Health care van rides a road less traveled

For city residents with limited access to medical services, Yale’s mobile clinic fills a critical void.

The Community Health Care Van parks in front of an apartment house with plywood nailed over the windows. Orange spray paint on the Congress Avenue tenement demands, “Whose Livable City Is This?”—a reference to New Haven’s anti-blight initiative. It is cold and rainy, the kind of weather that discourages patients from venturing out to the mobile clinic. But enough people show up to make for tight quarters.

Joel stoops to walk inside.

“It’s a good day because we’re alive to see it,” the lanky man says with a grin as he brushes raindrops from his jacket.

This is an optimistic time in Joel’s life; with the assistance of the van staff, he has just signed up for substance abuse treatment. But first he needs a physical and a tuberculosis test, and the van takes walk-ins. Waiting weeks or even days for an appointment at a clinic would be difficult and risky for a man who says he is “just trying to find the strength one day at a time.”

Entering its 10th year of service to New Haven, the van has always emphasized free, immediate and dignified care, says Frederick L. Altice, M.D., HS ’89, associate professor of medicine (AIDS Program) and director of the Community Health Care Van initiative. Altice got the idea for a mobile clinic a decade ago while working with New Haven’s needle exchange program. He saw people come in with abscesses that went untreated until they were acute enough to land the client in the emergency room.

With a small van borrowed from Yale-New Haven Hospital’s Primary Care Center, Altice began following the needle exchange van once a week. Along with a social worker and HIV counselor, Altice provided primary care, mostly to injecting drug users. Today, a newer, 36-foot van serves patients 11 hours a day, five days a week throughout the city. The rotating staff includes senior physicians, residents, HIV specialists, a nurse practitioner, a physician associate, an HIV counselor, a drug treatment coordinator, a case manager, outreach workers and a number of volunteers. Usually four staff members ride on most trips. Many others are immediately available by cellular telephone.

The van’s impact on the community is well-documented: a 41 percent reduction in emergency department visits for clients who are injecting drug users, a 66 percent success rate in getting drug users to complete all three shots in the hepatitis B series, and promising results using buprenorphine to reduce heroin cravings. For clients who do not qualify for entitlements, the van may be their only treatment option. Where possible, the aim is to move the patient toward a community health center or some other fixed source of primary care. In 41 percent of the cases, that transition is successfully made. The van has done promising work on TB screening with undocumented residents, says Altice, which he expects to publish soon. Similar work is going on with the homeless.

About half of the 500 to 600 patients who visit the van each month arrive with issues unrelated to drugs. On the same morning that Joel needs a physical to get into treatment, a teenage girl with seashells braided into her hair, powder-blue tennis shoes and a handbag that says “Princess” takes a seat in the van. “I’m here for two reasons,” she announces with studied nonchalance, “a pregnancy test and an HIV test.”

Within minutes, she has seen a mental health counselor, a physician and an HIV counselor. She is relieved to get test results quickly and without a lecture. As she leaves with condoms she smiles and says, “I’ll be seeing you.”

“Everybody I meet on the van is always nice,” says Michael, 28, who takes his daily HIV medications here. “This gets my morning going.”

Much of the ongoing care the van provides also is the basis for research that might help patients far beyond New Haven. Some clients take their HIV medications in the van as part of an effort to increase adherence. Data collected so far show that the directly observed medication program works, according to Robert Douglas Bruce, M.D., clinical instructor of medicine. Some patients, he says, have seen their viral loads fall and their T cells rise substantially. The research project is funded by the National Institute on Drug Abuse.

Research funding has largely sustained the van, says Altice. The mobile clinic is an ideal setting for many other investigations. For example, he is eager to monitor HIV therapy for inmates released from prison. HIV tends to be well-managed in prison, but viral loads often rise after release.

Aside from research grants, fund-raising efforts have been difficult, Altice says, in part because the clientele arouses little public sympathy. It is precisely that lack of sympathy that the van staff is determined to combat. For example, many patients say they have been treated terribly by other health care providers, which makes them reluctant to seek treatment. Charly began coming to the van for primary care after her release from prison. Though she found work immediately after returning to New Haven, her job provides no health benefits. Charly says that on the van she gets a measure of respect she rarely finds elsewhere: “You don’t have to be afraid to tell them about nothing,” she says. Perhaps that’s the secret of the van’s success.

—Colleen Shaddox

Biomedical engineering becomes a department, uniting several disciplines

In eight years, biomedical engineering at Yale has grown from a fledgling undergraduate major to the university’s newest department.

