threats will help us.
June Carolyn Erlick:
And collaboration is a key factor in that.
Michael Starnbach:
Collaboration is a key factor to that. We don't know what to make the vaccine against if we don't know the kinds of diseases that physicians are encountering in other places in the world. Even if they're not spreading rapidly, what is endemic in areas, viral populations that cause low level disease that are not public health concerns right now? But just being aware of what's out there, helps us to try to deploy tools in advance of those becoming more virulent.
June Carolyn Erlick:
That's fascinating. You've talked a lot about these collaborations. Do you have anything else to add?
Michael Starnbach:
I'm excited to continue with the center. I learn a lot from the center. I like being part of the center. I always imagined myself as a professor at a small liberal arts college and sitting down to dinner with faculty who studied music and art and architecture and design, history, math and that's sometimes difficult to achieve in a spread out university setting like Harvard. And what the Rockefeller Center has provided to me is that community of scholars in fields very different from my own that I now know well, I know their work well and I count those faculty as friends. That has been career changing for me in terms of not things that I can get grants on specifically, but things that enrich my academic life at the university.
June Carolyn Erlick:
Thank you very much. You've been listening to Dr. Michael Starnbach. He's a Professor of Microbiology at Harvard Medical School and a member of the Doctor Class Executive Committee. Thank you for coming.
Michael Starnbach:
Thanks for having me to the program.