A Global Perspective on Medicine

Yale has become a university of the world, and the School of Medicine is looking beyond national borders for solutions to pressing issues in medicine, science, and public health.

In 2005, Yale University published a blueprint for its development as a global university titled “The International Framework,” which was updated last fall. These documents set forth three major goals: to prepare students for leadership and service in an increasingly interdependent world, to attract the most talented students and scholars to Yale from around the world, and to position Yale as a global university of consequence.

As one of Yale’s graduate and professional schools, the School of Medicine is part of this vision. We attract gifted students from all around the world; the student body includes 131 medical students (23 percent of the total) who were born outside the United States, and more than 60 visiting medical students from other nations come to Yale each year for elective clinical rotations. The School of Public Health has an exceptionally global student body, with nearly a third of its students born outside the U.S. A high percentage of the graduate students (23 percent) and postdocs (70 percent) in medical school departments come to us from Asia, Europe, Africa, the Americas, and other regions of the world.

Capacity building and a world of solutions

With interest in global health among students steadily increasing, it is the school’s goal to send them into the world with a nuanced understanding of global health issues and, increasingly, with a first-hand appreciation for the experience of practicing clinical medicine and public health and conducting research in other countries. Why is this important? One has only to look at the international response to the earthquake in Haiti several months ago for evidence of the responsibility that nations feel for one another, especially in times of crisis. The world has grown smaller, communication is instantaneous, and we all have a stake in the health and success of other nations. The speed of the aid that was sent to Haiti, including several delegations of Yale clinicians in February and March, demonstrates the interconnectedness we experience and the importance of every country to the health and well-being of its neighbors.

The School of Medicine’s efforts in global health are motivated by several keys ideas. Over the years, there has been a shift in thinking, away from simply providing service in resource-poor countries toward helping those countries to develop their capacity to train leaders, scientists, and clinicians and to participate in the international community. We also recognize that the contributions to be made by other nations hold great value for medicine and biomedical science. As a global university, we need to look beyond our borders for talent and ideas. Further, disease does not respect national boundaries, and solving the most daunting problems in medicine, which affect individuals all over the globe, requires the combined power of many minds. In order to do the best science, we need to get out into the world and conduct research that cannot be done here.

In genetics, for example, there is a wealth of information in the DNA of populations where consanguineous marriage is common, and researchers such as Rick Lifton, Murat Gunel and Arya Mani have made groundbreaking discoveries about the genetic basis of cardiovascular, renal, and central nervous system diseases based on their work in Turkey, Iran, Saudi Arabia, Israel, and other countries. In infectious diseases, Erol Fikrig, Gerald Friedland, Rick Altice, Elisabetta Ullu, and Choukri Ben Mamoun are all doing work that extends Yale resources to help solve hugely challenging problems that are global in nature—work toward new vaccines for dengue fever and malaria, for instance, and research on West Nile virus, HIV/AIDS, Lyme disease, and African sleeping sickness. Jorge Galan and colleagues in microbial pathogenesis are applying discoveries about host-pathogen interactions toward the development of next-generation vaccines that do not require the use of live attenuated bacteria. And Richard Flavell’s immunobiology lab is developing an experimental mouse with all the components of a rudimentary human immune system for safer preclinical testing of vaccines in the future.

More than two dozen faculty members in public health are conducting research abroad, teaching, and designing courses in global health. Their work runs the gamut from molecular studies at the nanoscale to the analysis of social networks in disease transmission and prevention, to the improvement of health care systems. For example, Serap Aksoy studies the mechanisms of transmission of African sleeping sickness by tse-tse flies, while Elizabeth Bradley works with hospital leaders in Ethiopia to improve the delivery of care there. Diane McMahon-Pratt is working on a collaborative project to develop a vaccine against leishmaniasis. Tongzhang Zheng is PI on a research training grant for the study of air pollution control in China. And Public Health Dean Paul Cleary directs the Center for Interdisciplinary Research on AIDS, which conducts HIV prevention research all over the world. These are just a few areas of investigation that provide examples of global engagement. Dozens of other projects in nearly all the academic departments are pursuing similar paths with spectacular results.

A growing infrastructure

Yale University and the School of Medicine have invested significantly in assembling resources to help faculty and students pursue their international ambitions. In creating this infrastructure for study, research, and collaboration, the intent has been to assist individuals at Yale so that they can concentrate on doing what they do best and benefit from the experience and expertise of others. Here are some examples:

