By Amy Roeder
The doctor didn’t want to talk about Lawrence Deyton’s sore throat. Although Deyton’s visit to the Harvard medical campus’ student health clinic happened more than 40 years ago, he recalls the interaction vividly. The physician was kind, his eyes full of concern, as he said, “Young man, I’m very glad that you’re here. I’d like to refer you to a psychiatrist.”
Deyton took a moment to process that statement. “I said, ‘For my sore throat?’ I thought maybe he’d confused me with another patient. Then I realized that, no, it was about me being gay.”
Deyton had disclosed the information in response to a question on his intake form, along with his vaccinations and major surgeries. It hadn’t seemed like a big deal. After all, it was 1975, six years after the Stonewall riots in New York City launched the LGBT rights movement, and more than two years after the American Psychiatric Association removed homosexuality from its list of mental illnesses. But in the small exam room, persistent stigma was getting in the way of his care.
“I said no,” Deyton (pronounced Dee-ton) says. “I didn’t want a referral to a psychiatrist. I wanted something for my sore throat.” Anger came later, he says. A naturally cheerful former Midwesterner who goes by his childhood nickname “Bopper,” he corrects himself. “Angry is not exactly the right word.”
More than anything, he was perplexed. He had arrived at the now-Harvard T.H. Chan School of Public Health after graduating from the University of Kansas and was still a little awed to be in this “temple of learning.” He found it hard to believe that a Harvard doctor would be so ill-informed as to see him as emotionally disordered. “It made me realize that massive education of the health and public health community needed to happen.”
Deyton was already taking a first step, as part of the effort to found the American Public Health Association’s LGBT Caucus of Public Health Professionals, one of several such organizations that formed about then to tackle stigma in health care.
Today, after a celebrated career in medicine, HIV/AIDS research, and health policy, Deyton is in a position to help shape future generations of doctors. As the Murdock Head Professor of Medicine and Health Policy and senior associate dean for clinical public health at George Washington University’s (GWU) School of Medicine & Health Sciences, he’s spearheading an updated curriculum that integrates population health and health policy with clinical course work beginning in the first year. He wants doctors to be educators, advocates, and agents of change in their communities. It’s a multidimensional role he knows well.
Care without stigma
Deyton speaks with youthful energy, but carries himself with body language that reflects the decades he’s spent putting patients at ease—cocking his head when listening and when telling a story, using hand gestures that seem to gently pull in his audience.
He grew up in suburban St. Louis wanting to practice medicine. His physician father and biostatistician mother met while setting up polio rehabilitation clinics and shared stories about their work around the dinner table with their five children. Deyton, the youngest, helped out at his father’s practice on the weekends and observed the close relationships his father enjoyed with patients. Back then, medicine seemed fun.
But coming of age in the late 1960s, he began to view the profession more skeptically. Medicine had a paternalistic and conservative side, he says, and doctors didn’t seem interested in using their positions to advance social justice. Although he took premed courses as an undergraduate, they were just part of a wide-ranging self-designed major in “urban health” that also included courses in social work and journalism. His adviser was Harvard Chan School alumna Mildred Webb Sigler, SM ’62, who taught him that there was a field where he could apply his interests toward making the world a better place: public health.
After earning his SM degree, Deyton moved to Washington, D.C., to work as a health policy analyst. Outside his day job, he met a group of LGBT health professionals providing services to gay men out of a church basement. He joined the volunteer staff and later helped them separate from the Washington Free Clinic to form a new, more comprehensive facility. The Whitman-Walker Clinic (now known as Whitman-Walker Health) was named after gay poet Walt Whitman, who cared for wounded soldiers during the Civil War, and Mary Edwards Walker, a 19th-century activist physician who wore men’s clothing. It was envisioned as a place where care would be both state-of-the-art and affirming of patients’ identities.
Staying true to himself has been an important part of Deyton’s life since around age 12, when his parents first felt compelled to inform him that his given name was in fact not “Bopper” but “Lawrence.” “Bopper” had been his first spoken word, and it just stuck, he says. Headed to junior high school and a new crop of teachers and classmates, he insisted on keeping it.
“That’s a theme that has returned often in my life,” he says. “I tell my students, ‘Just speak. Say who you are and what you want to do, and don’t worry about what anybody else thinks.’”
After several years’ volunteering with Whitman-Walker and work as an analyst on Capitol Hill and with the then-Department of Health, Education and Welfare, which included helping advance national smoking-cessation policies and programs, Deyton realized that he was longing for more direct interaction with patients. He took premed classes in the evenings at a community college and entered medical school at George Washington University in 1981. Several months later, a piece of mail would change his life.
