yale medicine A fallen student’s Paul MacLean’s A Yale alumna in autumn 2008 endearing legacy triune brain theory the rain forest 4 16 30

A huge nih grant boosts bench-to-bedside research, but many scientists still want to follow their noses 18

yale medicine autumn 2008 CONTENTS

on the cover 2 Letters Illustration by Jeffrey Fisher 4 Chronicle 8 Rounds 10 Findings 12 Books & Ideas 16 Capsule

18 Mapping the future of medicine With its largest grant ever, Yale is assembling resources to help clinical scientists focus on ideas—and leave the red tape to others. By Jill Max

24 Is the straight road too narrow? Demands for cures and a flat NIH budget are putting pressure on scientists to produce findings that go right to the bedside. Still, there’s value in finding what you’re not looking for. By Pat McCaffrey

30 A life’s work in Indonesia Even as a medical student, Kinari Webb knew where she wanted to practice medicine. Now, she and her ecologist husband are working to bring health care to Borneo— while preserving the rain forest. By Jill Max

35 Faculty 38 Students 46 Alumni 62 In Memoriam 64 Follow-Up 64 Archives 65 End Note

On the Web yalemedicine.yale.edu On our website, readers can submit class notes or a change of address, check the alumni events calendar, arrange for a lifelong Yale e-mail alias through the virtual Yale Station and search our electronic archive. 2 letters

We should expect our yale medicine students to be literate Alumni Bulletin of the Yale University School of Medicine It was with some sadness that I Autumn 2008, Volume 43, No. 1 read of the teaching of ethics by Editor in Chief my colleague, Alan A. Stone, m.d . Michael Kashgarian, m.d. ’58, hs ’63 ’55, to his students at Harvard Professor of Pathology and of Molecular, Law School. [“A Passport to the Cellular and Developmental Biology Young,” Yale Medicine , Spring Editor 2008] Stone felt obliged to turn Michael Fitzsousa Director of Communications to the movies because “few stu - dents had read Sophocles or Managing Editor yale medicine Dostoevsky, Austen or Flaubert.” John Curtis A new cancer hospital Anna Deveare Smith Harvey Cushing’s spring 2008 on the rise returns to New Haven photographic legacy Contributing Editors 4 6 26 I was reminded of how startled

How the West was won: A former pharmaceutical plant’s new life Janet Emanuel, ph.d. as part of the Yale campus I was some years ago to discover 18 Peter Farley Main Campus that one of my patients, a gradu - William Hathaway ate student in literature at Yale Jennifer Kaylin and a magna cum laude gradu - Karen Peart ate of Yale College, had never Cathy Shufro read a work by Shakespeare. Marc Wortman, ph.d.

95 te sta er Int

k ra Contributors t m Should our top law and A medical schools be admitting Jenny Blair, m.d. ’04 Terry Dagradi West Campus people who haven’t even a John Dillon rudimentary reading knowl - Charles Gershman edge of the Western canon? Jill Max Perhaps what is needed is not Pat McCaffrey how to reach us a “new passport to the young,” Melinda Tuhus Yale Medicine welcomes news but a reactivation of the old Copy Editors and commentary. Please send one. And perhaps we cannot Rebecca Frey, ph.d. Michelle Komie letters (350 words or less) and absolve ourselves of some of Anne Sommer news items to Yale Medicine , the blame for the illiteracy of Mailing List Inquiries 300 George Street, Suite 773, the young until we make it Claire M. Bessinger clear to them that we expect New Haven, CT 06511, or via Communications Coordinator e-mail to [email protected], and them to be literate. Cheryl R. Violante include a telephone num ber. Victor A. Altshul, m.d . ’60 Website Coordinator Submissions may be edited for Associate Clinical Professor Printing length, style and content. of Psychiatry The Lane Press visit us on the web Yale Medicine is distributed to alumni, yalemedicine.yale.edu Med school missing faculty, students and friends of the from cover School of Medicine, as well as to leaders in Yale University alumni activities. I find an interesting example of the complex relationship Abbreviations commonly used in Yale Medicine include hs to denote the final between the School of Medi- year of residency for house staff, fw for cine and the main campus the final year of a fellowship, eph for the represented by the absence of Department of Epidemi ology and Public the topography of the medical Health and the School of Public Health campus on the cover of last and ynhh for Yale- New Haven Hospital. spring’s issue of Yale Medicine . Postal permit held by Yale University, Robert B. Duckrow, m.d . ’75, hs ’79 155 Whitney Ave., New Haven, CT 06520 Associate Professor of Neurology Copyright © 2008 Yale School of Medicine and Neurosurgery All rights reserved. address correspondence to Editor, Yale Medicine 300 George Street, Suite 773 8

0 New Haven, CT 06511 0

2 Telephone: 203-785-5824

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y yalemedicine.yale.edu. starting point 3

Basic science vs. translational research, and medicine and rain forests

In the autumn of 2006, Yale became one of a handful of More than two years ago, in May 2006, we heard medical schools to receive a ctsa grant from the National from Kinari Webb, m.d. ’02, who asked if we’d be interested Institutes of Health ( nih ), a boon to translational research in an article about her work in Indonesia. Four years out here and around the country. Once the program was up of medical school, Webb had laid the groundwork to open and running we asked writer Jill Max to take a look at the a clinic in a remote area of Borneo. In addition to her desire new Yale Center for Clinical Investigation, created and to provide medical care to an underserved area, she and funded with the goal of supporting clinical research. This her husband, a Harvard ecologist, wanted to link that to pre - enhanced emphasis on translational research also prompted serving the region’s rain forests. For more than a year Jill us to explore the tension between basic-science research— Max has been in contact with Webb, following the progress knowledge for knowledge’s sake—and the bench-to-bedside of the clinic, which opened in the summer of 2007. Her goals of those who start out with a cure or treatment in report begins on page 30. mind. Boston-based science writer Pat McCaffrey talked to scientists at Yale and found that, largely due to a flat nih John Curtis budget, scientific research is going through hard times. Managing Editor But some scientists also worry that basic research is taking a back bench to translational research.

SECOND OPINION BY SIDNEY HARRIS 4 chronicle news from cedar street

for Women in Medicine and a mentor to Rainof, that their daughter loved Yale and was happy here. Her phone calls, they told Waxman, were always filled with her enthusiasm for her classmates, teachers and patients. What friends remember best about Rainof is her warm and welcoming smile. “Like everyone else,” her A student’s warm heart boyfriend and classmate James Troy said at the Rose Garden memorial, and “amazing” smile “I was instantly won over by her amaz - Mila Rainof’s embrace of others ing smile.” A friend and classmate, has inspired an enduring memorial Ellen House, recalled sharing clinical at the medical school. rotations with Rainof and all the patients asking for “the smiley one.” As the 96 members of the Class of Margaret A. Drickamer, m.d. , associ - 2008 processed to Old Campus for ate professor of medicine, recounted a Commencement on May 26, they trip to Seattle with Rainof to attend a paused at the corner of York Street and conference. They walked all over the South Frontage Road. One by one, each city, she said, talking and telling stories. graduate placed a carnation in memory “We laughed, we cried—and we did of Mila Rainof, a classmate who was not go to some poster sessions.” Beyond with them in the procession. Rainof’s warm and friendly demeanor, On April 19 Rainof was struck by a Drickamer said, was a determination s i t

r car as she crossed the intersection. She to help people. “Mila really cared u c

n died the next day of her injuries. At a about people, especially when she felt a h o j medical school town meeting called by responsibility for their welfare, and she m.d The death of Mila Rainof, a month before her Dean Robert J. Alpern, ., on the steadfastly refused to let anything get in graduation, sent a shock throughout the medi - Monday after Rainof died, Alpern said, the way of that caring,” Drickamer said. cal school. Her classmates posted her photo and “The medical school family h as lost a Karen J. Jubanyik, m.d ., assistant left flowers at the site of the accident. member way too young in age.” professor of surgery (emergency medi - In the wake of her death, Rainof’s cine), described a difficult shift at friends and classmates have found many Yale-New Haven Hospital the day after ways to honor her. Her close friends Rainof died. “I just thought, ‘What stood by Rainof’s parents and sister would Mila do?’ ” Jubanyik said. “She when they came to New Haven and would contribute any way she could. organized a memorial service in the She would go to the patient’s side, medical school’s Rose Garden. Others hold their hand and genuinely listen began collecting photos and remem - to them.” Friend and classmate Maggie brances for a book to be given to her Samuels-Kalow said, “Mila was the per - family. Students have organized efforts son that you wanted at your side when to improve safety at intersections near the patient was getting sicker and you the medical school. (See sidebar.) A didn’t know what to do.” memorial scholarship and award fund is Kristina Zdanys, one of the class co-

8 being established at the School of Medi- presidents, said that the students in the 0 0 2 cine to honor and perpetuate Rainof’s Class of 2008 are a close-knit group and n

m memory, in particular her compassion - would have felt the loss of any of their u t

u ate spirit and humanistic approach to members, but that Rainof was special. a e n

i medicine. Students also planted a cherry c i

d tree in her honor on Harkness Lawn. e

m Rainof’s parents have shared with e l a

y Merle Waxman, director of the Office 5

After a tragedy, the medical Plans are already under way to school community mobilizes improve four intersections adjacent to around traffic safety the medical school area. They are part of a larger plan for street improve - On the afternoon of May 22, about ments as part of a deal struck between two dozen students, faculty and staff Yale-New Haven Hospital and the from the School of Medicine marched city for the construction of the Smilow from Cedar Street to the corner of Cancer Hospital. The model will be York Street and South Frontage Road, the intersection at Cedar Street and “Whenever she walked into a class or where Mila Rainof, a fourth-year medi - Congress Avenue, which has pedes - Marigolds, she was always smiling or cal student, died after being struck by trian crossing lights that flash and had something nice to say,” Zdanys said. a car a month earlier. count down the seconds remaining “If you asked people to think of a Pedestrians have long dreaded this for a safe crossing. person in the class who always made and other intersections near the medi - The hospital will also relocate a truck people feel good … she would be the cal school. Drivers in a hurry to reach loading dock at South Frontage Road first person,” said Rachel Wattier, who the Route 34 Connector feeding into and York Street under the adjacent Air has been leading a committee that has Interstate 91 and Interstate 95 rou - Rights Garage. Traffic that now leaves met with city and university officials to tinely run red lights and ignore pedes - the garage onto South Frontage Road improve traffic safety. trian crossing signals. will leave through a roundabout to be A few days before Commencement, Students have organized a Traffic built where the Route 34 Connector students, faculty and others gathered Safety Group since Rainof’s death— meets the garage. at the intersection where the accident their goal is to make the streets safer In light of the planned improve - occurred. Bearing signs that read “Yield for pedestrians. ments, the safety group is developing 4 Walkers,” and “No Turn on Red,” the “It is important that we honor Mila materials to promote pedestrian group asked drivers to slow down and and keep the traffic safety effort in the and cycling safety, petitioning the city respect the traffic lights. spirit of what she would have done,” government to enforce the city’s 25 “There was really no one to blame,” said Rachel Wattier, a fifth-year medical mile-per-hour speed limit, and calling Gregory L. Larkin, m.d. , professor of student who is leading the traffic group. for strict enforcement of traffic surgery (emergency medicine), said at a “A lot of people have deep-seated con - regula tions governing stop lights and meeting in The Anlyan Center the day cerns about traffic that they were never signs, cell phone use, bicycle lanes after Rainof died. Larkin had been the able to act on. People see an opportunity and crosswalks. attending in the emergency room when to have their concerns addressed.” —J.C. an ambulance delivered Rainof. The day before the accident, Larkin had been her teacher, instructing her in the use of ultrasound. Rainof was scheduled to begin a residency in emergency medi - cine in Oakland, Calif., after graduation. On the morning of April 19 Rainof was on her way back to her York Street apartment after working out in the gym in Harkness Dormitory. A truck was leaving the loading dock of Yale-New Haven Hospital against a red light. As Rainof crossed South Frontage Road, also against the red light, the truck s i cleared the intersection and cars in the t r u c three oncoming lanes moved forward. n h

Two swerved to avoid her, but a third o j struck her when she was just a yard away from the curb and safety. She died A few days before Commencement, students, faculty and staff at the medical school rallied at the next day of severe head injuries. the intersection of York Street and South Frontage —John Curtis Road to urge drivers to respect traffic rules. 6 chronicle

“Yale Green Plan” in 1998. In 2002, the university’s Advisory Committee on Environmental Management proposed a set of environmental principles, and in 2005 President Richard C. Levin committed the university to reducing greenhouse gases to 10 percent below 1990 levels by the year 2020. Implementing a sustainable labora - School of Medicine goes green Adding such features to previously tory renovation that could be bench - as it aims for lower carbon planned renovations costs more— marked and measured by a national emissions by 2020 between 1 and 2 percent of the $8.2 standard would not come easily. Success mil lion price tag of the Sterling renova - is measured by the U.S. Green Building The Yale School of Medicine’s sustain - tions that were completed in 2006— Council’s Leadership in Energy and ability campaign is ambitious and costs but Yale can’t afford not to do it, said Environmental Design ( leed ), but the a little extra, but it’s perfectly willing to Virginia Chapman, director of construc - organization had not set standards for accept hand-me-down jeans—in fact, tion and renovation for the School of lab renovations. “ leed was designed for that’s part of the point. Medicine’s facilities office. “We’re sav ing new buildings or full-building renova - Denim discarded in the jean manu - the university money as a by-product of tions but not laboratories nor smaller- facturing process, which now helps reducing carbon emissions,” she said. scale renovations of the kind we do here insulate the Sterling Hall of Medicine’s Still to come, Chapman added, are at the medical school,” Chapman said. C wing, is one of many recycled materi - renovations to the second and third The work on the third floor of the als that are lightening the university’s floors of Sterling’s I wing, the Brady C wing created a yardstick in 2006 carbon footprint. The building’s recently Memorial Laboratory, the Hunter when it became the first laboratory renovated lab casework, ceiling tiles and Building, the sixth and seventh floors ren ovation project in the United States wall insulation also come from such of the Laboratory for Epidemiology and to gain leed gold certification for its recycled materials as wheat straw board Public Health and the Laboratory for sustainable features. Among those fea - and soy-based spray foam. In total, the Surgery, Obstetrics and Gynecology, all tures, said Robert Skolozdra, an associ - sustainability campaign squeezes more of which will incorporate green features. ate at the architec tural firm Svigals & light from the sun, diverts trash from Yale’s overall sustainability strategy Partners, which designed the renova - landfills and conserves water and heat. began with the student-initiated tions, are sensors that switch lights on only when a person is in the room. “Daylight harvesting”—adding win - dows—maximizes available light. The project eased the strain on landfills by recycling 85 per cent of construction and demolition debris. Lab faucets have reduced their output from 2 to 1.5 gallons per minute, and low-flush toilets and urinals have been installed. Water use is now down 35 percent overall. As green renovations continue at the medical school, officials know that the older buildings will pose a chal - lenge, but The Anlyan Center, which

8 opened in 2003, is also “a big energy 0 0

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m designed, “other concerns outweighed u t

