Awards of Courage
Martin Markowitz, M.D.
Honoring with Pride 2001 Honoree
A staff investigator at the Aaron Diamond Research Center and director of the Center’s clinical research program, Dr. Martin Markowitz has been involved in some of the most cutting edge AIDS-related research of recent years. Currently, he is conducting pioneering research aiming to develop strategies that could allow patients to stop taking anti-HIV drugs for prolonged periods without suffering adverse effects.
Dr. Markowitz was recently presented with amfAR’s Award of Courage at the Foundation’s annual Honoring with Pride benefit in New York and was interviewed following the event. Portions of that interview are excerpted below.
Tell us about how you came to join the Aaron Diamond AIDS Research Center and what it’s been like to work there?
I did my sub-specialty training here in New York from 1981 to 1984, and then began working part-time on the first AIDS unit here in New York City at St. Clare’s Hospital as their hematologist/oncologist. Frankly, between that and my private practice, I probably saw enough human suffering to last a lifetime. By 1990, I felt I wanted to do more and thought I had the ability to challenge myself further. And as it happened, David Ho came to New York at that time. So I got rid of everything, and I found my way to ADARC. I started at ground zero, knowing a lot about clinical medicine but nothing about the world of the laboratory. Slowly but surely I eked out my laboratory projects and got interested in drug resistance. Then in 1994-1995, the whole world turned “right-side up.”
God, what a thrill it was to actually be part of a team that contributed to our fundamental understanding of why this infection behaved the way it did and that set the stage for successful treatment. I still laugh to this day—I remember having dinner with a friend of mine, and he asked why I was doing this when I was at a point in life when things were starting to become profitable and easier. I told him that I just wanted to make a difference, and I realize I was given an amazing opportunity to make a huge difference. At least that’s the way I see it. I’m very thankful to Irene Diamond and David Ho, the two people who gave me that opportunity. I have had fantastic colleagues. We’re a small team like the “little engine that could.” My nurse Arlene and I were the only ones on our “clinical team” for years. We got it done; I don’t know how we did it, but we did it. So that’s how I got here. I always say David Ho threw me a pass, and I caught the ball and ran with it. I think I’ve proved my worth, and I feel like I’ve been a valuable part of the team.
I think people who can work together can make more of an impact on the world than people who think they can do it all by themselves. Not only do I feel I’ve had a wonderful team here but I feel that my study subjects have also been colleagues. They’re just on the other side of the research. They’re giving of themselves while I’m taking a lot. In return for that, we try to be as kind and considerate as we can. You don’t always win; sometimes you do the wrong thing. But we haven’t hurt anyone, and at the same time, we haven’t cured anyone either. I think the stories of some of our first patients, who’ve been treated for a long time, are very telling. I remember one of them crying, and he said, “I’m not crying for me, I’m crying for you because I know how hard you work.” I think that sums up how selfless a lot of the people are that we’ve been able to meet along the way. It’s really been wonderful. I have an open door policy here and so many people come for help. It’s nice to be able to do that. It’s not only rich people—although some of them are rich and very well connected—but poorer people as well. Some of them even come from other countries.
I’m very proud to have been part of this effort. I’m very proud to be associated with this institute. You meet wonderful people in this field. I think in some ways HIV can attract some of the most competitive people on earth, but it also attracts some of the most compassionate people. A lot of us went into it when it wasn’t fashionable, when it wasn’t even known, and when it was so scary that people ran. But things have changed. We only have a small little microcosm of the world, and my vision is always to ask, “Where’s my next horizon?”
My next horizon is to try to help bring what we’ve experienced as a miracle here to the less fortunate of the world. We’re trying to get something going in a couple places and trying to get some studies going—one in Southeast Asia. I have some good ideas, but they are a bit off beat and nobody’s brave enough to help do it.
What are some of the problems you have faced with that?
It’s a very radical kind of study. You take people with low CD4 counts, and you try to get them up and keep them there for awhile, and then you take the drug and give it to someone else. So you’re sharing drugs and it’s very, very hard to get by. It’s been onerous.
Without the pharmaceutical industry, we’d be nowhere in this battle. Unfortunately, I think the pharmaceutical industry probably played the problems in the third world wrong, and they’re suffering for it now. Part of the problem has been that until very recently the prospect of delivering effective therapy in that environment was nonexistent. And when the prospects became clear, I think they should have said, “Fine, we’ll give you the drugs for cost, but it’s not our responsibility to foot the bill for everything. The Western world has to help.” But they didn’t do that. They seemed to fight tooth and nail until they were beaten into the ground.
