Kenneth Castro: a public health hero.

1456 www.thelancet.com Vol 378 October 22, 2011 Global tuberculosis eff orts owe much to the leadership of Rear Admiral Kenneth Castro. As Director of the Division of Tuberculosis Elimination at the US Centers for Disease Control and Prevention (CDC), he leads a team of technical experts dedicated to tuberculosis elimination, prevention, and control activities in the USA and internationally. But, he says, he never planned a career in medicine and initially wanted to be a marine biologist. “However, I quickly realised that Darwin and Jacques Cousteau who made the subject so glamorous were both independently wealthy and that option was not open to me”, he jokes. Growing up in his home town in Puerto Rico during the 1950s, Castro says his decision to follow medicine was inspired by a couple of dedicated local doctors and by the Jesuits at high school, who instilled in him the value of both service to others and intellectual pursuit. He went on to train in epidemiology, and then specialised in internal medicine and infectious disease. Early on, while working in the Hispanic urban poor communities of the Bronx, Castro was exposed to community-oriented primary care, which helped shape his philosophy of medicine with a strong social conscience. Then, in 1983, he took the fi rst steps on the path to becoming a disease detective when he joined the CDC as an Epidemic Intelligence Service offi cer with the AIDS Program. Here, Castro was introduced to epidemiology as a way to develop the evidence base for sound public health policies. But it was something of a culture shock, he recalls: “I was trained to be a good clinician and here I was walking into a classroom to learn about the principles of causal inference and not carry a stethoscope with me, and I wondered, had I thrown away those years of training?” Not so. Castro was able to successfully merge these two areas together, and has not looked back in his more than 25 years at the CDC. His introduction to HIV/AIDS came at an important time of initial discovery. “I was amazed to experience fi rsthand how applying the principles of epidemiology provided us with an understanding of patterns of disease transmission as well as, very importantly, how it wasn’t being transmitted, before we even knew what was causing it.” Castro was instrumental in clarifying the role of transmission of HIV, and his 1988 Science publication of a community survey in Belle Glade Florida was crucial in allaying concerns about casual and arthropodborne transmission of HIV in that impoverished community. Through his HIV work, Castro became involved in investigating outbreaks not seen before, such as multidrugresistant tuberculosis. As he learned more about tuberculosis and its link to social justice, Castro felt compelled to move into this area. He became one of the founding members of the STOP Tuberculosis Partnership. Launched in 2000, emphasis was placed on the unmet needs of service delivery, scientifi c discovery, and programme translation, and the development of a global plan to control tuberculosis. In its fi rst decade, Castro believes “the partnership has brought global attention to tuberculosis, and mobilised action across the stakeholders, but in the next decade the focus has to be tackling the social determinants of health”. He cautions that “Over time the biggest challenge is going to be to sustain the gains. I have seen in the US the paradox of declining tuberculosis and the propensity for decision makers to have premature declarations of victory and move on to the next health challenge without completely solving the previous one we were working on.” Castro laments the insuffi cient investment in new drugs for tuberculosis and worries about limiting access to eff ective drugs, such as moxifl oxacin. “How do we who work in the fi eld make sure those who need these medicines have access to them, whilst at the same time discourage their misuse in ways that end up driving the emergence and selection of drug-resistant pathogens?” He also thinks it’s time to stop vilifying private practitioners and engage with them. “At the end of the day most doctors want to do what’s right for their patients. These private practitioners are armies of workers who are caring for our patients, and if we make sure they do it right, that’s less work for the rest of us.” On new diagnostics, like the Xpert MTB/RIF test, Castro thinks that the global community needs to push for early promise to become a reality for patients, “We need to latch on to a clear vision of delivering same day diagnosis and treatment, if at all possible. We need to make a diff erence to the outcome of each person who we are trying to serve.” In an unusual distinction for a Division Director, Castro, who is a Commissioned Corps Offi cer in the US Public Health Service, was promoted to the fl ag rank of Assistant Surgeon General in 2000. He provides health advice to the Surgeon General in his specialty fi elds when needed. Other leadership roles have been in the response to the 2009 avian infl uenza pandemic and the 2010 Haiti emergency. Castro is modest about these achievements: “I credit my accomplishments to outstanding mentors, colleagues with a shared mission, and unwavering family support”. That attitude is one reason he is such an eff ective leader. Jim Curran, Dean of the Rollins School of Public Health and Co-Director of Emory’s Center for AIDS Research, says “Ken’s eff ectiveness is due to his considerable leadership skills and his respect for people. He is delightful to work with and for; he listens and understands the perspectives of others, including those in aff ected communities. And fi nally, his integrity is impeccable; he always delivers on his commitments. He is a true public health hero.”