NYCM Quill + Scope - Vol 3

QUILL & SCOPEVOLUME III SPRING 2010 New York Medical College QUILL & SCOPE PUBLISHED ANNUALLY BY THE STUDENTS OF NEW YORK MEDICAL COLLEGE VOLUME III. SPRING 2010. EDITORS IN CHIEF Edward Hurley Jenny Lam SENIOR GRAPHIC DESIGNERS Annabelle Teng Dennis Toy SENIOR WEBMASTER Michael Smith MANAGING EDITORS Linda DeMello Navid Shams Gavin Stern WEB COMMUNICATIONS Kevin Cummings EXECUTIVE FACULTY ADVISOR Gladys Ayala, MD EDITORIAL BOARD Gladys Ayala, MD Diana Cunningham, MLS Kenneth Lerea, PhD Stephen Moshman, MD Padmini Murthy, MD Sansar Sharma, PhD Noorjahan Ali Debasree Banerjee Christine Capone Edward Hurley Sean Kivlehan Jenny Lam James Naples Annabelle Teng Dennis Toy Research Humera Ahmed Jonathan Drake ART EDITORS Becky Lou Allison Navis WEB DESIGN Calley Levine Quill & Scope is an annual NYMC student publication dedicated to promoting awareness of the personal, social, economic, and ethical issues con-fronting the modern physician. It was founded in 2008 by medical students Christine Capone and Sean Kivlehan. The articles selected for publication have been chosen for their literary or artistic merit. They do not necessarily represent the opinions or views of the editors, faculty, or New York Medical College. All rights reserved. No part of this publication may be reproduced, stored in electronic format, or transmitted in any form without the express permission of New York Medical College. Inquiries concerning reproduction should be directed to: Gladys M. Ayala, M.D., M.P.H. New York Medical College ɒ Administration Building/Office of Student Affairs 40 Sunshine Cottage Road ɒValhalla, NY 10595 [email protected] STAFF EDITORS Commentary Loren Francis Janet Nguyen Rajdeep Pooni Aditya Sarvaria Alex Trzebucki International Medicine Stuart Mackenzie Yin Tong Michael Weinreich Poetry & Fiction Alanna Chait Marissa Friedman Danielle Masor Community Health Chris Ours Sarah Pozniak 1 ( : < 2 5 . 0 ( ' , & $ / & 2 / / ( * ( 2)),&(2)7+(35(6,'(17 WZ^/ Ed͛ ^ &KZtKZ lŽƌ ŝƚƐ ĞŶƚŝƌĞ ϭϱϬͲLJĞĂƌ ŚŝƐƚŽƌLJ͕ nĞǁ ?ŽƌŬ MĞĚŝĐĂů CŽůůĞŐĞ ŚĂƐ ďĞĞŶ ƐƵƉƉŽƌƚŝǀĞ ŽĨ ŝƚƐ ƐƚƵĚĞŶƚƐ ĂƐ ƚŚĞLJ ƉƵƌƐƵĞ ƚŚĞŝƌ ĚƌĞĂŵ ŽĨ ďĞĐŽŵŝŶŐ ƉŚLJƐŝĐŝĂŶƐ͘ WŚĂƚ ŝƐ ŶŽƚ ƐŽ ǁĞůůͲŬŶŽǁŶ ŝƐ ŽƵƌ ŚŝƐƚŽƌLJ ŽĨ ƐƵƉƉŽƌƚŝŶŐ ŽƵƌ ƐƚƵĚĞŶƚƐ ĂƐ ƚŚĞLJ ƉƵƌƐƵĞ ĐƌĞĂƚŝǀĞ ĞdžƉƌĞƐƐŝŽŶ ƚŚƌŽƵŐŚ ƚŚĞ ĂƌƚƐ͘ lŽƌ ĞdžĂŵƉůĞ͕ Ă ŵĞŵďĞƌ ŽĨ ƚŚĞ CůĂƐƐ ŽĨ ϭϵϮϰ͕ 8ĞŶũĂŵŝŶ SĐŚŶĂƉƉĞƌ͕ M͘u͕͘ ǁĂƐ ĂŶ ŝůůƵƐƚƌĂƚŽƌ ǁŚŽƐĞ ĐĂƌƚŽŽŶƐ ĂŶĚ ĚƌĂǁŝŶŐƐ ŐƌĂĐĞĚ ƚŚĞ ƉĂŐĞƐ ŽĨ ƚŚĞ ǀĞƌLJ ĨŝƌƐƚ nĞǁ ?ŽƌŬ MĞĚŝĐĂů CŽůůĞŐĞ LJĞĂƌŬ͕ ǁŚŝĐŚ ǁĂƐ ĐĂůůĞĚ ƚŚĞ ͞lůĞƵƌͲCͲSĐŽƉĞ͘͟ lƚ ŝƐ ďĞůŝĞǀĞĚ ƚŚĂƚ ŚĞ ŵĂLJ ŚĂǀĞ ĚĞƐŝŐŶĞĚ Ă ǀĞƌƐŝŽŶ ŽĨ ƚŚĞ nĞǁ ?ŽƌŬ MĞĚŝĐĂů CŽůůĞŐĞ ƐĞĂůͶǁŝƚŚ ŝƚƐ ƐŝŐŶĂƚƵƌĞ ͞ƐŝŶŐůĞ ƐĞƌƉĞŶƚ͟ ĚĞƐŝŐŶͶ ƚŚĂƚ ǁĂƐ Ă ĨŽƌĞƌƵŶŶĞƌ ŽĨ ƚŚĞ ƐĞĂů ǁĞ ƵƐĞ ƚŽĚĂLJ͘ AŶĚ ƚŚĞ ŽƌŝŐŝŶĂů CŚŝƌŽŶŝĂŶ͕ ǁŚŝĐŚ ŚĂƐ ŵŽƌƉŚĞĚ ŽǀĞƌ ƚŚĞ LJĞĂƌƐ ŝŶƚŽ ŽƵƌ ƵŶŝǀĞƌƐŝƚLJͬĂůƵŵŶŝ ŵĂŐĂnjŝŶĞ͕ ǁĂƐ ƚŚĞ ďƌĂŝŶĐŚŝůĚ ŽĨ ŵĞĚŝĐĂů ƐƚƵĚĞŶƚƐ͕ ǁŚŽ ǁƌŽƚĞ ĂŶĚ ŝůůƵƐƚƌĂƚĞĚ ƚŚĞ ĨŝƌƐƚ ĨĞǁ ĞĚŝƚŝŽŶƐ ŽĨ ƚŚĞ ŵĂŐĂnjŝŶĞ͘ vŽůƵŵĞ ϭ͕ lƐƐƵĞ ϭ͕ ĚĂƚĞĚ ϭϴϴϰ͕ ĐŽŶƚĂŝŶĞĚ ĐůŝŶŝĐĂů ĐĂƐĞƐ͕ ŵĞĚŝĐĂů ƐĐŚŽŽů ŶĞǁƐ͕ ĞĚŝƚŽƌŝĂůƐ͕ ƐĞǀĞƌĂů ƉŽĞŵƐ͕ ĂŶĚ ĂŶ ĂƌƚŝĐůĞ ĞŶƚŝƚůĞĚ ͞vĂƐƐĂƌ CŝƌůƐ͛ SůĂŶŐ͘͟ ;1ŚŝƐ ĂŶĚ ŽƚŚĞƌ ŚŝƐƚŽƌŝĐĂů ƚƌĞĂƐƵƌĞƐ ĂƌĞ ƐĂĨĞůLJ ĞŶƐĐŽŶĐĞĚ ŝŶ ŽƵƌ PĞĂůƚŚ SĐŝĞŶĐĞƐ LŝďƌĂƌLJ ĂƌĐŚŝǀĞƐ͘Ϳ WĞ ďĞůŝĞǀĞ ƚŚĞ ĐŚĂƌĂĐƚĞƌŝƐƚŝĐƐ ƚŚĂƚ ŵĂŬĞ Ă ŐŽŽĚ ƉŚLJƐŝĐŝĂŶ͕ ůŝŬĞ ƚŚŽƐĞ ŽĨ ƚŚĞ ĂƌƚŝƐƚ͕ ĂƌĞ ĨŽƵŶĚ ŝŶ ƚŚĞ ĐŽŵƉĂƐƐŝŽŶĂƚĞ ŚĞĂƌƚ ĂŶĚ ƚŚĞ ĐƌĞĂƚŝǀĞ ŵŝŶĚ͘ lƚ ƐŚŽƵůĚ ĐŽŵĞ ĂƐ ŶŽ ƐƵƌƉƌŝƐĞ ƚŚĂƚ ŽƵƌ ƐƚƵĚĞŶƚƐ ŚĂǀĞ ƐƚƌĞŶŐƚŚƐ ŝŶ ďŽƚŚ͘ 1ŚĞLJ ĂƌĞ ĂƌƚŝƐƚƐ͕ ŵƵƐŝĐŝĂŶƐ͕ ƉŚŽƚŽŐƌĂƉŚĞƌƐ͕ ƉŽĞƚƐ͕ ĚĂŶĐĞƌƐ͕ ŶŽǀĞůŝƐƚƐ ĂŶĚ ǀŝĚĞŽŐƌĂƉŚĞƌƐͶĂŶĚ ƚŚĞLJ ĂƌĞ ŐŽŽĚ ƉŚLJƐŝĐŝĂŶƐ ŝŶ ƚŚĞ ŵĂŬŝŶŐ͘ 1ŚĞƌĞĨŽƌĞ͕ ǁĞ ǁĞůĐŽŵĞ ƚŚĞ ĐŚĂŶĐĞ ƚŽ ƐĞĞ ĨŝƌƐƚ ŚĂŶĚ ǁŚĂƚ ƚŚĞLJ ĐĂŶ ĚŽ ǁŝƚŚ ǁŽƌĚƐ ĂŶĚ ǀŝƐƵĂů ŝŵĂŐĞƐ͕ ĂƐ LJŽƵ ǁŝůů ĞdžƉĞƌŝĞŶĐĞ ŝŶ ƚŚŝƐ ůĂƚĞƐƚ ĞĚŝƚŝŽŶ ŽĨ CƵŝůů Θ SĐŽƉĞ͕ ƚŚĞ nĞǁ ?ŽƌŬ MĞĚŝĐĂů CŽůůĞŐĞ ƐƚƵĚĞŶƚ ŵĞĚŝĐĂů ũŽƵƌŶĂů͘ ÞƌĞƉĂƌĞ ƚŽ ďĞ ŵŽǀĞĚ ĂŶĚ ŝŶƐƉŝƌĞĚͶĂƐ ǁĞ ĂƌĞ͘ WĞ ĂƌĞ ƉƌŽƵĚ ŽĨ ŽƵƌ ƐƚƵĚĞŶƚƐ͕ ĂŶĚ ǁĞ ĂƌĞ ĞƐƉĞĐŝĂůůLJ ŝŶĚĞďƚĞĚ ƚŽ ƚŚĞ ƐƚƵĚĞŶƚ ĞĚŝƚŽƌƐ ǁŚŽ ĂƐƐĞŵďůĞĚ ƚŚŝƐ ǁŽŶĚĞƌĨƵů ĚŝƐƉůĂLJ ŽĨ ƚĂůĞŶƚ͘ l ŝŶǀŝƚĞ LJŽƵ ƚŽ ĞŶƚĞƌ ƚŚĞƐĞ ƉĂŐĞƐ ĂŶĚ ĞŶũŽLJ ƚŚĞ ĨƌƵŝƚƐ ŽĨ ŽƵƌ ƐƚƵĚĞŶƚƐ͛ ĂƌƚŝƐƚŝĐ ůĂďŽƌƐ͘ kĂƌů Þ͘ AĚůĞƌ͕ M͘u͘ ÞƌĞƐŝĚĞŶƚ ĂŶĚ CŚŝĞĨ LdžĞĐƵƚŝǀĞ CĨĨŝĐĞƌ N E W Y O R K M E D I C A L C O L L E G E 40 SUNSHINE COTTAGE ROAD, VALHALLA, NEW YORK 10595 TEL 914-594-4500 FAX 914-594-4565 [email protected] PAUL M. WALLACH, M.D., F.A.C.P. VICE DEAN FOR MEDICAL EDUCATION “Hi HRU? K School? KGoingtomall Havefun.ILY. LY2TTYL” Ourfamilyrepresentstheposterchildrenforthefamilycellphoneplan:fiveindividuals,fivephones…nowwith unlimitedtexting.ThatdecisionfollowedamonthwhereIwaschargedfor1800textmessagesmadebyone memberofourfamily;that’s60aday!Istillfindithardtobelievethatsheisabletosendthatmanytexts,but withoutadoubt,textmessagingisapartoftoday’s“communication”system.Whiletextmessagingisperfectly OKfortheoccasionalmessage,Iamconcernedthatrelyingontextingforamajoramountofcommunication