The Yale Corporation approved the formation of the interdisciplinary Department of Biomedical Engineering last summer with the participation of the medical school as well as the faculties of engineering and arts and sciences and the John B. Pierce Laboratory. Yale has offered an interdisciplinary program in biomedical engineering since 1996, led by James S. Duncan, Ph.D., professor of diagnostic radiology, biomedical engineering and electrical engineering, but the decision to create a department signals how far the field has come. “I see a whole new set of symbiotic capabilities coming out of this partnership,” said Paul A. Fleury, Ph.D., dean of the Faculty of Engineering. These include the marriage of computer modeling of tissue mechanics with clinical practice, the application of computer technology to enhance imaging data from MRI, and techniques for using biologically compatible materials to deliver drugs or cells.

The department already has 70 undergraduate and 30 graduate students. There are nine primary and four secondary faculty members, with plans to fill three more primary faculty positions. Ongoing research projects include bioimaging and intervention in neocortical epilepsy, modeling of drug transport for brain tumor therapy, motor control in low-back injuries, and fMRI for neurosurgical planning in epilepsy. The department is now housed in the Becton Science Center, but ground was broken in December for its new home in the Engineering Research Building on the corner of Prospect and Trumbull streets.

Fleury says the department is fully interdisciplinary, with several faculty members appointed in both the medical school and the Faculty of Arts and Sciences. “We expect that this arrangement will enable seamless relationships among the departments,” he said.

W. Mark Saltzman, Ph.D., chair of the new department, says the interdisciplinary environment and potential for collaboration are what drew him to Yale. Saltzman, who was previously at Cornell University, is working on drug delivery and tissue engineering. He says his top priorities as chair are to enlarge the faculty and to add new courses.

Fleury says the Yale program will succeed because it is closing a cultural gap. “Medical doctors often see engineers merely as gadgeteers who can supply methods or devices, but are not interested in or capable of engaging in the deeper roots of clinical and medical challenges,” he said. “Conversely, engineers are often skeptical of doctors’ scientific interests and depth. I am glad to say that these gap characteristics are vanishingly small here at Yale.”

—Jennifer Kaylin

Renewed “vows” herald a stronger link between Yale and London

When a trans-Atlantic group of psychiatrists and psychologists gathered at Yale in early December, it was as much a reunion of old friends as an academic symposium at the Child Study Center. Many in the group have known each other for years. They have written papers together, mentored and trained each other and collaborated on research and interventions.

The reason for the symposium, “Developmental Science and Psychoanalysis: Integration and Innovation,” was to formalize three decades of largely informal ties between Yale and the Anna Freud Centre in London. The symposium also celebrated the launching of the Anna Freud Centre Program at Yale and a revitalization of the Centre in London.

Alan E. Kazdin, Ph.D., director of the Child Study Center, likened the celebration to the renewal of wedding vows. “There has already been a very enduring marriage that has worked out very well,” he said. “Let’s go through the ceremony and vows again and chart the future.”

What the future holds for Yale’s participation in the program is a series of exchanges that will bring students and scholars across the Atlantic for training, research and study. Linda C. Mayes, M.D., the Arnold Gesell Professor of Child Psychiatry, Pediatrics and Psychology in the Child Study Center, will head the program at Yale and is one of three members of a new directorial team that will lead the Freud Centre.

According to Mayes, the program at Yale will offer training that includes exchanges for scientists and scholars, a master’s program, an undergraduate program and an international visiting-scholar program. The program will also include joint research projects focused on the science of early attachments and emotional development. “The idea is to have a continual exchange of ideas and very active collaborative clinical research,” she said.

The exchanges between London and New Haven go back three decades. In the early 1970s, the late Albert J. Solnit, M.D., HS ’52, who headed the Child Study Center from 1966 until 1983, forged a strong friendship with Anna Freud and introduced his Yale colleagues to her.

The Anna Freud Centre, which was established during World War II as the Hampstead War Nurseries to treat traumatized children, had become one of the leading centers for the treatment and study of children with a range of serious developmental and psychological disorders. The Centre’s collaborations with Yale involved professors at the medical and law schools as well as colleagues in the community and on the clinical faculty. The ties between these two institutions continued with the leadership of Donald J. Cohen, M.D. ’66, who led the Child Study Center from 1983 until his death in 2001 and who, like Solnit, served on the Centre’s board of trustees.

