Although the reunion in June officially kicks off with a Friday evening dean’s reception followed by the clambake on Harkness Lawn, in recent years a Thursday evening reunion of the Yale Surgical Society has increasingly drawn alumni to New Haven a day early. This year, early birds were treated to a discussion of the surgeon as artist. Other reunion talks included a discussion of terrorism by a psychiatrist who has worked with the Central Intelligence Agency (CIA) and a panel on advances in treatment of pediatric diseases. This year’s reunion also saw the election of a new president and vice president of the Association of Yale Alumni in Medicine.
At the New Haven Lawn Club on Friday, public health alumni heard a panel on the impact of genomics on their profession and, over lunch, a keynote talk on the potential for genetics and biotechnology to improve the lives of the poor.
From surgeons to artists
As an adult Bernard S. Siegel, M.D., HS ’61, returned to a boyhood hobby that had given him great pleasure. Painting, he said, is “a way of relieving the pressures of being a physician. It makes me lose track of time. I think it is the healthiest state I can be in.” Siegel, whose paintings of his family and a self-portrait in surgical scrubs were on display in the Cushing/Whitney Medical Library in June, was one of three speakers on “The Surgeon as Artist,” the theme of the 10th Annual Yale Surgical Society Spring Reunion in June.
Joining him in the discussion in Harkness Auditorium were surgeon and photographer James M. Dowaliby, M.D. ’67, HS ’72, associate clinical professor of surgery (otolaryngology), and surgeon and sculptor Ralph S. Greco, M.D. ’68, HS ’73, the Johnson & Johnson Distinguished Professor and chief of general surgery at the Stanford University School of Medicine.
Dowaliby has been taking pictures for 52 years. With his digital camera he documents family events and vacations and records his surgeries, but his personal and professional lives merged in this exhibit with two photographs of his sister-in-law as she prepared for radiotherapy to treat cancer. Dowaliby photographed her face as it was being fitted with a mask. He converted his color pictures to black and white, then increased the contrast to obtain stark, almost surreal images.
Unlike the other speakers, Greco—a professional sculptor for more than a decade, with gallery shows and sculptures in private collections around the country—said he has failed to find a link between surgery and his art. “I have searched in vain to find a connection that makes any sense to me between surgery and sculpture,” he said. “Surgery is about the pursuit of technical perfection, sculpture about the pursuit of beauty. Perhaps what they have in common is that in both, as we learn, we come under the influence of masters who influence us in many ways, some of which are not easily recognized.” Greco’s representational and abstract stone sculptures were among the photographs, paintings and sculptures by nine surgeon-artists on display at the symposium.
Other works on display by Yale surgeon-artists included those of John A. Anlyan, M.D. ’45; Paul A. Barcewicz, M.D., assistant clinical professor of surgery (gastroenterology); Wayne O. Southwick, M.D., former chair of orthopaedics; Michael O’Brien, M.D., Ph.D., assistant clinical professor of surgery (gastroenterology); Eiji Yanagisawa, M.D., HS ’59, clinical professor of surgery (otolaryngology); and Ken Yanagisawa, M.D., HS ’93, assistant clinical professor of surgery (otolaryngology).
Of tyrants and terrorists
Reunion activities started off Friday with a sobering presentation by psychiatrist and terrorism expert Jerrold M. Post, M.D. ’60, who has profiled terrorists and tyrants for the CIA. Terrorists, he said, tend to be “normal individuals” who have more in common with urban gang members or mobsters than with crazed fanatics. Indeed, terrorist groups screen out emotionally unstable individuals because they represent a security risk.
“You can’t explain terrorism on the level of individual psychology,” said Post, director of the political psychology program at the George Washington University and founder of the CIA’s Center for the Analysis of Personality and Political Behavior. The attractions of joining a terrorist group, he said, are rooted in collective psychology—alienated youth join to find purpose in their lives and they subordinate their individuality to the group cause as articulated by a destructive, charismatic leader such as Osama bin Laden. Group psychology binds the members together, and group and organizational psychology can push them to risky and destructive behavior, as they recognize that dissent leads to expulsion or death.
Religious terrorists are spurred by an ideology of hate toward nonbelievers. Although their war on modern influences depends on modern technology, technology is not the key to fighting terrorism, said Post. He proposed a program of strategic communication designed to inhibit potential terrorists from joining the group, produce dissent in the group, facilitate exit from the group and reduce support for the group. But as he showed the photo of a 1-year-old child wearing the bomb-draped vest of a suicide bomber, he cautioned that the so-called war on terror will be decades long. “We have already lost a generation,” he said. “Hatred and the attractions of martyrdom have been bred in the bone from childhood on.”