furthererodesourabilitytocommunicateeffectivelyinthemoreformalwrittenorspokengenres. Effectivecommunicationremainsacentralskillforphysicians,healthcarepractitioners,andhealthscientists. Highqualitywrittencommunicationcontributesextensivelytoourprofession.Inwriting,wecapturetheclinical courseofourpatientssothatotherhealthcareproviderswhocometoseethesamepatientunderstandour thinkingaboutthepatient.Inwriting,wesharescientificandotherscholarlyfindingswithcolleaguessothat ourworkcanbeevaluatedbypeersandsothatotherscanbenefitfromtheresearch.Inwriting,wesharethe storiesofourfieldandcontributetothefabricofmedicine.Thesestoriesaddtotherichnessofmedicineasan art,captureexperiencesthathavemovedus,andleavealegacyforthosewhofollow.Wespeakaboutour successesandourfailures,aboutourpatientsandourteachers,aboutourhopesandourfears,aboutwhatwe learnwhenphysiciansbecomepatients,aboutourrelationships,aboutwhatitmeanstobeadoctor.Similarly, theartisticexpressioninphotography,drawing,andothervisualartsalsocaptureourexperiencesrichly. IwashonoredtobeaskedtowriteanoteofintroductionforthisissueofQuill&Scope.Herein,ourstudents communicatebeautifullyabouttheirexperiencesasphysiciansͲinͲtraining.Theyhavewrittenreviews,poetry, commentaries,essays,clinicalexperiences,andscientificpapers.Theyhavepresentedartworkthatspeaks thousandsofwords.Iamproudoftheworkproductsofourstudentsthatarepublishedhere,acknowledge theirefforts,andwishthemgreatsuccessinthefuture. Ithankthemforchoosingtocommunicatesoeffectivelythroughthisvenueandencourageotherstosimilarly expressthemselves.Wewillallbericherforit.CongratulationstoeditorsJennyLamandEdwardHurley,and FacultyExecutiveAdvisor,Dr.GladysAyala. GTG.TTYL. Myverybest, PaulM.Wallach,MD ViceDeanforMedicalEducation 1860~2010 BUILDING ON THE EXCELLENCE OF OUR PAST Sir William Osler is regarded as the pre-eminent physician of the 20th century and ideal medical practitioner because of his humanism, his view that the practice of medicine is an art based on science, his thoughts on education, and his philosophy of life. Osler had a lifelong devotion to books and libraries. His influence and legacy, not only in the areas of clinical, educational, and literary spheres, remains strong and lives through his vast writings. Osler states that: "a library represents the mind of its collector, his fantasies and foibles, his strengths and weaknesses and preferences....The friendships of his life, the phases of his growth, the vagaries of his mind, all are represented.” As a foreword to this 3rd edition of the Quill and Scope, which coincides with NYMC’s Sesquicentennial Anni- versary, I have chosen to highlight some of Sir William Osler quotes that contemplate the importance of culture, of read- ing literature and non-science books, and the value of studying the humanities to the lifelong study of medicine. Taken from “The Quotable Osler”, edited by Silverman, Murray, and Bryan, 2003: No. 25: Books influence character. Carefully studied, from such books come subtle influences which gives stability to character and help to give a man a sane outlook on the complex problems of life. No. 26. Culture is helpful to physicians. A physician may possess the science of Harvey in the art of Sydenham, and yet there may be lacking in him those finer qualities of heart and head which count for so much in life....medicine is seen at its best in men whose fac- ulties have had the highest and most harmonious culture. No. 150. Cultivate your hearts and your heads. Be careful when you get into practice to cultivate equally well your hearts and your heads. No. 179. The practitioner also needs culture. One cannot practice medicine alone and practice it early and late, as so many of us have to do, and hope to escape the malign influences of her routine life. The incessant concentration of thought upon one subject, however interesting, then there's a man's mind in a narrow field. The practitioner needs culture as well as learning. No. 611. Without reading, a physician sinks to a low-level trade. A physician who does not use books and journals, who does not need a library, who does not read one or two of the best weeklies and monthlies, soon sinks to the level of the cross-counter pre- scriber, and not alone in practice, but in those mercenary feelings and habits which characterize a trade. No. 613. Reading benefits the mind. There is no such relaxation for a weary mind as that which is to be had from a good story, a good play or good essay. It is to the mind what sea breezes and the sunshine of the country are to the body -- a change of scene, a refreshment and a solace. No. 631. Expand your interest. Every day do some reading or work apart from your profession. I fully realize, no one more so, how absorbing is the profession of medicine; how applicable to it is what Michelangelo says "there are sciences which demand the whole of a man, without leaving the least portion of his spirit free for other distractions;" but you will be a better man and not a worse prac- titioner for avocation. With great