This year’s reunion was a jaw-dropping experience for the scores of alumni who toured Yale University’s new West Campus during the weekend. On the three buses shuttling alumni to the 136-acre campus in neighboring West Haven and Orange and in the corridors of one of the site’s research buildings, alumni marveled at the new space, its pristine laboratories and the low price. When Dean Robert J. Alpern, M.D., Ensign Professor of Medicine, led alumni down a hallway past a chemistry lab that seemed to stretch forever, the possibilities for research seemed equally endless.
After a brief tour of the lab and its 12-foot chemistry hoods followed by a lunch in the facility’s cafeteria, Alpern described the process that led to the university’s $109 million purchase of the site and its 1.5 million square feet of office, storage and research space, as well as some of the medical school’s plans for its use. “We don’t see this as a site for classroom teaching,” Alpern said, “but we do see this as a site for research, some of which will include student participation.”
The first research program to be based at West Campus will be the new Center for High-Throughput Cell Biology, headed by the new chair of cell biology, James E. Rothman, Ph.D. ’71, the Fergus F. Wallace Professor of Biomedical Sciences. The center will focus on developing tools and techniques for analyzing the cellular functions of the 25,000 known protein-coding genes in the human genome.
West Campus, Alpern said, may also be a site for clinical use. Yale-New Haven Hospital sees potential for building an emergency room, and Yale Medical Group could open clinical practices at West Campus, which has parking for 3,000 cars. “For people coming up from southern Connecticut, the thing they hate most is the last 10 minutes, driving into New Haven and trying to find parking,” Alpern said.
Bayer HealthCare, which had owned the site for decades, decided to close it down in 2006 after a corporate merger. The company put the property on the market hoping to sell it to another pharmaceutical firm, but the only bids came from developers interested in the land. “When it became clear that no pharmaceutical company was going to come into the bidding process … they told us they would love to get a bid from us,” Alpern said. “The developers were getting land. We were getting research buildings, office buildings and land. The biggest bonus is the time. If I convince [Yale President Richard C. Levin] that we need to start today on a new research building, it is a six-year time frame. … We have gotten something that would have taken six years.”
West Campus was also a central theme in Alpern’s State of the School address earlier that day at the Association of Yale Alumni in Medicine’s business meeting. “We want to establish programs of exceptional quality that greatly enrich science at Yale and outside of Yale,” Alpern said, explaining the vision for the new campus. “This needs to transform science at Yale.”
West Campus was not the only topic, however, in Alpern’s discussion of the state of the school. The School of Medicine, he said, remains one of the best in the world. “It has become absolutely impossible to get into the School of Medicine. We get over 4,000 applications for 100 spaces,” he said. “The top 1,000 applicants are indistinguishable, they are so fantastic.”
Among the new educational initiatives is a program for clinical clerkships in global health, which relies on established and ongoing programs with universities and hospitals abroad. “We used to let students pick a place in Africa and go there,” Alpern said. “Now we really try to have organized rotations.”
The medical school is moving away from the traditional “see one, do one, teach one” methodology through the use of such computerized models that mimic the human body as SimMan, a portable manikin that allows students to practice emergency treatment techniques and decision-making skills. “It is completely real,” Alpern said. “You see EKG, you see vital signs, you give medications. You don’t know that the patient isn’t real.” The medical school has also adjusted its financial aid policy (see related story, “New financial aid policy geared toward middle-income families and students”), in order to ease the burden on middle-income families.
The clinical practice, Alpern said, is the fastest-growing area of the medical school. The partnership with Yale-New Haven Hospital, he said, “has never been better.” The new liver transplant program had performed 33 procedures since the summer of 2007; in September 2007 the program completed the first split-liver transplant in the state. “We have overnight become a center for liver transplants,” he said.
At the alumni meeting that morning Christine A. Walsh, M.D. ’73, a professor of clinical pediatrics at Albert Einstein College of Medicine in New York, received the Distinguished Alumni Service Award in recognition of her service to her profession, patients and family. “It is icing on the cake to receive an award for something you absolutely love to do,” Walsh said.