The state of the school
After Post’s talk, alumni moved up the street to the dean’s reception in the Historical Library, followed by the clambake on Harkness Lawn.
The next morning the Association of Yale Alumni in Medicine (AYAM) elected Francis M. Lobo, M.D. ’92, to a two-year term as president. Jocelyn S. Malkin, M.D. ’52, HS ’54, FW ’60, was elected vice president. Christine A. Walsh, M.D. ’73, elected two years ago to a three-year term as secretary, will continue in that position for another year.
Lobo said he is assuming the presidency at a moment of “tremendous excitement. … The School of Medicine is seeing a vigorous expansion of the missions of research and patient care, as well as a very appropriate sensitivity to the special nature of our educational mission by Dean Robert Alpern. That will be a very exciting message to bring to the alumni,” he said.
Malkin, who is in private practice as a psychiatrist in Maryland, said, “I am particularly interested in the issue of women faculty, promoting equal working conditions and salaries for women.” Malkin has served on the AYAM executive committee and as a delegate and member of the board of governors of the Association of Yale Alumni.
Outgoing AYAM president Donald E. Moore, M.D. ’81, M.P.H. ’81, and Sherwin B. Nuland, M.D. ’55, HS ’61, each received the Distinguished Alumni Service Award at the Saturday morning business meeting. Moore was honored for his service to his community in Brooklyn, N.Y., where he has a private practice and makes house calls. “You have always put the patient first,” read his citation, which also took note of his teaching of medicine and his leadership in “embracing the cultural diversity that is a vital part of our school’s—and our nation’s—growth.”
Nuland was honored for his “distinguished and outstanding” career as a surgeon, and for his second career as a scholar, writer and lecturer in the history of medicine. His citation noted his humanitarianism as well. “When the Asian world was devastated by a tsunami, you immediately joined a Yale medical team to travel to Sri Lanka.”
Following the awards, Dean Robert J. Alpern, M.D., Ensign Professor of Medicine, discussed the state of the school, which he described as one of advancement and expansion. A strategic planning process begun last year has created new venues for communication and identified areas for allocation of resources. “The school cannot and should not invest in every conceivable area,” Alpern said. “The areas in which it does invest should be truly excellent and among the best in the nation.” Areas targeted for investment include faculty, new research and clinical programs, facilities, new research buildings, innovative medical education programs and student financial aid.
Childhood diseases grow up
Earlier that morning, at the annual scientific symposium, alumni heard from a panel of Yale researchers who are helping to rein in diseases that, in the not-too-distant past, presented parents with their worst possible nightmare: burying a young child.
Certain congenital heart defects, type 1 diabetes and cancer were often associated with poor outcomes, but “the tide is turning on those diseases,” said Margaret K. Hostetter, M.D., the Jean McLean Wallace Professor of Pediatrics, chair of pediatrics, and moderator of the symposium From Embryo to Young Adult: New Frontiers in Pediatrics. Three Yale faculty members described their research.
Martina Brueckner, M.D., FW ’90, is literally shining a light on the genetic roots of atrial isomerism—a condition in which the heart develops as a mirror image of its normal self. A team led by Brueckner, an associate professor of pediatrics (cardiology), discovered in mice that a “molecular motor” gene called left-right dynein, mapped in 1997, is crucial to a developing embryo’s “biological handedness,” the ability to tell left from right.
The process starts early. “By 56 days of human development, the heart is fully formed,” Brueckner said. “Handedness” is determined as early as 20 days, and if it doesn’t happen correctly it “can lead to a very, very malformed heart.” By examining embryos under special lighting in a microscope, Brueckner’s team discovered that the cells of the nodes (organizing centers) have hair-like structures called cilia that move fluid around the embryo leftwards, leading to asymmetric development of the heart. This doesn’t happen in embryos with the mutated form of dynein.
While only one in 8,500 people is born with inverted organs—and many live a healthy life without ever knowing of the inversion—the condition strikes one in 25 of Brueckner’s congenital heart patients. “They’re what we call our frequent flyers,” she said. “They keep coming back.”
The progress against type 1 diabetes has come in several large waves—the discovery of insulin in the 1920s and the advent of glucose self-monitoring in the 1970s—rather than incrementally. The next wave is the development of an artificial pancreas, which Stuart A. Weinzimer, M.D., an associate professor of pediatrics (endocrinology), called “our best shot” at diabetes management.