pleasure and honor I introduce you to the third edition of the NYMC Student Journal, the Quill and Scope. This literary journal showcases the work of many students. Through these original articles, commentaries, poetry and artwork we can cultivate our hearts and minds as Osler still teaches us today, more than 150 years after his life. Congratulations to Jenny Lam and Edward Hurley for their dedication and hard work as editors-in-chief, they have taken this journal to the next level. Congratulations to the entire editorial staff, everyone that contributed their time and efforts in making this successful, and especially to the students that contributed a piece of themselves in their schol- arly work. My sincerest good wishes to all the readers, new and old, of the NYMC Student Journal, Gladys M. Ayala, M.D., M.P.H. Senior Associate Dean for Student Affairs Executive Faculty Advisor Sifting through the 1880’s Chironian, the student publication of then New York Homeopathic Medical College, offers a fascinating glimpse into the hallowed halls of the school founded on 20 th Street and 3 rd Avenue. Its old, time-worn pages reveal how the driving force of medical students has changed little: an insatiable appetite for knowledge, humanistic desire to alleviate suffering, and the belief in just and equita- ble healthcare. The year 2010 marks New York Medical College’s 150 th anniversary. In honor of such a historical milestone, Quill & Scope dedicates this third volume to the faculty and alumni who tirelessly helped shape the College into the premier academic medical institution it is today. Since its founding in 2008, Quill & Scope has served as a forum for the discussion of the personal, ethical, political and socioeconomic facets of medicine that are not often discussed in the class- room or on the wards. Topics explored in the past two issues include healthcare disparities, contro- versies of vaccination, military medicine, bioterrorism and international aid. It showcases the wide range of literary, artistic and academic endeavors of burgeoning healthcare professionals as they reflect on today’s ever-evolving medical environment. Through editorials, commentaries, essays, poetry, and artwork, we hope to demonstrate that the practice of medicine continues to be founded on empathic and patient-centered care. The theme of Quill & Scope Volume 3 is as a retrospective on the transformations that have oc- curred over the years, beginning with the insights of Dr. Weg, a distinguished alumnus trained at Flower Hospital, to the advances of women in medicine and the construction of new buildings in the current campus location in Westchester. Readers will also find timely articles on health-care policy and universal health care, the influence of social networking on human rights movements, as well as the impact of information technology on the management of diabetes. The Quill & Scope has an annual distribution of 1,500 copies to students, alumni, deans, faculty and the Board of Trustees. With a staff of 30 students, more than 25 contributors from all four classes, and a faculty review board, the student medical journal has grown tremendously since its inception and established a presence at the College. We are grateful to our dedicated editors, the editorial review board, our advisor Dr. Ayala, generous donors and the student body, without whose support the journal would not have been possible. It is with great pride that we present to the New York Medical College community this collection of literary and artistic pieces by our fellow medical students, and we hope to continue in the tradi- tion of excellence first set by our predecessors many years ago. Edward Hurley & Jenny Lam Editors-in-Chief EDITOR’S INTRODUCTION CONVERS ATI ON Sitting Down with Dr. John Weg: Pulmonary Medicine Pioneer 2 Recently, the Quill & Scope’s Jenny Lam and Edward Hurley spoke with pulmonary medicine pioneer Dr. John Weg, Class of 1959, about his career, medicine in general and his time at New York Medical College. COMMENTARY Women in Medicine 6 Marissa Friedman The 150 th Anniversary of New York Medical College inspires a reflective look into the journey of women in medicine. In a time when women did not receive the same rights as men, a few courageous women pushed to open the field of medicine for all to study. One of these women, Dr. Clemence Sophia Lozier, founded the first women’s medical school in New York City, New York Medical College for Women. In 1918 this school became incorporated into the original New York Medical College, to be- come the co-ed school known today. Despite small growth in the numbers of women physicians throughout most of the 20 th century, women currently account for half of medical students in the United States. Planck Versus Poe: Scientific and Poetic Approaches 8 Anita Kelkar P A M Dirac wrote that "In science one tries to tell