  • The Yale Office of International Affairs offers support to faculty in establishing and maintaining collaborations abroad, drawing on existing relationships and expertise in North and South America, China, India, and other regions within Asia, the Middle East, Africa, and Europe. It maintains a Faculty Research Database (see link below) with details of faculty projects around the world. Donald Filer, associate secretary of the university, directs the office.
  • The Yale Global Health Initiative, the first endeavor of the university’s new Jackson Center for Global Affairs, was launched in the spring of 2009 with several key goals in mind. During the next several years, it will support and coordinate the efforts of students and faculty engaged in health-related projects and initiatives around the world, foster innovative educational programs, stimulate faculty research in other countries, and advance international partnerships and leadership in global health. Elizabeth Bradley is leading the effort, working with Deputy Provost Stephanie Spangler and with the support of Provost Peter Salovey and MacMillan Center Director Ian Shapiro.
  • The Yale Global Health Leadership Institute, debuted last summer to help develop the next generation of global health leaders. At its inaugural conference in 2009, the program hosted leaders from Ethiopia, Ghana, Liberia, Mexico, and Rwanda, who spent a week devising a strategy to overcome a health problem in their home country and an evaluation plan to measure progress. The delegations will return in June to discuss and advance the implementation of their plans. Professor Bradley is the faculty director, and Michael Skonieczny is the executive director of the initiative.
  • The Office of International Medical Student Education at the School of Medicine, established in 2006 and directed by Bob Rohrbaugh, facilitates the placement of Yale medical students in clinical elective clerkships at sites in Argentina, Borneo, China, Peru, South Africa, Thailand, Uganda, the United Kingdom, and Zambia. The office also administers the Visiting Student Elective Program.
  • The Downs International Health Student Travel Fellowship program awards some 15 scholarships a year to students conducting research abroad. Downs Fellows pursue their studies in the context of their host countries’ culture, health problems, and resources. Kaveh Khoshnood is chair of the Committee on International Health, which administers the program.
  • The Concentration in Global Health at the School of Public Health, which began last semester, has enrolled 30 students, who take such courses as Global Health Systems, Epidemiology and Control of Disease in Low- and Middle-Income Countries, and Seminar in Global Health, participate in internships, and write a thesis. This new concentration has been enormously popular, and students from across the medical campus have shown particular interest in the seminar series. Brian Seavey is the program manager.
  • Yale/Stanford—Johnson & Johnson Scholars in International Health, a program that dates to 1981, sponsors rotations abroad for Yale house staff and physicians from other institutions. Last year 62 residents and faculty traveled to five sites in Eritrea, Indonesia, Liberia, South Africa, and Uganda. For the past 10 years this program has been supported by a major grant from the Johnson & Johnson Foundation. Asghar Rastegar is the Yale co-director of the program.
  • Mulago Hospital in Kampala, Uganda, one of the five sites mentioned above, is the training location for some 35 medical residents, Yale medical and Physician Associate students, and practicing physicians each year. The collaboration between the Department of Medicine at Yale and the Faculty of Medicine at Makarere University in Kampala also brings three to five Ugandan physicians to Yale annually for six to 12 months and sponsors four Ugandan medical students each year, who spend one month on a clinical service at Yale-New Haven Hospital. The goal of the exchange is to broaden the education of the participants and increase the quality of care at Mulago by assisting with the training of specialists and subspecialists. Majid Sadigh is the Yale co-director.
  • Church of Scotland Hospital at Tugela Ferry, KwaZulu-Natal, South Africa, is a research and training site focusing on the diagnosis and treatment of HIV and tuberculosis co-infection. This is the site where extensively resistant tuberculosis (XDR TB) was discovered by Yale researchers. The site also offers training opportunity in HIV and TB to 12 to 15 residents and faculty recruited through the J&J program. Gerald Friedland is the site director.
  • The UCL-Yale Collaborative on Biomedicine was established in 2009 to launch joint projects in basic biomedical research, medical education, and clinical care, with expansion into the humanities and other disciplines possible in the future. In joint clinical programs to treat cardiac disease, the institutions are exchanging expert physicians to treat individual cases at each site and sharing clinical information and expertise, as well as conducting research. Other proposed areas of research include cancer, genetics, drug discovery, computational biology, and vaccine development. Michael Simons is the Yale co-director.
  • The World Fellows Program, which has contributed to the professional development of more than 140 emerging international leaders since its inception in 2002, is directed by YSM faculty member Michael Cappello. The program annually hosts 15 to 18 leaders in a wide variety of disciplines, including health, who spend a semester at Yale with full University resources at their disposal.
  • Dr. Cappello and YSM faculty member Elijah Paintsil have also launched Yale’s International Training Center for Global Infectious Diseases Research (ITC-GIDR), which seeks to build research capacity in resource-limited countries. Current training sites include Yale University, the University of Ghana in Accra, and the University of Sao Paulo, Brazil. A fourth ITC-GIDR site is currently in development.

Remarkably, these are just some of the most visible efforts in global health and international training and research. At the level of individual faculty projects and exchanges, close to 150 examples can be found by searching the Faculty Research Database at http://learn.yale.edu/world/data/.

I have heard President Levin describe Yale University’s international role in the following terms: In the 18thth century, Yale was Connecticut’s university. It evolved to become one of the very best universities in the United States. To maintain itself as a leader it must today be a university of the world. Engagement with the wider world has been a hallmark of Yale’s development during the past decade, and this inclination to think beyond our national borders is very much part of the School of Medicine’s philosophy.