The New Humanitarians Volume I - Center for Health & HIV Intervention and Prevention @ UConn

Welcome back to The Deep Dive. I am your host, and today we are tackling something pretty fundamental about just being human.

And I am your resident expert here. To help unpack the science side of things.

Which is great because I was looking at this operational report today, and it really hit me that we are essentially looking at a document about literally the most frustrating thing in the human experience.

Which is what exactly?

The gap. The gap between I know I should do this and I actually did it.

Ah, yes. The behavior gap.

Right. And we aren't talking about trivial stuff here, like forgetting to take out the trash or— or flossing, though honestly, that is definitely part of it.

Sure, it is all connected.

But today we are talking about life and death. We are talking about HIV prevention, cancer screenings, the stuff where the information is clearly there, the logic is totally sound, and yet—

and yet people just do not do it.

Exactly. People just do not do it.

Yeah, and you are right. This report we are looking at today on CHIP—

that is the Center for Health Intervention and Prevention, right?

Correct. The center at the University of Connecticut. This report is essentially a massive case study on trying to close that exact behavior gap.

Yeah. And it was written by the founder, Jeffrey D.

Fisher, which gives it a really unique perspective because what is fascinating to me isn't just the psychology in this report, although that part is completely revolutionary. It is the structure, right?

Because this isn't just a science lesson for you guys listening. It is a story about two brothers. A Thanksgiving turkey, and how you actually build a machine that changes human behavior on a global scale.

And crucially, how you keep that machine running when the university gives you exactly $0 to start with.

Oh man, that part blew my mind. We are definitely going to get into the weeds of how university research actually works later on.

The money part.

Yes, the money part, because I really do not think people realize it is a business.

It is a massive business.

But let's start with the mission of this deep dive. CHiP was built to create scientific knowledge about health behavior, right?

Yes. And not just to study it in a vacuum, but to use it to design practical theory-based interventions that save lives.

They were specifically going after intractable problems, the things people thought could not be solved.

Primarily the HIV and AIDS epidemic.

Right. But the story does not start in a high-tech lab.

Not at all.

It starts with the Fisher brothers, Jeff and Bill. And right off the bat, this report mentions this detail that sounds like it was written for a movie.

The birthdays.

Yes. They were born on the exact same day, exactly 3 years apart.

Which, if you know anything about probability, is just wild.

I can only imagine the shared birthday parties growing up. But beyond the shared cake and the typical sibling rivalry, they shared this very specific generational anxiety.

Yeah, the report calls it a curse.

The curse of growing up in the 1960s.

That really stood out to me too. Usually scientists talk about curiosity or, you know, the pursuit of objective truth as their motivation.

Right.

But Fisher frames it as a burden. Like, if you grew up in the '60s during all that social upheaval, you could not just sit in a lab.

You had a moral imperative.

Exactly.

Yeah.

You had to go out and change the world. You had to be relevant to society.

But the field they both ended up choosing—

Social psychology.

Yeah, social psychology. That wasn't exactly set up for changing the world back then, was it?

Not at all. And this is a really key bit of context the report lays out for us. They overlapped at Purdue University for their training.

Okay.

And back then, social psychology was very ivory tower.

Meaning what exactly?

Meaning if you were doing applied work, which means trying to solve actual messy problems in the streets, you were kind of looked down on.

Wow. Really?

Yeah. The prestige was all in the pure theory, not the practice. The report actually says the field eschewed applied work.

So they are at Purdue. They have this training. They have this coast to change the world, but their field tells them not to.

Right. Until they meet their mentor, Dr. Don Byrne.

And he basically tells them to ignore the snobs.

Essentially, yes. He pushed them to apply rigorous experimental methods to real-world stuff, specifically human sexuality and condom purchasing behavior.

Which was a huge pivot. And then the '80s hit.

And the HIV pandemic starts.

And suddenly that ivory tower mindset wasn't just snobbish anymore.

It was dangerous.

Yeah. You had a global emergency that was entirely driven by human behavior, by sex.

And the people who studied human behavior for a living were just sitting on the sidelines theorizing.

