Learning to direct people and health resources in a bioterror emergency is the focus of “Public Health Management of Disasters,” offered at the School of Public Health for the first time this year. From left, students Emily Cheung, Eli Blitz, Sarah Reese and Brian Stout.

Hoping for the best, preparing for disaster

The lessons of September 11, at the core of a new Yale course, put public health in the spotlight.

This past fall, Yale’s School of Public Health introduced a new course on coping with disasters. Earthquakes, hurricanes and volcanoes are on the agenda, as well as famines, wars and epidemics. But the real focus is how to confront the ongoing threat of bioterrorism.

Since September 11, 2001, universities across the nation have been developing public health programs aimed at training students and professionals for future terror attacks and emerging health threats, including anthrax, smallpox and other methods of germ warfare.

Yale’s new course is just a first step toward plans to develop a Yale Center for Bioterrorism and Disease Outbreaks. Such a move would have been unimaginable a few years ago for lack of interest, necessity and—most important—funding. Today, however, public health is under a welcome spotlight, viewed with increasing importance as part of the Bush administration’s goals for homeland security.

Of the government’s $2.9 billion budget for fighting bioterrorism, $20 million was earmarked this year for developing a nationwide disaster response network of academic public health programs linked with state and community health agencies. Already, some 20 universities have received funds from the Centers for Disease Control and Prevention (CDC). In September, the Association of Schools of Public Health, in cooperation with the CDC, approved Yale’s application for a grant to establish a Yale Center for Public Health Preparedness, but has not yet decided whether to award nearly $1 million in funding.

Heading up the Yale initiative is Brian P. Leaderer, M.P.H. ’71, Ph.D. 75, deputy dean of the School of Public Health and vice chair of the Department of Epidemiology and Public Health. Along with other leaders in public health, Leaderer is confident the focus on bioterrorism will spill over into more resources for disaster response in general.

“Bioterrorism looms as a real potential problem,” Leaderer says. “But if you think about it, many of the competency areas in bioterrorism would apply to a large range of public health events.”

In the classroom, students taking “Public Health Management of Disasters” get a broad overview of the practical consequences of disasters at home and overseas. They also learn about the complexities of orchestrating people and agencies that are involved in disasters—the police, the military, hospitals, fire departments, federal investigators, charities, support services, religious groups, families of victims, phone companies, electric companies and the media, to name only a few.

Public health, says course co-director Linda C. Degutis, M.S.N. ’82, Ph.D. ’94, can provide leadership in disaster planning and emergency response. “Who’s where, and what’s everybody doing? Somebody’s got to know,” says Degutis, associate professor of surgery (emergency medicine) and public health. “Who are the players? What are their capabilities? What we’re trying to highlight in the course is how public health can play that coordinating role.”

Degutis, along with David C. Cone, M.D., associate professor of surgery (emergency medicine), tries to get students thinking about disaster relief from all angles. In Florida, for example, how do you handle a large elderly population in the aftermath of a hurricane? How do people dependent on Meals on Wheels get food when the roads are washed out? How do you shelter older, more fragile people in a gymnasium?

Examining the lessons of September 11, for which scientific studies of disaster management of the aftermath are only now being completed or published, Degutis and Cone rely on anecdotal accounts by disaster workers, as well as media accounts such as The New York Times’ detailed reporting on the structural collapse of the Twin Towers.

Guest speakers with nationally recognized expertise supplement lectures by core faculty. One guest, Eric K. Noji, M.D., M.P.H., is an epidemiologist with extensive field experience with disasters such as the Kobe, Japan, earthquake. Recently appointed as a special assistant for homeland security and disaster medicine to the U.S. surgeon general, Noji has been advising public health schools such as Emory’s in starting up public health preparedness centers.

“Public health is a growth industry now for several reasons,” says Noji. “Before, there was no career pathway for faculty; now there is. There was no money to support research; now there is. A lot of things which prevented programs like this are no longer the case.”

Aside from the influx of funds, the other motivation for disaster management education has been student demand. Even before Yale started thinking about a public health preparedness center, Degutis and Cone were planning a disaster course: students, jolted by September 11 and an anthrax fatality close to home in Connecticut, had asked for one.

Neha Vibhakar, 24, a second-year student in environmental health sciences, reorganized her schedule so she could take the disaster management course.

“Hopefully, we won’t have to use it,” said Vibhakar, who plans to study medicine after finishing her public health degree. “But it’s a tool that every doctor needs to have.”

—Anne Thompson

For AAP’s voice on smallpox,vaccine question, especially for the young, is crucial

When the American Academy of Pediatrics’ committee on infectious diseases reconvened for the first time after September 11, 2001, bioterrorism was a topic. Several people had died after coming in contact with anthrax-laced letters, and there was concern that future attacks would involve smallpox. The committee needed a pediatrician to serve as a liaison between the academy and the Centers for Disease Control and Prevention (CDC) in discussions of smallpox.

