Preparing for a tidal wave

With an epidemic in the making, Russian scientists come to Yale for training in HIV prevention.

For decades the Iron Curtain limited personal freedoms within the Soviet Union and the Eastern Bloc, as well as social exchanges between East and West. Until it fell in the early 1990s, it also kept at bay the HIV/AIDS epidemic sweeping Western Europe. The number of new HIV infections in Russia hovered at only 200 a year. By 1996, however, largely due to injection-drug use, the number of cases rose to 1,546. Last year 18,140 new cases were reported in Russia, where health authorities expect that total HIV infections will reach a million by the year 2002.

“Russia is confronting what is a very early, but likely to be very massive HIV epidemic,” said Robert W. Ryder, M.D., John Rodman Paul Professor of Epidemiology and Medicine. He is also director of Training and Research in HIV Prevention in Russia, a training project for Russian physicians and scientists. Ryder and his Russian colleagues have established a multidisciplinary research center at St. Petersburg State University to develop, conduct and evaluate HIV prevention programs. “The most pressing need,” Ryder said, “is to establish a cadre of young Russian scientists trained in modern public health methods who are committed to returning to Russia to fill the enormous void in this area.”

Funded by the Fogarty AIDS International Training Program at the National Institutes of Health, the project has brought 10 Russian scientists and physicians to Yale for long-term training since 1998. In February of this year a four-day workshop brought top faculty from the university in St. Petersburg to Yale to learn about the institutional review board system that oversees many of the clinical trials conducted in this country.

Among the Russian scientists at Yale is Natalia Khaldeeva, M.D., Ph.D., who has treated patients with the disease since 1989. “Our experience here in the United States has been extremely valuable,” she said, noting that many resources available here, such as anti-retroviral drugs, are scarce in Russia. During her 18-month stay at the School of Public Health, Khaldeeva has been learning how to conduct clinical trials with new anti-retroviral regimens in HIV-infected patients and has been studying HIV treatment standards and research protocols. She also has received training in HIV prevention methods and studied at the Center for AIDS Intervention Research at the Medical College of Wisconsin, Yale’s partner in the program.

Prevention efforts, Ryder believes, can have a broad impact in Russia. “There are few other countries of similar size where one has such enormous possibilities for HIV prevention,” he said.

This year the project was extended to India and China and has begun short-term training of researchers who are involved in World Bank projects on HIV prevention. “In the next two years injection-drug use will be the major mode of transmission in China,” said Zunyou Wu, M.D., Ph.D., a research scientist at the Chinese Academy of Preventive Medicine. “We also expect that sexual transmission will increase dramatically.”

“We have seen what this epidemic has done in sub-Saharan Africa,” said Michael H. Merson, M.D., dean of public health and principal investigator of the Fogarty grant. “We hope that our efforts can help avoid a similar tragedy in Russia, India and China.”

Never a cross word. Always a crossword.

The medical school’s chaplain is moving on after 17 years of nurturing students.

After a lifetime of tending first to children, then to young adults, Alan C. Mermann, M.D., M.Div., is about to embark on a third career, ministering to the elderly and the sick. Mermann, 76, retired in June as the medical school’s second chaplain, a post he assumed “temporarily” 17 years ago.

With its pots of coffee and stacks of newspapers, magazines and crossword puzzles, Mermann’s basement office has offered students a respite from the rigors of medical education. Some have come for something to drink or to sack out on the sofas. Others have sought counseling about personal matters. The chaplain also has chaired a committee on pediatric ethics and taught courses on serious and chronic illness, pairing students with patients who can talk about what it is like to have a life-threatening disease. “I found a patient for each student,” Mermann says. “It was a patient with something serious such as metastatic cancer, AIDS, renal failure or leukemia. The patient taught the student what they were going through. They recounted their experiences with physicians such as the characteristics of the good doctor and the not-such-a-good doctor.”

Mermann never has stopped studying and last year acquired a master’s degree in the history of medicine. He has articulated his beliefs on faith and ethics in two books, Some Chose To Stay: Faith and Ethics in a Time of Plague and To Do No Harm: Learning to Care for the Seriously Ill, and was the author of the Yale Physician’s Oath, which he administered to each graduating class at Commencement. Asked if his courses have helped shape more compassionate physicians, he answers, “It may be that the half of the class that takes the course is the half that doesn’t need to.”

Mermann’s interest in the health of children led him to the Deep South in the 1960s at the peak of the civil rights movement. He testified before the Senate and co-authored the report on child malnutrition that helped launch President Johnson’s War on Hunger. His travels through the South sent him on a search for answers to the question of good and evil that led him, at the age of 50, to the Yale Divinity School. In 1982 he gave up his pediatric practice in Guilford and a year later took on the chaplaincy. It was to be a temporary position.

