Omar Siddiqi Interviews Victor Valcour for Without Borders February 6, 2017
Dr. Omar K. Siddiqi, MD, of Beth Israel Deaconess Medical Center, and a global health researcher currently working in Zambia, interviews Dr. Victor Valcour, MD, PhD, Associate Professor of Geriatric Medicine and Neurology at the UCSF Memory and Aging Center and Co-Deputy Director of the Global Brain Health Institute. Dr. Valcour is currently engaged in global health research related to dementia
WITHOUT BORDERS PODCAST TRANSCRIPT
Siddiqi: Welcome, everyone. This is Omar Siddiqi, the director of the global neurology program at Beth Israel Deaconess Medical Center, and welcome to the podcast Without Borders, in conjunction with the American Academy of Neurology’s Global Health section. Today, we have the privilege of speaking with Victor Valcour, who is a professor of medicine at the University of California San Francisco with joint appointments in geriatric medicine and neurology, who is engaged in global health research related to dementia, and will be talking about that hopefully extensively today. Thank you for joining us, Dr. Valcour.
Valcour: Thank you for having me.
Siddiqi: So just to get started, could you just tell us a little bit about your background, and particularly how your interest in global health, and perhaps even with dementia, developed?
Valcour: Yeah, I think that that’s probably one of the more difficult questions you’re going to ask. In my career, things have kind of iterated through my training to where I am today. I’ve always had an interest in old people, I think since I was a child. I was interested in our neighbors who were older, and I knew that I would always have an affinity around that. I didn’t know at the time that I’d be a doctor; in fact, I initially trained to be a teacher. But when I did enter medicine, this interest in taking care of older people just continued, and that’s what led me to be involved in geriatric medicine, and my interest in dementia, which of course is related to older age.
So I’ve completed a training track that included not only internal medicine and geriatric medicine, but I’ve done a two-year neurobehavior fellowship in dementia. When I did my internal medicine training, I had the opportunity to work at a hospital in South Africa in the Transkei, one of the original homelands of South Africa. And something must have led me to do that initial experience, but of course, as many of your listeners probably know, it was transformative. I think when I was in medical school in rural Vermont, they thought I was going to stay in Vermont, and that was part of why they were excited to have me go to school there, to populate the doctors, but I ended up doing something that’s quite a bit different. And I’ve now had the opportunity to work in places around the world and engage in medicine, and mostly around understanding cognitive disorders.
So that’s a bit of who I am; internal medicine, geriatric medicine, and neurobehavior. At current , I work at UCSF, and in our clinics, care for mostly people with cognitive disorders who are older - so mostly over 80. And a lot of my international work is in HIV, so I’ve looked at how HIV affects the brain throughout the world, and I do research around that and also see patients here at UCSF. Most recently, we had the opportunity to establish the Global Brain Health Institute, where I serve as deputy director at the UCSF site, and that’s been really a remarkable opportunity for us to train the next generation of world leaders around brain health around the world.
Siddiqi: So, I’ll tell you, some very unique interests, and a nice path of how you got there. I’m curious—when you were in the Transkei, was it in the—around what timeframe, what year was it? Was it in sort of the heyday of the epidemic at that time? Though we kind of still are in it, but—just tell us about that experience, and what timeframe that was.
Valcour: Yeah, that’s a great question. I went to the Transkei shortly after Apartheid was abolished; I was in my final year of residency training, and, so it was 1996. It was an interesting time to be a clinician in South Africa, particularly with the HIV epidemic. In the hospital that we worked at, we essentially would identify people who were wasting to have either tuberculosis or HIV, and if they had tuberculosis, there was some hope, in that we could admit them and provide treatment, although many of your listeners, and you, would certainly know that that’s not quite as simple as it sounds, but at least there was an opportunity. If people were given a presumptive diagnosis of HIV, they were essentially sent home. So it was a very dark time in the area, and I think for medicine and particularly around HIV, but I think also politically; very challenging to be in one of the original homelands as this transformation was occurring, particularly as a white man. It was an experience that I’ll never forget.
Siddiqi: And it was an interesting time, actually, I think—I was around South Africa around that time; I don’t know if it was Thabo Mbeki or Nelson Mandela, but South Africa was actually somewhat late in the game in terms of just acceptance and ART and whatnot, so it was a difficult and challenging environment to work in, I imagine.
Valcour: Yeah, I agree with you.