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n m i

t energy use, she said. e r l a a m y —John Dillon 7

New financial aid policy et cetera • • • s

geared toward middle-income o n e

families and students l l PROVOST LEAVES FOR OXFORD a d n

a Provost Andrew Hamilton, ph.d. , is leaving

Some students opening acceptance let - r ters from the School of Medicine this Yale after 11 years to become the next vice chancellor of the University of Oxford spring had another reason to celebrate. in England. While their colleagues in the Class of “As a noted scientist, a successful depart - Another reason for the change, said 2008 graduated with an average debt ment chair, university citizen and provost of $115,000, a new financial aid formula Belitsky, was that high debt often influ - these past four years, Andy has had a remark - should ease that burden for middle- ences specialty choice. For example, able impact on Yale since joining our faculty income families. primary care physicians are in critically in 1997,” said President Richard C. Levin. Dean Robert J. Alpern, m.d ., Ensign short supply nationwide, perhaps in part Hamilton helped create the Yale Center Professor of Medicine, announced the because they are less well reimbursed for Genomics and Proteomics and the Yale new policy in April. Formerly, parents than their colleagues in some specialties. Institute for Nanoscience and Quantum with a combined income over $45,000 Of the 97 Yale students who matched Engineering. He has been instrumental in were expected to help pay the costs this year, only four entered primary care, developing plans for research programs and of their child’s medical education. and another three entered family medi - core facilities for Yale’s new West Campus. Hamilton also helped to create the new Beginning this academic year, that cine. The American Medical Student interdisciplinary Humanities Program and threshold has been raised to $100,000. Association has stated that the current has supported Yale’s investments in the arts. American model of financing medical The “base loan” (the amount students After joining Yale, Hamilton became are expected to borrow before receiving education harms efforts to improve chair of the chemistry department in 1999. scholarship funds) has been raised from physician diversity and patients’ access He became deputy provost for science and $17,000 to $18,000, keeping it among to care. technology in 2003 and provost in 2004 the lowest in the country. The new Richard Silverman, director of ad- after then-Provost Susan Hockfield, ph.d ., formula applies to all current students. missions, speculates that the change was appointed president of mit . “What we were expecting was may also affect the diversity of the appli - In September, Peter Salovey, ph.d ., dean not realistic,” said Richard Belitsky, cant pool. “If another school is widely of Yale College was named provost. m.d ., the Harold W. Jockers Associate perceived to be generous or liberal in —John Curtis Professor of Medical Education and its financial aid policy, it might get more 62 YMG MEMBERS IN TOP DOCS LIST deputy dean for education. applications from candidates who The change was made possible after assume that Yale, because of the name, New York Magazine ’s 2008 list of the region’s top physicians includes 62 physi - Yale’s endowment income added $1.1 is only for the wealth y,” he said. Tuition, cians from Yale Medical Group ( ymg ). million to the medical school’s finan - fees and expenses at the School of Yale’s “top docs” are in 40 specialties and Medicine this year are expected to range cial aid budget. The school’s financial serve patients of all ages. aid committee then decided that stu - from $62,000 to $69,000. The list, which appeared in the magazine’s dents from middle-income families Other medical schools are also June 16 issue, is based on the Top Doctors needed the extra funds most. Especially changing their financial aid policies. New York Metro Area guidebook, published needy families did not need to borrow In March, citing concerns about debt annually by Castle Connolly Medical Ltd. more than the base loan, as School of and specialty choice, Harvard Medical The publishers ask doctors throughout the Medicine scholarships make up the School raised its parental-income region which of their colleagues they would difference, while affluent families were threshold to $120,000. recommend to a friend or relative. The less burdened by tuition costs. The “If a student wants to be a neurosur - guide book includes the top 10 percent of the resources of students from middle- geon instead of going into primary metro area’s physicians. New York Magazine publishes a shorter list—the top income families, though, consistently care,” said Alpern, “I’d hate for them to quarter of the top 10 percent. fell short of the old financial aid for - do it just because of the loans they had.” “Our strong representation in the New —Jenny Blair mula’s estimate, and these students York metro area highlights the fact that ymg were forced to borrow above the base is a regional and, in some cases, national loan to pay what the school required. practice,” said David J. Leffell, m.d., ceo “They should have been borrowing of ymg . “Patients throughout New York and $68,000—four times the unit loan— Online: Yale Netcasts New England are coming to see ymg as a but the average debt was $115,000,” Richard Belitsky: A Great Doctor Is Not What medical destination of choice.” said Alpern. 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With virtual lives on the line, patients into ambulances as quickly as • • • simulations help responders possible? Or to save the greatest num - et cetera ber of lives? The complexities mount assess triage systems CHOCOLATE AND PRE-ECLAMPSIA when one considers that every disaster Imagine being the first paramedic on is unique—it is almost impossible to Eating chocolate may lower the risk of pre- the scene after a tanker truck has compare triage systems in the real eclampsia, a dangerous condition in preg - nancy characterized by increased blood plowed into a city bus. Traffic is snarled, world. Now, though, Cone has begun pressure and proteinuria, according to a Yale cars are honking and people are scream - working with a new tool to study study published in the journal Epidemiology start ing. Who needs your attention most— and other triage systems: a in May. But the study is not a free pass for the man on the concrete holding his virtual-reality (VR) simulator. chocoholics. Eating too many sweets can bloodied knee or the woman on her While studying in Italy for a mas - cause health problems, said Elizabeth W. back with closed eyes? What about the ter’s degree in disaster management in Triche, ph.d. , of the Yale Center for Perinatal, people inside the overturned bus? And 2004, Cone saw a VR simulator used to Pediatric and Environmental Epidemiology, what is that white vapor drifting from train Dutch firefighters and realized that who led the study. the truck’s tank? the software could be adapted for triage Triche’s team wanted to find out whether In emergencies, prioritizing care research. Developed by the Dutch com - chocolate—especially dark chocolate for victims is called triage. The word pany E-Semble, the simulator looks like with antioxidants that confer cardiovascular comes from the French trier , “to select” the highly realistic video game Grand benefits—would protect pregnant women against pre-eclampsia. The study found that or “to sift,” a usage that goes back to Theft Auto . Learners at a laptop “walk women who had more than five servings a Dominique Larrey, the chief surgeon of around” a vivid scene, assessing and week had a lower risk of pre-eclampsia; those Napoleon’s armies. A victim might be triaging victims. Dangers and distrac - who had high levels of theobromine, a by- color-coded as red, meaning he needs tions, like toxic spills or television product of chocolate consumption, were help immediately; yellow, meaning he reporters, can be added to the scenario. nearly 70 per cent less likely to develop pre- will need help soon; green, meaning The learners are timed and their eclampsia than women who had low levels. he has minor injuries; or black, mean - actions exported into a database that “This looks promising, but we need to ing he cannot be helped with available can then be analyzed. do more research into how much and what resources. But sorting human lives in Working with emergency medicine type of chocolate is the most beneficial,” this way is still more art than science. resident John Serra, m.d. , and sup - Triche said. This uncertainty persists because, ported by the Centers for Disease —John Curtis although many rules exist to help res - Control and Prevention and the Laerdal A VIPER’S VENOM AND STROKE cuers, it is hard to evaluate whether Foundation, Cone plans to teach para - those rules actually save lives. The medic students two different triage What does snake venom have to do with decades-old Simple Triage and Rapid systems several months apart, then stroke? Depending on the results of a study in which Yale-New Haven Hospital ( ynhh ) Treatment ( start ) system color-codes compare how they did with each system is participating, possibly a lot. patients as described above. But like in identical VR scenarios. “Once we get Doctors at ynhh are administering other such systems, said David C. Cone, the software tuned, then we can design ancrod, a drug derived from the venom of m.d. , associate professor of surgery the larger studies,” said Cone. He plans the Malayan pit viper, to eligible patients (emergency medicine) and of epidemi - eventually to use the tool to explore who enter the hospital with symptoms of ology, “we have no idea if it works.” whether rules for triage are even neces - acute ischemic stroke. Cone has spent his career thinking sary, or whether victims are better off In such cases doctors may administer a about disasters and mass-casualty triage. being triaged by experienced rescuers clot-breaking agent—tissue plasminogen acti - He studies emergency medical services who rely on clinical gestalt. vator, or t pa —but it must be given no more and plans for chemical, biological and VR may one day allow researchers than three hours after symptoms appear. nuclear terrorist incidents. He has run around the world to collaborate, Ancrod has an anticoagulant effect and can be disaster simulations at Tweed-New exchange scenarios and compile administered up to six hours later. “If ancrod is safe and effective,” said Joseph Schindler, m.d ., Haven Airport complete with volunteers “libraries” of standardized victims. assistant professor of neurology and neurosur - smeared with fake blood. But triage Cone hopes the controlled VR environ - gery and clinical director of the Stroke Center research is inherently difficult. For one ment will allow for real progress in at ynhh , “it will double the time frame during thing, said Cone, “we don’t even know triage research and ultimately save which stroke patients can be treated.” what we want a mass-casualty triage more lives during real disasters. ynhh is the only Connecticut hospital system to do.” Is the best system the —J.B. in the trial, which is expected to last one to one that’s easiest to teach? Quickest to two years. apply? Is the most important goal to get —Charles Gershman 1 yale medicine autumn 2008 0 f I t s i o a n n o p

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METASTASIS AND A HYBRID CELL Metastasis, the spread of cancer throughout the body, may be caused by a hybrid cell that takes on the most dangerous features of two different cell types, according to a review by Yale scientists in the May issue of Nature Reviews Cancer . Bacteria disable immune designed to destroy the bacteria. The According to dermatology researchers cells by exploiting a macrophage ordinarily kills bacteria by John M. Pawelek, ph.d., and Ashok K. genetic similarity exposing them to a destructive acidic Chakraborty, ph.d ., the natural hybrids environment, but the ank proteins pre - take on both the white cell’s migratory The bacteria that cause Legionnaires’ vent the acidic compartment from being ability and the cancer cell’s tendency to disease and Q fever, both of which are transported to the bacteria by mimick - divide uncontrollably. The hybrid can travel linked to pneumonia, use a clever form ing a natural process that occurs during to other organs and seed new cancer sites. “This is a unifying explanation for of mimicry to survive inside host cells, cell division. metastasis,” said Pawelek. “We expect this according to a team of Yale scientists. Roy believes that more such survival to open new areas for therapy based on Both bacteria use genes that have tricks of gram-negative pathogens will the fusion process itself .” So far, one case evolved in tandem with genes in their be found, and that the diseases may one of fusion in humans and many cases in hosts and that disarm the immune day be preventable with a vaccine that mice have been reported. Pawelek said sys tem cells that are trying to kill them, disables the ank protein and allows more research is needed to be certain that the researchers reported in the journal macrophages to complete the job of fusion accounts for metastasis in humans. Science in June. destruction. “This study at least gives us —J.B. “Because of their lifestyle, trying to a foothold,” he said. identify how these organisms cause —J.B. A CLUE TO EVOLUTION disease has been really difficult,” said After 16 years of research, Yale scientists Craig R. Roy, ph.d ., associate professor have produced the first images of a group II of microbial pathogenesis, referring to intron, a cellular molecule whose ancestor the fact that the bacteria live inside may have opened the door to the evolution their host cells. Roy’s team knew that of higher organisms. Anna Marie Pyle, ph.d ., professor of some disease-causing bacteria inject molecular biophysics and biochemistry, and proteins into human cells. What those her team crystallized the intron of a salt- proteins are and what they do, though, tolerant bacterium that lives in the Sea of was unknown. Japan. High-resolution images of the crys - Previous research on the genomes tal, which appeared in Science in April, of the bacteria, Legionella and Coxiella , sup port the hypothesis that the intron had turned up many genes with areas shares a close evolutionary heritage with called ank s (ankyrin repeat homol ogy the human spliceosome, a complex molecu - domains). These genes bear a strong lar machine found in higher organisms that y

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i stretch of the genome. eukaryotic cells, those cells with a a r nucleus that are found in humans and c “The molecules showed us their struc - ture, their active site and their activity,” said other advanced life forms. Legionella This image of a cell infected with Legionella Pyle. “We were even able to visualize their and Coxiella appear to have “hijacked” shows host cell microtubules, which have been labeled using green fluorescent protein associated ions.” Pyle hopes the introns may genes from their hosts in order to sur - to show the bacterial compartments closely be developed into agents for gene therapy. vive in the cell. In fact, some species of aligned on the microtubule network. —J.B. these bacteria cannot exist outside a eukaryotic cell. Roy’s lab showed that ank proteins are secreted into macrophages— immune system cells—and once inside, the proteins turn off mechanisms 12 books &ideas bookshelf

When the doctor is the patient doctor-patient with a foot infection brought his own bag of opiates to the hospital. And as patients, Klitzman’s inter- Robert Klitzman’s resistance to his own depression led viewees were often upset by the carelessness with which him to explore what happens when doctors get sick. their doctors addressed their fears. A surgeon told one doc - tor-patient that a procedure carried a 5 percent chance of Robert L. Klitzman, m.d . ’85, expected the grief that followed dying. The patient would rather have heard that he had a the death of his sister Karen, who died at the age of 38 in 95 percent chance of living. the World Trade Center on September 11, 2001. But he did Just as Klitzman resisted the notion of his own depres - not expect that he would be unable to sleep and would sion , his colleagues also denied that they were sick. They suffer from persistent flu. Or that he would stop listening to told him, “I feel like I have a magic white coat. Illness hap - music and take no pleasure in reading. pens out there—not to me.” Klitzman noted that magical When friends told Klitzman that he was depressed, thinking is part of our everyday lives: “When we blow out he rejected the idea. As a psychiatrist, of course, he knew the birthday candles, we all make a wish.” But doctors that emotional depression often manifests itself in the body. deny their irrationality, contending, “We do not engage in “I’d read it in textbooks,” he acknowledged. Eventually magical thinking. We’re trained scientists.” Klitzman did recognize that it was depression, not flu, that Perhaps because doctors see themselves as scientists, was making him feel that his body had “given way” beneath they are reluctant to discuss religion or spirituality with him. “Going through it myself made me realize how much their patients, as Klitzman’s research suggests. Yet “when I didn’t know about what it was to be a patient,” he said. patients are lying in bed, that’s what they’re thinking That realization, he said, was “a defining moment.” about,” he said. He advocates adding at least a lecture on Klitzman, a research scientist and associate professor the topic during medical school. of clinical psychiatry at the hiv Center for Clinical and A reviewer wrote in the New England Journal of Medicine Behavioral Studies at the New York State Psychiatric that Klitzman’s book “goes to the very heart of the question Institute and Columbia University, had already written five of what a physician is.” In addition, When Doctors Become books. In fact, he’d gotten his start as a writer by reviewing Patients serves as a lasting memorial to Karen Klitzman. books while a medical student at Yale—a starting point —Cathy Shufro he recommends to students today. His role models included Richard A. Selzer, m.d. , hs ’61; Sherwin B. Nuland, m.d. Robert Klitzman’s depression after the loss of his sister on 9/11 ’55, hs ’61; and Howard M. Spiro, m.d .—Yale physicians led him to explore what he who are also prominent authors. Klitzman had already con - calls the “odd hybrid” of doctors templated writing a book about doctors as patients. Now, who become patients. however, “It was no longer an academic question.” When Doctors Become Patients is the product of inter - views with 70 physicians of all ages who were facing cancer, heart disease, Huntington disease, bipolar disorder, hiv and other illnesses. Klitzman analyzes such common y 8

themes as denial of illness, doctors choosing doctors, e 0 l 0 n 2 “self-doctoring,” going public about one’s disease, over- a m n

s e m working, coping and the role of spiritual beliefs. l u r t a u

Klitzman found that the doctors viewed themselves h a c e

n either as patients or as doctors, “as if individuals had a i c i

d zero-sum identity.” In reality, Klitzman said, “They’re not e

m entirely doctors and they’re not entirely patients.” Klitzman

e Bookshelf focuses on books and authors at the School of Medicine. l a

y called this “odd hybrid form” the “doctor-patient”—one Send suggestions to Cathy Shufro at [email protected]. book notes 13

Polarities of Experiences: program for using praise and that the attachment system, and The Future of Medicine: Relatedness and Self-Definition rewards to alter children’s behav - particularly the degree of felt Megatrends in Health Care That in Personality Development, ior. Kazdin provides a step-by-step security— or lack thereof—in Will Improve Your Quality of Life Psychopathology and the method that relies on positive relation to early attachment by Stephen C. Schimpff, m.d. Therapeutic Process reinforcement and a reward sys - figures, provides a paradigm for ’67, hs ’69 (Thomas Nelson by Sidney J. Blatt, ph.d. , profes- tem for dealing with behavior relationships that forms a scaf - Publisher) This book describes sor of psychiatry and psychology problems. The book describes fold for the developmental and evaluates health care inno - (American Psychological Associa- approaches for children of differ - unfolding of sexuality in all its vations in areas including tion) The author proposes that ent ages; discusses ways to manifestations. These manifesta - genomics, imaging, pharmaceu - psychological development is a involve siblings; and provides tions include infantile and adult, ticals, the operating room, and lifelong personal negotiation scenarios for coping with such masturbatory and mutual, and alternative and complementary between two dimensions: relat - commonplace difficulties as normative and perverse sexuality. medicine. The author combines edness, which he terms the tantrums, dawdling, resisting scientific fact with personal anaclitic dimension; and self- homework and delaying bedtime. Apoptosis and Cancer: stories and experiences to definition, or the introjective Methods and Protocols describe the tools, techniques dimension. He contends that Saving Sickly Children: The edited by Gil Mor, m.d. , ph.d. , and treatments that are mak - emphasis on one developmental Tuberculosis Preventorium in associate professor of obstetrics, ing a difference in health care. line at the expense of the other, American Life, 1909-1970 gynecology and reproductive sci - These innovations include vac - however, can lead to a variety by Cynthia A. Connolly, r.n. , ences, and Ayesha B. Alvero, m.d. , cines that prevent cancer and of mental disorders. Within this ph.d. , assistant professor of nurs - associate research scientist in chronic disease; surgery simula - framework, Blatt sees mental ing and the history of medicine obstetrics, gynecology and repro - tion and robots in the operat - dis orders as compensatory exag - (Rutgers University Press) The ductive sciences (Humana Press) ing room; and smaller, more gerations of the normal polarities author provides an analysis of This book, a collaboration powerful medical devices that of relatedness and self-definition public health and family welfare between academics and industry- help a patient’s heart beat, rather than clusters of present or viewed through the institution based scientists, describes the relieve depression and replace absent symptoms. Blatt discusses of the tuberculosis preventorium performance of contemporary failing organs. research indicating that anaclitic of the early 20th century. This techniques for studying the and introjective persons respond facility was intended to prevent biology of apoptosis and its role Hip and Knee Surgery: A Patient’s differently to psychotherapy. He TB in indigent children at risk for in cancer. The protocols described Guide to Hip Replacement, Hip then argues that this conceptu- developing the disease or who within will aid both academic Resurfacing, Knee Replacement al ization of personality devel - came from families labeled as laboratory workers interested in and Knee Arthroscopy op ment has clear implications for irresponsible. Connolly further further characterizing the by Robert E. Kennon, m.d. , hs refining approaches to therapy. explains how the child-saving mechanism of apoptosis and ’04 (Lulu Publisher) This book themes embedded in the preven - industry-based researchers con - contains information for patients The Kazdin Method for Parenting torium movement continue to cerned with identifying new tar - considering treatment for hip or the Defiant Child: With No Pills, shape contemporary pediatric get molecules or screening for knee arthritis and related condi - No Therapy, No Contest of Wills health care delivery and family new compounds with potential tions. The author explains what by Alan E. Kazdin, ph.d. , the policy in the United States. clinical use. The text covers the to expect before, during and after John M. Musser Professor of newest methods as well as basic hospitalization; describes postop - Psychology, and director of the Attachment and Sexuality conventional techniques. erative exercises; and offers rec - Yale Parenting Center and edited by Sidney J. Blatt, ph.d. , ommendations for rehabilitation. Child Conduct Clinic (Houghton professor of psychiatry and psy - Illustrated sections discuss hip Mifflin) In this book and dvd , chology; Diana Diamond, ph.d. , and knee surgeries; nonoperative Kazdin lays out his science-based and Joseph D. Lichtenberg, m.d . treatment options; surgical (The Analytic Press) Each paper approaches, the latest minimally featured in this text forms a invasive surgery techniques; sep arate narrative strand that implant materials and designs; clarifies different configurations and potential complications of of the relationship between joint surgery. attachment and sexuality. 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PAUL OFFIT JOSEPH BERTINO CHARLES ZEANAH SARAH JANICKI Lawsuits could bankrupt A gene to protect bone marrow Children, foster care Bolero , dementia and vaccine program from chemotherapy and orphanages the creative process