Which brings us to the Thanksgiving table.

Yes, the origin of the whole project.

I just love this visual so much. It is Ohio. It is the mid-'80s. Jeff is at UConn. Bill is up at the University of Western Ontario.

Right.

Everyone else in the family is probably in food coma watching football. And you have these two brothers sitting at their parents' dining room table mapping out how to stop a global And they started with almost nothing. A thousand dollars.

A mere $1,000 grant from the Society for the Scientific Study of Social Issues.

A thousand bucks to stop a pandemic.

It sounds ridiculous now, but that was the seed. They were looking at the relationship between fear of AIDS and preventive behavior.

And out of that collaboration, and eventually a breakfast at a conference in Vermont, they crystallized what became the core of everything they did.

The IMB model.

Yes. Let's really get into this because this is the meat of the report. The IMB model is the intellectual engine of the whole CHIP Center.

It stands for Information, Motivation, and Behavioral Skills.

Which sounds simple. It almost sounds like corporate speak, to be honest.

It does. But the report argues that the reason most public health campaigns completely fail is that they only pick one of these.

Usually just the first one, right?

Correct. Information. Think about early AIDS campaigns.

Just giving people the facts.

Exactly. Here is a picture of the virus. Here is how it spreads. The underlying assumption was just, if you know the facts, you will change your behavior.

Which is nonsense. I mean, I know a donut is bad for me. I have the information.

We all do.

But I still eat the donut.

Right. So then public health officials realize that, and they add the M, motivation.

Okay, so you have to actually want to change.

You need the personal attitude, and you need the social norms around you to support that change.

But the Fishers realized there was a third leg to this stool that everyone was missing.

Behavioral skills.

So break that down for me. What is a skill in the context of, say, safe sex? Because it is not like learning to weld or learning to play the piano.

It is more subtle than that, but it's just as technical. Let's say you have the information. You know condoms prevent HIV.

Okay.

And you have the motivation. You do not want to get HIV.

Right.

But you are in the heat of the moment. Maybe you are shy. Maybe you are worried your partner will get angry or offended.

Oh, I see.

Do you have the actual social skill to stop the action, negotiate the situation, and insist on protection without completely killing the mood or risking rejection?

So it is like script training.

Exactly. It is having the literal words ready and having the confidence to say them.

It's self-efficacy.

Yes. If you don't have the skill, to go up to the counter and buy the condom or have that awkward conversation, the information and the motivation are completely useless.

You'll just cave.

You'll cave every time. And this model, the IMB model, it moved prevention beyond just scaring people.

Or handing them a pamphlet.

Right. It meant you had to actually teach people the literal skills to protect themselves.

That is such a massive aha moment. You can't just scare people. You have to teach them how to handle the social awkwardness of staying alive.

It was a total game changer.

So armed with this new model, they started the AIDS Risk Reduction Project, ARRP. This was back in 1985.

Yes. But by 1997, things in the funding world were shifting.

They needed to go bigger.

Right. The word project felt too small. They were competing for these huge federal grants against massive community organizations.

So Jeff Fisher petitions the university to turn this project into a full-blown center.

And the university administration gives him the classic yes, but—

A very big but.

A huge one. They approved the center, but they gave him absolutely $0.

No budget at all.

No salary support, no building fund, nothing. They basically said you can have the shiny title, but you have to go out and hunt your own meat.

Succeed in getting outside funding or close down.

Exactly.

And this is where the report gets into the business side of university research, which I think is fascinating.

Most people totally misunderstand it.

Yeah, we tend to think universities generously fund their researchers' work, but in reality, successful researchers fund the university.

It is a complete inversion of how the public sees it. It comes down to something called indirect costs.

Okay. Explain indirect costs for the listener.

Sure. So when CHP applies for a federal grant from, say, the NIH, the National Institutes of Health, let's say it's for $1 million, right? The government gives them the million dollars for the science that pays the researchers. It buys the lab equipment. It pays for travel.

The direct stuff.

Exactly. But then the government writes a second check, an extra chunk of money directly to the university just for overhead.