Siddiqi: Okay. So, did you have the interest in dementia going in to that, remind me, or did it come from seeing HIV patients with cognitive disorders during that period that really, really cemented it for you?
Valcour: No, I wasn’t seeing patients necessarily with cognitive disorders at the time; I was serving as a general clinician at the hospital, and mostly, my time was spent training nurse practitioners. So we would go out into the rural clinics and see patients in the clinics, and I spent most of my time working with the nurse practitioners who were doing the exams and then presenting the cases to me, and we would use them as learning experiences. It was really around general medicine. It was a lot around hypertension management; we saw frequent strokes, and a lot of trauma as well, and so my work at that time was really not focused around HIV per se. But if you served any time in the ER, you would see these individuals come through, so that was what I was speaking to with regard to that experience.
Siddiqi: Gotcha.
Valcour: The interest in dementia came when I then—perhaps because I was so interested in different settings and people—I chose to go to Hawaii to do two years of training in geriatric medicine. Really an absolutely fascinating learning experience around predominantly a Japanese-American population in the hospital where the training program was based. And that training program was tightly linked to a launch to a new study of dementia in Japanese Americans that had grown out of a study of cardiovascular health, and those opportunities really cemented in me an interest in addressing this issue around dementia. The HIV focus at that time was—came almost as an aside, an opportunity that arose while I was doing training, and launched a career, but not something I would have necessarily chosen at the time.
Siddiqi: Dementia’s an interesting perspective to have on—in terms of global health. You bring up—so you’ve seen dementia populations in various settings, and even among neurologists, I think people treat dementia—sort of lump it as a category, although, realizing there are sort of various layers. But could you talk about some of the worldwide, some of the regional variations in dementia and the causes and how that differs based on common—based on country, and what you’ve learned?
Valcour: I think a lot of it would be driven by what’s been done, what’s been assessed, and how carefully people have been able to evaluate this. It’s hard to imagine any place on the planet that doesn’t suffer from the challenges of dementia, yet it’s often a silent epidemic. And the opportunities to understand the different types of dementia is limited in many settings where there are competing priorities, and this is often a marginalized disease. So it’s hard to speak about the details of the different types of dementia, but it’s also pretty well established that if you look carefully enough in any location, it’s hard to find one that hasn’t a burden of dementia. And that burden is going to increase, because the world’s population is increasing, and where that burden will increase the most is where the aging populations are likely to just blossom in the next two to three decades, and that’s predominantly low- and middle-income countries. So the opportunities for prevention and engagement at this time are unprecedented in this field. It’s an issue that will become increasingly urgent.
And speaking back to what we’ve done, we’ve been talking about with HIV, there certainly is a lot more to be done in HIV, but when you think about malaria, tuberculosis, polio, HIV, there have been great strides made, and we’re beginning to see a tip in the balance of things that are causing the chief mortality and morbidity around the world, from those that are infectious, leading on into those that are more chronic diseases. So the timing around understanding and preventing dementia is really right at its—it’s just about to blossom, I think, and people will recognize it more and more.
The other large challenge, to speak to your question, is that it’s such a silent disease; if you look at the global burden of caring for dementia, it’s hard to estimate entirely because most of the burden is hidden. It’s hidden in people, for example, that I’ve talked to in Cuba, who stopped working so that they can stay home and take care of an elder who has dementia, because there’s not an opportunity to get the assistance that they need. People who we’ve talked to most recently in the Seychelles who are just starting to come out of the woods that they have elders at home with dementia—they’re establishing the very first Alzheimer’s association on the island, and there’s this grassroots effort to really address the burden that has been largely hidden. So it’s a little bit difficult to answer specifically around the types of dementia and the frequency, because I think a lot of it has been relatively hidden, and challenging in terms of specific diagnosis of dementia.
Siddiqi: And so, in a resource-limited setting, just by nature, there’s not a lot of things to offer patients, in particular around a variety of conditions. So what can be done for a dementia patient in sub-Saharan Africa or in a resource-limited setting for example in Southeast Asia, etcetera, that would help the health system?