A program that encourages child - In a new approach to cancer When Nicolae Ceau şescu took In 1930, when Maurice Ravel hood vaccinations could collapse treatment, researchers are study - power in Romania in 1965, he com posed Bolero , his best-known under unproven allegations that ing a form of gene therapy that believed that his country needed work, he may have been in the the shots cause disease, an expert may make bone marrow more a larger work force. He decreed, throes of frontotemporal demen - warned at grand rounds for the resistant to chemotherapy, said Charles H. Zeanah Jr., m.d ., tia ( ftd ), a neurodegenerative Department of Pediatrics in May. allowing for higher doses and Sellars-Polchow Professor of disease that usually affects Paul Offit, m.d ., chief of infec - better outcomes. Psychiatry at Tulane University, peo ple in their late 50s. Ravel’s tious diseases at Children’s “We are turning the tables,” that all women must bear metic ulous handwriting had Hospital of Philadelphia, said that said Joseph R. Bertino, m.d ., five children. become irregular, he had lost his the fallout from a 2008 court interim director and chief scien - The economy didn’t improve, bags and tickets on a concert decision would discourage vac - tific officer of the Cancer Insti- Zeanah told an audience at pedi - tour and, while conducting one cine makers from continuing tute of New Jersey, at Yale Cancer atric grand rounds in May, but of his works, he had uncharacter - pro duction. Since 1955, when a Center grand rounds in May. “This more children entered the coun - istically skipped from the open - bad batch of polio vaccine killed therapy will allow for safer use of try’s orphanages. “Children with ing movement to the coda. 10 people, testing and regulation drugs and an increase in dosage. a history of institutional rearing In a talk at neuroscience grand of vaccines have improved. But If we do this we can protect have a high risk of psychological rounds in May, Sarah C. Janicki, subsequent court rulings that patients from a wide variety of and social problems,” Zeanah m.d. , m.p.h. , hs ’08, said Ravel’s vaccine makers could be held chemotherapy drugs.” said. In 2000, Zeanah and Charles case is not unusual— ftd has liable without being negligent Bertino, who was director of Nelson, ph.d. , of Harvard and been linked to strong bouts of led to “a flood of lawsuits” in the Yale Comprehensive Cancer Nathan Fox, ph.d. , of the creativity. “Over time a series the 1970s. Center from 1973 to 1975, said University of Maryland began a of patients were coming to light, In 1986 Congress created the this approach calls for introduc - four-year study of 136 children patients with ftd developing National Vaccine Injury Com- ing a drug-resistant gene into who ranged in age from 7 to 33 creative skills,” she said. pensation Program to protect hematopoietic progenitor cells. months, and found that their Although the reasons for vaccine makers while compen - That could limit the drugs’ tox- development lagged in most this connection are not clear, sating those harmed by faulty icity and preserve the marrow’s areas. Half of the 136 children the brain’s left temporal lobe vaccines. But Offit said that the ability to produce infection- were then placed in foster appears to be involved. And program took “a sad turn” in fighting white blood cells. care, previously unavailable in the disorder appears to release 2008 when a special “vaccine Oncologists would then be able Bucharest, and half remained artistic inhibitions—artists court” composed of epidemiolo - to prescribe higher doses of in institutions. move from representational to gists and clinicians ruled that chemotherapy, potentially lead - Foster care enhanced devel - more abstract forms of expres - claims can be granted even if ing to improved outcomes. opment in most areas, but sion. But as the disease pro - it’s only possible—with no epi- Bertino said two clinical complete recovery was rare. For gresses, that process reverses demiological evidence—that trials—one for lymphoma and cognitive development and itself. “As [the patients’] lan - vaccines are responsible. another for pancreatic and attachment, recovery seemed guage skills declined, their art About 5,000 children who breast cancer—are in the plan - to have more to do with the became fairly representational claim to be harmed as a result of ning stages. timing of interventions than instead of a creative manipula - vaccination await a decision —John Curtis their duration. Children who tion to generate new thought,” that could bankrupt the vaccine entered foster care before their Janicki said. program. If the decision allows second birthday, Zeanah said, —J.C. for monetary compensation, were more likely to recover “it could eliminate the program,” from the severe deprivations Offit said. of Romanian orphanages. —John Dillon —J.C. 16 capsule

A theory abandoned but still compelling

By Peter Farley In 1977 readers were enthralled by The Dragons of Eden , a book by the astronomer Carl Sagan that explored the evolution of the human brain. Dragons won the 1978 Pulitzer Prize for general nonfiction and helped to launch Sagan’s celebrity as a spokesman for science in the 1980s. The real star of the book, however, was a theory of human neural organi - zation that took root some 30 years earlier in writings by Paul D. MacLean, m.d . ’40. MacLean, who died last December at age 94, was a highly original—some say eccentric—thinker whose model of the triune brain, though now discredited, has had a last - ing cultural impact. “Paul never traveled with the herd,” said Thomas R. Insel, m.d ., director of the National Institute of Mental Health, who worked alongside MacLean for 10 years at the Laboratory of Brain Evolution and Behavior in Poolesville, Md. Insel remembers his colleague as irreverent and uninhibited. MacLean once roamed through a room, Insel recalled, feeling the scalps of visiting scientists to ascertain the presence or absence of a skull protuberance he t s

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m encephalographic recordings in patients 17

opposite Paul MacLean believed that the neocortex was a relatively late development in the mammalian lineage, but there is now a consensus that homologues of this structure exist in simple fish, and even in insects.

below In MacLean’s triune brain (top), the neocortex has only partial dominion over the emotional responses of the more primitive limbic system (bottom). “This situation,” he wrote, “provides a clue to understanding In Paul MacLean’s triune brain, primitive emotions the difference between what we ‘feel’ and overruled conscious thoughts. what we ‘know.’ ”

with psychosomatic illnesses and ego and id. The theory’s conceptual epilepsy at Massachusetts General beauty and intuitive appeal lent it enor - Hospital, MacLean had become mous staying power; it is still covered convinced that the emotional compo - in many textbooks and course lectures nents of these disorders were seated in biological psychology. in deep brain structures that he called But according to Terrence Deacon, the visceral brain (and renamed the ph.d ., an expert on the evolution limbic system in 1952), which included of human cognition at the University the hippocampus, amygdala and of California, Berkeley, subsequent cingulate gyrus. research has revealed that MacLean’s Since all mammals possess variants basic premise—his “‘hats on top of of these structures, MacLean concluded hats’ view” that brain systems were that they are phylogenetically ancient added by accretion over the course of and that the emotional responses they evolution—was mistaken. “Adding produce are only weakly regulated by on is almost certainly not the way the such newer, human structures as the brain has evolved,” said Deacon. neocortex. “Our affective behavior con - “Instead, the same structures have tinues to be dominated by a relatively become modified in different ways in crude and primitive system,” he wrote. different lineages.” Twenty years later, MacLean rounded Nonetheless, Deacon said, the force out his picture of the triune (three of MacLean’s personality gave his in one) brain by adding what he termed ideas a special resonance. “His death the R-complex (for “reptilian”)—struc - represents the passing of an era, tures in the brain’s core and brain stem because he was really the model of that govern basic survival functions— the move towards understanding the to the neocortical and limbic systems he brain in evolutionary terms,” said had defined previously. Deacon. “A lot of our contemporary The theory saw its fullest expression advances ride on top of his work, in MacLean’s 1990 magnum opus, The even though in hindsight it was mis - Triune Brain in Evolution , which was leading. That happens a lot in the based on wide-ranging anatomical stud - sciences, and we don’t often give credit ies of brains in animals as diverse as to the false starts that really push us alligators and monkeys. In its casting of along the way.” a cognitively sophisticated neocortex unable to fully restrain the primal emo - Peter Farley is the managing editor of the tional responses of the limbic system, bimonthly newsletter Medicine@Yale . ) 2 (

MacLean’s model was a neuroanatomi - r e cal cousin to Freud’s tripartite view of g n i r p

the mind, with its warring superego, s 18

Medical schools are relatively new to the game of large-scale clinical research; however, they are sponsoring studies to test new therapies with increasing frequency. With its largest grant ever, Yale is plunging headlong into human trials and assembling resources to help clinical scientists focus on ideas—and leave the red tape to others.

By Jill Max Illustrations by Jeffrey Fisher 8 0 0 2 n m u t u a e n i c i d e m e l a y 19

About six years ago, Thomas O. Carpenter, m.d ., professor of pediatrics (endocrinology), wondered why he was seeing an increasing number of infants with nutritional rickets. He examined some of the infants’ medical records and found that although rickets is presumed to be caused by a vitamin D defi - ciency, fewer than half of the infants had low levels of the vita - min. Many appeared to be calcium-deficient as a result of being weaned from breast milk to juices and soda. With fund - ing from the Gerber Foundation, Carpenter began a large- scale three-year study in 2005 that involved 800 babies from inner-city New Haven health clinics and the Primary Care Center at Yale-New Haven Hospital. By screening infants at their well-child visits, Carpenter aims to define the prevalence of early rickets in New Haven, determine how much of it is due to vitamin D deficiency versus calcium deficiency and look for changes in biomarkers that can be spotted before bone disease is evident. The study is already showing results: Carpenter found that elevated levels of parathyroid hormone, which is used to diagnose rickets, can also be used to predict who may eventually develop the disease, so that doctors can begin to treat children to ward off the disorder before symp - toms are present. He is also searching for other genetic factors that may represent an increased susceptibility to the disease. Such clinical research is not a novelty at Yale. But these efforts are now being organized and supported on a much broader scale under the umbrella of the Yale Center for Clinical Investigation ( ycci ). The center was launched in early 2006 to coordinate research programs among Yale’s health science schools and the surrounding community. It is also intended to support faculty research efforts while at the same time ensuring that patients are protected and receive high-quality care. ycci ’s mission dovetails with the National Institutes of Health ( nih ) Roadmap for Medical Research, which was implemented in 2002 near the end of a five-year period in which Congress doubled the nih budget. The Roadmap helped garner public support for nih -supported research and provided a framework for bringing medical knowledge from the laboratory to the patient. In October 2006 the School of Medicine was one of 12 institutions around the country to receive a Clinical and Translational Science Award ( ctsa ); at $57.3 million the five-year award is by far the largest nih research grant in the school’s history (see related story, page 24). When fully implemented in 2012, the ctsa initiative is expected to provide $500 million annu - ally to 60 academic health centers working in concert. nih Director Elias A. Zerhouni, m.d., said that ctsa will “trans - form how clinical and translational research is conducted.” Yale has traditionally been strong in basic science and has been successful in identifying drug targets and such other methods of combating disease as tissue engineering or large-scale public health interventions aimed at disease pre - vention. But until recently a center for translating ba sic sci - ence discoveries into clinical practice had never taken hold. 2 yale medicine autumn 2008 0 M a p p i n g

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Breuer is now well versed in running a clinical trial. component of ycci , was developed at the School of Medicine For other researchers who lack the experience to put together in 1999 to award the ph.d. to physicians training in clinical an effective study, however, ycci offers expertise in trial research. Under the ctsa it has expanded to offer courses design, regulatory issues, protocol development, biostatistics to medical, nursing and public health students. In addition, and epidemiology, budget and recruitment. The center also 20 junior faculty members and senior fellows who are com - offers research nursing support, data management, laboratory mitted to careers in clinical or translational research have services, and both inpatient and outpatient facilities to conduct received 18- month grants for salary and research support trials. A new online database at yaletrials.org provides detailed through ycci ’s Scholar program. Drawn from the three Yale information about all clinical trials at Yale, so that patients health schools, the grant recipients are pursuing research interested in a specific disease can search for a trial related to projects under the guidance of individualized mentorship it. ycci also integrates the efforts of Yale’s institutional review committees. “We’re investing in them like we invest in boards ( irb s) into the process. These panels, comprising training a ph.d. , which involves having people from diverse clinicians, faculty, students and members of the community, backgrounds looking at their work from different perspec - must approve every research project that involves humans, tives,” said Sherwin. even a paper-and-pencil survey. The medical school’s two irb s The work of Mary E. Tinetti, m.d ., director of the meet weekly to discuss the several hundred new proposals Yale Program on Aging, serves as an example of the kind and more than 1,500 requests to renew ongoing studies that of research the program strives to advance. While training come their way each year. in geriatrics more than 20 years ago, she recognized that In the world of clinical trials, some studies, such as a slew of health conditions—such as incontinence, delir - Breuer’s work, attempt to treat an existing condition, while ium and injuries caused by falls—were neglected by the others try to answer basic questions about the course of dis - health care system yet have a major impact on quality of life eases or ways to prevent them. Carpenter’s work does both. and functioning. His nutritional rickets study is helping doctors treat the dis - Tinetti identified characteristics linked to an increased ease before it can do damage, but he also conducts research risk of falls and conducted a study to determine whether on X-linked hypophosphatemia ( xlh ), the most common interventions targeting these risk factors would prevent form of inherited rickets in the United States. xlh can lead to falls and injuries. Until that time, most clinical trials deformed bones and debilitating arthritis. Carpenter estab - focused on a single intervention; however, Tinetti and her lished the Yale Center for xlh , an nih -sponsored Center of colleagues developed a new multifactorial trial design in Research Translation ( cort ), one of eight in the country that which patients receive a combination of interventions tailored serve as a model of translational research in academic medical to their particular risk factors. For example, the intervention centers. Some of the center’s projects interface with ctsa , for patients who experience a drop in blood pressure when such as clinical trials studying the effect of a medication moving from lying or sitting to standing consists of specifically aiming to suppress the hyperparathyroidism that increased hydration, specific exercises to do before getting occurs with xlh . Carpenter is also conducting an observa - up, and a reduction in medications likely to affect blood tional study to characterize the disease in patients past child - pressure changes on standing. In the mid-1990s, Tinetti and hood and he is trying to determine the chemical and skeletal colleagues followed a group of 320 patients and controls for features of xlh in older patients. “Understanding the disease two years and found that patients who received such inter - has opened up a whole new mechanism of how minerals are ventions reduced their risk of falling by about 30 percent. regulated in the body,” said Carpenter. That area of research The next step was to see whether this reduction in falls would includes new therapies applicable not only to xlh but also to also occur when real-world clinicians, rather than investiga - other disorders in which the body’s handling of phosphate has tors, were responsible for carrying out the interventions. For gone amiss, such as chronic renal failure. the past eight years, she and col leagues have been conducting a study in the greater Hartford area to train health care prac - Focus on training titioners to incorporate compo nents of fall prevention into Perhaps the single most important aspect of the ctsa —and their practice. The real- world trial was funded by the West by extension ycci— is training young researchers to con - Hartford-based Donaghue Medical Research Foundation, said duct clinical studies. “In the past, most physicians learned Tinetti, the Gladys Phillips Crofoot Professor of Medicine on the job, sort of like an apprenticeship,” said ycci Director (geriatrics) and professor of epidemiology (chronic diseases) Sherwin. “But the kind of sophistication that’s now required and investigative medicine. to do clinical research and the kind of mentorship background In an article published in the New England Journal of you need to do research today are much more involved than a Medicine in July, Tinetti and her colleagues reported that the simple apprenticeship.” The Investigative Medicine Program, fall prevention programs resulted in an 11 percent reduction in which serves as the administrative home for the educational falls compared to the control group, and 10 percent fewer 2 yale medicine autumn 2008 2 M a p p i n g

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Patient-volunteers help important part of what we do in life that could change someone Such are the rewards of clinical find cures on medicine’s health care,” she said. else’s life,” said Stephanie, referring studies that patients often repeat front lines Some participate in hopes of to two days of bone scans, X-rays the experience. Jan Davey, who is obtaining treatment for a disease and ultrasounds at Yale-New Haven participating in the keeps study, Every day at the medical school, from which they or a loved one Hospital. “My generation is writing has also signed up for three ancil - patients and control subjects suf fer. Terri Rathbun’s 16-year-old the textbook on this disease,” said lary studies. “We wouldn’t be undergo imaging tests, hop on daughter, Molly, has childhood Jean, who hopes the study will where we are in health care if we treadmills and swallow medica - absence epilepsy—short seizures ben efit her grandson and future hadn’t been doing clinical research tions in the name of advancing in which the person appears to grandchildren. all these years,” she said. knowledge. Some do it to con - blank out. Her condition has not Clinical trials require not only —Jill Max tribute to society and research, responded to medication. To assess sick but also healthy subjects. some are lured by the payments Molly’s brain function, she under - One 76-year-old woman partici - offered, and some hope to help find went mri scans while performing pates in the Alzheimer Disease a cure and ease a loved one’s suf - cognitive tasks. Her mother is hop - Neuro-imaging Initiative even fering or that of future patients. ing the study will benefit other though she is healthy. As part of That last consideration is what children; in the meantime, it has the three-year study she gets mri motivated Kriste Gill to enroll her helped her recognize how well and pet scans every six months newborn twins in a study on early Molly has coped while living with so that researchers can compare indications of autism. A speech seizures. According to her mother, the mental changes that occur pathologist with a professional Molly hopes that participating in in normal aging, mild cognitive interest in the study, Gill also has this study “will open up opportuni - impairment and Alzheimer dis - a 22-year-old brother with autism. ties for other kids so that seizures ease. She hopes that the trial “I get to give back to research for don’t define their lives.” will lead to a cure that will help a disability that’s very near to us,” For cancer patients Kathy Willie family members and friends she said. For the past two years, and Geralyn Spollett, a trial for who have the disease. Gill’s babies have undergone treatment of her 2-positive breast Because he has a family history developmental assessments. The cancer was a chance to receive of heart disease, 27-year-old Niall exams are not physically invasive, chemotherapy that might have McComiskey agreed to a stress and Gill has learned much about reduced or eliminated their tumors test on a treadmill, administra - the twins’ development. And if before surgery. Willie initially didn’t tion of adenosine to increase any signs of autism should surface, want to undergo chemotherapy, his heart rate and a pet scan. she’s confident the research team but her decision paid off; during a McComiskey also said that the would flag them and recommend partial mastectomy her surgeon $200 he was paid did n’t hurt, and next steps for further evaluation. found no trace of the tumor. for some people, financial com - A different concern brought Although the treatment didn’t pensation is reward enough. For Jan Davey into the Kronos Early change the course of Spollett’s others, it’s a combina tion of fac - Estrogen Prevention Study ( keeps ), treatment—she ended up needing tors that spur them to partici - a study to determine whether early a mastectomy as well as chemo- pate. One 40-year-old veteran, menopausal hormone therapy therapy and radiation—she a recovering alcoholic and addict pre vents or delays heart disease. believes it was a positive experi - who suffers from post-trau matic Davey, 61, has a 27-year-old daugh - ence. “I felt lucky to be in the trial stress disorder, had two reasons ter and sees the need for research because of the consultation and for undergoing pet scans as part that may benefit future genera - support,” said Spollett, who will of a study to measure the levels tions of women. Participants have follow-up blood work in of neurotransmitters in brain tis - commit to taking hormones or a September. sue. He wanted to understand placebo as well as undergoing Social responsibility also moti - the chemical imbalances in his periodic lipid profile tests and vagi - vates patients. Jean O’Brien, 65, and brain; he was also paid about nal ultrasounds for four years. As her daughter Stephanie, 32, have $700 to participate in the study. a clinical research nurse in Cardio- X- linked hypophosphatemia ( xlh ), Thomas O. Carpenter, m.d. , pro- vascular Medicine and at Yale the most common form of inher - fessor of pediatrics (endocrinol - Cancer Center, Davey understands ited rickets in the United States. ogy), offers a $25 grocery card the demands and rewards of They joined in a study designed to to participants in his nutritional clinical trials but had never before define the features of the disease in study, which he said is an effect- participated in one. “It’s a very adults. “It’s a few days out of my ive incentive. 24 25

Is the straight road too narrow?

Congressional demands for cures and accountability—combined with a flat nih budget —have increased pressure on scientists to produce findings with direct application to disease. Nonetheless, there’s great value in cultivating the art of finding what you’re not looking for.