Researchers have two of the three elements needed, Weinzimer said. One is the insulin pump, developed at Yale in the 1970s, which is now portable enough (once the size and weight of a laptop computer, it is now no larger than a pager) to be in widespread use. A 2002 Yale study of the latest devices found that they cut episodes of hypoglycemia in half.
The second innovation is the round-the-clock glucose monitor. Some models can read blood sugar levels without puncturing the skin, and others sound an alarm when levels are abnormally high or low. While “we have a lot of work do to on these,” Weinzimer said—they still don’t give a completely accurate picture over a 24-hour period—“there is a place for them.” The third component to creating an artificial pancreas, under study at Yale, uses a computer that gets the insulin pump and glucose monitor “to talk to one another,” signaling the insulin pump to respond to a patient’s individual needs. “We’re getting closer and closer,” he said.
In 1997, one in 640 Americans was a survivor of childhood cancer, and that rate is expected to rise to one in 250 in five years. The progress is such that doctors face a task their peers could only dream of a generation ago—coping with problems faced by an ever-growing pool of childhood cancer survivors. “This is a growing population,” said Nina S. Kadan-Lottick, M.D., an associate research scientist in pediatrics (hematology/oncology), but “there are costs.” Many survivors have problems with growth and fertility, don’t do well in school, have self-image problems, suffer from neurocognitive impairment, develop subsequent malignancies and live shorter lives. To help the survivors of childhood cancer, especially those recovering from leukemia, Kadan-Lottick directs the HEROS clinic, a unique clinical program within the section of pediatric hematology/oncology at Yale.
Kadan-Lottick said her team is looking at the role of family strains, mechanisms of coping with life after cancer and what types of chemotherapy are more likely to lead to other medical problems later.
“There are many opportunities for screening and intervention,” she said. On the bright side, “cure is the rule, not the exception, for children with cancer.”
Public health and the human genome
“Race is really a social phenomenon, not a biological one,” said Kenneth K. Kidd, Ph.D., professor of genetics, psychiatry and biology at Yale, the keynote speaker at alumni day at the School of Public Health, held at the Lawn Club on Friday, June 3. His speech kicked off a discussion of genomics and public health, an area in which health practitioners are still feeling their way.
Citing studies of 42 genetically diverse populations from around the world, from the Mbuti of Africa to the Yakut of Siberia, he said that despite obvious, skin-deep differences, the genetic diversity found within any given human population far outweighs the diversity between populations. Nearly all potential genetic variations are found in every population. “It’s really impossible to define a boundary of a race based on these differences,” he said.
Panelists at this year’s public health reunion explored how the genomic revolution might be applied to epidemiology, while cautioning against over-emphasizing genetic causes of disease and neglecting environmental and behavioral causes. At least two speakers said the promise of genomics has been “oversold” to the public. As Kidd stressed in his talk, there is still much to learn about human genetic variations.
The 400 or so variants he has studied represent a tiny, “Eurocentric” fraction of the estimated 6 million in the human genome. “We need to know how much variation there really is and how it is distributed around the world,” he said, before genomic data can be used to relate human diversity to public health problems. As an example, he cited a study that appeared to link variants in the dopamine transporter to smoking in the United States population. But when he looked at the same gene in populations around the world, he found much more variation among the populations, irrespective of smoking, that called the original results into question.
Despite such caveats, public health professionals will be in the forefront of using genomic data, noted panel moderator Paul A. Locke, M.P.H. ’80, J.D., Dr.Ph., a visiting scholar at Johns Hopkins. Five panelists described how genomics is already affecting their piece of the public health puzzle.
Alan Goldberg, Ph.D., director of the Center for Alternatives to Animal Testing at Johns Hopkins, said genomics will eventually allow toxicologists to use fewer animals in tests. Genomics, he said, will lead to in vitro replacements “that are both good science and allow humaneness.”
Lloyd M. Mueller, Ph.D. ’84, an epidemiologist at the Connecticut Department of Public Health, noted that genomics’ impact on policy is “promising, but challenging to translate.” And, he cautioned, this promise is oversold to the public. For example, said Mueller, the Connecticut Legislature recently mandated an expanded battery of newborn screening tests, some of which have not been systematically studied and yield test results that do not lead to specific treatment decisions. Audience members worried about the potential legal and ethical ramifications of tests with still-unknown false-positive and false-negative rates that are designed to detect diseases for which there are no known interventions.
Herbert Yu, M.D., Ph.D., associate professor of epidemiology and director of Molecular Epidemiology Shared Resource at Yale Cancer Center, discussed the effects of heredity, lifestyle and environment on DNA methylation, a process involved in gene expression. Disruptions in methylation can cause disease, and Yu noted that methylation patterns can be inherited but can also be changed by environment, lifestyle and exposure to chemicals.