people, in such a way as to be understood by every- one, something that no one ever knew before. But in poetry, it’s the exact opposite." Dirac's quote con- fronts us with the question: Do both the scientific and poetic approaches ultimately enjoy equal success in expanding human knowledge? Antidepressants Misrepresented 12 Steve Rockoff In a January 2010 study conducted at the University of Pennsylvania, investigators determined that for patients who had less than “very severe depression”, antidepressants have no measurable effect on de- pressive symptoms when compared to placebo. This resounding statement was widely circulated by every major national media outlet. If true, it has powerful implications for the millions of Americans who are currently prescribed antidepressants. The commentary at hand highlights several glaring flaws in the design and conclusions of these researchers’ meta-analysis, in an attempt to portray their findings in a less alarming and more realistic light. An Examination of Three Model Healthcare Delivery Systems 18 Gavin Stern The United States is just now beginning its journey into a universal healthcare delivery system. On March 30, 2010, President Obama signed into law the “Health Care and Education Reconciliation Act of 2010” (H.R. 4872), which completed the work of the “Patient Protection and Affordable Care Act” (H.R. 3590) signed on March 23, 2010. The effects of this legislation are phased in over the course of this new decade, but the final product is far from certain. Implementation could be legislated away with one election cycle. This article examines three model healthcare delivery systems that the United States could look towards on its march to universal coverage: those of France, Germany, and the Netherlands. Homeopathy 24 Charles Volk For the first 50 years of NYMC's history, the school taught a form of medicine called 'homeopathy'. What is this form of medicine and what would it be like to go to a homeopathic medical school? The author shares his experiences in the world of alternative medicine and the time he spent in a homeo- pathic academy learning about energy medicine, impossibly diluted compounds, how the germ theory is wrong, how science is incorrect, and how miasms are at the core of all human suffering. Our Valhalla: Thirty-Eight Years of the ’New’ NYMC 29 Gavin Stern “Our Valhalla” describes the history of the New York Medical College Valhalla campus, now nearly 40 years old. The article details how the campus evolved into its present form, including events leading to the closing of Flower & Fifth Avenue Hospital. Research for this article included consultation with fac- ulty, articles from the New York Times, and archived yearbooks. Photographs were collected from the Health Sciences Library and are interspersed throughout the issue. I NTERNATI ONAL MEDI CI NE A Lesson from Iran: Improving Rural Primary Health Care in The United States 34 Navid Shams In 1979, about a third of Iran’s population was living in rural areas that were mostly out of contact with health services. In the times of change that followed the revolution, primitive infrastructure and lack of resources challenged the development of a rural primary health care program. Successful implementa- tion of novel techniques, such as the use of front line health workers, led to political commitment, the program’s expansion, and much improved health status indicators. The program is now considered the foremost example among rural primary care systems. Consequently, Iranian experts have recently begun aiding in the development of a similar program in Mississippi, a state with some of the worst health sta- tistics in the country. Social Networking Tools in the Modern Era of Human Rights Protection 37 Odessa Balumbu, Richard Fazio, Mera Geis, and Michael Karsy Human rights are fundamental liberties that should be guaranteed to all human beings. These include things such as access to education and health care, food security, freedom from persecution and access to shelter, safety and security. Human rights promotion and international development have become popular philanthropic efforts and new technology is helping younger generations participate more easily. Whether through activism, fundraising or volunteering, there are many ways to make a difference. Pro- moting the awareness of and access to human rights is a job everyone can and should be a part of. Another Look: Medical Cooperation and the Israeli-Palestinian Conflict 42 Danielle Masor P A M Dirac wrote that "In science one tries to tell people, in such a way as to be understood by every- one, something that no one ever knew before. But in poetry, it’s the exact opposite." Dirac's quote con- fronts us with the question: Do both the scientific and poetic approaches ultimately enjoy equal success in expanding human knowledge? Njinga 46 Stuart Mackenzie This piece