By Pat McCaffrey Illustrations by Jeffrey Fisher

The stereotype of the basic researcher—driven by curiosity, looking at the ways in which antibiotics recognize and bind absorbed in the arcane, immune to practical considerations— to the bacterial large ribosomal subunit and shut it down. is only half right. The need to unravel a puzzle, to uncover Hard data about molecular interactions are like gold to sci - the beauty and order in biological systems, or simply to entists looking to design new antibiotics—as they are now follow one’s nose, asking and answering questions, is both doing in a company that Steitz helped found. the initial impulse and sustaining force for many a career “When I started solving protein structures as a gradu - in basic research. Yet these scientists are not indifferent to ate student, I had no idea, nor did anyone else, that this the practical applications of their work. They are just not would ever be of any practical benefit whatsoever,” Steitz starting out with that particular end in mind. says. “We just wanted to know, how does this machine Take structural biologist Thomas A. Steitz, ph.d ., work? … Our work has led to translational research, but Sterling Professor of Molecular Biophysics and Biochemistry. it wasn’t the goal. I never thought that I would end up build - Beginning with his doctoral work more than 40 years ago, ing a pharmaceutical company around the study of the Steitz has fixated on one question: How do proteins and structure of the ribosome.” nucleic acids carry out their diverse jobs in cells? For Steitz, It is a cliché of scientific exploration that even the that question is best answered by looking at the macro- most esoteric work can yield unexpected benefits. From molecule’s shape; he is a leader in charting the topology of synthetic insulin, the first biotech drug (a result of studies proteins and nucleic acids at the atomic level. of bacteria) to the latest frontier of rna -based therapies Steitz and his team were the first to see one particu - (started by work in worms), Steitz posits that every single larly important biological machine eight years ago when medical discovery of major importance made over the last they solved the molecular structure of the large subunit of 30 years has its roots in basic research. “If you trace back the ribosome, the protein-making factory inside all cells. through the history of molecular biology, which made bio - That discovery, coming after five years of effort, a few dead technology possible, you find that it all came from basic ends and a little luck, has turned out to have practical research,” he says. benefits. Many antibiotics work by interfering with the func - So why are Steitz and his colleagues so worried about tions of bacterial ribosomes. Steitz’s lab was soon busy the future of creative, idea-driven biological research? He 2 yale medicine autumn 2008 6 t g q U t m a C “ i a r t o r r l h o o fl a S c f a a n “ R a I f a f a b 2 r t t s e o h h n h o o r o e e o e W W o s r p n n n

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still recognize research that is new and exciting and worth (ycci ), under the direction of Robert S. Sherwin, m.d ., the taking a chance on. But in a super-competitive environment, c.n.h . Long Professor of Medicine, received a $57.3 million those off-the-wall, risky, creative projects lose out,” he says. grant in 2006—the largest single nih grant ever given to Yale. That grant included existing grants to Yale of $25.8 mil - Enter the Roadmap lion, so the net increase to Yale was $31.5 million. Another Money, or lack of it, is not the only threat basic researchers recent nih award supports the training of medical students perceive. Many report a growing unease with the wider to carry out clinical research. world’s view of their work, and with what some think is a No matter the merit of those programs, they create mistaken assessment of its value. Among researchers, there a perception problem, says Carolyn W. Slayman, ph.d ., is a palpable feeling that a recent and highly visible growth Sterling Professor of Genetics and deputy dean for academic in support for clinically oriented translational research and scientific affairs. Compared to an average RO1 grant programs means less funding for basic research. In this of about $1 million over four years, the new awards were regard, some re-searchers blame a set of programs collec - eye-popping. “To starving scientists who are worrying about

tively called the nih Roadmap for Medical Research for their own RO1, it’s hard to see Roadmap grants awarded in draining support from their labs. huge and very visible chunks of $20 or $40 or $50 million,” The Roadmap had its start at the end of the period of Slayman says. “Their immediate reaction is, how many rapid budget growth. Anticipating that the public and its laboratories like mine could be kept going very happily for representatives in Congress would be looking for payoff on years with that money?” their investment, the then-new nih director, Elias Zerhouni, Even so, the idea that the Roadmap is a drag on basic m.d ., initiated a mass consultation in 2002 with hundreds science funding is exaggerated, says Jordan S. Pober, m.d. , of scientists to identify gaps in nih programs. Over the ph.d ., professor of immunobiology, pathology and dermatol - course of a year, Zerhouni identified areas in which the nih ogy and vice chair of the Section of Human and might do a better job of supporting multidisciplinary teams Translational Immunology. as well as translational and clinical research. The process The numbers support his view. Taken together, was dubbed the Roadmap; its first projects began in 2004. Road-map projects account for less than 2 percent of the There was controversy about the Roadmap from total nih budget; moreover, fully half of Roadmap fund - the beginning. Just as RO1 funding was tightening, basic ing goes to individual researchers in the form of RO1 researchers watched money flow to translational research, or similar grants. The real culprit, Pober says, is the stag - multi-investigator grants and clinical research. nation of the overall budget. His message: “There is The School of Medicine has certainly benefited from pain, to be sure. But don’t blame the Roadmap, blame that funding stream. The Yale Center for Clinical Investigation the budget.” 2 yale medicine autumn 2008 8 s i t M b o p S a t a v c M S I R t r g t a u s “ b C o d m s o o i h o a I r u a e

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29

“The same way that fruit flies find bananas, mosqui - and the public, and even on budding young scientists as the toes find humans,” Carlson explains. “They both depend funding freeze continues. on their sense of smell.” That insight propelled him into Pietro De Camilli, m.d ., Eugene Higgins Professor the field of malaria, a disease that infects hundreds of of Cell Biology and co-director of the program for Cellular millions of people around the world each year. Carlson is Neuroscience, Neurodegeneration and Repair, sees this working with European and African colleagues to find loss of perspective in his experience with up-and-coming chemical compounds that confuse the sensory receptors on researchers. “There is a perception I see in young people a mosquito’s nose and prevent them from finding humans. that if they want to be a scientist and successfully compete In the future, he foresees using a similar approach to for funding, they have to work on applied problems. keep crops free of agricultural pests. Carlson says the work A career in basic research seems less and less attractive.” may also be adapted to use odor receptors as detection The boom-and-bust cycle of congressional appropria - devices for explosives. tions to nih over the last decade has left some senior re- For two decades, Carlson has been able to keep his searchers struggling to maintain long-term projects. When research program on track with an uninterrupted stream of young investigators see their mentors not being funded, funding from nih . His applied research draws support from they get the message, says stem cell researcher Diane private foundations, including the Bill and Melinda Gates Krause, m.d. , ph.d. , professor of laboratory medicine and Foundation for the malaria work. Nonetheless, he says, cell biology and associate director of the Yale Stem Cell “I do worry about the nih dropping support for individual Center. “This is dissuading people from trying to succeed labs exploring questions that excite their curiosity about as academic researchers. We certainly make it look difficult basic science.” to our students and postdoctoral fellows.” At current levels, the nih budget overall is a prescrip - The long view tion for slowing medical progress in the future, not speed- The Nobel Prize-winning biologist Arthur Kornberg, m.d ., ing it up, according to immunologist Flavell. He supports liked to tell a story that starts with a surgeon out for his the Roadmap but cautions that any success depends on morning jog. While passing a lake, the doctor sees a man in maintaining a healthy basic research environment and push - the water about to drown. So he dives in, pulls the man ing forward with applied and clinical programs. One without out, resuscitates him and continues running. the other makes no sense, yet increasingly he sees outstand - A bit farther down the path, another man is flailing in ing re searchers unable to win grants. Unless something the water in another part of the lake. The surgeon saves changes soon, he says, we may find ourselves 20 years down him, and no sooner sets off jogging again than he sees two the road with an impressive clinical and translational infra - more people in trouble in the water. He notices his friend, structure but few new basic findings to translate. YM a neuroscience professor, loitering nearby and calls out for Pat McCaffrey is a freelance writer in Boston. him to save one person while the surgeon rescues the other. When the neuroscientist does not move, the exasperated surgeon shouts at him, “Why aren’t you doing something?” The neuroscientist answers calmly, “I am doing something. I’m desperately trying to figure out who’s throw - Online: Yale Netcasts ing all these people in the lake.” thomas steitz: The point is, of course, that the fight against human Mapping the Ribosome. disease occurs on several fronts. Someone has to rush in and richard flavell: save today’s victims. Solving fundamental problems, how - Mouse With a Human Immune System Could Revolutionize ever, requires other people with different skills and interests. Research. Neither group is more important than the other. That is pietro de camilli: one message that researchers fear is being lost on lawmakers Getting the Message. 30

A life’s work in Indonesia By Jill Max Kinari Webb came to medical school knowing how and where she Photographs by Erick Danzer wanted to practice medicine. Now, she and her ecologist husband are working to bring health care to a remote corner of Borneo while preserving the rain forest.

Kinari Webb, a 2002 graduate of Indonesian island of Borneo. Webb preserve the rain forest of nearby the School of Medicine, visits has opened a clinic that serves Gunung Palung National Park. with a family in the town of Suka- the local population. She and her dana in a remote corner of the husband are also working to 31

Webb spent a year traveling park with a rain forest under siege throughout Indonesia to find the from logging, and the region’s right place to launch her clinic. three clinics and 60,000 people Sukadana is next to a national shared a single physician.

Pak Rudi, a 40-year-old who eke out a living by harvesting lumber. In the 1960s, from a remote corner of the rain forest covered 82 percent of Indonesia—now it covers island of Borneo, Indonesia, 49 percent. Since the 1980s more than half the rain forest was in bad shape. Walking in Borneo, one of the largest of Indonesia’s 17,500 islands, even a few steps left him has been destroyed. short of breath. In the fall Webb first visited the island as an undergraduate at of 2007, with his wife and Reed College in Portland, Ore., and was both entranced several family members, he by the beauty of Gunung Palung, with its mangrove forests traveled for eight hours by and verdant mountains shrouded in gentle mists, and motorboat and motorcycle horrified by the extent of the region’s illegal logging. While taxi to reach the coastal the government has tried to protect the rain forests through town of Sukadana, where mass tree plantings and international carbon-trading he had relatives who urged schemes, villagers have few ways to earn a living. Some him to seek help at the work on rubber and oil palm farms. Others earn a few dol - local clinic. By the time his lars a week breaking boulders and selling the rocks to road- family carried him into the Alam Sehat Lestari clinic, known building crews. More than 7 percent of the former Dutch as asri , Pak Rudi was close to death. Although the clinic colony’s 245 million people live on less than a dollar a day. lacks an X-ray machine, the medical staff diagnosed Pak Rudi In asri ’s catchment area, many households survive on based on a physical exam and the medical history he and about $15 a month, and for many families, a shared weekly his family provided. Dilated cardiomyopathy due to a viral egg is the sole source of protein. Tree poaching, although infection a decade earlier was causing his heart to fill almost it pays less than $2 a day, remains an attractive option. his entire chest cavity — it was only later, after the doctors saw an old X-ray, that they realized how swollen the heart A life-changing experience had been. In a sense, Webb’s journey to Indonesia began during her In Indonesia, which has 16 physicians per 100,000 childhood in Dixon, N.M., a small town about an hour people, 12 times lower than the ratio in the United States, from Santa Fe. Her parents, both of whom have ph.d .s in medical care is a scarce commodity. In rural areas, the ratio psychology, were hippies who had joined the back-to-the- is even worse: where Pak Rudi lived — in West Kalimantan — land movement and taught Webb and her sister a love of three clinics and 60,000 residents shared one doctor. That animals and nature. Webb majored in biology at Reed, changed when asri opened in June 2007 as the newest where she focused on orangutans. She pursued her studies clinic in the area. A small house with three exam rooms with a determination that would serve her well later: she and a lab for basic tests, the clinic is run by Kinari Webb, went to the library, looked up articles on orangutans and m.d . ’02, who also led Pak Rudi’s medical team. asked every author for a job. In 1993, between her junior “I figure there are not very many humans on the and senior years, she worked at a research station in Gunung planet who are crazy enough to do something like this,” says Palung National Park, one of the world’s few remaining Webb, who spent a decade preparing to open her clinic orangutan habitats. in the rain forest. “Something like this” refers to her dual One day a research assistant approached her with a dreams of bringing health care to Borneo and promoting cut on the palm of his hand, and although the wound was forest conservation. It’s no accident that her clinic is next to not serious, he acted as if it were life-threatening. It dawned Gunung Palung National Park—558 square miles of forest, on Webb that for people living in remote areas a seemingly swamps and mountains that contain 5,000 species of trees, routine injury could have dire consequences. Since she wild orangutans, sun bears, agile gibbons, proboscis mon - had no medical training, Webb whipped out her copy of the keys, wild boars and hundreds of bird species. This pristine health care manual Where There Is No Doctor , by David Werner, habitat is in danger from logging companies and poachers cleaned the cut and closed it with improvised butterfly 32 A life’s work in Indonesia

below Webb examines a woman middle A family relaxes on their bandages made of adhesive tape. The cut healed and Webb in Sukadana. With limited resources front porch in Sukadana. Webb was hooked; she knew that she wanted to become a physi - and frequent power failures, Webb has engaged the townspeople in cian and that she wanted to help people in rural Indonesia. often improvises her treatment. She a dialogue about conservation and has used honey to treat a diabetic offers health care credits at her Her experience at Gunung Palung was life-changing ulcer; cardboard to make inserts for clinic for those who promise not for other reasons as well. She met Campbell Webb, ph.d ., shoes; and mucuna beans, with to engage in illegal logging. a biologist and ecologist who was pursuing his doctorate at their high L-dopa concentration, to Harvard. At first they resisted romance in an isolated setting treat Parkinson disease. under the scrutiny of their colleagues. But candlelit dinners (there was no electricity), bathing in waterfalls (there was no plumbing) and two months alone at their camp weakened their resolve. They were married as soon as Kinari graduated from Reed. In Gunung Palung the idea of the interconnectedness of living things took hold in Kinari Webb’s mind. For several species of trees, for example, propagation depends on orangutans that eat their fruit and defecate the seeds. On a more global level, Webb realized that timbering not only reduced rainfall and lengthened the dry season, but also contrib uted to global warming. Webb decided to focus her energy on a new project: she would provide health care to a population in desperate need, but she would also use it as an incentive for villagers to stop cutting down trees.

A decade of preparation More than 10 years passed before she could bring her vision to life. During that time she laid the groundwork for asri, whose name means “beauti- ful and harmoniously balanced.” She came to Yale knowing exactly where she wanted to practice medicine. When it was time to apply for her residency, Webb looked for a family medicine program that would provide the best training for practicing medicine in a developing nation. At Contra Costa Regional Medical Center in Martinez, Calif., she delivered more than 250 babies and performed enough C-sections to qualify for privileges at any hospital in the United States. “She got this incredible preparation to be out in the middle of nowhere right Webb and her husband, and be the first person to do whatever has to be done,” Cam, make their home in Suka- said Nancy R. Angoff, m.p.h. ’81, m.d. ’90, hs ’93, associate dana, but the couple spend as

8 dean for student affairs.

0 many as five months of each year 0 2 apart. Campbell Webb, a Harvard In early 2005, just before completing her residency, n

m ecologist, travels throughout Webb returned to Indonesia to help in the aftermath of the u t Indonesia and Malaysia for his u tsunami that devastated coastal areas of more than a dozen a work with the Arnold Arboretum. e n

i countries on the Indian Ocean in December 2004. She was c i

d distressed to see that the efforts of many of the agencies e

m and organizations were ineffective and little of the aid was e l a

y reaching those who needed it most. This only fueled her 33 determination to open her own clinic. After her residency, Gunung Palung National Park is she set up Health in Harmony (healthinharmony.org), one of the world’s last habitats for orangutans, but logging, legal and a nonprofit organization to manage fundraising. Cam Webb illegal, has led to deforestation of moved to Bogor, West Java, which his wife used as a base more than 70 percent of Borneo’s while she searched for a location that was both close to rain forest since 1980. a rain forest and in an area with few health care resources. “The whole process was like stepping off a cliff,” she said. After almost a year of searching, Kinari Webb realized that Sukadana, just outside Gunung Palung, was the perfect spot. It’s two airplane flights and a two-hour drive through mangrove swamps from Jakarta, Indonesia’s capital. The heart of the park’s forest is still uncut, so there is conserva - tion work to be done, and the local population has unmet medical needs. The location also worked for Cam Webb, who got a job as a senior research scientist with Harvard and is working with the Center for Tropical Forest Science, the world’s largest tropical forest research program. His work takes him from his home base in Sukadana to his office in Bogor, and to sites throughout Indonesia and Malaysia where he does research in plant biodiversity and teaches a Harvard field course on Bornean ecology. Before she set up shop, Webb recruited college and medical school classmates to help raise start-up money through a combination of Indonesian and American grants worked with Webb in the aftermath of the tsunami and and private donations. Despite support from the Indonesian visited asri in April 2007. government, Webb faced innumerable delays in securing “What they were able to accomplish in four months is permits to open her clinic. Every time she produced a docu - almost impossible to imagine in a country that moves that ment, bureaucrats demanded yet another. Even worse, officials slowly,” said Jeremy Sussman, m.d ., who spent a few weeks had their hands out for bribes, which she refused to give. at asri in November 2007 as part of the Johnson & Johnson On June 12, 2007, asri opened its doors. A five- Physician Scholars in International Health Program at minute walk from an undeveloped beach, asri is on the out - Yale, which sends residents to underserved areas around the skirts of Sukadana (population 12,000), a sleepy town with world. Webb appreciates the opportunity to tap into the a pungent fish market and several stores packed with flip- expertise of volunteers like Sussman. “It’s good for my doc - flops, rattan baskets and plastic buckets. A forest stretches tors to have someone else teaching them besides me,” up the hills surrounding the village, and gibbons can be she said. “It helps to have a wider variety of opinions and heard calling through the trees. Orange with a bright blue ways of doing medicine.” roof, the six-room clinic is surrounded by houses, rice fields The clinic is already bursting at the seams— asri and gardens. It has three exam rooms, a dental exam room treated 3,000 patients in its first nine months and is booked and a room for patients to sleep overnight, plus a lab for three weeks in advance. Webb has started to think about a malaria and TB smears, blood work and urinalysis. There is new building and plans to open a hospital. The nearest a small pharmacy with a refrigerator, but Webb would like hospital is two hours away and anything more than minor to have a solar-powered model since the electricity blacks out surgery requires a seven-hour journey to Pontianak, the as often as five times a day. When that happens Webb lights regional capital. candles, and if an emergency requires electricity she turns Because her resources are limited, Webb finds inno- on a generator. She would like to add an X-ray machine to vative ways to treat her patients, some of which she has the ultrasound, ekg machine and other equipment on hand. picked up from visitors like Werner. Webb has used honey to The staff of 15 includes two Indonesian doctors, a den - treat a diabetic ulcer on a hand, fashioned cardboard shoe tist, three nurses, a pharmacy assistant, a conservation direc - inserts for a boy who had trouble walking, and used mucuna tor and an organic farm manager. “Kinari has surrounded beans from the clinic’s organic garden (they have a high con - herself with a system that can support this project and she’s centration of L-dopa, which increases dopamine levels) to sort of the spark in the middle, the lifeblood of the project,” treat Parkinson disease. She and her staff treated Pak Rudi said Roger Barrow, m.d ., associate clinical professor of with aspirin, diuretics and blood pressure medications. In family medicine at the University of California, Davis, who June 2008, Webb learned that Pak Rudi had died; he went 34 A life’s work in Indonesia

