Robert E. Black, MD, MPH

In the second edition of the Department of International Health Legacy Series, Robert E. Black, MD, MPH, discusses his distinguished career in public health. Black, who was chair of International Health from 1985 to 2013, has received numerous accolades for his contributions to global health, including the Prince Mahidol Award for Public Health in 2010, the Canada Gairdner Global Health Award in 2011, and the Pediatric Nutrition Lifetime Achievement Award from the American Society of Nutrition in 2018. He was recently honored at the School during the installation of Judd L. Walson as the inaugural Robert E. Black Chair in International Health. You can watch the ceremony here. 

In this Q&A, Black reminisces about how he came to join the Department and its early challenges. He also shares stories about his time living and working in Peru and Bangladesh and the colleagues who helped build the Department from eight faculty to more than 150 when he stepped down. Black is currently a professor in the Department and leads the Johns Hopkins Institute for International Programs, which is a network of multi-disciplinary researchers, educators, and advocates at the Bloomberg School who are committed to helping improve women’s and children’s health, nutrition, and survival by strengthening public health policies and programs in predominantly low-income countries.

You started your career as a physician. What led you to public health? 

When I went to medical school, I thought I would be a clinical physician doing the things that physicians do. My father was a pharmacist, so I had somewhat of an image of what physicians did. After medical school, I trained in internal medicine and then infectious disease as a sub-specialty. That’s when I really got interested more in preventing infections rather than treating them. 

While I was doing my infectious disease fellowship, I got an MPH from UCLA. This led me to the conclusion that if I really wanted to do public health and control of infectious diseases, I should go to the CDC. I joined the Epidemic Intelligence Service Program, EIS, in Atlanta. During that two-year program, I learned how to do outbreak investigation and public health intervention studies, which are different than research in a clinical setting. 

Did you have an "aha" moment that helped you decide to devote your career to public health? 

No, there wasn’t a specific moment. I can certainly think back on the first year of my infectious disease fellowship. I was spending a lot of my time caring for a lot of very ill patients who had cancer and serious life-threatening diseases, who got infections as part of their immunosuppression from the disease itself, or the chemotherapy drugs they were taking. I remember thinking this is very important work, but I thought focusing on prevention and larger populations would bring more enthusiasm, excitement, and benefits. That took me into the whole world of public health, especially in low-income settings, where at the time the rates of death from childhood diarrhea were enormously high.

Where did you go after finishing the EIS program at the CDC? 

While in the EIS, I had the opportunity to go to Bangladesh for three months in 1975 overlapping into ’76. I really got interested in working on research related to infectious diseases in that country. Shortly after I returned to Atlanta, I applied and was selected for a position with CDC at the center where I had been working in Bangladesh. This allowed me to return for two years at what is now called icddr,b. Professor Abdullah Baqui was based there at the time and that is where our very productive decades-long collaboration began.  

And this leads into when I started working on diarrhea. Obviously, the main concern with diarrheal disease is in children. Seeing first-hand how malnourished children are more susceptible to infections and mortality also began my work on the infection-nutrition nexus. Diarrhea and other infectious diseases are very related to malnutrition. 

Globally, child mortality has dropped dramatically over the last two decades. But there are still millions of preventable deaths every year. What do you think are the biggest challenges to keep the trend line going down?

Certainly there continue to be infectious diseases, such as diarrhea, pneumonia, and malaria, and infections in newborns such as sepsis and meningitis. They're obviously very important. But as those causes come down higher proportions of deaths are due to other things, including pregnancy complications and prematurity. That's why neonatal deaths have become a greater fraction of childhood deaths—the other causes have gone down.

And with the epidemiologic transition from high number of deaths due to infectious disease and malnutrition, we will have to increasingly address globally conditions that are more associated with high-income countries now, including noncommunicable disease and injury.

Earlier you mentioned your collaboration with icddr,b. What are some other organizations that have helped shape your career? 

In India I’ve worked closely for many years with the All India Institute of Medical Sciences in New Delhi, I had a great collaborator, Dr Raj Bhan, with whom I did some of the first studies on zinc deficiency and risk of infectious diseases.

After I came back from Bangladesh, I was working for the University of Maryland’s Center for Vaccine Development and had the opportunity to live in Peru. I was supported by an NIH international infectious disease collaboration grant. Brad Sack was the PI at Hopkins and I was the PI at University of Maryland.