is based upon my experiences over the course of 18 months in Lusaka, Zambia with the Cen- ter for Infectious Disease Research in Zambia (CIDRZ). I worked with patients in HIV/AIDS clinics across the country, coordinating community health initiatives and assisting in small business develop- ment for HIV support groups. In this setting, the limits and discrepancies in access to health care, nutri- tion, employment and education were stark and sobering, but it wasn’t necessary to venture into the heart of a compound to witness the risk factors faced by most Zambians. A simple commute to work was enough to see the effects of poverty and the threat of disease. My work and time in Zambia has im- pressed upon me the importance of understanding a patient’s life and context outside of the clinic, in order to treat them effectively within the clinic. COMMUNI TY HEALTH Cancer Education and Awareness Program: Education and Its Role in the Prevention of Cancer 50 Sukhpreet Singh As U.S. healthcare accelerates into an era of science fiction, we find that most diseases are treatable via technological intervention. This has, unfortunately, reduced the role of the physician as the patient’s teacher and advocate in the clinical setting. The Cancer Education and Awareness Program attempts to tackle one of the worst diagnoses a patient can receive, and dispel the misconceptions the general popu- lation has about the prevention of disease. We do this by reaching out to high school students in the local community, and through the method of storytelling, we teach them the science behind the disease. This allows them to be able to appreciate a more tangible aspect of disease that seems generally out of their reach. CEAP has tried to bring back the role of the physician as an educator by taking this role straight into a high school classroom. We hope this will allow our target audience to learn about the relevant consequences of their decisions now, and to impact their health in the future. POETRY & FI CTI ON Alanna Chait - Life Fuel 53 Daniel Waintraub - For Only A Moment 54 Navid Shams - Resident 56 Andrei Kreutzberg - Medamorphosis 57 Poonam Kaushal - Vitality 58 Jordan Roth - The Shell 60 Linda DeMello - It’s Gonna Be All Right 61 ORI GI NAL FI NDI NGS Telemedicine Management of Diabetics in an Underserved Community 64 J. Paul Nielsen and Pranav Mehta, M.D. Information technology via telemedicine offers the potential for cost-effective and active management of type 2 diabetes mellitus for people in high-risk underserved communities such as Harlem, NY and the Bronx, NY. Telemedicine is the use of telecommunications technology for medical diagnostic, monitor- ing, and therapeutic purposes to communicate information instantaneously from one location to another, such as from a patients’ home to a hospital. We compared the baseline Hemoglobin A1C levels to the levels recorded after the patient was enrolled in the Housecalls telemedicine program for at least 3 months. The initial results indicate that the Housecalls program is effective in improving compliance and management of diabetes. The initial success of the program is encouraging and demonstrates a great po- tential for the use of telemedicine in monitoring chronic disease. Can Cycles of Neddylation and Deneddylation Provide Points for Possible Therapeutic Intervention? 67 Nadia Nocera Neddylation plays a critical role in proteosomal degradation and the progression of the cell cycle. Inter- fering with the process of neddylation and deneddylation could provide points of therapy by promoting cell death or cell cycle arrest in cells that are undergoing rapid proliferation, such as in tumors. The cy- cle of neddylation and deneddylation is essential for cellular processes, and if it is inhibited or amplified in some way, this may disturb the proliferation of tumor and with further research, it may be used as a target for cancer therapy. Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female 72 Lea Alfi In this clinical vignette, a third year medical student explores what may be ailing a 67-year old woman with ascites and lower extremity edema. MEDI CAL S TUDENT RES EARCH FORUM Resilience in the Third Year of Medical School: A Prospective Study of the Associations Between Stressful Events Occurring During Clinical Rotations and Student Well-Being 76 Paul S. Nestadt, et al Wait List Death and Survival Benefit of Kidney Transplantation among Extra-renal Transplant Recipients 77 James Cassuto et al Racial Differences in Bronchopulmonary Dysplasia Severity for Neonates with Mitochondrial Su- peroxide Dismutase Polymorphism 78 Edward Hurley et al. Using Fluorescence in situ Hybridization (FISH) to Examine the Prevalence of ETS Gene Fusions in a Large Prostatectomy Cohort. 