The chaplaincy was created in 1967 and first filled by David Duncombe. “One of the things the medical school has done in the past,” Mermann says, “is to provide a number of places where students can seek advice. All the way from ‘Where’s the best pizza?’ to ‘I need a psychiatrist.’ I think it’s a shame to lose one of the places where students can go to talk about things in depth that are important to them.”

The office endured and so did Mermann, who, helped by students who rallied to its defense, survived an attempt in the early 1990s to abolish the office for budgetary reasons.

After 17 years he felt it was time to move on. Although unsure of his plans, Mermann, a pro bono pastor at the Norfolk Congregational Church, hopes to continue ministering, possibly to the elderly. He also is at work on two books, one on the history of medicine, the other on depictions of disease in literature. Looking back on his tenure as chaplain, he describes his interactions with students as “a gift.” “They are so bright and intelligent and questioning and hopeful that it has been a very encouraging experience to see them coming along with everything they have to offer.”

Mermann was the second and last chaplain at the medical school, which decided not to fill the position after he left. According to Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs, Mermann, the man, can never be replaced, but the students have other resources for personal and religious counseling.

But Yale has not seen the last of Mermann. As he told a reporter several years ago when interviewed for an article on medical education, when he dies Mermann plans to be going “up there.” He was referring not to the Pearly Gates, but to the third-floor anatomy laboratory, to which he has bequeathed his earthly remains for the training of future physicians.

CAB construction gets under way

With an occupancy date of March 2003, construction of the Congress avenue Building (CAB) continued on schedule in late June. The 450,000-square-foot building was designed to increase teaching and laboratory space and is part of a $500 million investment in medical school facilities. After excavating the site, crews began foundation work, pouring vertical walls and footings. The work was expected to continue through August, and in September, delivery of steel beams is to pave the way for erection of the building’s skeleton. Updates on the construction as well as photographs can be accessed at http://info.med.yale.edu/cab.

Major awards to support work in addiction, HIV

With $17 million in grants awarded this year, Yale investigators are furthering their efforts to slow the spread of AIDS and reduce drug abuse. Two grants will fund separate programs that rely on peer counseling as well as interventions involving physicians. The National Institute on Drug Abuse (NIDA) and the National Institute on Mental Health (NIMH) awarded the grants to Yale and other institutions in Connecticut.

One NIDA grant provides $11 million over five years to establish a clinical trials network to evaluate drug-treatment protocols. “Typically, clinical trials research is based on a small, often homogeneous population,” said Kathleen M. Carroll, Ph.D., associate professor of psychiatry and principal investigator for the grant. “We will be able to evaluate a range of treatments in community treatment programs and reach a large, diverse population.” Yale is one of six regional centers in the country working on this project. When it is complete, it is expected to include between 20 and 30 regional centers. Joining Yale in this national effort are the Connecticut Department of Children and Families, the Department of Mental Health and Addiction Services and a nonprofit managed care company, Advanced Behavioral Health.

NIDA and NIMH also have awarded the University of Connecticut (UConn) and the Yale School of Medicine $6 million for projects to stem the spread of AIDS. The NIDA grant will fund a study of a peer intervention group composed of active and recovering drug users who are HIV-positive. They will attempt to counsel fellow addicts and convince them to obtain treatment for HIV/AIDS. The study will measure enrollment in primary care services, adherence to HIV treatments, entry and retention in drug treatment, reduction of risky HIV behaviors and increase in medical knowledge. Robert Brodhead, Ph.D., a sociologist at UConn, is the principal investigator.

The NIMH grant funds an effort to determine whether the doctor-patient relationship can be used to promote HIV risk reduction. Physicians worry that anti-retroviral therapies may lull patients into the false notion that their disease is no longer a threat. “Some still engage in risky behaviors, so we continue to see new infections, but with a virus that is more resistant to drugs,” said Gerald H. Friedland, M.D., director of the AIDS Program at Yale, and co-investigator on the study. The principal investigator is Jeffrey Fisher, Ph.D., a psychologist at the University of Connecticut.

Faculty, students react to proposals for curriculum

Faculty and students have welcomed proposals to revise the medical school curriculum even as they raise questions about some of the specifics, according to Asghar Rastegar, M.D., professor of medicine and a member of the Dean’s Committee on Medical Education. The committee, formed two years ago by Dean David A. Kessler, M.D., to take a thorough look at medical education, has recommended integrating the teaching of basic and clinical sciences, strengthening clinical experiences in the first two years and revisiting basic science in the clinical years. (Yale Medicine, Spring 2000, “Deconstructing Education.”)

The committee plans to submit a draft report to Kessler by September 1. The report will include the committee’s recommendations as well as input from faculty and students, said Rastegar, deputy chair of internal medicine. Kessler may send the report back to the committee for revisions, or pass it on to the new deputy dean for education, Herbert S. Chase Jr., M.D., for implementation.

Led by Ralph I. Horwitz, M.D., chair of the Department of Internal Medicine, and Charles A. Janeway Jr., M.D., professor of immunobiology, the committee has met weekly for more than a year to discuss a restructuring of the four years of medical school. Under the committee’s proposals, basic science course work would end in December of the second year, students would take a month-long course in clinical skills, then move on to laboratories or the wards.