I worked with the Nutrition Research Institute. Originally it was called the Anglo-American Clinic, which provided treatment for malnourished children. It was founded by a faculty member, George Graham, who was half Peruvian. He also established the Department’s Human Nutrition program. As the burden of severe childhood malnutrition decreased in the country, the Institute transformed into focusing more on research.

I also worked with researchers at Cayetano Heredia University in Peru with many other Hopkins faculty, including Bob Gilman, who lived in Peru for 25 years. My collaborations there were mainly on infectious diseases such as typhoid fever. 

How did you end up moving from the University of Maryland to Johns Hopkins?

There were only two official connections I had with Hopkins at the time. One was with Brad Sack working in Peru, where I was living when the search for a chair opened up. The other was with Mathu Santosham, who was living on the Apache Reservation in Arizona. We collaborated on many studies there during the ’80s and I would like to especially recognize him for all he’s done to build the Department. 

I don’t believe I knew about the chair position. But, Carl Taylor [the Department’s first chair] had decided to go to China as the UNICEF representative, and DA [Henderson] the dean at the time, did not succeed in abolishing the Department, which he tried to do. The search committee just contacted me and asked me to apply.  

The Department was much smaller when you became chair, wasn’t it? 

I believe there were just eight full-time faculty before I came. There were two main areas of work in the department. One, led by Carl Taylor, was on primary healthcare, particularly in India. But it also included some other studies, national work force assessments or situational analysis, related more to health systems than diseases. 

The other was nutrition, which was very small with only two faculty in Baltimore. There were some other obvious needs gaps in the Department. For example, in spite of our dean, D.A. Henderson, being one of the leaders in smallpox eradication, there were no fulltime faculty working on vaccines. 

Did you recruit Mary Lou Clements-Mann who established the School’s Center for Immunization Research? 

Yes, as part of the “dowry” from the Dean when I got selected as chair. He gave me the ability to recruit and fund two faculty. The first was Neal Halsey, who later established the Institute for Vaccine Safety. And the second was Mary Lou Clements, with whom I worked at the University of Maryland. We were able to bring over a part of a large NIH vaccine grant from Maryland to Hopkins, and that became the foundation for the Center for Immunization Research.

Nutrition was also a critical area to build. I recruited Ken Brown, who was a Nutrition Division faculty member who was living in Peru and one of my collaborators there, to head the Nutrition Division. He did a great job. When he left it was in good shape to hand over to other faculty.

Was there anyone working in the Department’s Social & Behavioral Interventions space?

I knew it was important in terms of our current programs, but I initially did not intend to create SBI as a separate program. Early on we had three anthropologists, including Peggy Bentley who went on to be the Associate Dean for Global Health at UNC’s public health school. There was a lot of social science expertise because we really needed to figure out ways to set up behavior change interventions, and also to understand cultures and how to motivate people. 

I'm happy it did morph into a full program. And that group began a lot of the courses in the school on qualitative research methods. SBI, I would say, is still home to the core faculty for qualitative research methods at the School. And it came from the need that we had in that area of expertise and skills from the beginning. 

You have been a part of many policy achievements, including global and national recommendations for zinc supplementation. Can you tell us a little about moving from evidence to policy change? 

I started that work in Peru because I was trying to understand the links between nutrition, infection, and zinc. It's an essential mineral with important roles within the immune system. When I started—with fairly crude methodologies—I was seeing how zinc deficient kids were more susceptible to infections. Then I started doing zinc supplementation trials, including some of the first on both zinc for treating diarrhea and zinc for preventing infectious diseases.

I was fortunate, because at the time I had a USAID research cooperative agreement which really allowed me quite flexible funding. I was able to develop a research agenda with USAID and map out what studies we needed to address various aspects related to zinc.

This was in the ’90s, and interestingly, there was an unanticipated, theoretical concern that providing zinc might be adverse to people with HIV infections. So, we did a trial in South Africa and HIV-infected children. It actually showed benefits.

The research continued to be funded and through the work of many faculty and students and colleagues abroad, we accumulated enormous amounts of evidence of its benefits. 

Then in 2004 we worked with WHO and UNICEF to get their recommendation that zinc, along with fluids, be given for treatment of children with diarrhea everywhere.

Once the recommendation was in place, the next step was getting zinc on what's called the Essential Medicines List, which contains the most effective treatments and is used by governments around the world in their health care planning.