And what's the percentage on that?

Usually it ranges from 40% to over 60%.

Wait, 60%?

Yes.

So if I bring in a million dollars for my actual study, the university gets $600 grand just for hosting me.

Essentially, yes. For electricity, for administration, for keeping the building standing.

That flips the script completely.

It really does. So when Fisher started bringing in these massive grants, we're talking big numbers here, from 2000 to 2008, CHIP brought in over $40 million in grants.

$40 million?

Yes. And out of that, he was writing a check to the university for over $9 million in in pure indirect overhead.

So CHIP was not a charity case for UConn at all.

Not even close. It was a cash cow.

A total financial asset.

Right. And that is why that $0 start is so incredibly risky for a researcher. If you don't get the grants, you starve and your center closes. But if you do, you become an empire.

And the report lays out the math perfectly. It notes that while CHIP costs the university about $7.1 million in operations and paying for new buildings, it brought in over $9 million in indirects alone.

It funded its own growth and paid for the university's infrastructure.

It is geometric growth. Their research expenditures went from $1.4 million in 2002 to $8.3 million just 5 years later.

They scaled up massively.

Yeah, going from 1 admin staffer to a team of 11 plus roughly 100 grant-funded research staff.

But the report waves a pretty big yellow flag here too.

About growing too fast.

Exactly. Fisher warns about the danger of outstripping your administrative ability. If you bring in all this science money, but you don't have the backbone to support it—

Like the payroll and the HR and grant management.

Right. If you don't have that, the whole thing can just collapse under its own weight.

It is the classic tech startup problem just happening inside an academic institution.

Totally.

But let's go back to the science for a second. So they survive the $0 scare. They secure a huge $3.5 million grant from the NIH. What were they actually doing with it?

They used it to tackle a massive blind spot in how the world was handling HIV.

Positive prevention.

Right. Up until CHIP came along, almost all prevention work everywhere was focused on negative people.

Keeping the uninfected people safe.

Exactly. Almost nobody was designing interventions for people living with HIV, the seropositives.

Which, when you say it out loud now, it seems crazy. I mean, wouldn't the people who already have the virus be the most important group to work with to stop the spread?

You would think so. But there was this intense stigma at the time. There was a pervasive sense that if you were positive, it was game over for you.

Wow.

But CHIP argued that if you help positive people manage their behavior, you stop the transmission right at the source.

But there was another angle to this too, right? Protecting the patient themselves.

Exactly. Just because you have HIV doesn't mean things can't get worse.

Like because of different strains.

Right. They focused heavily on preventing reinfection with different strains, particularly drug-resistant ones. If you already have HIV, getting a second highly resistant strain can be completely catastrophic for your treatment.

And they didn't do these interventions by sending in a bunch of guys in lab coats to lecture people, did they?

No, they didn't. And this is honestly my favorite part of their whole operational model. They use peer-based interventions.

Walk the walk and talk the talk.

That is the exact philosophy.

Yeah.

Think about it. If you are an active injection drug user and a doctor from a fancy university walks up to you with a glossy pamphlet, you are going to ignore him.

Because he doesn't know your life.

Exactly. But if another user, someone from your own circle who really knows the struggle, comes up and shows you how to bleach a needle or tells you where to get clean ones, you listen to them. You listen because they have credibility.

And they did this with urban minority high school students too, right? Teaching other students.

Yes.

Yeah.

But it is incredibly risky, and the report is remarkably honest about this.

How so?

When you employ active drug users or high-risk teens as your intervention staff, things can go wrong very quickly.

Because human lives are messy.

Exactly. Peer networks are often unstable. Sometimes your peer educators relapse or they start behaving antisocially.

It is not a controlled laboratory environment.

No, it is messy science. Because the real world is messy.

So speaking of messy, another big area they tackled was medication adherence.

A huge problem.

Now I personally struggle to remember to take a basic daily vitamin, but for HIV patients on antiretrovirals or ARVs, the stakes are totally different.

The statistic Fisher provides in the report is just intense.

95%.