With donations from the United States, Webb has been able to offer eyeglasses to villagers in Borneo. On a single day last year she handed out 93 pairs in one village.

off his medicines for a month, in part because of the difficul - service, mobile clinic visits and clinic discounts. No one is ties of transportation from his village. ever denied health care, but Webb would like to provide Patients with cancer, diabetes, high blood pressure, incentives for the long-term health of both the community severe diarrhea and a variety of other ills come to asri , and the environment. “We don’t know yet whether the but the area’s biggest health problem is tuberculosis. More incentive is strong enough on an individual level or on than 20 percent of the local population has TB, Webb esti - a community level for people to actually change their behav - mates, and she has trained and hired workers to institute a iors,” said Cam Webb, “but even if it doesn’t work we’re Directly Observed Therapy program, in which they visit doing a lot of education. If we get even a portion of forest patients to monitor them while they take their medications. restored, then it’s having a positive effect.” Poverty plays a major role in many of the diseases Although the program is still in its infancy, its reputa - Webb treats and is also a barrier in receiving treatment, but tion is spreading. The managers of an elephant conservation Webb doesn’t believe in free health care. “It’s reasonable project on the Indonesian island of Sumatra have approached that you pay for it, but it’s also reasonable that you pay for it Webb about replicating the asri model. She hopes that other in a way you can actually afford,” she said. “It gives patients organizations around the world will also recognize its poten - dignity.” That’s why health care credits are a key component tial. Meanwhile, each day brings satisfaction that her vision of her program. Patients and their families can pay for is working. “I’m feeling kind of like a parent whose child has their treatment by cleaning the clinic, doing laundry, wash - just started to toddle around,” she said. ing equipment or providing manure for the organic garden. At the end of a long day treating patients, Webb will They can also undertake conservation work, as Pak Rud i’s sometimes provide an evening meal to village children family did. During the month he spent recuperating at a who stop by her thatched-roof house. Many of their neigh - nearby relative’s house, his family worked in the organic gar - bors consider the Webbs’ house, with its cement floor and den next door to the clinic. Area villagers are learning organic no plumbing, quite modest, but the couple finds it charm - farming, and vegetables from the garden feed the clinic ing. A pump from their well fills a water tank on a hill staff and patients. Webb expects to have produce to sell in the that drains to a sink and they use a squat toilet which they local market to help pay for medicine and other supplies. flush with water from a bucket. When Cam Webb is home, the two often paddle their Linking health care to ecology dugout canoe to a small island, where they watch the sunset Getting the local population to understand why they should or go for a swim. When she’s on her own, Kinari writes worry about the environment pervades almost everything thank-you notes to donors and answers e-mail before falling Webb does. When asked why she and her colleagues bicycle into bed, where she may be awakened by a raucous serenade instead of driving to the clinic, she says, “Because biking is from gibbons camped out in the trees behind her house. healthier, cheaper and better for the environment.” The If she had any doubts about the course her life was clinic’s staff held a series of meetings in villages surround - taking, a recent boat ride into the park, where miles of grass - ing Gunung Palung to discuss the connection between health land have replaced the once-majestic forests, convinced her and the environment and identify incentives that would that this is exactly where she wants to be and where her motivate the villagers to protect the park from logging. It is future lies. She plans on spending the next few decades in

8 here that Webb’s effervescent yet soft-spoken demeanor this remote corner of the world, but her patients hope 0 0

2 works its charm. Indonesia is the largest Muslim nation in the clinic will be around even longer, so that they won’t have n

m the world, but in West Kalimantan there are no restrictions to worry whether a simple cut on the hand might end in u t

u on women’s social liberties, and she engages villagers in tragedy. As one village leader put it, “We hope that asri will a

e asri n lively discussions. ’s staff and local residents came up be forever and ever.” YM i c i

d with a plan: communities would work toward a “green” con -

e Jill Max is a freelance writer in Trumbull, Conn.

m servation status, meaning no illegal logging in the previous Erick Danzer is a freelance photographer based in Indonesia. e l a

y month. In return, they receive one month of free ambulance faculty 35

James Rothman Joan Steitz Pasko Rakic

Leading cell biologist Rothman earned a ph.d . in Yale professor receives Kavli Prize for a Yale bio logical chemistry from Harvard to head department Medical School in 1976. He then Albany prize neuroscientist spent two years as a postdoctoral james e. rothman , ph.d. ’71, joan a. steitz , ph.d. , Sterling pasko rakic , m.d., ph.d. , chair associate in the laboratory of one of the world’s leading cell Professor of Molecular Biophysics and the Doris McConnell Duberg Harvey F. Lodish, ph.d. , a pre- biolo gists, has been named chair and Biochemistry, is one of the Professor of Neurobiology, profes - eminent biochemist at the Massa- of the Department of Cell Biol- first two women scientists to sor of neurology and director of chusetts Institute of Technology. ogy and the Fergus F. Wallace receive the Albany Medical Center the Kavli Institute of Neuroscience In 1978, Rothman moved to the Professor of Biomedical Sciences. Prize in Medicine and Biomedical at Yale, was named one of the Department of Biochemistry at Rothman will also launch the Research, America’s top award in inaugural recipients of the Kavli Stanford School of Medicine as an new Center for High-Throughput medicine. She shared the award Prize, given for the first time assistant profes sor. He continued Cell Biology at Yale’s West with Elizabeth H. Blackburn, ph.d ., this year. The 2008 laureates his research at Princeton Univer- Campus, formerly the site of fw ’77, sc.d.h. ’91, the Morris were selected for groundbreaking sity from 1988 until 1991, when Bayer HealthCare. Herzstein Professor of Biology research that has significantly he became the founding chair of Rothman came to Yale from and Physiology at the University advanced understanding of the the Department of Cellular Columbia University’s College of of California, San Francisco. The unusual properties of matter on Biochemistry and Biophysics at Physicians and Surgeons, where two will share the $500,000 an ultra-small scale, the basic Memorial Sloan-Kettering Cancer he was a professor in the Depart- award. Now in its eighth year, the circuitry of the human brain and Center in New York and vice chair ment of Physiology and Biophysics, prize is the largest in medicine in the nature of quasars. Rakic, of the Sloan-Kettering Institute. the Clyde and Helen Wu Professor the United States and the second one of seven scientists to receive Rothman succeeds cell biolo - of Chemical Biology and director largest in the world outside of the $1 million prize, was honored gist and immunologist Ira S. of the Columbia Genome Center. the Nobel Prize. for a pioneering series of anatomi - Mellman, ph.d ., who was chair Under Rothman’s leadership Steitz is best known for her cal studies carried out over the and Sterling Professor of Cell Yale’s Department of Cell Biology pioneering work in rna . She dis - past three decades that revealed Biology at the School of Medicine will be significantly expanded covered and defined the function how neurons in the developing until 2007, when he joined the and will be co-located at the of small ribonucleoproteins cerebral cortex are generated and biotechnology company West Campus along with its pres - (sn rnp s) in pre-messenger rna — how they assemble themselves Genentech as vice president for ent location at the main campus into interconnected circuits that oncology research. James D. the earliest product of dna tran - of the School of Medicine. direct higher-order sensory and Jamieson, m.d ., professor of cell scription—and was the first to At the Yale Center for High- motor functions. The seven win - biology and director of the medi - learn that these cellular complexes Throughput Cell Biology, Rothman ners will receive a scroll, a medal cal school’s m.d ./ph.d . program, (sn rnp s) play a key role in process - will lead multidisciplinary teams and a share of the overall prize served as interim chair of the ing messenger rna by excising of scientists to develop tools and for each area. department. noncoding regions and splicing techniques to rapidly decipher the together the resulting segments. cellular functions of the 25,000 Her breakthroughs into the previ - known protein-coding genes in the human genome, providing ously mysterious splicing process fresh insights into disease and have clarified the science behind identifying new molecular targets the formation of proteins and for therapy. For more than two other biological processes, includ - decades, Rothman has performed ing the intricate changes that seminal research on membrane occur as the immune system and trafficking. brain develop. Rothman graduated summa Steitz earned her ph.d . from cum laude from Yale College in Harvard in 1967. After completing 1971 with a degree in physics. His postdoctoral work in Cambridge, research interests were inspired England, she joined the Department by cell biologist and Nobel laure - of Molecular Biophysics and ate George E. Palade, m.d ., who Biochemistry at Yale as an assist - founded Yale’s Department of ant professor and later became Cell Biology. an associate and full professor, as well as chair of the department. 36 faculty notes

Jack Elias Andrew Diane Krause Harlan Krumholz Michael Snyder Mary Tinetti Amy Arnsten Henry Cabin Hamilton

Seven faculty members of the In April two faculty members Cabin has been associate section of Dermatology. Edelson has School of Medicine were elected were awarded 2008 Young chief of cardiology at ynhh and made fundamental contribu - to the Connecticut Academy of Investigator Awards from associate chair, Department of tions to the study of cutaneous Science and Engineering. They narsad , the world’s leading Internal Medicine. T-cell lymphoma ( ctcl ), a dis - are Jack A. Elias , m.d ., Waldemar charity dedicated to funding ease caused by malignant T von Zedtwitz Professor of Medi- research on psychiatric disor - David C. Cone , m.d ., associate lymphocytes that affects the cine and chair of the Department ders. They are among 220 early- professor of surgery (emergency skin. He identified and charac - of Internal Medicine; Andrew D. career scientists in the United medicine) and of epidemi ology, terized this cancer and his Hamilton , ph.d ., provost of the States and 11 other countries has been appointed editor in research group played a central university and the Benjamin who will receive funds this year chief of Academic Emergency role in deciphering the basic bio - Silliman Professor of Chemistry; from narsad to advance their Medicine, the journal of the logic properties of ctcl cells, Diane S. Krause , m.d ., ph.d ., profes - research on mental illnesses. Society of Academic Emergency both in delineating the patho - sor of laboratory medicine and Each will receive $60,000 over Medicine. genesis of the malignancy and cell biology; Harlan M. Krumholz , the next two years. Savita G. in developing effective ther a- m.d ., the Harold H. Hines Jr. Bhakta , m.b.b.s ., plans to gain a Stephen C. Edberg , ph.d ., profes - pies for it. Along with his Professor of Medicine and pro - better understanding of how sor of laboratory medicine and research team, Edelson devised fessor of epidemiology and cannabinoids (chemical com - director of the Yale-New Haven and implemented the first fda - public health and investigative pounds found in marijuana) Hospital microbiology labora - approved selective immunother - medicine; Nancy H. Ruddle , induce schizophrenia-like behav - tory, has been awarded the apy for any cancer, a treatment ph.d ., the John Rodman Paul ioral and cognitive effects in American Society for Micro- now referred to as transimmu - Professor of Epidemiology and healthy people and exacerbate biology’s BD Award for Research nization. This treatment has Public Health and professor of symptoms in patients with in Clinical Microbiology. This been administered worldwide immunobiology; Michael P. Snyder , schizophrenia. Fei Wang , ph.d ., award honors a clinical micro- to patients with ctcl and has ph.d ., the Lewis B. Cullman will use multimodal mri tech - biologist for outstanding proven to be a safe and clinically Professor of Molecular, Cellular nology to study adolescents research accomplishments lead - effective cellular “vaccine” for and Developmental Biology and with bipolar disorder. The study ing to or forming the foundation ctcl patients. Since 2003 Edelson professor of molecular biophysics will identify abnormalities in of important applications in has been director of Yale Cancer and biochemistry; and Mary E. the structural integrity of con - clinical microbiology. Edberg’s Center. In January he announced Tinetti , m.d ., the Gladys Phillips nections in brain circuitry serv - contributions to clinical micro- he would step down once a Crofoot Professor of Medicine ing the emotional processing biology range from basic science, successor is appointed. and professor of epidemiology that are implicated in the illness, through applications and tech - (chronic diseases) and investiga - as well as associated disruptions nology transfer, to critical analy - Christine Jacobs-Wagner , ph.d ., tive medicine. in circuitry function. sis of current microbiologic the Maxine Singer Associate findings and principles as Professor of Molecular, Cellular Amy F.T. Arnsten , ph.d ., professor Henry S. Cabin , m.d ., professor of applied within the context of and Developmental Biology, has of neurobiology, was selected medicine (cardiology), has been public health problems. His been designated a Howard by narsad in April to receive named medical director of the research has resulted in more Hughes Medical Institute inves - its prestigious Distinguished Yale-New Haven Hospital ( ynhh ) than 180 publications. tigator. She is one of 17 Yale sci - Investigator Award. narsad Heart and Vascular Center. Cabin entists who now hold the will provide a one-year grant of will be responsible for day-to-day Richard L. Edelson , m.d ., director prestigious appointment. $100,000 to advance her research operations associated with the of Yale Cancer Center, has been Jacobs-Wagner is one of the on schizophrenia. Arnsten’s cardiovascular service line, includ - named the inaugural Aaron B. world’s leading experts on the past work on prefrontal cortex ing inpatient services, and diag - and Marguerite Lerner Professor internal cellular workings of 8

0 and executive function has con - nostic and interventional bacteria. Her descriptions of the 0 2 tributed to the development of catheterization laboratories. In inner mechanisms of bacteria n

m new treatments for attention addition, Cabin will participate on have led to an appreciation of u t

u deficit disorder. an executive council and work the survival strategies of these a

e collaboratively with other multi - ancient organisms and new n i c

i disciplinary physician leaders in insights into how to study mod - d

e medicine, radiology and surgery ern human illnesses. m

e to build a comprehensive cardiac l a

y and vascular center. Since 1994, 37

David Cone Richard Edelson Christine Brian Smith Ronald Vender Jacobs-Wagner

Ruslan Medzhitov , ph.d ., received the University of Siena in Italy, in Ronald J. Vender , m.d ., ’77, hs ’80, the Howard Taylor Ricketts May. Rosenbaum has been fw ’82, a nationally recog nized Award from the University of studying the ultra-structure of gastroenterologist who special - Chicago in May. The Howard the intraflagellar transport ( ift ) izes in therapeutic endoscopy Taylor Ricketts Award is given in process at the University of and inflammatory bowel dis - memory of Ricketts, the scientist Siena with his col leagues there. ease, started on June 1 as chief for whom the Rickettsia genus of ift was discovered in the medical officer ( cmo ) for Yale microorganisms is named. The Rosenbaum laboratory in 1992 Medical Group ( ymg ) and associ - award recognizes an individual and was shown to be respon - ate dean for clinical affairs at who has made an outstanding sible for the formation and the School of Medicine. He contribution in a field of the maintenance of almost all cilia reports to David J. Leffell, m.d ., medical sciences. and flagella. Analysis of the chief executive officer of ymg genes underlying the ift process and deputy dean for clinical Curtis L. Patton , ph.d ., professor have led to new insights into affairs . Vender, a clinical profes - emeritus in the School of Public the role of cilia and flagella in sor of medicine, built a clinical Health, was one of 13 people to polycystic kidney disease and practice in the New Haven area receive a Seton Elm/Ivy Award other human diseases. and has held leadership and this spring. Patton was honored teaching roles at Yale-New for bringing previously unrecog - Brian R. Smith , m.d ., professor Haven Hospital, the Hospital of nized African-Americans to public and chair of laboratory medi - Saint Raphael and Milford light. Yale’s recognition of Edward cine, has been elected president Hospital. He chaired the A. Bouchet, a distinguished of the Academy of Clinical National Affairs Committee of New Havener, Yale College’s first Laboratory Physicians and the American College of Gastro- African-American graduate and Scientists, the major academic enterology and currently serves the first African- American to earn society for laboratory medicine. on the board of trustees. He has a ph.d . anywhere in the nation, is published numerous research due in part to Patton. He also cel - Edward L. Snyder , m.d ., professor papers with colleagues on the ebrated the work and legacy of and associate chair for clinical Yale faculty. One of the appeals Cortlandt Van Rensselaer Creed, affairs in the Department of his new position is the m.d ., another distinguished New of Laboratory Medicine, has chance to return to his alma Havener and the first African- been voted president-elect of mater and work with colleagues American graduate of Yale Uni- the National Marrow Donor he’s known since he was a stu - versity. In 2007, on the occasion Program. He will begin his two- dent. “There are a number of of the 150th anniversary of year term in January. people with whom I was a resi - Creed’s graduation from the School dent who are on the fac ulty. of Medicine, Patton and his col - Scott A. Strobel , ph.d ., professor Some of my teachers and men - leagues organized a series of of molecular biophysics and tors are still here,” Vender says. events culminating in the dedi ca - biochemistry, has been awarded “I am being very warmly and tion of a new memorial to Creed the Schering-Plough Research generously received by my col - at the Grove Street Cemetery. Institute Award. The award is leagues and former mentors. I given by the American Society feel that I am coming back to a Joel L. Rosenbaum , ph.d ., professor of Biochemistry and Molecular place I never left.” of cellular and molecular biology, Biology to recognize outstand - received an honorary degree from ing scientific contributions made by young researchers early send faculty news to in their careers. Strobel gave Claire M. Bessinger, Yale Medicine, the award lecture, “Three Views 300 George Street, Suite 773, of rna Catalysis: Ribozymes, New Haven, CT 06511, or via e-mail Ribosomes and Riboswitches,” to [email protected] at the society’s annual meeting in San Diego in April. 3 yale medicine autumn 2008 8 s a L C T w L r a r i e n u o z t i b a c d a