Valcour: You don’t even have to go to low- and middle-income countries to have that question asked; I get asked this question all the time, even in my clinics. There’s often a sense of futility around making a diagnosis of dementia, because people are concerned about what could be offered. There’s also a sense that there are no therapeutic options, and usually, people look to pills, and pills that are going to have a large impact on cures, such as penicillin, and that kind of a breakthrough hasn’t come through with dementia. So your question is not just isolated to low- and middle-income countries; I think this is a challenge around the world. We see with great frequency the benefits of just understanding the disease, that the disease occurs, and the opportunity for people to have planning around their own fate, and that is often—requires early diagnosis, and discussion around that. I just spoke to you a bit about the burden of this disease that affects caregivers and family members, and having a diagnosis can sometimes help a lot, because people want to do their own planning and understand what’s going on. In many cultures, this is considered being crazy, and so there’s a lot of stigma and social isolation that we can begin to whittle away at.
So those are maybe a little bit more oblique responses to what you’re saying, but let me step back and be a little bit more concrete about things that can be done. Just this week at the Alzheimer’s meeting in Toronto, it was announced that some forms of cognitive stimulation and social interaction may have benefits towards decreasing the progression of this disease. And more and more, we’re understanding that the factors that affect the heart are affecting the brain as well, so diabetes, hypertension management, lifestyle characteristics will likely have a profound impact on the global burden by even having a small impact on an individual level. So since these diseases are increasing in a lot of these places, we see there’s an opportunity to perhaps have some prevention strategies. And education is one of the factors that has been linked to dementia frequently, so even there, there are opportunities where things can be done. So we think there are opportunities for primary prevention; is that’s what you’re speaking to? But also secondary and tertiary prevention around alleviating the burden of this disease for the people that are caring for the individual, but also allowing the individual to have some sense of his or her own fate.
Siddiqi: And do you find that there’s a lot of heterogeneity in the way that dementia is taken care of, based on the—I imagine based on the setting, the culture, even?
Valcour: I would say that my experience with that is not as large as it probably is for other people. Most of my experience internationally has been around HIV, where there’s a frequent amount of cognitive impairment, but the impairment doesn’t typically—with access to treatments, doesn’t particularly commonly progress to this relentless dementia that we see in Alzheimer’s disease. So the settings in which I’ve learned a lot about this has been more in the setting of mild impairment that, with treatment, we can generally stabilize to some degree. But the limited experience I have, I do recognize a lot of variability in how it’s viewed. There are some cultures that really adore their elders and really focus a lot on care for elders and have large supportive environments, and there are other places where I don’t see that tight social network as closely as in other places. The language around dementia differs from place to place; as I was just alluding to, in some places that I’ve worked or visited, there’s really a sense that it’s a crazy person’s disease, and there’s not a sense of what the neurologic underpinnings of this is. I think we’re going to learn a lot more about that as we begin to bring in people from around the world who will learn from each other, and we will of course learn from them; really, the wonderful thing about the Global Brain Health Institute is we’ll have these cohorts of individuals from varied locations where we can start to explore exactly the question you’re asking, and get it from the people that are best able to inform it.
Siddiqi: So it seems the Global Brain Health Institute is an amazing opportunity, and I haven’t heard of anything like it in terms of centralizing caregivers, providers, being able to source questions. Can you tell us a little bit about the genesis of it and how it came into being, and what your vision of it is?
Valcour: I think the one thing I would say is that we had a visionary group that we solicited - that we begin to think about this space, that worked with us over a series of two years, to try to identify what this is. I think in large part, the Global Brain Health Institute grew out of training that has been occurring here at the Memory and Aging Center UCSF for decades, through my boss, Bruce Miller, training people from around the world. But this just opened up great opportunities for us. The Atlantic Philanthropies, which funded this, is really focused on social change, and moving…kind of moving the arrow in a way that societies are more positively dealing with issues around social justice, and this was one of the initiatives that they were quite interested in, in terms of things that we could do around the world to affect the lives of people today. So we spent a lot of time really thinking about how we could have an impact on brain health, and we use that term broadly, because we think it is kind of a broad opportunity. And we also will be bringing in multiple disciplines, because we think that will foster the creativity and the learning that will allow us to be transformative in this space. So I may be a little bit vague about that, but the big thing was is that the—there were programs around training that were already existing, and really a visionary group of people who wanted to move this forward, and together we came up with this concept where we will train 40 people per year, and we hope that about half of the individuals will come from low-, middle-income countries. We’re currently focusing a lot on Latin America and South America, as well as the regions around the Mediterranean, and it’s in its infancy; we are just now enrolling our first class.
Siddiqi: And so when is it—so there are fellows, physician fellows, I read, and health professionals who are eligible; that doesn’t necessarily have to be medical doctors, from my understanding of the reading. Is that correct?