Robert S. Baltimore, M.D., volunteered and has since found himself the academy’s main spokesman on the topic.

“I had no idea what I was in for,” said Baltimore, professor of pediatrics and epidemiology, sitting in his office at the School of Medicine. Although he specializes in pediatric infectious diseases, Baltimore, like his peers in the academy, had no specific experience with smallpox. The virus had not been seen in the United States since 1949, when Baltimore was in grade school. His own research focuses on infections in newborns and hospital-acquired infections, and Baltimore studied smallpox only generally as an infectious diseases fellow in the 1970s at the Walter Reed Army Medical Center and the Army Institute of Research.

So Baltimore started educating himself, reading about the virus and collecting a grim photo archive on his computer showing the effects of smallpox on children. He had help from colleagues in the department’s infectious diseases division, who met every two weeks throughout 2002 to discuss bioterror-related topics in their journal club. “The group wanted to make sure we had a very detailed knowledge,” Baltimore said.

As the academy’s representative, Baltimore holds conference calls with the CDC’s “smallpox working group” and travels to Atlanta for CDC meetings. In addition, he has become embroiled in the debate over how best to vaccinate the public in the event of an attack. At issue are competing proposals of mass vs. “ring” vaccination—whether to inoculate everyone, or just those in the vicinity of people infected.

In the fall, CDC officials were moving away from the center’s earlier support for a ring vaccination strategy and recommended making the vaccine available to the general public. [As Yale Medicine went to press President Bush announced plans to inoculate up to 500,000 frontline troops and 10 million civilian health care and emergency workers against smallpox, but advised against vaccination for the general public at this time.] Baltimore thinks mass vaccination would be a mistake, and on behalf of the academy has advocated the alternate approach. Children are more susceptible than adults to serious complications, he said. And there is the worry that individuals who avoid vaccination for health reasons might be exposed to the live vaccinia virus anyway, through contact with those who have been vaccinated.

There are three situations in which the vaccine could be fatal. In people with certain skin conditions, including eczema, the vaccine can spread, causing pustules to form over the entire body. Those with immune systems compromised by aids or chemotherapy, for example, may also become seriously ill from the vaccine. And in rare cases, some of those vaccinated will develop oozing, infected sores in the injection site that spread and invade deep tissues without healing.

In the first two instances, said Baltimore, children are more at risk. Many skin disorders disappear with adulthood, which means more children have them, and immune deficiency may not be apparent in young children.

For adults, the fatality rate for smallpox vaccine is about one per million. For infants, the rate is about 5 per million and there are serious adverse reactions in about 400 per million—a rate that decreases with age. The CDC has the antidote for severe reactions, an antibody-rich blood product known as vaccinia immune globulin, but current quantities are minuscule. Baltimore also is concerned about the vaccine itself. The CDC is diluting stockpiles of the old vaccine to stretch it while new vaccine is manufactured. But neither the diluted version nor the new one has been tested on children.

Even if at-risk children and adults are not inoculated, they can be infected through contact with people who have received or administered the vaccine and have it on their skin. “Mass vaccination carries with it risks that can’t be justified,” Baltimore said. “The information that all public health people have been given is that the chances of a smallpox outbreak are remote. Should there be additional information that says this isn’t true, we would say this should be reconsidered.”

—Anne Thompson

An appreciation of the human form, in the studio as well as the operating room

From his house in Old Lyme, Conn., Wayne O. Southwick, M.D., surveys a green tidal marsh, and beyond, the blue waters of Long Island Sound. The breadth of that vista, punctuated by four former fishermen’s cottages near the water and two lighthouses in the distance, reminds Southwick of the open spaces of his native Nebraska.

Southwick attributes his interest in art to the landscape of his childhood. In the town of Friend (pop. 1,100), boxcars and silos were the only embellishments, and “I thought of them as sculptures,” says Southwick, former chief of orthopaedic surgery at Yale. Now, as he looks out on Smith Neck marsh 32 miles east of New Haven, Southwick is surrounded by real sculptures—his own and those of his mentor, the Italian-born Bruno Lucchesi. Southwick also sees his own work when he walks down Cedar Street, where his bronze of a young man and woman playing basketball, An American Dream, stands near the Jane Ellen Hope Building. And this winter, a show by members of the Yale University community includes his bronze of a woman nursing a 2-year-old, Taking Nourishment. Southwick is among 19 artists exhibiting work at the Yale Physicians Building Art Place. The show, running from October through March, includes works ranging from pastels to shadow boxes, quilts and jewelry.