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accepted Rainof’s posthumous medi- college and Harvard Medical School. cal degree. And the class gift was While at Harvard he became a U.S. a donation to a scholarship fund in citi zen. He is now a neurosurgeon at Rainof’s memory. the Johns Hopkins School of Medicine. Maggie Samuels-Kalow and Ellen (For the full text of the address, visit House took the podium to offer their medicine.yale.edu/ysminfo/top_story/ reflections. They recalled Rainof’s com- 2008/05/commencement_speech.html) mitment to her friends and patients as well as her seemingly boundless Commencement awards Celebration, loss and an warmth and compassion. Samuels- This year’s Bohmfalk Prizes for excel - exhortation to dream Kalow urged her classmates to find lence in teaching went to Leigh V. other ways to remember Rainof. “We Evans, m.d ., hs ’02, assistant professor Marking their own graduation, honor her memory in less tangible of surgery (emergency medicine), for students in the Class of 2008 ways, in the ways we treat each other clinical sciences, and to Aldo J. Peixoto, remembered a fallen classmate. and our patients,” she said. m.d ., associate professor of medicine “Let’s celebrate today, as Mila would (nephrology), for basic science. Commencement was a day of mixed have wanted us to,” said House. Thomas P. Duffy, m.d ., professor of emotions for graduates in the Class Commencement speaker Alfredo medicine (hematology), received the of 2008. As they celebrated their own Quiñones-Hinojosa, m.d ., offered Leonard Tow Humanism in Medicine passage from students to physicians, as inspiration his own life story, Award. The Leah M. Lowenstein they also mourned the loss of their recounting how he packed his few pos - Awards went to Nina Horowitz, m.d ., classmate Mila Rainof, who died on sessions into a bag 20 years ago and, assistant clinical professor of surgery, April 20 after being struck by a car. with $65 to his name, crossed the border and to Andres S. Martin, m.d., (See related story, page 4). illegally from Mexico to California. The m.p.h. ’02, associate professor in the Rainof’s absence was palpable same hands that now probe “the most Child Study Center and of psychiatry. throug hout the day’s events. As the beautiful organ in the human body— Eve R. Colson, m.d . ’89, associate medical and public health students the brain” were once bloody and raw professor of pediatrics, received the marched to Old Campus, each left a from pulling weeds on the farms of the Alvan R. Feinstein Award. Lynn D. carnation at the site of the accident at San Joaquin Valley. After an industrial Wilson, m.d ., m.p.h. ’86, professor of York Street and South Frontage Road. accident almost killed him, Quiñones- therapeutic radiology and of dermatol - During the ceremony on Harkness Hinojosa’s father told him, “You have ogy, received the Francis Gilman Blake Lawn, Merle Waxman, m.a. , associate been given a gift. Life is short.” Award. And the Betsy Winters House dean, ombudsperson and director Quiñones-Hinojosa went on to Staff Award went to Vikram Reddy, m.d . of the Office of Women in Medicine, graduate from a California community —John Curtis

above Deans Nancy Angoff and Richard Belitsky before the procession to Old Campus.

left Former Beatle Sir Paul McCartney was among those who received an honorary doctorate from Yale this year. 4

yale medicine autumn 2008 0 s b W l n t d t p d t B e b t P “ A T P C t a d C m O r a i h h h h o N l t r s e o o y u u i l h b a s u m e o . e i d

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JOHN CURTIS HAROLD SHAPIRO (2) 41

PA students don white coats in new ceremony marking their entry to medicine

Second-year students in the Physician Associate ( pa ) program helped their 37 first-year colleagues in the Class of 2009 don the white coats that symbol - ize the medical profession on the after - noon of March 20. Medical students have long participated in this tradition, but it is only the second time that Yale pa students have joined in the ritual. And unlike their medical colleagues, they celebrated not the beginning of their training, but a different milestone. The donning of the white coat in the Medical Historical Library marked the transition from learning in the class - room to learning on the wards from real patients. “We wanted to incorporate into a ) 3 ceremony the idea of trying to instill in ( I D A the students the ethical responsibility R G A D

of being health care providers and the Y R R E reverence with which they should prac - T tice,” said Mary L. Warner, m.m.s c., pa- c, director of the pa program. “The White Coat Ceremony is a rite of passage, serving as a reminder of your need to balance excellence in the medical sciences with demonstrated compassionate care,” said keynote speaker Cynthia B. Lord, pa ’91, direc - tor of the Quinnipiac University pa program and president-elect of the American Academy of Physician above At the White Coat Ceremony for stu - top Michelle Smith smiled as she got help Assistants. “The white coat should dents in the Physician Associate Program, from Tamara Brining. second-year students helped first-years don the never be a symbol of status, hierarchy coats that symbolize their entry into clinical above Jason Fleury helped Megan Dieterich or power.” medicine. In turn, the first-year students placed don her white coat. —Melinda Tuhus School of Medicine pins on the coats of the second-years. Thea Cogan-Drew, president of the first-year class, right, put a pin on Karen Edwards’ coat. 4

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Sarah Frasure, right, got a congratu- latory hug from classmate Lindsay McGuire at Match Day in March.

Match Day 2008

Nationally, this year’s match was the largest ever — more than 28,000 appli - cants competed for 22,240 slots as first- year residents. At Yale, 97 students matched. And for the third time in the last four years, all students found a match. “I couldn’t be happier,” said Nancy R. Angoff, m.p.h. ’81, m.d. ’90, hs ’93, associate dean for student affairs. This year’s match also saw a high number of students entering psychiatry —nine chose the field, the most ever at Yale.

California Alameda County Medical Center, Oakland Mary Hatcher, emergency medicine Mila Rainof, emergency medicine

California Pacific Medical Center, San Francisco Sean McBride, medicine-preliminary

Santa Clara Valley Medical Center, San Jose Jenelle Jindal, medicine-preliminary Maulik Shah, medicine-preliminary S I

Stanford University Programs T R U

Louis Salamone, general surgery C N H O

Sutter Medical Center of Santa Rosa J Rachel Friedman, family medicine

UCLA Medical Center, Los Angeles Griffin Hospital, Derby Yale-New Haven Hospital David Peaper, clinical pathology Anne Ackerman, surgery-preliminary, Louvonia Boone, medicine-preliminary Mary Allison Arwady, medicine/ Elizabeth Wahl, internal medicine/ urology pediatrics primary Hospital of Saint Raphael, New Haven Eric Arzubi, psychiatry University of California, San Francisco Jennifer Dominguez, medicine- District of Columbia Erik Carlson, orthopaedic surgery Jessica Beard, general surgery preliminary Children’s Nat’l Medical Center/ Claudia Castiblanco, ophthalmology Tina Dasgupta, radiation oncology Keith Gipson, transitional George Washington University Douglas Davis, medicine/primary- Rasha Khoury, obstetrics and Nandakumar Narayanan, medicine- Ephat Russcol, pediatrics preliminary, diagnostic radiology gynecology preliminary Jennifer Dominguez, anesthesiology Uniformed Services University of the Yunie Kim, internal medicine/primary Karen Shoebotham, transitional Ryan Hebert, surgery-preliminary, Health Sciences Kiera Levine, psychiatry Hannah Yu, medicine-preliminary neurosurgery Melissa Wollan, obstetrics and Maulik Shah, neurology St. Vincent’s Medical Center, Kristin Hoffmann, medicine/primary- gynecology Krishan Soni, internal medicine Bridgeport preliminary, dermatology Michael Swetye, psychiatry Scott Kennedy, transitional Lily Horng, internal medicine Walter Reed Army Medical Center James Troy, internal medicine Rasika Jayasekera, psychiatry Amanda Sandoval, psychiatry Pavithra Venkat, obstetrics and University of Connecticut Program, Kimberly Johung, medicine- Indy Wilkinson, anesthesiology gynecology Farmington preliminary, radiation oncology Kimberly Schinnerer, medicine- Keith Gipson, anesthesiology Rachel Laff, Internal medicine/primary preliminary Connecticut Jeannine Ruby, general surgery Tamara Lazic, medicine/primary- Greenwich Hospital preliminary Claudia Castiblanco, medicine- Nandakumar Narayanan, neurology preliminary 4

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r e , y y e , 45

below left Gene-Fu Liu and bottom Yunie Kim discussed Julia Marsh, right, celebrated. the Match with faculty member Cyrus Kapadia. below right Kristin Hoffman will stay in New Haven for a dermatology residency.

Ohio Rhode Island Cleveland Clinic Foundation Rhode Island Hospital/Brown Al Makkouk, orthopaedic surgery University, Providence Alexander Diaz de Villalvilla, Pennsylvania medicine/pediatrics Children’s Hospital of Philadelphia Roger Williams Medical Center Kevin Lau, pediatrics Program, Providence Tamara Miller, pediatrics Tamara Lazic, dermatology Ashley Neal, pediatrics

Drexel University College of Tennessee Medicine, Philadelphia Vanderbilt University Medical Center Abby Hochberg, medicine- Jennifer Giltnane, pathology preliminary, dermatology Washington Hospital of the University of Swedish Medical Center Program, Pennsylvania, Philadelphia Seattle Lu Anne Dinglasan, diagnostic Soledad Ayres, family medicine radiology University of Washington Affiliated Pennsylvania Hospital, Philadelphia Hospitals, Seattle Lu Anne Dinglasan, medicine- Corinna Levine, otolaryngology/ preliminary research University of Pittsburgh Medical Natalya Lopushnyan, surgery- Center preliminary, urology Misaki Kiguchi, vascular surgery Amy Meadows, pediatrics/psychiatry- adult and child Danielle Smith, obstetrics and gynecology 4

yale medicine autumn 2008 6 a l u m n i

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, o r o f v i d e

john curtis 47

This year’s reunion was a jaw-dropping Medical Group could open clinical School of Medicine. We get over 4,000 experience for the scores of alumni practices at West Campus, which has applications for 100 spaces,” he said. who toured Yale University’s new West parking for 3,000 cars. “For people “The top 1,000 applicants are indistin - Campus during the weekend. On the coming up from southern Connecticut, guishable, they are so fantastic.” three buses shuttling alumni to the the thing they hate most is the last 10 Among the new educational initia - 136- acre campus in neighboring West minutes, driving into New Haven and tives is a program for clinical clerkships Haven and Orange and in the corridors trying to find parking,” Alpern said. in global health, which relies on estab - of one of the site’s research buildings, Bayer HealthCare, which had owned lished and ongoing programs with uni - alumni marveled at the new space, the site for decades, decided to close it versities and hospitals abroad. “We used its pristine laboratories and the low down in 2006 after a corporate merger. to let students pick a place in Africa and price. When Dean Robert J. Alpern, The company put the property on the go there,” Alpern said. “Now we really m.d ., Ensign Professor of Medicine, market hoping to sell it to another try to have organized rotations.” led alumni down a hallway past a pharmaceutical firm, but the only bids The medical school is moving away chemistry lab that seemed to stretch came from developers interested in from the traditional “see one, do one, forever, the possibilities for research the land. “When it became clear that teach one” methodology through the seemed equally endless. no pharmaceutical company was going use of such computerized models that After a brief tour of the lab and its to come into the bidding process … mimic the human body as SimMan, a 12-foot chemistry hoods followed by a they told us they would love to get a portable manikin that allows students lunch in the facility’s cafeteria, Alpern bid from us,” Alpern said. “The devel - to practice emergency treatment tech - described the process that led to the opers were getting land. We were niques and decision-making skills. “It university’s $109 million purchase of get ting research buildings, office build - is completely real,” Alpern said. “You the site and its 1.5 million square feet ings and land. The biggest bonus is see ekg , you see vital signs, you give of office, storage and research space, the time. If I convince [Yale President medications. You don’t know that the as well as some of the medical school’s Richard C. Levin] that we need to patient isn’t real.” The medical school plans for its use. “We don’t see this as start today on a new research building, has also adjusted its financial aid a site for classroom teaching,” Alpern it is a six-year time frame. … We have policy (see related story, page 7), in said, “but we do see this as a site for gotten something that would have order to ease the burden on middle- research, some of which will include taken six years.” income families. student participation.” West Campus was also a central The clinical practice, Alpern said, The first research program to be theme in Alpern’s State of the School is the fastest-growing area of the medi - based at West Campus will be the new address earlier that day at the Association cal school. The partnership with Yale- Center for High-Throughput Cell of Yale Alumni in Medicine’s business New Haven Hospital, he said, “has Biology, headed by the new chair of meeting. “We want to establish pro - never been better.” The new liver cell biology, James E. Rothman, ph.d . grams of exceptional quality that greatly trans plant program had performed 33 ’71, the Fergus F. Wallace Professor enrich science at Yale and outside of procedures since the summer of 2007; of Biomedical Sciences. The center Yale,” Alpern said, explaining the vision in September 2007 the program com - will focus on developing tools and for the new campus. “This needs to pleted the first split-liver transplant in tech niques for analyzing the cellular transform science at Yale.” the state. “We have overnight become func tions of the 25,000 known protein- West Campus was not the only topic, a cen ter for liver transplants,” he said. coding genes in the human genome. however, in Alpern’s discussion of the At the alumni meeting that morning West Campus, Alpern said, may state of the school. The School of Christine A. Walsh, m.d . ’73, a professor also be a site for clinical use. Yale-New Medicine, he said, remains one of the of clinical pediatrics at Albert Einstein Haven Hospital sees potential for best in the world. “It has become College of Medicine in New York, build ing an emergency room, and Yale absolutely impossible to get into the received the Distinguished Alumni 4

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fig ures that move in time with the telemedicine at the Yale Surgical Society soundtrack. This preference for audio - Spring Reunion, which was held this visual synchrony may be part of the year in his honor. He now leads the reason that autistic people watch lips Medical Informatics and Technology so intently—they’re drawn to the syn - Applications Consortium at vcu . chro nous occurrence of lip move - Telemedicine, he said, is “the applica - ments and speech sounds. The team tion of telecommunications and infor - showed that mouth-looking exceeds eye- mation science to support the delivery looking as early as 5 months of age of health care at a distance.” in at-risk infants. Telemedicine is already with us in Volkmar and Klin hope that in the many ways, he said. Picture archiving near future babies held on a parent’s lap and communication systems, now can watch a video while eye-tracking com mon, allow radiologists to diagnose technology monitors their gaze and patients from thousands of miles away. offers an early diagnosis of autism. But Preoperative clearance can also be done Former chair of surgery Ronald Merrell was little research on effective treatments remotely, as Merrell and a team of honored at the Yale Surgical Society Spring has been done in children under the age surgeons demonstrated when they Reunion. In his address, Merrell described telemedical techniques that bring medical of 3. Klin told the audience that a task cleared the way for patients in the education around the world. force for extending therapies to babies Dominican Republic to undergo sur - has been formed. “We need a rapid- gery before the surgeons had arrived. response system for the very young A satellite dish installed on the roof of children who can’t wait.” an outbuilding provided the link for low-bandwidth video. Telemedicine’s global reach In medical education, Merrell said, At $10,000 per hour for analog satel - telemedicine can be as simple as lite time, said Ronald C. Merrell, m.d ., Internet access in Kenya from solar- the world’s first telemedical surgery powered laptops, or as sophisticated “was a little bit, well, unwieldy.” as the class he once taught from the The former chair of surgery at Yale operating room for a group of medi - referred to a pioneering open-heart cal students in Russia. “Education operation in Houston in 1965, when a can be distributed in virtual reality in satellite linkup connected legendary ways that really do work,” Merrell surgeon Michael E. DeBakey, m.d ., to said, adding that he hoped such tech - viewers in Geneva. More recently, a niques would reduce our “separation surgeon in New York performed the and alienation from the developing first fully remote surgery on a patient world.” Telemedical techniques might in France. The momentous event was one day beam top-quality medical underreported, said Merrell, because education into medical classrooms the press conference was scheduled for around the world. September 11, 2001. “I would make this integral to the Merrell, who left Yale in 1999 to training of medical students interna - become chair of surgery at Virginia tionally,” he said. “As long as it’s inter - Commonwealth University ( vcu ), dis - active, I think we can do as well as we cussed the past, present and future of could in a classroom.” 5 yale medicine autumn 2008 0 a c t e w p s t u a a t h a E f t h n h i “ S w l c s p o t e c c a h U G d p u A A e t r h h o e o t a S y o l o x s r s n b f e r o e u e c e a a r e e s

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Smith was one of four panelists to is responsible for delivering health care discuss the importance of ethics in to poor people, many of them immi - emergency planning and public health. grants who have never encountered Speaking from their own experiences— Western medicine. And he must main - which range from military action to tain the morale of a staff that is ham - anthrax attacks—the panelists made a strung by scarcity and the difficulty of strong case for ethics training in public caring for this patient population. In health education and decision making. the face of such pressures, it would be James L. Hadler, m.d. , fw ’80, easy to think of ways to trim and skimp, )

m.p.h 2

. ’82, who recently retired as Krause said. “But we never go there.” (

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m.a d chief of the infectious diseases section Bruce Jennings, ., a lecturer in a r g at the Connecticut Department of ethics at the School of Public Health, a d

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Public Health, often juggles benefits explored the philosophical underpin - r e to the community and individual nings of the others’ real-world stories. t rights. (See related story, page 58.) He The idea that society serves the individ - usually favors the welfare of the com - ual and not the other way around, he munity “when the individual can’t pre - said, sometimes “butts heads” with pub - dictably be harmed.” But determining lic health when officials must weigh an the chances of harm isn’t always easy. individual’s liberty against the greater During a meningitis outbreak on col - public good. Debates from the early lege campuses just a few days before days of aids provide an example. As the the end of a semester, for example, epidemic silently spread, public health Hadler had to decide whether to vacci - officials pushed for greater tracking and nate more than 12,000 students with surveillance of cases, while others jet-injector guns that carried a small argued that to do so would infringe on aids risk of cross-contamination with blood- privacy rights. Since the era began, top Christine Walsh received the Distinguished borne pathogens or with injections that he said, “it has been impossible to take Alumni Service Award, for her contributions would take much longer to administer, a purely libertarian [standpoint] and it to the school and the profession, from Dean thereby putting students at risk of has been impossible to be purely utili - Robert Alpern. meningitis infections. After consulting tarian.” But, he added, “We have to above Tobias Carling, Vikram Reddy and with an ethicist and the Centers for figure out how to get respect for per - Walter Longo at the Yale Surgical Society Disease Control and Prevention, and sons and liberty—and outcomes and Spring Reunion. researching different brands, Hadler health—together.” authorized the use of jet-injector guns. On a smaller scale, there are the Awards and the state of the school problems of running an inner-city Dean Paul D. Cleary, ph.d ., delivered clinic. “Do we rob Peter to pay Paul?” good news to those gathered at Alumni asked Thomas J. Krause, m.p.h. ’81. Day 2008 at the New Haven Lawn For Krause, that question isn’t just Club—the School of Public Health hypo thetical. Krause is chief operations has gone through a successful re- officer at Southwest Community Health accreditation process. And, Cleary said, Center in Bridgeport, where most of his changes are in the works for the school, patients are self-pay or have Medicaid, including a revamping of the global and every year he faces budget cuts. He health program. 5 yale medicine autumn 2008 2 a P N b o s a m w w ’ w g d t e A B g h “ h h 7 h W a t r l y p l i e e e u r l i o i e e 5 l o v o a o e i u

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t w l n i s e e t e o n c h a a , n r r t s e , d s , reunion reports 53