How were you able to get WHO to add zinc to its Essential Medicines List?

My doctoral student at the time, Christa Fischer Walker, wrote the documentation with me and a colleague at WHO, Olivier Fontaine. It wasn’t simple. You must actively engage with the policy processes. You don't just publish and sit back and say, I hope somebody pays attention to this. We had to push back against the naysayers and the doubters. 

Over the last several decades, how have you seen global public health changing in general and in relation to the Department in particular?  

Things are definitely changing. The disease burden is changing. The relationships with collaborators are changing. 

I think we've always had very respectful relationships with our collaborators and participants in our studies and they have worked in ways that were mutually beneficial. But I think the expectations now are even higher. Certainly, I don't think it was ever a one-directional relationship, from us to them. But maybe at times it appeared that way because the funding came to us, and then we contracted to the local organizations.

I think now that's changing with the Gates Foundation funding more directly into other countries. And we will have to figure out what our role is. Where do we fit into this in the future? What technical skills and additions do we bring? We have to bring value. And how do we continue to do that as the world is getting more sophisticated everywhere. It's a big discussion in the strategic planning of the Department. How do we respond to these changes and expectations and funding models.

We have very good long-term relationships. In some of those cases, we have a more formalized understanding, sometimes written, sometimes unwritten. I think in the future we need to be more intentional about how we work together. It's not just our faculty building capacity at other institutions, through informal training or degree programs. It's by-directional. We need to learn from each other about how to work in these settings to solve problems.

There's also the changing disease burden that we talked about before. Yes, there's still a half a million deaths per year from diarrhea, but that's no longer the major cause of death in most places. It will keep me busy until I want to retire. But it's not going to be the major thing 15 years from now, for sure.

Our department has to evolve into focusing on problems of the future, the disease burden problems and social risk problems. We probably would do that just through funding patterns. But it really should be intentional.

What are some areas we need to pay attention to in terms of collaborations to make us good partners?  

We need internal mechanisms to make us good partners. It’s not just the obvious things, such as: Am I a good collaborator? Am I a good mentor? Am I a culturally sensitive person? All those things are necessary. But, do we pay our bills on time? We have research partners with workers—who are not wealthy people with big savings accounts—not getting paid for months at a time. That's what I mean by being good partners. It goes way beyond what we think of as the obvious faculty issues. It’s institutional.

In terms of the changing global disease burden, what are some of the areas we should expand into? 

We know that noncommunicable diseases are going to be increasingly the major problems of the world. We already do some work in these areas. But, I think that it is going to take some time to figure out how we expand into these areas and how we recruit faculty to lead, and how we transform some of our work to really address those problems. The most obvious area for us in NCDs is nutrition-related diseases, because we already do a good bit of work in that space.

The big question. How would you explain your legacy and what are you most proud of?

I'm proud that we have four excellent PhD programs that are methodically very sound. We train excellent students and offer a very high-quality product to the world. After I became chair, working with students became how I did research. It has been the most productive, successful, and rewarding way to do the work. I hope that the two dozen PhD students I’ve worked with got as much out of it as I have. 

Externally, in terms of research. I would say there are two areas where I think I've accomplished the most. The first is on nutrition, zinc in particular—moving from the research to recommendations and programs. That's where I've gotten these awards from the King of Thailand and the Gairdner award.

But the area that probably has had more impact has been working in knowledge synthesis and evidence-based advocacy, specifically the 2003 Lancet Child Survival series and the 2008 Lancet Nutrition series. Honestly, without any humility at all, I think that they were fundamentally important in moving the child survival and the nutrition agenda forward. It changed the focus of nutrition programs to the first 1,000 days from conception through the second birthday. That was seminal. It made huge differences. Before that, nutrition programs were all over the place, and these papers provided a very direct and important focus. 

The other part was identifying the impactful interventions to reduce malnutrition and mortality. People call it the “Lancet 10.” Ten interventions that we identified in that series. So, to the extent that you can make a difference in policy and in programs, I think those had a lot more impact than any piece of research that I've done. 

Finally, I have to say being able to build a department of really good productive faculty has to be number one. It took a sustained and collaborative effort. I am extremely thankful for the support and dedication of the many faculty, students, and staff who have helped build this exceptional department.

Interview conducted and edited by Brandon Howard, Communications Manager, and Sara Woodward, Senior Development Officer, from the Department of International Health at the Johns Hopkins Bloomberg School of Public Health.