“A previously healthy 33-year-old man …”
It was a day he’ll never forget. Deyton walked out of a lecture hall—located downstairs from the office where he now sits as a professor and dean—to check his mailbox. Inside was a black-and-white publication dated June 5, 1981: The U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR). It described five cases of rare pneumonia among young, previously healthy gay men in Los Angeles. Someone had made copies and put one in every student’s mailbox. It was the first medical report on what would come to be known as HIV/AIDS.
“I just looked at it and my heart sank,” Deyton says. “I knew something awful was happening to my community.”
A month later, MMWR would report 26 cases of Kaposi’s sarcoma, a rare cancer, among gay men in California and New York City. By December, HIV had been reported in intravenous drug users, blood transfusion recipients, and immigrant Haitians. With cases escalating daily, and the risk of death within a year of diagnosis a staggering 40 percent, people began to panic.
For Deyton, the virus started appearing very close to home. While in medical school, he watched friends die and learned of others’ illnesses upon entering their hospital rooms on his teaching rounds. And he knew that he himself was at risk.
Reflecting on the impact HIV/AIDS had on his life, Deyton recalls a blue address book he used to keep. In the early years of the disease, a third of the personal and professional contacts in his book died—about 50 people. He made a mark by each lost name in his book, which he still keeps in a box in the home he now shares with his husband. “It’s a totem of remembrance and survival,” he says. “I’ll never throw it out.”
Inevitably, the experience shaped him as a physician. At a time when so little was known about HIV, and health care providers feared for their own safety, Deyton became a “translator from both sides of the bed,” he says. He sees his role as providing his patients with honest information about their health and compassion for their fears.
In his own life, action became a survival technique. His skills and identities—as a public health professional, clinician, and gay man—converged to give him a “sense of purpose and power,” he says. “This allowed me to not run screaming from the room, but to run toward the epidemic and become a member of the team that took it on.”
Speaking the language of activism and science
In addition to his clinical work, Deyton became a dogged researcher in this brand-new field. During his residency at Los Angeles County Hospital, he assisted with “shoe-leather epidemiology” at the University of Southern California—including conducting surveys in an HIV hot spot of Hispanic men in East LA. The team discovered that while the men identified as strictly heterosexual, actually they often had casual sex with each other after drinking and socializing on weekends, a behavior then unknown to epidemiologists.
Deyton then sought out an infectious-disease fellowship. His top choice was the National Institutes of Health (NIH). There, on his way out the door after a promising interview, he told Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, that he would be happy to start work early, if needed. (Deyton says that it was romance as well as science that made him eager to return to D.C.) Two weeks later, Fauci offered him a job and created a pathway so that Deyton could complete his residency as the first full-time physician in the NIH’s AIDS clinic, monitoring patients on drug trials.
As the epidemic raged on, activists grew impatient with the pace of research and demanded a voice in the process. NIH had been giving money to universities for biological and virological research, but patients rarely stuck with those studies for long, Deyton says. Most were from marginalized groups that didn’t trust the institutions. Following a series of protests by ACT UP and other organizations, Fauci met with activists and tasked Deyton—who could speak the languages of both activism and science—with figuring out a way to respond to their concerns.
Deyton developed the first NIH-funded community-based research program, funding a network of front-line providers in places like LGBT health clinics, homeless shelters, and IV drug use programs. These providers and their patients developed the research priorities, which included traditional drug trials such as validating the antiretroviral drug DDI, the second to be licensed, and questions around when to start treatment. Another study looked at how best to treat peripheral neuropathy, a common side effect of HIV/AIDS and the early drugs, that causes pain in the hands and feet.
It was a cutting-edge approach at the time, Food and Drug Administration Commissioner Margaret Hamburg said in 2011 when she nominated Deyton for a Samuel J. Heyman Service to America Medal—known as the Oscars for government workers. “It brought research to communities that needed it. He understood the disconnect between patients and research, and he found a new way to do testing and develop products.”
Back then, however, funding was limited, prompting difficult decisions around which groups to support. Guided by a rigorous scientific process, Deyton stood by his choices even as members of his own community burned him in effigy alongside Fauci at a protest.
Ultimately, Deyton helped lead more than 200 NIH-funded clinical trials of new HIV therapeutics and brought thousands of marginalized patients with HIV/AIDS into studies, including African Americans, drug users, and those with little or no access to care.
In 1996, the research community’s work finally started to pay off. Deyton was the medical officer on a double-blind NIH-funded study called ACTG 320, looking at whether adding a third drug, a protease inhibitor, to a two-drug combination then being used—most took AZT and 3TC—would be more effective at controlling the virus and possibly extending survival. Deyton was a part of the Data and Safety Monitoring Board (DSMB) meeting when the first results were unblinded, showing that the regimen was working, providing durable results.
“It was one of the most powerful moments in my life. I remember sitting in the DSMB meeting and I started to cry, and I wasn’t the only one,” he says. He lowers his voice and draws out the words: “People were living.”