Improved outcomes for autism
Diagnosing autism these days, said Fred R. Volkmar, M.D., director of the Yale Child Study Center, is something like filling out a form to diagnose deafness. “You’d say ‘I want a hearing test!’ … We’re trying to make the diagnosis [of autism] … more like a hearing test.”
Although researchers have found some genetic markers for autism, diagnosis is still a complex process requiring far more than a simple hearing exam. The current diagnostic gold standard requires the judgment of an experienced clinician who looks for certain behaviors in a child and discusses the child’s developmental history with his or her caregiver. Most cases aren’t diagnosed until the child is between the ages of 3 and 5; however, recent advances have allowed clinicians to diagnose the disorder in children as young as 2. Clinicians and researchers at Yale are now developing ways to spot autism even earlier.
Formal diagnostic criteria became available only in 1980, and research and interventions developed since then have led to improved outcomes. Autistic children now apply for college, Volkmar said—something unthinkable 25 years ago. “In a university setting,” Volkmar joked, the odd social behaviors typical of people with autism “are often more easily tolerated and people can fit right in.”
Volkmar and his colleague Ami Klin, Ph.D., director of the Yale Autism Program, described new diagnostic techniques at this year’s reunion symposium. The new approaches allow clinicians to deduce what a child is thinking by tracking what she looks at. Klin’s team recently found that toddlers who were later diagnosed with autism, when shown a video of a woman speaking tenderly into the camera, pay attention mostly to her mouth or to background objects. Other children typically watch the woman’s eyes.
The eye-tracking technology that led to this discovery has been central to research at the Child Study Center since 2000, when Warren Jones, now a graduate student in neuroscience, proposed its use to Klin. Using this technique, researchers found that autistic adults watch actors’ mouths or background objects during emotional movie scenes rather than the actors’ faces. Brain imaging studies confirmed that people with autism see human faces the way normal people see objects.
The youngest subjects of eye-tracking technology, though, are infants. The team created a video of a human figure rendered as a series of moving dots along with a spoken soundtrack; they then showed the video to babies. Infants later diagnosed with autism tended to look at both upright and upside-down figures, while normal babies preferred the upright figures. The autistic group, though, were more interested in figures that move in time with the soundtrack. This preference for audiovisual synchrony may be part of the reason that autistic people watch lips so intently—they’re drawn to the synchronous occurrence of lip movements and speech sounds. The team showed that mouth-looking exceeds eye-looking as early as 5 months of age in at-risk infants.
Volkmar and Klin hope that in the near future babies held on a parent’s lap can watch a video while eye-tracking technology monitors their gaze and offers an early diagnosis of autism. But little research on effective treatments has been done in children under the age of 3. Klin told the audience that a task force for extending therapies to babies has been formed. “We need a rapid-response system for the very young children who can’t wait.”
Telemedicine’s global reach
At $10,000 per hour for analog satellite time, said Ronald C. Merrell, M.D., the world’s first telemedical surgery “was a little bit, well, unwieldy.”
The former chair of surgery at Yale referred to a pioneering open-heart operation in Houston in 1965, when a satellite linkup connected legendary surgeon Michael E. DeBakey, M.D., to viewers in Geneva. More recently, a surgeon in New York performed the first fully remote surgery on a patient in France. The momentous event was underreported, said Merrell, because the press conference was scheduled for September 11, 2001.
Merrell, who left Yale in 1999 to become chair of surgery at Virginia Commonwealth University (VCU), discussed the past, present and future of telemedicine at the Yale Surgical Society Spring Reunion, which was held this year in his honor. He now leads the Medical Informatics and Technology Applications Consortium at VCU. Telemedicine, he said, is “the application of telecommunications and information science to support the delivery of health care at a distance.”