1948 landscapes and some portraits and Betty McCleary Hamburg . and has had a showing of his Herold spent eight years as 60th Reunion works in Indianapolis. Dave and chief of plastic surgery at the The 60th reunion of the Class of Kayoke Morton came from Pueblo, University of Illinois medical 1948 was a great success. As of Colo. They have been doing a lot school. He was made an honorary June this year 31 of the 55 of us of traveling, including trips to member of British Association who graduated in 1948 were still Japan to see Kayoke’s relatives. of Plastic Reconstructive and around, and 15 attended the Bud and Esther Rowland , Jack Aesthetic Surgeons, of which reunion along with nine of the and Ann Strominger and Paul there are only eight in the United wives. They were a pretty vigor - Talalay came from Columbia, States. Tom is the Richard and ous bunch of 80-somethings. Harvard and Johns Hopkins Susan Smith Distinguished Three of our five living respectively. I mention them Professor of Medicine at Harvard women members were there. together because they probably and a member of the Dana The prize for vigor has to go to represent the most successful of Farber Cancer Institute. In 1972 Elizabeth Fuller Elsner , who spends our academicians. Paul is the John he was given the Albert Lasker the winter in Alaska where she is Jacob Abel Professor of Molecular Medical Research Award for addicted to cross-country skiing. Pharmacology at Hopkins. He is demonstrating that a combina - She had to take time off this past widely known for his studies of tion of chemotherapeutic agents year to get a new hip but she is vegetables like broccoli that could result in long-term sur - now back to her old sport. She induce protective enzymes in the vival and even cures in some spends the summer in Massa- body and help prevent cancer. In leukemias and lymphomas. This chusetts and came down on 2005 he was awarded the presti - award is often a prelude to the Saturday morning with Nan gious Linus Pauling Award in Nobel Prize. Betty reports having Godley . Nan still does some vol - recognition of his work. Jack is a two careers, first as a professor unteer work at Harvard. Sylvia professor at the Dana Farber at Harvard and then as the first Preston Griffiths also does volun - institute at Harvard. He has stud - director of child psychiatry at The teer work at Columbia. ied histo-compatibility in man Mount Sinai Medical Center in The prize for the longest trip and other vertebrates leading to New York City. After retiring from goes to Al and Ruth Fisk who the understanding of mecha - Mount Sinai, she began a second came from California. They live nisms of immune recognition. In career as president of the William in the Sonoma valley and until 1999 he received the Japan Prize, T. Grant Foundation. Herold recently had a small vineyard. the largest mon etary reward for couldn’t come because his wife is They also won a gold medal in scientific investigation. Bud was so frail. Tom couldn’ t make it for 2003 at the Cal State Fair for chief of the department of neu- health reasons. Betty thought she their pinot noir. They have now rology at Columbia’s Neurologi- could come in on Saturday but given up the vineyard and keep cal Institute and was widely something must have interfered. busy with duplicate bridge, gar - known for his work on stroke. Looking forward to seeing all dening and leading environmen - Paul and Betty Goldstein , Paul of you on our 65th. tal walks. Next longest was Jock and Margaret Koehler , and Dick Ben Rush Bishop , who is retired from an Richardson represent our clini - academic career at Minnesota in cians who remained in the 1953 internal medicine and research Northeast. Paul is the only mem - 55th Reunion in the physiology and biochemis - ber of the class who remained in try of diabetes. He now pursues a New Haven and has been an Our 55th class reunion welcomed hobby in creating rustic furniture anchor for returning alumni. He 10 of our members, who had from buckhorn wood. In listing now spends winters in Florida. lively discussions in many venues. our longer travelers I overlooked When he is in New Haven he Two of our married sets, Ed and Dick Buker who is the last mem - spends one day a week in his Rhoda Powsner and Ora and ber of our class still seeing clinic. Dick Peterson is now Howie Smith , added greatly to patients. He is the county health retired. He drove down from the pleasure of the weekend. officer of Chester, Mont., and is Southbury, Conn., with his Attending some of the reunion in charge of disaster planning daughter Melanie Barry. Paul activities were Claude Bloch , Fred for his area. He attended with and Margaret drove down from Lane and José Ramírez-Rivera . Tom Candace Chang . Newbury, N.H. Paul served us for Gentsch was accompanied by Bob and Mary Lempke joined 50 years as class secretary. He’s wife Betty. Hyla and Bob Melnick the group on Friday from still pretty active despite acquir - had to leave early Sunday to wel - Indiana. The OR at the Richard L. ing four artificial joints. come a new grandchild who had Roudebush Indianapolis VA During the spring I contacted arrived on Saturday. Maureen Medical Center was named in almost everyone in our class. I’d was with Hal Bornstein . Many Bob’s honor. 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semiretirement soon. Richard New Haven community. Rick warming and spirited evening. Morehead invites us all to Santa Young attended, fresh from his Those not in attendance were Fe, N.M., for next year’s West third tour of duty in Iraq. Rick is missed but also well represented Coast reunion—a necessary loca - a pediatric neurologist and chair in embarrassing vignettes. tion due to global warming (i.e., of pediatrics at the Hospital of Remember this when you no more West Coast). Jim Ogilvie Saint Raphael in New Haven. consider your plans to attend is happy to “see a happy and pro - Neil Handel attended by phone, the 35th! Seth and I will get to ductive Class of ’68. We’re not unable to make it from Los work on a class survey to provide done yet!” Jerry Rauch and wife Angeles where he is a plastic a little more detail on everyone’s Nancy have been traveling inter - surgeon and the proud father of lives. Have a great summer. nationally, rebuilding their house three young children. I am a gas - Duke Cameron and volunteering at an animal troenterologist in Dallas, run a Seth Powsner shelter. Peter Kirkpatrick says this colon cancer research laboratory, event brings back good memo - and still work on my medical 1983 ries. And Chuck Post has been school thesis. 25th Reunion semiretired for 8 years, sailing We swapped tales about along the East Coast and the family and professional activi - “Spectacular” describes our Caribbean, doing surgery in the ties, tried to exchange informa - reunion. As we gathered on Third World and bicycling in tion about those who weren’t Harkness lawn, at the 333 Cedar various countries. there, and made up what we St. rotunda, and in the Historical Donald Lyman didn’t know for certain. We Library, it seemed as though just have produced two deans ( Lee yesterday we were students. 1973 Goldman at Columbia and Dave Attendees included: Mark Boytim and Anne Boytim , Nancy 35th reunion Bailey at UC Irvine); several department chairs ( George Lister Crocker , Dianne Edgar , Gerri Among those who made the pil - in pediatrics at Southwestern Goodman , Linda Grais and John grimage were Marv Chassin and Medical Center, Bob Buchholz , Freund , Tammy Harris , Rob wife Barbara, now in Phoenix, who just stepped down from Homer , Ana Lamas , Judy Melin , where Marv practices oncology. orthopaedics at Southwestern, Elizabeth Nolan , David Norton , Marvin Miller is the class geneti - Jerry Rosenbaum in psychiatry Dan Oren and Jeanette Kuvin cist; he came from Dayton, Ohio, at Mass. General, and probably Oren , Alan Reznik and Elizabeth with wife and children. Sesh Cole more); and many division chiefs Reznik , David Schwartz , Susan and wife Pat came from St. Louis, and other academic leaders. Seward and David Seward , where Sesh is in pediatrics at We look forward to seeing more Steven Sockin and Susan Sockin , Washington University. They left of you at future reunions. Michael Silverberg , Michael Tom . the next day for Dartmouth’s Richard Boland Among us are expert clini - graduation. John Brown has cians, educators, chiefs, chairs, retired from his surgical practice 1978 partners, directors, trustees, in Vancouver, Washington, and researchers and administrators 30th Reunion spends time in Mexico and throughout the country. We dis - Florida; he noted that John Jr. has The Class of 1978 reconvened in cussed our residencies, fellow - presented him with grandchil - New Haven this June for their ship training, current or prior dren. Chris (Kull ) Walsh arrived 30th reunion. Sightings included practice experiences in allergy from New York with husband Rich Baron , Duke and Claudia (Ana , Steve ), ent (Mike T. ), er Sean. Chris is a pediatric cardiolo - Cameron , Howard Chase and Med ( Elizabeth ), ophthalmology gist at Einstein and has a daugh - Claudia McNamara, Stuart and (Gerri ), orthopaedics ( Alan , ter in her own training program. Amy Forman , Bob Gelfand and Mark ), primary care specialties Harry Romanowitz and wife Sheila Susan Boulware, Ken Lee and (Tammy -FP ; Judy , Sue -IM; Dave N. , drove up from Stamford, Conn., Ruth Daniel, Yvette Piovanetti and Nancy -pedi). We talked of teach - where Harry practices pediatrics. Jose Martinez , Barb and Jordan ing, research and practice at Yale Doug Maddox and wife Kathryn Pober , Seth Powsner and Elizabeth and in New Haven ( Alan , Dan , flew in from Atlanta, where Doug Yen, Mike Rogawski , Bern Shen , Rob ). We talked of clinical lead - is ent chair at Emory. Tom Smith and Joann Bodurtha, ership roles in anesthesia ( Dave On Saturday, Joe Eichenbaum , Marcia Wade and David Officer, S. , Mike S. ), of management/VC who practices ophthalmology at John Wagner and Julie Budd, work in life sciences ( Linda ), in Mt. Sinai, and wife Ingrid joined Jonathan Weinberg , and Susan pharmaceutical research ( Dan ), us. Randy Zusman came from Wong . Dean Alpern joined our of health care administration Boston; he has been at Mass. class for dinner at the Graduate and policy work ( Dave N. , Judy , General since graduation. Tom Club, either because of our illus - Nancy et al). Most talked of edu - Sweeney and Jim Sullivan were trious record of charitable giving cating medical students and res - both in attendance, representing to Yale or our legacy of mischief idents ( Ana , Dan , Dave S. , Gerri , surgery and medicine in the … you decide. 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showed up on Saturday night year in Yale’s primary care inter - Rebecca Seekamp is excitedly and danced some salsa. He’s on nal medicine program. moving from Boston, where she faculty at Yale. Sus Waikar is a Nataliya Uboha is beginning is a practicing family doc, to San nephrologist at the Brigham in her second year of an internal Francisco, where she will become Boston and lives with his wife medicine residency at Yale. She a clinician-educator in Stanford’s and kids in Brookline, Mass. and husband Doug have bought family medicine department. Steven Williams is a plastic a home in New Haven. Joahd Toure was found moon - surgeon in San Ramon, Calif., Danny Kanada had “two lighting in the Yale-New Haven where he lives with his wife. more weeks” of Yale radiology micu . He is finishing up a Robert Steve occasionally goes to residency on reunion day. He’s Wood Johnson Clinical Scholars Honduras on medical missions. headed to ucsf for a cross- fellowship, moving to “the city” Ashley Wivel lives with son sectional fellowship. for a health care consulting posi - Jackson in Philadelphia, where Pramita Kuruvilla is in the San tion and still marveling at the she works for GlaxoSmithKline as Francisco Bay Area working as a recent purchase of a washer and a pharmacovigilance specialist. hospitalist and teaching family dryer with wife Viviana. Say that 10 times fast! medicine residents at Contra Sunny Ramchandani is now a Lori Etter Costa Regional Medical Center. primary care internist with the Matt Goldenberg is an emer - U.S. Navy in Bethesda, Md. He 2003 gency psych attending and is looking forward to seeing his consultant/liaison at Dartmouth. fellow classmates at the next 5th Reunion He is contemplating focusing reunion! If there had been one thing the on refugee mental health and Susan Rushing worked as an 20 of us in attendance agreed forecasts “liberation” in the attorney before returning to upon, it was that everyone looked near future. medicine. She has two years left the same and no one seemed to Namita Seth Mohta lives in in psychiatry training at U Penn, have changed a bit. On the other Cambridge, Mass., with husband where she assists with health hand, words cannot adequately Vinay and 10-month-old daugh - law lectures at the med and capture all we have been through ter Aanika. She is a clinical strat - law schools. She and husband since graduating, so I will not egy consultant at Partners Health Karl Richter have two children, attempt the impossible. Instead Care and a hospitalist at Brigham Elizabeth, age 2, and Kaitlyn, here are brief updates on those and Women’s Hospital. age 2 months. who made it to the reunion: Kyeen Mesesan Andersson As for me, I am working on Severine Chavel Greenspan is met husband Richard during childhood obesity prevention finishing her dermatology her three years in South Africa as a special assistant to the residency at Yale and will begin completing her m.d./ph.d . president of the Robert Wood private practice in Stamford, She is now starting a postdoc Johnson Foundation and as an Conn., while remaining a volun - at Yale. obesity medicine consultant to teer attending at Yale. Severine Ada Emuwa , a family medicine Harvard Health Publications. I and husband Mike have a 10- physician, is moving with | dream of resuming clinical month-old girl—Sophie! Mike husband Chi to Nashville, Tenn., work in obesity treatment and Greenspan , one of several “Yale and will practice in United lifestyle medicine in the lifers” in attendance, is finishing Neighborhoods-Health Service Promised Land (San Francisco). his psych residency after win - Core Clinics for the underserved. Our goal is to have the entire ning the “world’s strongest man Satish Nagula finished an IM class show up for the 10-year competition.” He will pursue residency at Penn and is now liv - reunion. In the meantime, join a forensics fellowship at Yale, of ing in nyc with wife Shreya, our soon-to-be-created Facebook all places. where he is completing his final group to keep in touch and share Sean Christensen is begin - year of a GI fellowship at news of the many bundles of joy ning a four-year derm residency Memorial Sloan-Kettering. brought into the world thus far at Yale and proudly acknowl - Marta Rivera is a hospitalist at as well as other life transitions. edges his and Elin ’s official Yale-New Haven Hospital after Mark Berman status as “lifers.” Elin Lisska enjoying a highly recommended Christensen is now a partner in seven-month primary care stint an internal medicine private in Hawaii post-residency. She has practice in Madison, Conn. Elin accepted a position in primary and Sean just bought a house care in Virginia Beach, Va. in Guilford. They are also cel - Dave Ross is finishing his third ebrating their second wedding year in the Yale adult psych- anniversary. neuroscience research training Doug Davis has “finally” gradu - program, where he continues ated from the m.d./ph.d . pro - researching his passion—music gram and is beginning his intern and the brain. 5 yale medicine autumn 2008 8 a J b l e d y a p e u

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side, Hartford does, but … they’re associate dean at Wesleyan. They have A primary care physician all small compared to New York or three grown children. finds peace of mind in Chicago,” he said. “To me, [Connecticut] Hadler plans to work as a public concierge medicine is a perfect laboratory to try to take health consultant to the state and to on the challenges of diversity and New York City. He will also write scien - On a typical day two years ago, Steven health disparities.” tific papers, deliver talks and continue Fugaro, m.d . ’81, saw a patient in his Hadler grew up in Bethesda, Md., to teach at the School of Public Health. solo primary care practice every 10 to where his father worked as a naval —Jenny Blair 15 minutes. Onerous paperwork and architect and international consultant. economic difficulties made it hard for The family hosted exchange students the San Francisco-based physician to and had friends from other countries, provide the quality of care he felt his and Hadler says those experiences—and 3,000 patients deserved. “I was becom - his stint in Pakistan as an exchange ing increasingly dissatisfied with what student—gave him and his three sib - I was doing,” he said, “although I was lings a global perspective. probably too busy to be reflective of it He attended McGill University in at that point.” Montreal, then went to Columbia Then MD 2, a concierge medicine University’s College of Physicians and group, based in Bellevue, Wash., Surgeons. After an internship at approached him. Would he like to join Roosevelt Hospital in Manhattan, them as a concierge physician and Hadler joined the Indian Health Service gain the time and resources to provide in a position supported by the cdc as a extraordinary care for a small number tuberculosis control officer. He com - of patients? His decision to do so pleted his residency at Waterbury changed his life and made him part of Hospital in Connecticut, did an infec - a controversial trend in primary care. tious diseases fellowship at Yale- New Fugaro had opened a private practice Haven Hospital and then earned an after an internal medicine residency at m.p.h . Finally, he and his wife and two the University of California, San children spent a year in China as part Francisco, and eight years in academic of a School of Medicine exchange with medicine. Although he loved primary Hunan Medical College. He began as care, physicians in that field are under Connecticut’s state epidemiologist the tremendous pressure to see patients in following year. great numbers—time is tight, reim - The job, he said, has allowed him to bursement rates are stagnant and combine diverse interests and to work pre ventive care must take a back seat with people from all walks of life. to immediate problems. Few medical “Public health is dynamic,” he said. students choose the field, and many “I love that aspect of the job.” weary primary care physicians are Hadler lives in New Haven with retir ing early or taking jobs in industry his wife, Alice, who speaks several or administration. These doctors are in languages and whose experiences short supply. with adult education on the Navajo Enter concierge medicine. In this reservation with her husband grew model, introduced in 1996 by MD 2 into a teaching career; she is now an founder Howard Maron, m.d ., patients 6

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- r l r h e - g t d e e s e o s , notes 61

Arthur Beaudet John Patti Jonathan Lewin Paul Rothman Lu Anne Dinglasan Carolyn Graeber Kevin Lau Robert Jahn