That is what it’s been like trying to get the projects going in developing countries. The fear of starting something that they can’t finish is overwhelming for the drug companies, and they question the ethics of starting something they don’t think can be finished. I don’t know about you, but if I were a 27-year-old mother of four in Africa, I wouldn’t mind getting another two or three years of life, even if soon after I’d be starting down the other road again. But, who knows what’s going to happen now. The whole ethical question of drug access didn’t quite sit right, and the world has finally woken up. The sad reality is that despite all the talk, I know for a fact that there are very few people getting treated right now.
Do you see drug distribution in the third world as being a major issue in the coming years when it comes to HIV/AIDS treatment, or do you think things like more research funding in the U.S. are going to overshadow it?
It’s all going to happen. I think here at home, people are obviously going to need new drugs and are going to try to go after new targets to get better results. We have problems with drug toxicities that really are not tolerable, and we have to understand them better and try to come up with treatments that are not as toxic. We have a little bit of a clue, but not much of a clue. I’ve always felt, and I still feel, our number one goal should be to develop drugs that are just as active but less toxic. In my clinical research program, we are trying to come up with ways to get people off drugs for prolonged periods of time. I don’t think it’s realistic to say somebody has to be treated for life, especially young people. It’s very, very hard. Yes, diabetics do it; if you have to do it, you do it. But of course, if you can not have to do it that would be better. That’s why we are working to understand better ways of trying to suppress the virus with drugs, seeing if we can further reduce residual viral burden after treatment, and hopefully introduce exogenous immunogens in some kind of vaccines to stimulate healthy immune responses that will keep things in check. These are hopes and dreams. I always tell patients when I’m enrolling them in our studies, it’s a goal, not a promise.
I’ve had this vision for awhile about somehow having a world fund for helping people in other places get access to drugs in an effective health care system. I would love to be part of something like that. In order for that to be successful it has to be grassroots. It has to be sustainable so that just like our health care system, it is basically self-sustaining in generating income. We have to generate the same thing in these countries. It might not be money, but it could be drugs in return for a job, drugs in return for adopting orphans, drugs in return for supervising other people taking drugs. You can be creative about it, forming a society where taking therapeutic drugs is a viable option.
What in your career are you the most proud of?
What I derive happiness from is really seeing that the work I have been involved with has allowed people who were preparing for death to now be enjoying life. Early on there were some people who didn’t get the benefits. I had a patient who came to us with no T cells and a viral load of over a million. It was almost certain that she was going to die. But things changed for her, and now she has a cute little baby. What could make you feel happier?
But it’s hard to feel too proud when you stop and think that in just the time we’ve been talking, two adolescents in America got infected with HIV, and two people in Zambia probably died of HIV. I was in Zimbabwe recently, and the number of people that are dying is unbelievable. The cemeteries are so busy, and the number one industry in these countries is death and dying. About 25% of the population is infected. I was taken to a new cemetery that had just opened and it was already half full. And they don’t believe in cremation, it’s part of the culture that they can’t cremate, so they’re running out of room. It’s really something.
Is this the sort of thing that keeps you motivated to continue working?
I’m one of those really obnoxious people who bounce out of bed, and bounce into the clinic. I really enjoy seeing our patients. I have a very unusual job. Not only do I have patient contact, which is kind of fun in a way because our patients are really nice people and really fun people. Like I said, they don’t come to me whining, saying, “Make me better.” They’re basically coming and saying, “I want to participate in this study, so let’s do it and let’s be partners.” And then I come here to the lab and we have interesting projects going on. So every day is always different, exciting, and interesting. It’s rare that I sit there and say, “Boy, am I bored.” There are always a million things to do.
The saddest thing of all is when somebody thinks they’re special and HIV will not hurt them. But HIV is the great equalizer. It acts the same in nearly everyone no matter how rich you are, how poor you are, how good looking you are. Untreated, nearly all go down the same road. It’s so amazing that people say, “It’s not going to happen to me, I’m gonna beat this.” And they don’t. It’s been really, really terrible. And I don’t think that people really understand what an amazing and dramatic effect this has had on my generation. I’m in my late 40s now, and I have a really close friend who is a woman from Germany who told me that it broke her heart after the war because all the boys she danced with when she was a young girl were dead. And I said, well, I feel the same way; everybody I used to dance with is dead. It’s like a holocaust, and people have just disappeared. I think a lot of us that have survived have had some really damaging long-term effects. But for me I’m just so happy to be alive, to have survived that horrible period, and to have the opportunity to do something about it.