Telemedicine is already with us in many ways, he said. Picture archiving and communication systems, now common, allow radiologists to diagnose patients from thousands of miles away. Preoperative clearance can also be done remotely, as Merrell and a team of surgeons demonstrated when they cleared the way for patients in the Dominican Republic to undergo surgery before the surgeons had arrived. A satellite dish installed on the roof of an outbuilding provided the link for low-bandwidth video.
In medical education, Merrell said, telemedicine can be as simple as Internet access in Kenya from solar-powered laptops, or as sophisticated as the class he once taught from the operating room for a group of medical students in Russia. “Education can be distributed in virtual reality in ways that really do work,” Merrell said, adding that he hoped such techniques would reduce our “separation and alienation from the developing world.” Telemedical techniques might one day beam top-quality medical education into medical classrooms around the world.
“I would make this integral to the training of medical students internationally,” he said. “As long as it’s interactive, I think we can do as well as we could in a classroom.”
A focus on ethics in public health
As Lawrence O. Gostin, J.D., associate dean and the O’Neill Professor of Global Health Law at the Georgetown University Law Center, surveys the health landscape around the world, he comes to an obvious yet troubling conclusion. “Rich countries just don’t care enough,” he said, calling the response of the United States and other affluent countries to health inequalities “limited and quite pathetic.”
Gostin, the keynote speaker at the School of Public Health’s Alumni Day symposium, said that government leaders need to pay closer attention to health threats in other parts of the world. “Infectious diseases don’t respect national borders,” he said, noting that health issues pose serious ramifications for international commerce, trade, tourism and government stability. “States with unhealthy populations provide a great opportunity to harbor terrorists.” Even the CIA, he said, uses infant mortality as a marker of political stability.
While such headline-grabbing events as the recent China earthquake and the East Asian tsunami of December 2004 are typically followed by a “powerful humanitarian response,” Gostin said that help to meet such basic necessities as sanitation, clean air and water, pest abatement and vaccines is more urgently needed in developing countries. “It’s disarmingly simple and inexpensive,” he said. “They don’t need state-of-the-art facilities or foreign aid workers parachuting in to rescue them; they just need basic stuff they can run themselves.”
Noting that governments currently exist in a state of “global health anarchy,” Gostin proposed the creation of an international framework convention on global health modeled on the Kyoto Protocol, which raised the visibility of climate change as a global threat. The framework convention, an idea that is already being discussed by the World Health Organization and other international agencies, would convene key stakeholders for the purpose of addressing health disparities and developing global health solutions.
When it comes to health, “the poor suffer much more than the rich,” Gostin said. “Health disparities are no less important than global warming and other issues of the times.”
The panel that followed Gostin’s talk also pursued the subject of ethics and public health. On the panel was Stewart D. Smith, M.A., M.P.H. ’96, a former Navy officer, who served in the first Gulf War and was in the Pentagon on September 11. Since leaving the military, Smith has made a career as a consultant who helps organizations prepare for disaster. However, he has yet to see a company disaster plan that includes an ethics analysis. “Everybody assumes that ethics is common sense, that they intuitively know the right thing to do, and—guess what—they really don’t. They need to be taught; and the time to do it isbefore disaster strikes,” he said. For example, a recent government survey found that 73 percent of its employees would not come to work during a flu outbreak. Would it be ethical to require them to? “Get real,” said Smith. “Ethics is real.”
Smith was one of four panelists to discuss the importance of ethics in emergency planning and public health. Speaking from their own experiences—which range from military action to anthrax attacks—the panelists made a strong case for ethics training in public health education and decision making.
James L. Hadler, M.D., FW ’80, M.P.H. ’82, who recently retired as chief of the infectious diseases section at the Connecticut Department of Public Health, often juggles benefits to the community and individual rights. (See related story, “School of Medicine goes green as it aims for lower carbon emissions by 2020.”) He usually favors the welfare of the community “when the individual can’t predictably be harmed.” But determining the chances of harm isn’t always easy. During a meningitis outbreak on college campuses just a few days before the end of a semester, for example, Hadler had to decide whether to vaccinate more than 12,000 students with jet-injector guns that carried a small risk of cross-contamination with blood-borne pathogens or with injections that would take much longer to administer, thereby putting students at risk of meningitis infections. After consulting with an ethicist and the Centers for Disease Control and Prevention, and researching different brands, Hadler authorized the use of jet-injector guns.