Valcour: Yeah, we don’t even have that level of scrutiny, to be quite honest; what we…the level of scrutiny that we’re—kind of the commonality of all the individuals who we’ll train is this drive to be the person who will be a leader in a space that will benefit brain health. So, I think really what we’re looking for is exceptional individuals who can help us move this agenda forward without stating any specifics around the degree or the types of training. We’ve really coalesced around people who have completed their training; I think that’s probably the closest that I would come to a criteria. But if you look at our website, we’ve already—we’ve accepted our first class of fellows; there will be eight of them. And the range of disciplines are from neurologist to occupational therapist to anthropologist; we have two artists-slash-musicians; we have a lawyer. It’s really a broad sense of, how can we move this target forward in a broad way, and really with a public-facing policy perspective.
Siddiqi: And are they from—are there fellows outside the United—in that class, were there people from outside the United States represented?
Valcour: We have two sets of trainees; one is what we call the Atlantic fellows, and those will have more intensive two-year experiences. About half of them—off the top of my head, about half of them are from either the US or Ireland, which is our partner organization, which I failed to mention—Trinity College Dublin is the partner organization with UCSF that has established us. So, half of our trainees will be initially training at Trinity College in Dublin. But half of them are coming from kind of the US and Ireland, and the other half are coming from these other regions. So in our first class of fellows, we have a neurologist from Brazil, an epidemiologist from Colombia, a neurologist from Cuba, a neurologist from Spain, a linguist from Spain, an artist from the UK, a musician from the US, a lawyer from the US, so it’s quite a mix of region and discipline.
Siddiqi: So it sounds like you’re looking for advocates also; it doesn’t necessarily have to be someone who’s going to go back and be heavily into academia in the setting that they return to, but more advocating and bringing awareness for the issue around dementia, and sort of advance the cause—would that be accurate?
Valcour: I think leaders in the space that we are thinking about and the space that you and I operate in, typically around academia, often have pretty strong roots in the science that they are working in, and some of these individuals will have exceptional skills around leadership. I think the way I would rephrase what you said is more that we want our trainees to have a pretty strong appreciation not only for dementia—the disease, how it’s treated, and the cultural context of it—but also, we’d like them to leave with the skills to understand the health economic impact of what they may achieve, and how they can affect policy in their country. So, I think it’s a little bit different than that. Yes, we will probably have people that are more defined as advocates who will join the program, but essentially, we’re trying to teach a curriculum that provides the skills around leadership and also what’s needed to move this target forward in regions. Although they may not necessarily be advocates themselves, an outstanding neurologist who establishes the first program around dementia in a country, who has the skills to understand the health economic impacts of policies that are being produced in that country, and then the tools to understand how to affect them so that they’re more beneficial—that would be almost an outstanding situation for us.
Siddiqi: And will you have some people who will come to San Francisco or will be in Dublin, and have a research mentor return—say it was a neurologist, because it will mostly be neurologists and our audience - would, out of interest, who would then return to their home country, and become physician scientists or around epidemiology to be a research partner? Is that another thing that you envision, potentially?
Valcour: I think that that’s going to happen by nature. As I was suggesting, I think we find—and not always, but we find that a lot of the most effective people are really thinking about the science that’s behind what’s being propagated, and—but they’re very socially minded and leadership-oriented. So I think that this would be a natural—it’ll be natural for the people we train to have those skills. And just to perhaps be a bit frank about the individuals who are coming, it’s pretty clear that they do. Some of them are—you know, in this first class, anyway—some of them are already establishing important epidemiologic programs within their countries, have partnered with their ministries of health and other outside partners to kind of understand the prevalence of dementia in the regions that they’re working in. So I think it’s almost—I think it will happen, yes.
Siddiqi: It’ll be really interesting to see how it blossoms as you sort of—as the graduates return to their home countries. I didn’t get to touch on—you yourself are involved in work in Asia and Africa; you alluded to it previously. Could you just tell us a little bit more about your research programs in those regions?