I moved to New York in 1981, and nearly all my friends died, miserably and brutally. I can’t say that I have as many friends as I used to. I think after a while you get a little gun shy. People don’t die as quickly anymore, but the treatments are not perfect. Yet, when you think of the alternative, it’s pretty unbelievable. I’m a trained oncologist and I have seen what women with breast cancer will do and go through without any hope. But they redefine their reality. Plus there are a lot of women with breast cancer that are young and have kids. They would define their reality by being happy about just seeing their kid another day—this propels them. You know HIV infection was as deadly as metastatic breast cancer just 6 or 7 years ago, and all of a sudden it’s not. I can’t say that everybody is benefitting from therapy. That’s not the case, and we still have a lot of work to do. But a huge number of people are doing well, and as drug development continues, treatment options will improve. And hopefully, people that are hanging on by a thread are going to be pulled back.
Other advocacy groups often complain about AIDS getting too much attention. How do you feel about this?
HIV/AIDS is unique in that early on it infected a very particular group of people who were well educated and highly accomplished. And I think that people have learned from the experience, but I don’t think that the voice of people with lung cancer, for example, could possibly be as unified because it’s so much more diverse. The voice of women with breast cancer has really been heard, and I think that they have sort of looked at how gay men with HIV mobilized themselves. Many women with breast cancer are young women who have never had children. They tend to be women who have had careers and therefore they are more likely, when doors slam in their faces, to put their foot in them and say “No way.”
I think the American population in general gets pushed around when it comes to health care and access to health care. Our government spends our tax dollars on what it decides is a priority. It’s sort of sad I think. We’re not a very activist country in that sense. If you go to Europe, people are very involved and very passionate about their politics. As Americans, we tend not to discuss things like that. We might have opinions, but we sort of keep them to ourselves.
What do you see as some of the most promising research going on right now? And what are your own personal goals?
Vaccine, vaccine, vaccine. I think the field as a whole has been focused on understanding the infection and treating the infection. And now comes the realization that, wait, we’ve got to work on the vaccine as well. And the vaccine might have not only prophylactic or preventative benefits, but it might even have therapeutic benefits. There’s a lot of really exciting stuff being done now that looks promising. Of course proving that a vaccine is effective is going to take a long time. And I think the other really spectacular area that’s translating into treatment is going after these new targets, particularly the drugs that interfere with the virus’s ability to get into and infect a cell. It’s very elegant work translated into very real, tangible results.
What are you working on right now?
My two major areas are trying to understand why HAART has not been completely suppressive and how we can optimize it so it is completely suppressive. I’m still focused on identifying newly infected people, getting them treated with what we hope is going to be optimized HAART, and trying to get them off drugs after a period of time. We are trying to learn from our experience and from the experience of others to do that. I have a very active program studying drug resistance and trying to understand some of the intricacies and subtleties as to why drug-resistant viruses may or may not be transmitted. We have some really exciting clinical studies coming up to try to understand how the multi-drug resistant virus is interacting with the host and examining whether this is different from the way a wild type virus does. And getting down to issues of pathogenicity—is pathogenicity the equivalent of replicativeness? We really don’t have an answer. So that’s a pretty full plate. Also, I’m trying to get programs off the ground in Haiti and Southeast Asia.
Additionally, I’m on the board of Mother’s Voices, where our focus is prevention. Two adolescents are infected every hour, and I hear that in 2001, oral sex has become the goodnight kiss for teenagers. I was shocked but the percentages are just unbelievable. Most kids look to their parents for sex education, and most parents don’t talk to their kids about sex. I don’t have kids of my own, but I have three nephews whom I adore and am very, very close to. Have I ever talked to them about HIV/AIDS? No. Have I ever talked to them about girls or sex? No. It’s scary to realize that despite all the good work we’ve done in treating, we haven’t done a lot of prevention. In our primary infection program, I’ve been trying for five years now to try to figure out how to reach women, how to reach heterosexual men of color. We just can’t figure it out. But we just have to keep trying.