Yes. Patients on ARVs must take their medication 95% of the time.

Which is an incredibly high bar for anybody, let alone someone dealing with a chronic illness.

It is. But the consequence of missing doses isn't just that you get a little sicker. If you miss doses, the virus mutates.

It becomes resistant.

Right. And once that happens, it is untreatable. And even worse, that newly resistant strain is now transmissible to other people.

So what was CHFP's solution to this?

They went back to the IMB model. They developed tailored software interventions.

Software?

Yes. Instead of a doctor just scolding a patient and telling them to take their pills, The software dynamically assesses why a specific individual patient is missing their doses.

So diagnosing the exact gap.

Exactly. Is it just forgetfulness? Are the side effects too harsh? Is the patient dealing with severe depression?

It is the behavioral skills application again. Do you have the specific skill to manage your complex medical regimen?

Precisely. Yeah. And because these theory-based models worked so incredibly well for HIV/CHIP, eventually started diversifying.

They branched out.

They realized that these exact same psychological principles apply to almost everything in human health.

So the report mentions they moved into cancer prevention.

Yes, and diabetes management.

Exercise genomics. Even safe driving.

They even created a whole subcenter within CHIP called the Center for Health Communication and Marketing to look at how social media and marketing influence health behaviors.

So looking ahead, or at least looking ahead from the time this operational report was written, CHIP was facing some major crossroads. It sounds like they were almost becoming a victim of their own massive success.

The biggest challenge outlined is succession. Jay Fisher notes in the report that he intends to retire within 5 years.

And moving from a founder-led organization to a decentralized one is incredibly difficult.

It is. This center was driven by the sheer passion of the guy who started it at his parents' dining room table. Transitioning that to a sustainable institution requires a totally new structure.

He talks about creating cores, right? Decentralizing the leadership so it's not just one person steering the massive ship.

Yes. And the funding landscape was changing dramatically too.

The federal money.

Right. The NIH budget was leveling off. Fisher realized they could not just rely on federal grants forever.

So they had to pivot again.

They needed to start aggressively seeking private funding. Places like the Gates Foundation or the Robert Wood Johnson Foundation.

And then there's the fundamental dilemma of focus with all this diversification.

Right.

Do you stick exclusively to what you are globally famous for, which is HIV, or do you chase the new funding into totally new areas like obesity or alcohol abuse?

It is a strategic tightrope because if you diversify too much with finite funds, you risk diluting the exact expertise that made you successful in the first place.

Do you take money away from what works to bet on something entirely new?

You have to innovate to survive. But you absolutely cannot abandon your roots.

It is amazing to step back and think about the whole trajectory of this story.

It really is.

We started with two brothers born on the exact same day, feeling this profound curse of the 1960s to go out and change the world.

And they ended up building a multimillion-dollar international research center that literally changed how the entire medical community thinks about human health behavior.

It really heavily validates their early decision to leave pure theory behind.

They proved definitively that applied social psychology isn't just some lesser version of science. It is a vital, life-saving tool.

By getting their hands dirty and mixing academic theory with the messy reality of human lives, they genuinely saved lives.

It is a pretty incredible legacy for a conversation that just started over a Thanksgiving turkey.

It shows that sometimes the biggest changes really do start in the smallest, most ordinary places.

Absolutely.

So as we wrap up this deep dive today, I want to leave you, the listener, with a thought about that I-M-B model.

It applies to everyone.

Think about something in your own life that you have been struggling to change. Maybe it is your fitness routine. Maybe it is a bad financial habit, or maybe it is literally just flossing your teeth every night.

You likely already have the information. You know exactly what the facts are.

And you probably have the motivation. You genuinely want the good result.

But ask yourself this: are you actually lacking the specific behavioral skill?

Do you literally know how to have that awkward conversation, how to execute the move, how to navigate that exact moment when it gets hard and you want to quit?

It might not be a lack of willpower at all. You might just be missing the practical techniques to pull it off.

And that is a powerful thought to leave you with. Thanks for taking the deep dive with us today. We will see you next time.

Mm-hmm.