A new framework for tobacco control
Deyton left the NIH a few years later to work on improving HIV/AIDS care at the nation’s single largest health care provider—the Veterans Administration (VA). The VA was then caring for more than 20,000 people with the virus. Leveraging the VA’s new electronic medical records system, Deyton was able to see by facility, and even by doctor, whether patients were getting tested appropriately and receiving the right medications. Over time, his role expanded, and he took on programs in areas including hepatitis C, pandemic preparation, and tobacco control.
At the time, tobacco use among veterans was higher than the national average. Deyton instituted a new policy—a prompt in the medical record that required providers to ask whether a patient would like help quitting—that contributed to an 11 percent reduction in tobacco use by veterans in the system.
It’s an issue Deyton takes personally. His mother was a smoker and had resisted his entreaties to quit. After learning about the dangers of tobacco use in greater depth as a graduate student, Deyton decided to make her an offer she couldn’t refuse: If she would stop smoking, he would cut off the long brown ponytail that he loved and she detested. She agreed, and both kept their ends of the bargain. She lived another 35 years. After her death, he discovered the ponytail in a box with her important papers.
In 2009, Deyton became the first head of the FDA’s Center for Tobacco Products, which was empowered by a new law to regulate the industry. Hamburg said in a 2013 statement that Deyton’s “excitement, dedication, and passion for public health quickly turned a legal statute into a landmark national tobacco product regulation program designed to reduce the impact of tobacco in the nation’s health, especially among youth.”
The job required a novel regulatory standard rather than the FDA’s usual requirement that products be “safe and effective,” given that there are no safe tobacco products, and that their “effectiveness” actually leads to addiction, disease, and death. Deyton and his FDA colleagues developed and implemented a science-based standard by which products brought to market must improve population health and not make it worse. Under his leadership, the agency also required for the first time that companies disclose the ingredients in tobacco products, place restrictions on manufacturing and marketing of products such as flavored tobacco that were aimed at youth, improve enforcement against sales to minors, and launch the first longitudinal study of tobacco use.
Echoing his tenure running community research programs at NIH, there were activists who wanted him to go beyond his mandate. “Some expected me to come in and cut the tobacco industry off at the knees,” he says, “but I had to also balance the needs of consumers using a legal product.”
Deyton faced multiple legal challenges from the tobacco industry, as he had anticipated, but physicians proved to be an unexpected disappointment. He had proposed a new rule to place graphic warning labels on cigarette packages. During the required public comment period, the vast majority of the responses were from the tobacco industry. Medical associations submitted comments in favor of the ruling, but very few individual doctors personally chimed in to support the proposed rule.
“I was crestfallen,” Deyton says. The tobacco industry sued to block implementation of the warnings, and the judge ruled in its favor. Although Deyton doesn’t know if more comments from clinicians would have made a difference, he believes it would have bolstered the case.
“I was kind of angry about it,” he recalls, “but I realized that we don’t teach physicians that this is part of their role—and maybe we should.”
Creating more Boppers
In 2013, Deyton, who still maintains a clinical practice, was invited to speak at GWU’s White Coat ceremony, a celebration at the start of medical school. He recounted the story of his career and advised students to find ways to use their roles for good in their communities. As students came up one by one to the stage to be helped into their first white coats and then shake Deyton’s hand, several whispered to him that they wanted his help becoming the type of doctor he described. Conversations with students after the event led to a series of discussions with GWU leaders and eventually a tantalizing opportunity to put his ideas into practice.
As Jeffrey S. Akman, the university’s vice president for health affairs, described it in a GWU publication: “We created a new position for Bopper, and then we turned him loose to create lots more Boppers.”
Under the new clinical public health curriculum Deyton created, medical students study “Patients, Populations, and Systems” for two hours each week. The course integrates with their clinical studies—for example, students learn about community and policy interventions to control childhood asthma in Washington, D.C., after they’ve covered the lungs and pulmonary system. As part of their course work, students attend three intensive summits in which they work together to develop innovative public health solutions for major public health challenges such as ending HIV. On the final day of each of these three-day events, students present their ideas to government, community, and public health experts. The goal is to train physicians to not simply dispense prescriptions and instructions but to also help play a role in addressing the conditions that made their patients ill in the first place.
And for their clinical rotations, many students head to Whitman-Walker, where they learn about providing respectful care to the LGBT and HIV communities. Deyton hopes that some of them will enter public service. “There is no more exciting calling,” he says. “I like the pure joy of exploration of applying scientific principles to the good of the population.”
When they ask him for career advice, he says, “Be generous with your ideas and be nice. You can teach an intelligent person anything, but being nice will take you far.”
Amy Roeder is associate editor of Harvard Public Health. Photography by Kent Dayton/Harvard Chan, Olivia Anderson/The George Washington University, and the National Institutes of Health (NIH)