Valcour: Yeah, I’d be happy to. I mean, I think, some of these things just happen as opportunities, that if your mind is open to them, you can jump on them and build something out of it, and when I was working at the University of Hawaii, one colleague who had worked on —I think a pretty important research study and had funding - lost the funding that she had because she moved to Bangkok. She moved to Bangkok with her husband, and they, together— ran one of the first vaccine studies against HIV that was successful, in Thailand. And rather than give up on that opportunity for this funding, we kind of fought back and decided we were going to try to do some work in Bangkok. And the long story, I’ll spare you, but the short story is that, over time, we established an office—a research office in Bangkok that we call SEARCH, and SEARCH operates some of the most cutting-edge research studies going on in the world right now around acute HIV and cure around HIV. And so, this occurred over the course of about 15 years; we established this office, and it’s been one of the most—it’s been one of the most satisfying experiences I’ve ever had in my life to partner in a way that allows a group, this SEARCH research group, to be very autonomous, independent, and driven by local leaders, and really, when we talk about having an impact on policy, they’re kind of like—they’re kind of the poster child around this. With the work that they have done at SEARCH, they have been able to push forward an agenda at the government level to start treatment with HIV at the earliest diagnosis, rather than any immunosuppression. So that research office is still vibrant; a lot of the work has been funded through grants I’ve written around how HIV affects the brain, reservoirs that may exist in the brain, the earliest effect on the neurologic system that occurs during HIV, how children growing up with HIV have developmental challenges and whether there are resilient factors that we can identify and try to augment in that setting for children who are now adolescents and young adults growing up with disease. That office is pretty autonomous at this point; there’s some funding sources from a number of different investigators. It’s led by a really amazing woman, Dr. Nitaya, who runs a very tight shop and is able to do transformative research in the space that the NIH is really very proud to have in their portfolio. So that’s been a lot of the work that we, early on, did, and through my connections there, we also started to do some work in East Africa, where we’re looking through the PEPFAR programs at what’s working and what’s not working terribly well. And it’s hard to think about HIV care and how to make it work very well without considering the impact of things like gender-based violence and depression and cognitive impairment. So, through the partnerships that I’ve had there with the US military HIV research program, I’ve been delighted to participate in this survey of 3,000 HIV-positive individuals in Uganda, Kenya, Tanzania, and Nigeria, and we’re just starting to understand the data as the enrollment continues, so that’s been a real wonderful opportunity, and it’s taught me a lot about how you assess function, how you assess cognition, how you assess depression in varied settings. Those are the main programs that we’ve been fortunate enough to run through my research portfolio.
Siddiqi: And have you had—because we’ll have, hopefully, a lot of students and residents, those interested in behavioral neurology or maybe even geriatric medicine—have you had residents or trainees come and work with you at these sites or do projects related to your research?
Valcour: Yeah, we certainly have. At the SEARCH Thailand site, we’ve had to establish a program to really try to contain it. The opportunities for residents and medical students to do work has been there for several years, and in fact, I think, as we’re speaking, we have two students who are working on projects there now. Several years ago, we established a fellowship—a neuro-HIV fellowship for neurologists, predominantly, where they can spend a year working in the office in Bangkok, seeing patients with HIV through some of our studies. Our first fellow, Joanna Helmuth, is now a third-year fellow here in neurobehavior, and hopefully will be transitioning soon to faculty. And our second fellow is a neurologist from Hong Kong, Phillip Chan, who had such a wonderful experience he’s spending his second year with us. And we just brought on our third fellow, who will be starting in the fall, and she’s a pediatric neurologist, which will be really exciting for us, because we have a number of pediatric studies that are underway as well. So yes, we have several opportunities. There’s more information about that program at searchthailand.org—all one word; searchthailand.org. Or our International Neuro-HIV Cure Consortium; that’s INHCC.net. So that’s where you can find the advertisement for the fellowship opportunity.
Siddiqi: Great, great. So you provided—between the GBHI and what you just mentioned, there is sort of a wealth of resources you’ve made available to people who can pursue, I think, a really interesting field, which is sort of—cognitive issues, and behavioral neurology, and global health.
Valcour: We’re excited about the GBHI—the Global Brain Health Institute—as well, and that website just launched last week, so maybe you’ve had a chance to look at it, but I would urge your listeners to go to GBHI.org and learn a little bit more about that program.
Siddiqi: Yeah, I did have it; it’s really, really well-done—and there’s actually a nice video, you know, sort of going into the mission, so I would encourage any listeners to go to the GBHI website, as Dr. Valcour has mentioned. Well, thank you; this is a lot of information, and really, really fascinating for me, and hopefully for all of our listeners. And I hope you—I’m sure you’ll drum up some interest from our community going forward.
Valcour: Hey, it’s a pleasure to be asked to speak on this forum, and I appreciate the work that you’re doing, and that of all your listeners, who are really engaged in making the world a better place to live.
Siddiqi: Thank you, Dr. Valcour.
Valcour: Bye-bye.