This interplay of behavior, environment and genetic luck was also addressed by Marta Gwinn, M.D., M.P.H., the director for science at the Office of Genomics and Disease Prevention at the Centers for Disease Control and Prevention, and Kathleen R. Merikangas, Ph.D., senior investigator and chief of the Section on Developmental Genetic Epidemiology at the National Institute of Mental Health and a research affiliate in epidemiology at the School of Public Health, where she was a professor until 2003. The underlying heterogeneity in populations will allow doctors to distinguish between hereditary and sporadic cases of cancers or other diseases, and to identify subgroups that are more susceptible to environmental risk factors. “Risk factors coupled with genetics and biology become meaningful,” said Merikangas.
She went on to add, however, that “genomics has been grossly oversold.” Discoveries such as the putative “gene for smoking,” she said, could make people feel they are absolved from responsibility for their high-risk behaviors. “We need to help people understand and not overinterpret the role of genes,” she said.
Past progress, future challenges
At the public health alumni day luncheon, Interim Dean Brian P. Leaderer, M.P.H. ’71, Ph.D. ’75, began by praising his predecessor, Michael H. Merson, M.D., the Anna M.R. Lauder Professor of Public Health, who stepped down in December after 10 years as the first dean of public health at Yale. “I think it is really important to all of us as graduates to acknowledge what he has done,” Leaderer said, citing a twofold increase in the size of the faculty, improved facilities, increased visibility for the school and the creation of the Center for Interdisciplinary Research on AIDS.
As the search continues for a new dean, however, a report from the provost’s office has noted some areas for improvement. The report called for continuing a strong focus on research, an improved educational program and an examination of administrative structure, Leaderer said. And, the report said, the school lacks a critical mass. “We are too small and we lack the money and infrastructure to grow,” Leaderer said. The subtext to this discussion, he added, was independence. EPH, which is accredited as a school of public health, has long sought to be free-standing, rather than a department of the medical school. “The university’s response was that there will be no independence in the foreseeable future.”
In response to the provost’s report, the school has begun a strategic planning process. “We are paying more attention to the quality of our teaching,” Leaderer said. The school is also planning a one-year master’s program for those with a degree in health-related science. And a new program with Yale College would create a joint five-year program in which undergraduates could major in public health and after graduation spend another year obtaining an M.P.H.
Jerald A. Fagliano, Ph.D., M.P.H. ’85, was inducted into the Alumni Public Service Honor Roll for his service to Vermont and New Jersey in the area of environmental health. David A. Newman, M.P.H. ’96, received the Eric W. Mood Alumni Award, established in 2005 to recognize an alumnus or alumna demonstrating outstanding promise as a new professional in public health. As corporate director of environment, health and safety at Millipore, a bioscience company headquartered in Billerica, Mass., he developed, implemented and evaluated programs for the company. James S. Marks, M.D., M.P.H. ’80, the senior vice president and director of the health group at the Robert Wood Johnson Foundation, received the Distinguished Alumni Service Award. He was previously in a top leadership post at the Centers for Disease Control and Prevention.
Marks said people often miss the connection between public health and their daily lives. “We have to make that connection—that screenings, getting your flu shot are connected to living the kind of life you want,” he said.
“… those other 5 billion people ...”
After lunch, Peter A. Singer, M.D., M.P.H. ’90, the Sun Life Financial Chair in Bioethics and director of the Joint Centre for Bioethics at the University of Toronto, received the 2005 Award for Excellence. He began his remarks by pointing out the difference in life expectancy in the United States and sub-Saharan Africa. “Eighty years and rising and 40 years and falling. If that isn’t the mother of all ethical challenges, what is?” he asked, before pondering how technology and genomics can improve global health. Showing a slide of children in a coastal village in India, he said, “They are all barefoot and they live in thatched houses. … Right in the middle of their village is an information kiosk where they can access the Internet.” The point, he continued, is “the potential of science and technology and innovation to better the lives of the poor. I want to argue that genetics and biotechnology have comparable, if not greater, potential.”
As an example he pointed to “the largest mass poisoning in world history” in Bangladesh, where 50 million people are affected by exposure to arsenic in drinking water. At the bottom of the country’s wells are bacteria responsible for the arsenic, he said. But in Australia there are bacteria that remove arsenic from water. Genomics, Singer said, has the potential to solve the problem in Bangladesh. Sequencing the genomes of these two bacteria could yield a way to offer a solution to the problem, he said.
“We need to keep the focus on those other 5 billion people in the world, those that have half the life expectancy of people in this room,” Singer concluded.