Last July, the Centre appointed a new directorial team that includes, in addition to Mayes, Peter Fonagy, Ph.D., and Mary Target, Ph.D. Fonagy is the Freud Memorial Professor of Psychoanalysis and Director of the Sub-Department of Clinical Health Psychology at University College London. Target is a senior lecturer in psychoanalysis, also at University College London.

—John Curtis

Newspaper heralds a new day in medical education—almost two centuries ago

Stop at medical grand rounds on any given Thursday morning and you’re likely to encounter Samuel D. Kushlan, M.D. ’35, HS ’37, a retired gastroenterologist who has served on the faculty for 65 years and who turned 92 in February. Kushlan graduated from Yale College in 1932 and from the School of Medicine three years later, and his view of the school’s history is a long one.

Kushlan’s appreciation of the medical school’s earliest days recently grew larger, however, when he was given a copy of a 19th-century newspaper documenting the school’s establishment by an act of the Connecticut legislature. The slightly yellowed but well-preserved copy of the Connecticut Mirror, from November 5, 1810, includes the text of the act creating the Medical Institution of Yale College. The new school was the joint responsibility of Yale College and the Connecticut Medical Society, which today has its headquarters on St. Ronan Street in New Haven.

Yale’s first medical students could expect to draw on the expertise of an initial faculty of four and core facilities consisting of “a Cabinet of anatomical preparations,” “a collection of specimens, in the Materia Medica” and a botanical garden to be planted “as soon as the funds of the college can afford such establishment.” Medical students who had finished college were required to study medicine for two years before entering the profession; those who hadn’t would spend three years in class. In addition to attending lectures, the students were expected to apprentice under a local physician or surgeon in good standing.

Kushlan came upon the newspaper through the good graces of Richard Lodish, principal of the lower school at Sidwell Friends in Washington, D.C., where Kushlan’s granddaughter chairs the school’s parents’ organization. A collector of education memorabilia, Lodish thought of Kushlan when he saw the copy of the Mirror advertised on the Internet. Lodish has another New Haven connection: his daughter, Maya B. Lodish, M.D. ’03, received her medical degree from Yale last May and is now a resident in pediatrics at Johns Hopkins.

While some early features of academic medicine remain unchanged (the act describes in detail the responsibilities of various committees, for example), recent graduates will be amused and possibly dismayed by one provision of the 1810 legislation noted below its description of the curriculum: “The price of the ticket for the whole of the above courses of lectures shall be fifty dollars,” the act stated. But students had other expenses to take into account as well. Before passing their exams, they were required to pay $10 to the treasurer of the medical society, $4 to each of their examiners and $8 to the president of the university. Full freight is likely to be a great deal more when the medical school marks its 200th anniversary six years from now.

—Michael Fitzsousa

Limits on stem cell research may preclude development of key therapies, panelists say

Nobody knows whether stem cells, the body’s so-called “master cells” that can differentiate into other cells, will ultimately be useful for repairing diseased or damaged tissue. Current knowledge about possible therapeutic uses remains so limited, according to speakers on a panel on potential applications of the technology, that commercial development remains a distant hope in most cases. And panelists warned that medical applications may never occur because of current restrictions on research involving human embryonic stem cells.

According to Marc D. Beer, chief executive officer of ViaCell, a Boston-based company that banks stem cell-rich blood from umbilical cords for study and possible therapeutic use, “Stem cells have the potential to cure.” But because of federal limits on the use of human embryonic stem cells, he said, “research is being curtailed. I’m watching basic research leave this country.”

Beer was one of the panelists taking part in the third annual Yale and New Haven Biotechnology Reception in October. He pointed to recent successes in experimental clinical trials in which insulin-producing islet stem cells from donor pancreases have completely cured type 1 diabetes in some patients. “Lack of cells,” said Beer, “is the biggest problem” for wider application of the transplant procedure.

Panel moderator Erin Lavik, Sc.D., assistant professor of biomedical engineering, studies the use of stem cells for repairing damaged spinal cords. She said government restrictions, coupled with a possessiveness on the part of those who developed a few approved stem cell lines, are hampering research despite the fact that “we do not know the potential of these cells.”

“When you don’t know,” said fellow panelist Earl M. Collier Jr., executive vice president of Genzyme Corp., “that’s not the time to legislate.”