Southwick says that the qualities that led him to pursue orthopaedics also drew him to sculpture. And sculpture, in turn, has influenced the way he sees the human body as a physician. Interning at Boston City Hospital after earning his medical degree at the University of Nebraska in 1947, Southwick discovered that he enjoyed treating broken bones. “I love the anatomy of the human frame,” he says. In medicine, he often felt he had little to offer patients, especially before the advent of penicillin. He chose orthopaedics, doing a residency at Johns Hopkins, because “I like doing things.”

Instead of going to the movies, he and his wife, Ann, wandered in museums and even went to Paris to see an exhibit of his favorite artist, Aristide Maillol, the 20th-century French sculptor of the female nude. But it wasn’t until the early 1980s that Southwick began lessons in sculpture at Lyme Academy, not far from his home. There he met Lucchesi and began weekly trips to New York City to study with him.

Sculpting sharpened Southwick’s powers of observation as a physician. Looking for scoliosis, “I could see the symmetry or asymmetry of the body more acutely after looking at models and various positions of the spine, but more than that—the other way round—I think knowing what’s underneath the skin helps you think about sculpture.”

Ironically, sculpting also requires suppressing anatomical knowledge. Southwick says sculptures work better if they exaggerate certain features, like the anterior superior iliac spine (the pelvic bones). The head should be smaller than in real life, the neck longer. These alterations “orient your view of things.”

Southwick has retired from surgery (while his son, Steven M. Southwick, M.D., professor of psychiatry, carries on the family name at Yale). The senior Southwick and Lucchesi recently collaborated on a sculpture for the new Connecticut Hospice building in Branford, Conn. Southwick felt honored to work with Lucchesi. “In my mind, he’s the greatest living representational sculptor.” Lucchesi himself has three sculptures on the Yale medical campus, including a bronze of a mother and child in the atrium of Yale-New Haven Hospital.

Lucchesi appreciates that Southwick is using his talents to create realistic sculpture at a time when “everyone is doing a block with a hole in it.” He describes Southwick’s discovery of the art form as a revelation: “A neophyte finds a new religion: he finds sculpture—and he transmits that enthusiasm to other people.”

As for the work itself, what does Lucchesi think? “He trained me,” Southwick says with a laugh. “He thinks I’m better than I was before.”

—Cathy Shufro

For an expert from Iran, reasons to worry about AIDS

An emerging epidemic of HIV/AIDS in Iran could have disastrous consequences for the country and the region, according to Kaveh Khoshnood, M.P.H. ’89, Ph.D. ’95, assistant professor of epidemiology at the School of Public Health and a native of Iran. Although 70 percent of Iran’s 20,000 AIDS cases are drug users, according to UNAIDS, the government only recently lifted a ban on drug treatment centers, Khoshnood told congressional staffers in Washington on October 15. The briefing was organized by the American Iranian Council. “This shift in government policy created an opening for the Iranian medical and public health community to become engaged in a national debate regarding alternative approaches to drug addiction and the HIV/AIDS epidemic,” said Khoshnood, who along with Yale colleagues has brought Iranian physicians to Yale to study science-based models for treatment of opiate addiction and prevention of HIV infection.

—John Curtis

Et Cetera

Yale scientists among most cited

Yale University ranks fifth among federally funded U.S. universities for the citation impact of its published research, according to a Science Watch survey.

The ranking was calculated by using publication and citation data to gauge how often during the past five years papers by Yale authors were cited by other scientists in 21 major fields of science and the social sciences. That number was then compared with a worldwide cites-per-paper average.

The four universities that ranked above Yale in the two-part survey were Harvard, which came in first, followed by Stanford, the Massachusetts Institute of Technology and the University of California, San Diego.

“We consider citations to be very significant,” said Chris King, editor of Science Watch, a newsletter published by the Institute for Scientific Information in Philadelphia, “because they reflect what scientists themselves deem to be important. When they cite a paper, they’re saying, ‘This work is important. It’s germane to what I’m doing.’”

—Jennifer Kaylin

Three join Institute of Medicine

Each year a few dozen select physicians and scientists are named to the Institute of Medicine of the National Academy of Sciences to serve as unpaid advisors to the government. Among those elected last October for their contributions to health and medicine were three Yale faculty members: Michael H. Merson, M.D., the dean and Anna M.R. Lauder Professor of Public Health and chair of the Department of Epidemiology and Public Health; Richard P. Lifton, M.D., Ph.D., chair and professor of genetics and professor of medicine and molecular biophysics and biochemistry; and Michele Barry, M.D., HS ’77, professor of medicine and public health. As members they will contribute their knowledge and professional judgment to the development of findings and the formulation of recommendations, most of which relate to public policy.

—John Curtis


			Originally published in Yale Medicine, Winter 2003. Copyright © 2003 Yale University School of Medicine. All rights reserved.