I have often been asked if I could go back in time and change my career, what would I change?
I probably wouldn’t change my decision to go to medical school. Discovering biology, biochemistry, human physiology, evolutionary medicine, neuroscience, and neurology has been and remains exhilarating. I am an addicted learner and consumer of news related to biology and medicine. However, knowing what I know now, I would probably not become a neurologist. I would study epidemiology to do global and public health. Why? As a jobbing neurologist, you are focused on diagnosing and treating individuals with disease; your impact is relatively small. In comparison, as a public health doctor, you think about population health and preventive medicine, where your influence is potentially much more significant. To be blunt, I would prefer to prevent people from getting multiple sclerosis (MS) rather than diagnosing and managing their MS.
I was quite an unusual medical student in that I gave up attending lectures midway through medical school, preferring to teach myself in the library. I must have been the only student in my class who read the rather lengthy public health textbook we had been recommended. As a consequence of this, I unexpectedly won the public health prize in my fourth year. In my end-of-year viva, I went off-piste and discussed many topics not covered in the rigid lectures and curriculum. I remember the external examiner and me heatedly debating the Cuban barefoot doctor programme and why it was such a good model for Africa. As a result of my unexpected success, the head of the department was super-impressed and thought I would follow him into a public health career after my house job, but I didn’t. Was this a mistake?
My next exposure to public health was during my year of national service. I was conscripted into the South African military for one year. After my officer’s course, I was posted to head up the medical epidemiology unit at the South African Medical Service headquarters. I had to teach myself epidemiology. I also taught myself how to code and became an expert user of Epi-info, the databasing and analysis program run by the CDC in the US.
I did some extraordinary things during my year in the military. For example, I did a ‘top-secret’ HIV surveillance study and modelled the South African HIV epidemic. I set up a national register for South African veterans disabled in war. It was called the Curamus database. I studied many sexually transmitted and other infectious disease outbreaks in the SA military. I introduced a weekly report of notifiable diseases and coded a live dashboard to spot emerging disease outbreaks very early. I met the top generals and had a weekly audience with the Surgeon General; he was a mensch. Upon completing my military service, I got a commendation and medal from the Surgeon General for my services to the military. I have always played this part of my career down because of the reputation the South African military has in maintaining the apartheid state. However, on reflection, my time in the military has been very informative, at least from a public health perspective.
I have always remembered the lessons I learned from teaching myself epidemiology, computer coding, and report writing. At that stage of my career, I should have realised that public health was for me. Instead of thinking deeply, I left the military and enrolled as a neurology trainee in the Johannesburg General rotation program; the rest is history.
At the age of sixty, it is only now that I have finally reversed course and am following my instinct to do public health. I did my last official NHS clinic on Tuesday - apart from our MS nurse and visiting fellow, nobody noticed. I will now be spending my last few active years trying to prevent MS. As far as I am concerned, EBV is the cause of MS, and we now need to prove it.
People who are EBV-negative are protected from getting MS underpinning using a sterilising EBV vaccine to prevent MS. A sterilising EBV vaccine, however, has yet to be developed and remains a challenge due to the complexity of EBV biology. The mechanism of how EBV causes MS is unknown. Most people think it is due to molecular mimicry; I am not convinced as there is emerging evidence that people with MS have a different and possibly aberrant immune response to EBV. This new data supports the case for testing immunotherapies, including therapeutic EBV vaccines, as potential treatments for MS.
The possibility that intermittent lytic EBV infection, either peripherally and/or within the central nervous system, is driving MS disease activity makes a case for testing EBV antiviral therapies in MS.
EBV vaccine studies, be they prevention or treatment trials, and testing EBV antivirals will happen regardless of whether or not I am involved. This is why I plan to focus on symptomatic EBV infection or infectious mononucleosis (IM).
IM increases one’s risk of getting MS. However, the mechanism of IM increasing MS risk is unknown. Treating IM with EBV antivirals may reduce this risk and is a strategy that needs to be explored. My central hypothesis is that treatments to shorten the period of illness and severity of IM will reduce the risk of MS. Whatever immunological process that occurs during IM may be prevented with an effective antiviral therapy. This theory is analogous to using antibiotics to treat streptococcal pharyngitis to prevent the development of rheumatic fever and other post-streptococcal autoimmune diseases. So, I am retraining to become an infectious disease expert to set up a diagnostic and treatment pathway for purulent pharyngitis. By doing this, I hope to capture a new cohort of patients with IM for study and, more importantly, to test antivirals to treat IM. If I can get this working locally in East London, it could be scaled up nationally and internationally.
How many of you had IM? How many of you had complicated IM, such as prolonged fatigue or another complication? Imagine if your IM was promptly diagnosed and treated with an effective antiviral. Maybe you would not have developed MS. Wouldn’t that be a fantastic story to tell?
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Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
Farewell - no fanfare