1960s 1980s Steven I. Rosenfeld , m.d . ’80, is Cornell Medical Center, where an assistant clinical professor she plans to stay for a year-long Arthur L. Beaudet , m.d . ’67, Josef Bohm , m.p.h. ’89, will be of ophthalmology at the Bascom fellowship in women’s imaging. the Henry and Emma Meyer joining the faculty of City Palmer Eye Institute in Miami. Thompson is a partner at the Professor and chair of the University’s New York City He received two awards from New York City law office of Department of Human and College of Technology as an the American Academy of Proskauer Rose. Molecular Genetics at Baylor assistant professor within their Ophthalmology at its annual College of Medicine, has been Health Services Administration meeting in November 2007: Lu Anne V. Dinglasan , m.d. ’08, elected to the Johns Hopkins program. Bohm is a former the Senior Achievement Award and Kevin C. Lau , m.p.h. , m.d . University Society of Scholars. deputy principal to the Anglo- and the Secretariat Award for ’08, were married on May 31 at Beaudet and 14 other esteemed European College of Chiropractic “exceptional leadership and the Yale Club in Manhattan. scientists and clinicians were in Bournemouth, England. He is enthusiastic service.” He serves Dinglasan began an internship honored during the society’s a member of the adjunct fac - on the editorial boards of EyeNet in June at Pennsylvania Hospital 39th induction ceremony in May. ulty at the State University of Magazine , Focal Points , and the in Philadelphia and Lau began His accomplishments include key New York at Stony Brook. His Basic and Clinical Science Course, his internship at the Children’s discoveries in several genetic academic interests include Section 13: Refractive Surgery , Hospital of Philadelphia. disorders, including Angelman behavioral economics, health and is an associate examiner syndrome, Prader-Willi syndrome policy and finance. for the American Board of Carolyn P. Graeber , m.d. ’08, was and autism. Beaudet’s many Ophthalmology. married on April 26 to Robert E. honors include the March of Jonathan S. Lewin , m.d . ’85, Jahn at St. Thomas Episcopal Dimes/Colonel Harland Sanders has been inducted as a fellow Paul Rothman , m.d . ’84, was Church in Manhattan. Graeber Award for lifetime achievement in the American College of named dean of the University of began an internship in June at in genetic sciences. Radiology. Lewin is the Martin Iowa’s Roy J. and Lucille A. Carver the Memorial Sloan-Kettering W. Donner Professor and chair College of Medicine, effective Cancer Center in New York. Jahn 1970s of the Department of Radiology June 1. Rothman has served as is completing an m.b.a . at the at the Johns Hopkins University head and professor of internal University of Pennsylvania. Harvey Berger , m.d . ’77, and his School of Medicine. He holds medicine at the UI Carver College wife, Chrysanthi, are ecstatic leadership positions in such of Medicine and UI Hospitals and Mona Kotecha , m.d . ’04, was about the latest addition to medical societies as the Academy Clinics since 2004. An expert in married on April 5 to Nikhil their family, Isabella Grace of Radiology Research, Associa- rheumatology, he has provided Shanbhag, j.d . ’03, in Saratoga, Berger, born on March 6. Berger tion of University Radiologists clinical care for more than 20 Calif. Kotecha is a fourth-year is the founder, chair and ceo of and the International Society years, trained medical students, anesthesiology resident at the ariad Pharmaceuticals, Inc., in for Strategic Studies in Radiology. fellows, and residents, and pub - University of California, San Cambridge, Mass., an oncology lished extensively. Rothman’s Francisco. Shanbhag is an intel - company developing molecu - Troy Pappas , m.p.h . ’86, has been research on cytokines focuses on lectual property lawyer at larly targeted cancer drugs. appointed to the faculty of the their role in the development of Google in Mountain View, Calif. Fox School of Business at Temple white blood cells, the abnormal John A. Patti , m.d . ’71, was elected University in Philadelphia. He development of which can lead vice chair of the American has a dual appointment with to leukemia. send alumni news to College of Radiology ( acr ) Board Temple’s School of Tourism and Claire M. Bessinger, Yale Medicine, of Chancellors at the acr annual Hospitality and will be teaching 20 00s 300 George Street, Suite 773, meeting in Washington, D.C., in entrepreneurship and business New Haven, CT 06511, or via e-mail May. Patti, a member of the radi - strategy. This fall, he will teach Elizabeth K. Arleo , m.d . ’04, and to [email protected] ology staff at the North Shore entrepreneurism at Temple’s her husband, Joshua W. visit us on the web Medical Center in Salem, Mass., College of Health Professions. Thompson, J.D., announce the yalemedicine.yale.edu since 1975, is the immediate past He is the founder and president birth of their first child. Sophia chair of the acr Commission on of World Athlete, a sports and Arleo Thompson was born on Economics, current chair of the fitness management company May 31 and weighed in at 8 lbs., Task Force on Value Added and specializing in track and field. 3 oz. Arleo is in the final year of vice chair of the Commission on a radiology residency at New Government Relations. York Presbyterian Hospital-Weill 62 in memoriam

Rex B. Conn Jr. m.d . ’53, died of tech niques in myocardial preser - Washington, D.C. His interest in and Molecular Physiology and Parkinson disease on March 2 vation and blood conservation tropical diseases, and especially professor of medicine, died of in Philadelphia. He was 80. and established an open-heart pinta, a bacterial skin disease cardiovascular disease in New Born in Cedar Rapids, Iowa, program at Wake Forest’s endemic to Central and South Haven on April 15. He was 61. Conn taught at West Virginia Baptist Medical Center. He America, led him to the U.S. Hebert was a board-certified University in Morgantown, served on the board of gover - Public Health Service. Working nephrologist who devoted his where he established the nors of the American College of with the Brazilian government, career to the science of renal pathology department and Surgeons from 1983 to 1989. In Demis helped to eliminate fluid and electrolyte regulation. clinical laboratory. He served as September 1995, he was named pinta in that country. Demis He made major contributions to a radar specialist in the Navy professor emeritus at Wake subsequently served as profes - medicine, notably in the cloning Reserve during World War II. Forest; the A. Robert Cordell sor and chair of dermatology at of genes that mediate or regu - Conn was subsequently named Chair in Cardiothoracic Surgery Washington University in St. late the transport of sodium, to advisory committees at the was established in his honor. Louis from 1964 to 1966; at that potassium and calcium across National Institutes of Health, time he was the youngest chair cell membranes. His work won Walter Reed Army Medical Roger W. Davis Jr. , m.d . ’43, died of a major dermatology depart - him election to the National Center and the Armed Forces on March 16 in Springfield, Vt. ment in the United States. After Academy of Sciences in 2005, Institute of Pathology. From He was 90. After graduation accepting an appointment as and his research was the basis 1968 to 1977 he taught at Johns from medical school, Davis com - professor and chair of dermatol - for a new class of drugs used to Hopkins University School of pleted internships at Hartford ogy at Albany Medical College, treat hyperparathyroidism, a Medicine. Conn ran clinical Hospital in 1943 and 1946. From he collaborated to produce the hor monal disorder that affects labs both there and at Emory 1944 to 1946 he served with the text Clinical Dermatology . He many of the more than 1 million University, where he also taught. U.S. Army’s 174th Engineer also maintained a private der - patients worldwide with end- In 1987 he moved to Philadelphia, Combat Battalion. He completed matology practice. stage kidney disease. where he taught at Thomas residencies in orthopaedic sur - Hebert was born in 1946 in Jefferson Medical College until gery at the Hospital for Special Frederick James Finseth , m.d ., died Rockford, Ill., and lived for part his retirement in 2003. Surgery in New York City from in February in San Francisco. He of his childhood on the island of 1947 to 1949 and at Boston City was 67. A graduate of Harvard Great Inagua in the Bahamas, Alfred Robert Cordell , m.d., h.s. Hospital in 1950. He opened a Medical School, Finseth com - where his father was a contrac - ’50, died on April 9 in Winston- private practice in orthopaedic pleted a residency in surgery at tor for the Morton Salt Co. In a Salem, N.C. He was 83. After surgery in Hartford and worked Massachusetts General Hospital. profile published in 2006 in the receiving his medical degree as assistant medical director of He was assistant professor in Proceedings of the National and completing an internship the Aetna Life and Casualty Co. reconstructive and plastic sur - Academies of Sciences , he at Johns Hopkins University, From 1974 until his retirement gery at the School of Medicine recalled watching bulldozers pile Cordell came to the Yale VA in 1981, he served as a part-time from 1974 to 1977. He published dried sea salt into mountains 150 Surgical Services for an assistant physician in Springfield Hospital’s several papers on the impair - feet high and speculated that his residency in surgery from 1948 emergency room. ment of blood flow in the hand interest in metabolic salts may to 1950. Following a stint as a from cigarette smoking during have had its genesis there. He surgeon with the Medical Corps, D. Joseph Demis , ph.d., m.d. ’57, his years at Yale. From 1977 to entered Florida State University U.S. Navy Reserve, training in died on March 8 in Clifton Park, 1979 Finseth was an assistant at age 15 and graduated after general and thoracic surgery at N.Y. He was 78. After interning professor in plastic and recon - three years. Wake Forest University, and a in Seattle, Demis took a fellow - structive surgery at Stanford Hebert received his medical year as a visiting instructor in ship in biochemistry at Oxford University School of Medicine, degree from the University of the Department of Surgery at University. There he explained specializing in reconstructive Florida in 1970. Following train - 8

0 the University of Buffalo, he the biosynthetic pathway of surgery of the hand. He traveled ing in internal medicine and 0 2 returned in 1970 to Wake Forest, adrenaline in mammalian tissue widely and made annual trips to nephrology at the University of n

m where he became a professor and performed pioneering stud - teach at Tata Memorial Hospital Alabama at Birmingham ( uab ), u t

u of surgery. From 1979 to 1991 he ies that showed the effective - in Mumbai, India. He also taught he served on the faculty at uab , a

e served as the Howard Holt ness of antimetabolites as in South America, Singapore, Eastern Virginia Medical School, n i c

i Bradshaw Professor of Surgery treatment for psoriasis and simi - China and South Asia. the University of Texas Medical d

e and chair of Wake Forest’s lar skin conditions. He received School in Houston, Harvard m

e Department of Cardiothoracic further training in dermatology Steven C. Hebert , m.d ., chair and Medical School, and Brigham l a

y Surgery. Cordell developed at Walter Reed Army Hospital in c.n.h. Long Professor of Cellular and Women’s Hospital. In 1997 63

he joined Vanderbilt University Virginia H. Hulbert , r.n., m.p.h . ’50, and received a commission as Galon S. Rodabaugh , m.d., h.s. ’53, as director of the Division of died on January 31 in Ansonia, first lieutenant. Following an died on January 9. He was 95. Nephrology and the Ann and Conn. She was 97. After earning internship in surgery, gynecology Rodabaugh completed his medi - Roscoe R. Robinson Professor of her degree in nursing, Hulbert and obstetrics, and a fellowship cal degree and internship at Medicine. In 2000 he was worked for more than 30 years in urology, he began a urology Ohio State University in 1939; offered the chair at Yale, which as an assistant professor of practice in New London, Conn., practiced for several years in gave him the opportunity to lead health at Southern Connecticut in 1952. He joined the staff of Basil, Ohio; and served from 1942 a world-class department and State University, and as head Lawrence and Memorial Hospi- to 1945 as a captain with the U.S. continue his close collaboration nurse in the school’s student tal in New London and served Army Medical Corps in England, with Gerhard Giebisch, m.d. , a health department. as chief of urology there from France, Belgium, Holland, longtime friend and mentor. 1976 until his retirement in Luxemburg and Germany. He In the early 1990s, Hebert’s D. Frank Johnson Jr. , m.d . ’55, died 1986. Longo was a member of saw combat during in the Battle laboratory made three funda - on March 31. He was 78. After the American Board of Urol- of the Bulge and received two mental discoveries about the completing his internship, ogy, a fellow of the American Bronze Stars. After completing kid ney’s processing of potassium, Johnson joined the Air Force as College of Surgeons, and a certi - a residency at Yale in 1953, he sodium and calcium. His group a flight surgeon. Following a fied sex educator and therapist served as anesthesiologist at identified a channel that regu - residency in internal medicine with the American Association the Fairfield Medical Center in lates potassium excretion and is at Minneapolis General Hospital, of Sex Educators, Counselors Lancaster, Ohio, until his retire - involved in Bartter syndrome in 1961 he pursued a career in and Therapists. After retiring ment in 1984. type II, an inherited disorder that Billings, Mont. For 25 years he he served with Charles Pfizer causes loss of sodium and potas - was the continuing medical edu - Pharmaceuticals as principal William G. Wysor Jr. , m.d., h.s. sium through the urine. He and cation director for St. Vincent clinical investigator in the ’52, died on January 3 in Chapel his colleagues also identified two Hospital, where he founded and Viagra program. Hill, N.C. He was 81. After receiv - sodium chloride transporters that directed Montana’s first cardiac ing his medical degree from the are target sites for important rehabilitation program. He also Gordon V.K. Reid , m.d., h.s. ’ 69, University of Virginia, Wysor diuretic drugs. His subsequent helped to develop St. Vincent’s di ed on April 15. He was 72. After received post-graduate training discovery of a calcium-sensing icu , its weight control program receiving his medical degree at Yale and the Medical College receptor known as casr led to and its Lifecare outpatient from the University of Rochester of Virginia. In 1953 he entered the development of a new class clinic. He was an associate clini - and further training at Barnes private practice in South Boston, of drugs that modulate calcium- cal professor of medicine at the Hospital in St. Louis, Reid served Va. From 1957 to 1969 he served receptor activity. University of Washington School as U.S. Public Health Service lieu - as associate professor of medi - Most recently, with John of Medicine in Seattle. Later in tenant commander in the cine at the University of North Geibel, m.d. , d.sc. , Hebert demon - his career he focused on weight Epidemic Intelligence Service of Carolina ( unc ) School of Medi- strated in an animal model that management, directing clinics in the Centers for Disease Control cine. From 1969 until his retire - diarrhea could be reversed almost Billings, Helena and Bozeman, and was sent to India to do ment in 1990, he practiced with immediately by activating the Mont., while continuing to serve smallpox eradication. In 1968 he Durham Internal Medical casr receptor. Such treatment airline pilots in the state as a came to Yale to finish his training Associates. His honors included would have a major impact on senior aeromedical examiner des - in internal medicine, endocrinol - teaching awards from Escola health problems in developing ignated by the Federal Aviation ogy and gerontology. Shortly Paulista de Medicina in São countries, where diarrheal disease Administration. He was a mem - after joining a New Haven prac - Paulo, Brazil, where he was a kills some 3 million infants and ber of the North American tice in 1970, he co-founded the vis iting professor, and from the children each year. Society for the Study of Obesity. Community Health Care Plan, unc School of Medicine. Hebert was awarded numer - Among other honors, Johnson where he practiced until 1999. ous professional honors, includ - received the American Society of He then co-founded Endocrine ing the Homer W. Smith Award Bariatric Physicians’ Bariatrician Associates of Connecticut. Reid send obituary notices to from the American Society of of the Year award in 2002. was an associate clinical profes - Claire M. Bessinger, Yale Medicine, Nephrology, the A.N. Richards sor of medicine at Yale, attending 300 George Street, Suite 773, Award from the International Vincent J. Longo , m.d . ’46, died on in internal medicine and endo- New Haven, CT 06511, or via e-mail Society of Nephrology, and the February 18 in Niantic, Conn. crinology, and a preceptor for to [email protected] Carl W. Gottschalk Distinguished He was 85. During World War II, res idents from Yale-New Haven Lectureship from the American Longo was a member of the Army Hospital and the Hospital of Society of Physiology. Specialized Training Program Saint Raphael. 64 follow- up archives 50 and 25 years ago e s o r e d

f f e j After a life in medicine, a career in show business Report on Alumni Day The Case of Three —Alumni Bulletin Missing Hamsters Brock Lynch, m.d . ’47, had been singing and dancing with the May 1958 —Yale Medicine Fall / Winter 1983 Young@Heart Chorus for almost 10 years when it was written

up in Time magazine in June of 2005, and in Yale Medicine “In spite of a heavy snowfall the “Three infected hamsters reported [See “Tap Dancing Through Medicine,” Autumn 2005]. Since preceding weekend and snow flur - missing from their cage in the ani - the documentary Young@Heart was released in April, Lynch ries on the morning of Saturday, mal containment facility on the ninth floor of the Laboratory of and the other performers in the 27-member Massachusetts- February 22, many Yale Alumni in Medicine turned out for the Epidemiology and Public Health based group of elderly rock singers continue to tour to even annual Alumni Day activities at became overnight celebrities — greater acclaim. the school. Almost 200 were pres - of a sort. ‘Infected Yale Hamsters “Little by little, instead of drooping, it grew,” Lynch said ent at the afternoon business Escape’ was headline news for the wire services, major television and of the film, which was released only gradually in the United meeting in Fitkin Amphitheater. Dr. Samuel D. Kushlan (’35) radio networks and newspapers States. Word of mouth and a free showing at the Sundance presided. Dean Vernon W. Lippard across the nation, including the Film Festival soon accelerated the film’s popularity, and chorus spoke briefly on recent develop - New York Times , which devoted members have subsequently traveled not only to perform but ments at the medical school. Those almost half a page to the story. “The hamsters have not been to promote the film. Just prior to its release, Lynch traveled to attending then heard a lively dis - cussion of coronary heart disease found, and are presumed dead. Washington, D.C., and Boston with two other chorus members by Dr. Jeremy N. Morris, visiting Although their disappearance to answer questions from an audience of critics. professor of epidemiology.” caused considerable stir in the Children, adolescents, and college-aged audiences, he media and concern in the Univer- sity, the three rodents and others has long noticed, enjoy the live shows the most, while the older like them in the leph -9 facility demographic seems less appreciative. “They don’t go for that are of little threat to human music—that was the music [about which] they told their chil - health and the likelihood that dren, ‘Turn it down!’ ” But now that many audience members they escaped from the facility is have seen the film, Lynch said, the group has “rabid devotees.” practically nil. … “The hamsters were among Lynch recently sang with Young@Heart in Manhattan at several hundred research animals the historic Beacon Theater on Broadway, a mile from Memorial in a major study of Alzheimer’s Sloan-Kettering Cancer Center, where he was a surgical teaching disease … [they were] infected fellow in the mid-1950s. The “Alive and Well” concert tour also with Creutzfeld-Jakob virus, a so- called ‘slow virus,’ which is invari - included stops in Boston and the group’s home base of ably fatal, and causes symptoms Northampton, Mass. The set list included songs by the Rolling of senil ity similar to those of Stones, Nirvana and James Brown. Alzheimer’s disease. … The group plans next to develop a cabaret act, heavy on “A series of meetings has since been held to ascertain facts the soloists. More tours are also in the works. How do they do of the escape, and to plan reme - it? “With grit, guts and good medication,” said Lynch. dial actions.” —Jenny Blair 8 0 0 2 n m u t u a e n i c i d e m e l a y end note

PRETTY IN PINK During the academic year, the stainless steel tables in The Anlyan Center’s anatomy labs hold the “donors” who have offered their bodies for the education of future doctors and physician associ - ates. For most medical students this introduction to medicine is a charged and emotional experience. In May the students who com - pleted this first-year course spent two days wrapping pink fabric s i around the tables where they’d dissected the human body. Their t r u c

inspirations were the artists Christo and Jeanne-Claude, known n h o for their wrappings of such public spaces as the Pont Neuf in Paris. j Evoking the work of artists Christo and “To mark the school year’s end, student artists have this Jeanne-Claude, students wrapped dissection time wrapped the lab itself, transforming this familiar space and tables in the anatomy lab in pink cloth, an installation that helped them deal with their raising critical questions about our relationship to anatomy,” own reactions to the first-year course. wrote Ryan Blum in the program for the installation, called Re- covering the Anatomy Lab. The installation was open to visitors for about two weeks in May and June. “What is hidden in the site of dissection? What damage have we done, and how can we make amends? Can and should the lab be made beautiful? What about ourselves is changed? How can we help future classes of anatomy students with this difficult practice?” About 50 students gathered to bind the anatomy tables in bolts of fuchsia cloth, said Michael Otremba, who conceived of the idea with classmate Lauren Graber. “It’s a sterile, metallic environ - ment,” said Otremba, adding that students wanted to comment on what he called “an emotionally significant time.” The choice of pink was deliberate. “We wanted to be playful.” “I think it’s delightful,” said William B. Stewart, ph.d. , associate professor of surgery (gross anatomy), who has been guiding Yale medical students through the human body for 30 years. “Art is all about people coming to grips with their feelings.” —John Curtis yale medicine 300 george street, suite 773, new haven ct 06511 Non-Profit Org. U.S. Postage yalemedicine .yale .edu PAID autumn 2008 Burlington, VT 05401 Permit No. 696