The committee has proposed a reduction in scheduled hours in the basic science years from 1,400 to 1,100. During their clinical years students would have 12 months on the wards and an opportunity to schedule an uninterrupted block of six months for thesis research. The committee is considering ways to integrate basic sciences in a meaningful way in both the third and fourth years.

Faculty members want to ensure that adequate supervision is built in to the six-month period proposed for thesis research, Rastegar said. At “town meetings” held to discuss the proposals some faculty expressed concerns that basic science departments would lose control of their courses. Others believe that meaningful support of faculty who have significant teaching roles is needed to improve the educational environment.

Students, meanwhile, are concerned about the integration of basic and clinical sciences. “They wanted to be assured that, by condensing the first two years into 15 months, what would be achieved would be an enhancement of the quality and not just loss of time and material,” said Nancy R. Angoff, M.D. ’90, HS ’93, M.P.H. ’81, associate dean for student affairs.

Issues for future discussion include governance of the curriculum, strengthening clerkships and the role of technology in medicine and teaching.

Web site offers a wealth of data about the heart

A tour through the heart and chest, with side trips into a wide range of diseases and diagnostic and therapeutic tools, is now as close as a computer keyboard for medical students and physicians. Introduction to Cardiothoracic Imaging, a new Web site developed at the School of Medicine, has drawn visitors from along Cedar Street and around the world since its debut in December.

Visitors to the site can explore the material, which is organized under five topics: anatomy, techniques, findings, cases and references. Under anatomy, viewers can see drawings of the heart and chest, then click to an X-ray image. A click on the left pulmonary vein brings a brief explanation to the screen.

The text, charts, X-rays and drawings are designed for a variety of uses, said John Paton, director of academic computing and media services. Lecturers can pull individual slides and transfer them to a PowerPoint presentation. Teachers can download images for inclusion in quizzes and students can pull out the pages they need for study. “It is an effort to get all the material in one place and allow people to get whatever they feel would be helpful,” Paton said.

The site is a Web version of a CD-ROM produced in 1994 by C. Carl Jaffe, M.D., professor of medicine, and Patrick J. Lynch, M.S., design director at the Center for Advanced Instructional Media. The CD-ROM used artwork, diagnostic images and text entirely generated at the School of Medicine. Rather than continually update the CD-ROM, they decided to convert it to a Web format. After four months of work on the conversion, the site, at http://info.med.yale.edu/intmed/cardio/imaging/, was launched in December.

Visitors made about 10,000 page requests from the site that month. A fifth of the visitors were from education sites in the United States. By May, monthly page requests had increased to 17,000 pages, making it one of the most visited sites at the medical school.

Office provides new support for telemedicine

For many, the notion of telemedicine evokes the image of a doctor in the wilds, armed with only a cell phone, a stethoscope and a laptop, transmitting medical data to a modern hospital and receiving life-saving information in return. Two recent expeditions that took Yale physicians to Mt. Everest to test telemedicine concepts and tools have cemented that concept, as has Yale’s participation in a mobile surgical unit that uses telemedicine to bring health care to the jungles of Ecuador. But practitioners say telemedicine also may be as mundane as a second opinion obtained over the phone or consultations with physicians in rural areas where specialists are scarce.

Spyros G. Condos, D.Med., M.B.A., the director of the newly created Yale Office of Telemedicine, is in no hurry to define the topic. “The moment you define it,” he says, “you start limiting it.” The School of Medicine recently announced the appointment of Condos, an assistant professor of surgery, as director. Also appointed were Johanna Selles, R.N., Ed.D., as business manager, and Richard S. Stahl, M.D., M.B.A., as medical director.

According to Joseph B. Warshaw, M.D., deputy dean for clinical affairs, the new office formalizes and coordinates what had been a diffuse set of projects throughout the medical school. “It was departmental,” said Condos, “and sometimes one department doesn’t know what the other is doing.” The office will serve as a clearinghouse and resource center for telemedicine programs throughout the medical school. Its goal is a marriage of medical knowledge and information technology that will provide the best in clinical care domestically and overseas, while also training physicians around the world. Selles said the office is developing projects in Saudi Arabia, the Philippines, Greece, China, South Africa and India.

“We want to help people by providing information on how to accomplish their goals in telemedicine projects,” says Stahl, “This medical center is rich in educational content and has a lot to offer people and places.”

Also in Chronicle:

Russian scientists come to Yale  |  Med school chaplain moving on  |  CAB construction |  Awards support work in addiction, HIV  |  Curriculum review, part two  |  Web site offers views of the heart  |  New support for telemedicine    

Rounds  |  Findings  |  Et cetera   

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Originally published in Yale Medicine, Summer 2000.
Copyright © 2000 Yale University School of Medicine. All rights reserved.