79 Christopher J. LaFargue et al. Use of EGFR Genetic Analysis to Potentially Expand Treatment Options for Patients With Vulvar Squamous Cell Carcinoma 80 Susan L. Boisvert et al. Arachidonate 5-Lipoxygenase Expression in Papillary Thyroid Carcinoma Correlates with Inva- sive Histopathology and Promotes Extracellular Matrix Degradation via MMP-9 Induction 81 Nicolas T Kummer et al. ART AND PHOTOGRAPHY Eliott Lee - Administration 5 Ian Hovis - A young Ghanian woman captured in a balancing act on the streets of Accra 33 Katrina Bernardo - If They Knew… 48 Ava Asher - Man Huddled and Man Leaning 49 Anna Djougarian - Transformation of the Medical Student 52 Linda DeMello - Skull Rock 55 Luke Selby - Spring Break at Night 59 Radeeb Akhtar - Untitled Nude 63 Sabrina Perrino - Ocean Beach Pier 75 Julie Grimes - Wendell Park 82 Ann Tran - Infinity 83 In 1959, Dwight D. Eisenhower was president. Gas cost about 30 cents a gallon. To mail a let- ter, which people did in 1959, only cost four cents for a stamp! That same year, Dr. John Weg graduated from New York Medical College. After a five decade long career, he is still involved in research and teaching at the University of Michigan, where he is an emeritus professor in the Internal Medicine Department. A pioneer in the field of pulmonary medicine, Dr. Weg re- ceived a Medal of Honor award from NYMC in 1990. Recently, the Quill & Scope’s Jenny Lam and Edward Hurley spoke with Dr. Weg about his career, medicine in general and his time at NYMC. An edited transcript follows: Q&S: What motivated you to go into medicine? Dr. W: I’ve always been the type of person who wants to take care of people. Even in grammar school I would tell my friends that I wanted to be a doctor some day. Q&S: How has pulmonary medicine specifically changed since you started medicine? Dr. W: When I started, tuberculosis was the major problem for pulmonary disease. It was really wide spread. Many people unfortunately were put inside the sanitarium for months if not years. We started to try and ventilate people who had other kinds of lung disease like chronic obstruc- tive pulmonary disease (COPD) and the machines we had were not really adequate. We had an iron lung, which was great for polio because the person couldn’t fight against the machine, but somebody with COPD or severe asthma would fight against that machine and you couldn’t ad- just it, so we had to use pressure control ventilators which made you almost literally had to sit there and adjust the machine as their compliance and resistance changed in order for them to get an adequate breath. It was an exciting time. You didn’t have everything handed to you on a platter where the machine did everything automatically or almost automatically. I liked that. That was interesting. Q&S: Could you give us an overview of your career in terms of the mix of patient care, research, teaching, and administration that you have done? Dr. W: How do I spend my time? Probably close to half of my time was spent taking care of patients and much more than half of that was spent in the intensive care unit (ICU), which was a respiratory care unit, which then became a critical care medicine unit. When people get very sick they almost always need a ventilator for whatever reason they get sick, whether it be a dia- betic coma or something else. So the sicker you are, the more likely you are to require a ventila- tor. That was a subset of sick people. I finished my training with the Air Force as head of the pulmonary and infectious disease unit. Then I worked at Jefferson Davis hospital in Houston, which is part of the Baylor Medical School and opened the intensive care unit there, which was the first in Houston. It was phe- nomenal. We went from scratch, to teaching nurses how to do things when they come in to see the patient on each of the trips. Sitting Down with Dr. John Weg: Pulmonary Medicine Pioneer 2 And then when I came to the University of Michigan in 1971, it was the same study all over. We tried to open an ICU. I brought a nurse with a masters degree in pulmonary medicine from Houston, [she] provided a course for the nurses at the University of Michigan. And the same way, we had the nurses assigned and I would come in on different shifts to make sure they were doing what was correct, but more importantly to give them support so they would have it when they needed it. Mixed into all of that would be the research on how to provide better care in the intensive care unit – what’s a better way to ventilate. Then another area that I spent a fair amount of time in was improving diagnosis of pulmonary embolism. We have been conducting studies in that area and I’m not the PI of it all, but I was the one in Michigan for over 25 years now. Looking at dif- ferent ways of diagnosing, and looking at combinations of things that provide the most efficient diagnosis at the least cost and least invasiveness for the patient. I still am working on some of that. Q&S: You have done extensive research in venous