On a smaller scale, there are the problems of running an inner-city clinic. “Do we rob Peter to pay Paul?” asked Thomas J. Krause, M.P.H. ’81. For Krause, that question isn’t just hypothetical. Krause is chief operations officer at Southwest Community Health Center in Bridgeport, where most of his patients are self-pay or have Medicaid, and every year he faces budget cuts. He is responsible for delivering health care to poor people, many of them immigrants who have never encountered Western medicine. And he must maintain the morale of a staff that is hamstrung by scarcity and the difficulty of caring for this patient population. In the face of such pressures, it would be easy to think of ways to trim and skimp, Krause said. “But we never go there.”
Bruce Jennings, M.A., a lecturer in ethics at the School of Public Health, explored the philosophical underpinnings of the others’ real-world stories. The idea that society serves the individual and not the other way around, he said, sometimes “butts heads” with public health when officials must weigh an individual’s liberty against the greater public good. Debates from the early days of AIDS provide an example. As the epidemic silently spread, public health officials pushed for greater tracking and surveillance of cases, while others argued that to do so would infringe on privacy rights. Since the AIDS era began, he said, “it has been impossible to take a purely libertarian [standpoint] and it has been impossible to be purely utilitarian.” But, he added, “We have to figure out how to get respect for persons and liberty—and outcomes and health—together.”
Awards and the state of the school
Dean Paul D. Cleary, Ph.D., delivered good news to those gathered at Alumni Day 2008 at the New Haven Lawn Club—the School of Public Health has gone through a successful reaccreditation process. And, Cleary said, changes are in the works for the school, including a revamping of the global health program.
“We stopped admitting students to global health last year,” Cleary said. “We dissolved the division of global health and created a schoolwide global health program.”
In addition, he said, Elizabeth H. Bradley, Ph.D., professor of public health (health policy), is developing a global health leadership initiative that will bring practitioners from around the world to Yale. The school has also created an office of community health, led by Elaine O’Keefe, former head of the New Haven Health Department’s AIDS division and former health director for the town of Stratford. The new office will oversee student internships, Cleary said. “We will move from a less-than-optimal approach to a better-focused, more-managed program,” he said.
The Association of Yale Alumni in Public Health (AYAPH) presented several awards this year.
Robert E. Steele, M.P.H. ’71, Ph.D. ’75, M.Div., received the Distinguished Alumni Award for his contributions to the school and the profession. Steele has been on the AYAPH board since 2001 and served as president from 2004 to 2007. He is a founder and benefactor of the Creed/Patton/Steele Endowed Scholarship Fund, which supports future public health professionals. “It is important to support the institutions that have supported us,” Steele said as he accepted the award.
The Eric W. Mood New Professionals Award went to Keshia M. Pollack, M.P.H. ’02, Ph.D., who teaches at Johns Hopkins Bloomberg School of Public Health. She also works for a member of the Maryland General Assembly and advises a Baltimore community coalition seeking to alleviate childhood obesity.
The Award for Excellence in Public Health Practice was given posthumously to Virginia Alexander, M.D., M.P.H. ’41. Alexander received her medical degree from Woman’s College of Pennsylvania in 1925, but no Philadelphia hospital would accept Alexander, who was African-American, for training. Instead she completed her internship at Kansas City General Hospital, in Missouri, the designated hospital for people of color in that city. After receiving her public health degree from Yale, she became physician-in-charge of women students at Howard University in Washington, D.C. Her niece, Rae Alexander-Minter, Ed.D., and great-niece, Virginia Brown, accepted the award on her behalf.