Firsts in diabetes care: A conversation with James R. Gavin III, MD, PhD
James R. Gavin III, MD, PhD, was spending valuable time in a laboratory, painstakingly purifying finicky hormones from the pituitary glands of cattle when he discovered insulin.
“When [diabetes researcher Jesse Roth, MD] explained that insulin was commercially available, had been crystallized, and was stable in acid at room temperature, I said, ‘Sold!,’” Gavin told Healio.
He turned his focus to diabetes and became the first African American president of the American Diabetes Association in 1993. Now a clinical professor of medicine at Emory University School of Medicine and the Indiana University School of Medicine, Gavin is also the CEO and chief medical officer of Healing Our Village, a corporation that specializes in targeted advocacy, training, education, disease management, and outreach for health care professionals and minority communities.
Throughout his time in medicine, Gavin has taken an interest in the career development of physician researchers, contributing to the paths of more than 300 health care professionals from minority backgrounds. For his mentoring service, Gavin received the Endocrine Society’s Outstanding Mentor Award at this year’s ENDO annual meeting.
Healio: When did you decide to pursue a career interest in diabetes?
James R. Gavin III, MD, PhD: I was headed for a career as a bench scientist interested in hormone action. I had studied gonadotropin hormone chemistry and action in Leo Reichert’s lab at Emory University and had been fortunate enough to secure a postdoctoral position in Roth’s lab at the [National Institute of Diabetes and Digestive and Kidney Diseases], which was NIAMD at that time, where I was persuaded by [Roth] to continue my pursuit of the study of hormone action, albeit with a different hormone — insulin.
This was not a hard sell at the time because in order to study pituitary gonadotropin, I had to purify it from bovine pituitary glands, requiring laborious hours of extraction, fractionation and tedious purification. This was before the establishment of the National Pituitary Agency, so no commercially available, biologically active preparations of follicle-stimulating hormone (FSH) were available for use in experimental protocols at the time. Bovine FSH was also notoriously unstable using the purification procedures we followed at that time, and it turned out to be due to the co-purification of a neuraminidase, which cleaved some of the essential sialic acids from the hormone, causing it to lose activity. You might imagine the frustration of all those hours spent in a cold room, finally obtaining what was a highly purified FSH molecule that was completely biologically inactive.
When [Roth] explained that insulin was commercially available, had been crystallized, and was stable in acid at room temperature, I said, “Sold!” Moreover, in learning about this new hormone, I had to learn about the disease where it played such a dominant role, and that was my first exposure to insights about diabetes.
It was not my first exposure to the disease, however, as it turned out. I realized that it was the disease that had caused the debilitation and death of my beloved great-grandmother, “Mama” Rennie Lee Whitaker. She had been so loving and supportive and wise — and made the best cookies. The inexplicable loss of her vitality and then both her lower legs over time was a painful mystery to me as a young kid. It was due to diabetes. Many others in my family were also affected by this devastating disease.
I decided that this was the problem I needed to spend my career trying to solve. I needed different tools, however, so I had to pursue medical training, and off to Duke Medical School I went. The rest is, as we say, history.
Healio: Have you ever been fortunate enough to witness or to have been part of medical history in the making? If so, please explain.
Gavin: This is a fascinating question, and when I first read it, I was flooded with recollections of how fortunate I have been to be a witness to or actually part of historical events in medicine, more specifically in the field of diabetes. I will briefly point out two such events. The first was in 1993, when the results of the Diabetes Control and Complications Trial (DCCT) were announced in the same year that I became the first African American selected as president of the American Diabetes Association. The historical event of medical consequence was the definitive demonstration that intensive glycemic control truly succeeded in preventing or reducing eye, kidney and nerve complications of diabetes. This study substantially changed practice recommendations for the management of diabetes.
The next was in 2015, in Stockholm, Sweden, when the results of the first cardiovascular outcome study of an SGLT2 inhibitor, empagliflozin, were presented. In the presence of an audience of thousands of excited and curious endocrinologists and other health care providers, it was a stunning event when Silvio Inzucchi, MD, presented data showing that this diabetes drug actually reduced the risk for cardiovascular death in persons with type 2 diabetes and established cardiovascular disease. These results were the first in a series of outcomes with this class of agents — later to be joined by the GLP-1 receptor agonists — in showing that use of certain antidiabetes drugs could produce reduction of cardiovascular events, an outcome that had not been reliably achievable in the glycemic control trials with various drug classes in earlier years.
The demonstration of cardioprotection has changed the narrative and the management expectations in type 2 diabetes in ways none of us over the age of 40 would have ever imagined. What a remarkable linkage to see that in the DCCT we saw how much glycemic control actually matters, and this observation has now been joined — not replaced — by the finding that it is now possible to go beyond glycemic control to achieve the prevention/reduction of cardiovascular and cardiometabolic outcomes in type 2 diabetes using commonly available new classes of diabetes drugs. This has been a monumental and historic change in the history of medicine and diabetes. I am delighted to have been witness to these developments in my lifetime.
Healio: What advice would you offer a student in medical school today?
Gavin: I would remind students to enjoy the excitement of a lifelong journey of learning and service. I would urge that they be mindful at all times that they have chosen careers which call for a passion to serve, whether in the delivery of clinical care, championing of public health, performing diagnostic procedures, or doing research on urgent medical, scientific or health care problems. You are forging the path and leading the charge to improve human health. I would add that, in everything you do, you are seeking to make someone’s life better, to relieve pain, discomfort, hopelessness and suffering, while committing to do this for all persons in need, regardless of age, gender, race, ethnicity, religion or sexual preference. I would suggest without apology that if these notions don’t align with your core views on medicine as a career, it may be important to reconsider your direction. While medicine offers the opportunity to make a good living, it is more than a business; it offers the opportunity to have a good and meaningful life.
Healio: Whom do you most admire and what would you ask that person if you had 5 minutes with them ?
Gavin: I really admire Bill Gates as an example of a person possessed of enormous wealth and power who has chosen to pursue solutions to problems that pose threats to health, longevity and quality of life for humankind broadly, especially in areas that are the most under-resourced. He has really committed to envisioning a better, safer and more sustainable future for the planet, and has used his resources and global platform to attract others to these causes. I would ask him what events proved seminal for him in choosing to follow this visionary and activist path, and what does he think might prompt others among the mega-wealthy to do likewise?
Healio: What do you think will have the greatest influence on your field in the next 10 years?
Gavin: For a complex, dynamic disease like type 2 diabetes, the growing capabilities of personalized medicine generated by the rich harvest of huge real-world databases, novel combination therapies, integrated remote monitoring and user-friendly self-management programs will promote more effective prevention, earlier detection and improved management of this disease. The beneficial combined impact of these technology-derived developments on optimizing outcomes will be driven by the increasing use of algorithms derived from machine learning and tools of artificial intelligence.
Healio: What are your hobbies/interests outside of practicing medicine?
Gavin: I have an array of interests that are well known to many who know me. I love golf and I enjoy singing. Indeed, I still sing with a wonderful men’s chorus. I have pursued woodwork for many years, and I love designing and building items of furniture and pieces of art, many of which are on display in our art room. Finally, I have grown more enthusiastic, since locating to Florida, about growing plants and trees and take great pride in the quality and health of our citrus trees, mango and avocado trees and other decorative shrubs, vines and trees, which are simply a pleasure to behold.