thrombo-embolism. How would you describe the change in approach to this pathology since you started? Dr. W: You made the diagnosis on the physical exam, the chest X-ray, EKG, and blood gases, but as it turns out none of those was very helpful because they were not specific. Then in the late 1960’s we began using ventilation perfusion scans. Then one of the first multi-center stud- ies I was involved in was trying to evaluate how good that was in making a diagnosis. It turns out it was not very good. It can only assure you that there was a pulmonary embolism or not in roughly a quarter of the patients. In the others it was not specific enough to say if it was a PE or not. And then from that we moved on to do CT Pulmonary Arteriography and that is very accurate and very specific. However, what we realized there is a lot of radiation involved. Most recently we looked up Magnetic Resonance Angiography, which has no radiation. You don’t have to worry about the die causing problems with allergies but we found roughly a quarter of the stud- ies were not good enough to be interpreted as to whether it was a PE or not. We went back to look at the ventilation perfusion scans. The test was actually much better than we had thought. Ventilation perfusion scans got a new life. Q&S: With all of these progressions and improvements in technology, do you think the quality of medicine has been hurt at all? For example, would people depend more on the ventilation perfusion scans and then miss something that could have been diagnosed in the physical diagnosis? Dr. W: I think that is always a concern. Your really have to start with the basics. The most im- portant thing is to get a very good history from the patient, in real detail and take the time to do it. If you end up using the wrong test for the wrong patient then that usually leads to a wrong answer. All these tests are good only after you get an adequate, accurate history of the patient in great detail. Select from that what’s most likely to be right and then move forward. If you go right to the test, as some people do, you generate lots of costs, considerable radiation, and you expose some people that really aren’t going to benefit from the test. Sitting Down with Dr. John Weg: Pulmonary Medicine Pioneer 3 Q&S: What do you think has been the greatest discovery or invention since you gradu- ated from medical school, in the medical realm? Dr. W: I think there have been many contributions to a whole variety of areas. I think one large area is in visual images, whether it’s a chest X-ray or a CT or magnetic resonance. They really improve, if they’re selectively used, our ability to diagnose without first deciding to do some- thing like a laparotomy to find out whether someone has an intra-abdominal problem. I think they’ve made a major improvement in the diagnostic area. In other areas, just speaking of the things that I’ve been talking about, the need to adequately anti-coagulate patients with warfarin and then with heparin has improved greatly from when I first started. We really didn’t understand how to monitor the use of warfarin and we weren’t doing the right tests because we didn’t know what to do. So we moved from just looking at a prothrombin time to looking at something called an international normalized ratio (INR). With heparin, we now have a short acting one. Now whether any of that would be the greatest, I don’t know. You can make a great case for the antibiotics. And I don’t think the ones I mentioned are at all inclusive. Q&S: Can you compare and contrast the difference between the campus here, and I as- sume you went to the Flower Hospital? Dr. W: Flower Hospital [was] right in Central Park, as well as part of the medical school. If you went more than a block east from there or less, you were in a very low socioeconomic area with considerable rates of crime. There was no campus, we just had two buildings: the hospital and the one building of the medical school that were hooked together as one. There were no amenities. The students would find housing in the neighborhood, some was nice, some was not so nice – more was not so nice – and then others like myself commuted because I was married and we had children at the end of the first year. So I commuted from the Bronx for a little while, then I commuted from Flushing. The [Valhalla] campus is gorgeous. It’s really ex- panded. Q&S: What’s your theory behind sarcoidosis? Do you think it’s viral, bacterial, or purely autoimmune? Do you have a theory behind what causes sarcoidosis? Dr. W: The short answer is I have no idea. Years ago we looked at a group of patients with sar- coid. I started doing sarcoid when I actually went into the Air Force, to see whether they’re re- active to the atypical mycobacterium differently and they did all react. We postulated whether there was over-reaction to one of these atypical bugs, but it didn’t go anywhere. I