—Marc Wortman

For undergrads, mentor program offers a glimpse of a physician’s life

Five times during the fall semester, Shannon Gulliver, a Yale College senior majoring in microbiology, traveled from central campus to the medical school to observe Ali K. Abu-Alfa, M.D., as he tended to his patients. And her role at times went beyond mere observation. After palpating for edema on a dialysis patient’s ankle, for example, he turned to Gulliver and asked: “What is the significance of this finding?”

The pairing of Gulliver and Abu-Alfa, an associate professor of medicine and director of the Peritoneal Dialysis Program, came as part of a new program, Yale Medical Professions Outreach (YMPO), designed to introduce undergraduates to the world of medicine. “I’ve always been very interested in science, but I didn’t know much about patient relations,” said Gulliver. “I was lucky enough to get a doctor who could talk about what aspects are fun, what aspects are harder, lifestyle sacrifices you have to make, time commitment and emotional commitment. I asked him very direct questions, and he was really into explaining.”

YMPO was launched by students in January 2003 to create opportunities for undergraduates to observe physicians in their daily activities. “It’s absolutely one of the most important things we can do for undergraduate students,” said neurosurgeon Dennis D. Spencer, M.D., HS ’77, the medical school’s interim dean and a YMPO participant. For years as a Yale College freshman advisor, Spencer invited his advisees to observe his interactions with patients, but it was always “hit-or-miss” for other undergraduates seeking physician contact, he said.

Yale seniors Steven Hsu and Jason Choi started YMPO to fill what they saw as a lack of premed preparation for undergraduates. “Yale has so many programs for students but nothing like this,” said Hsu, who contacted Undergraduate Career Services and the medical school for guidance. A previous attempt at such a program ended when the founding students graduated. YMPO’s new leadership includes students from all classes to ensure continuity and growth. YMPO also started a lecture series, and in September added a Big Sibling/Little Sibling program that matches undergraduates with medical students. YMPO students must fill out an application and write an essay, and those selected are trained to comply with federal HIPAA regulations on patient confidentiality. Each student-physician pair sets its own meeting times for the semester. Sixty physicians are signed up, and last fall 70 students participated.

“I was immediately attracted to the program,” said Abu-Alfa. “Undergraduates are a body of students we don’t usually get to interact with. If you’re in love with what you do, to transmit that to a new generation is very exciting.”

—Mary Anne Chute Lynch

Yale ranked among best places to work

It’s often said that Yale is a highly collaborative institution, but how does one measure collegiality? The Scientist magazine did just that last fall in an international survey of 38,000 full-time U.S. faculty and researchers and found Yale among the best places to work in academia—third, actually, just behind Fox Chase Cancer Center in Philadelphia and Purdue University. Relationships with colleagues and the availability of resources were among the most important criteria for Yale respondents. “It is greatly rewarding to see our culture and investments acknowledged,” Provost Susan Hockfield, Ph.D., said of the October 20 report, which can be viewed online at www.the-scientist.com.

—Michael Fitzsousa

Et Cetera

New partnership in China

On a recent trip to China, President Richard C. Levin and other university officers cemented a program of exchanges between Yale and Fudan University in Shanghai. The Fudan-Yale Center for Education Cooperation, one of several programs between Yale and Chinese universities, will build on educational exchanges that began in 1996.

The new center will promote exchanges among scholars in history, East Asian languages and literature, genetics, biology, law, medicine and management. The centerpiece of the agreement is the Fudan-Yale Biomedical Research Center. Tian Xu, Ph.D. ’90, vice chair of genetics and special advisor to Levin on science and higher education in China, will direct both the education center and the biomedical center. Xu received his undergraduate degree at Fudan and his doctorate at Yale.

Xu said Yale has three goals—to help establish a world-class research center, to help Chinese educators reform their educational system and to promote understanding between the two countries.

—John Curtis

One paper, many implications

A Yale geneticist is among the authors of an article deemed by The Lancet last winter to be the most important biomedical research paper of the previous year.

The authors of the article, “Genetic Structure of Human Populations,” published in Science in December 2002, used genotypes of more than 1,000 people from 52 populations around the world to study human population structure. “The paper quantifies the degree to which biomedical research findings based on one group of individuals may be applicable to individuals from other populations,” said co-author Kenneth K. Kidd, Ph.D., Yale professor of genetics, psychiatry and biology. Kidd and colleagues in the United States, France and Russia identified six main genetic clusters and additional subclusters. They concluded that genetic risks of disease can be assessed with standard study designs if self-reported ethnic background is also considered.

—J.C.


			Originally published in Yale Medicine, Spring 2004. Copyright © 2004 Yale University School of Medicine. All rights reserved.