was on the NIH committee that looked at extensive studies, at viral studies, and they didn’t find anything. I didn’t do any of those studies but we looked at multiple people that were going to do research. It seems to be an altered immunity, but an altered immunity to what – I don’t think we know. Sitting Down with Dr. John Weg: Pulmonary Medicine Pioneer 4 Eliott Lee Administration Women in Medicine Marissa Friedman Looking across the rows of seats in the Cooke Auditorium at my fellow female medical stu- dents, I cannot help but feel a sense of accomplishment and gratitude. Especially as we begin to celebrate New York Medical College’s 150 th anniversary, I am reminded of how lucky I am to be alive in this day and age, when women actually have the opportunity to pursue a career as a physician. New York Medical College has played an important role in promoting the presence of women in medicine. Only three years after the founding of the original college in 1860, the as- sociated New York Medical College for Women was founded by Dr. Clemence Sofia Loz- ier. She was one of the first women in the United States to practice medicine, and is credited with being the pioneer of women’s medical education. Dr. Lozier first started as a teacher, opening a primary school for young women. Having a passion for helping others, she became inspired by the story of the first female medical doctor in the United States, Elizabeth Black- well. Blackwell graduated from Geneva Medical College in upstate New York in 1849. After hearing this, Lozier decided that she too wished to have a medical degree and tried to attend the same college. However, the medical college in Geneva decided that one woman physician was enough, and refused to admit Lozier as a student. Eventually, Lozier attended medical lectures at Central New York College at Rochester, and was finally admitted to Syracuse Eclectic Col- lege, where she graduated in 1853. 1 When Lozier returned to New York City to practice medicine, she was met with great suc- cess, despite the fact that she was a woman. She did however continue with her teaching roots and desire to educate women by holding various health-related lectures out of her own home. These lectures on familiar medical fundamentals, such as anatomy and physiology be- came packed with women. Lozier realized that there was a strong desire by women to learn medicine, and that prompted her to eventually create the New York Medical College for Women, the first school of its kind in New York City and the lower New York area. Although the College had an all-male faculty and only seven female students in its first class, it was responsible for some remarkable accomplishments. This includes the graduation of Elizabeth Stowe in 1867, as the first female physician to receive a medical education in New York City. When Stowe returned to her native country, she became the first female physician in Canada. This was followed by the graduation of Dr. Susan Mckinney in 1870 as the first Afri- can-American graduate in New York State and only the third in the nation. 2 This was undoubt- edly amazing considering that this was going on far before women had not yet even received the right to vote. As a matter of fact, at that time, the American Medical Association did not allow female doctors to become members. In addition, most hospitals did not permit women to obtain intern- ships, and thus the only hospital available to women for training was the Women’s hospital as- sociated with New York Medical College. It was not until 1918 that other hospitals such as Bellevue opened up its doors to female medical students 1 . It was also in 1918 that the New York Medical College for Women officially closed and transferred its students to the original 6 and previously male-only New York Medical College, thus transforming it into a place for both men and women to receive a medical education. Around this time, the AMA started to allow women to become members. 3 Despite the groundbreaking headway that began at the end of the 19 th century, the percent- age of woman physicians remained low throughout most of the 20 th century. By 1890, only 5% of physicians in the United States were women. This only increased to approximately 17% dur- ing the 1980s. Despite the small numbers, likely due to social constraints that categorized women as homemakers and a view that the medical profession was a “man’s job,” women still made remarkable contributions to the medical field. Dr. Gerty Cori is a name that may sound familiar to first year students as one of many No- bel laureates thrown on the screen during a lecture for Biochemistry. What many students might not realize is that Gerty Cori’s accomplishment goes far beyond just the discovery of the role of phosphorylase in glycogen metabolism. She was the first woman to receive the Nobel Prize in Medicine in 1947. This act contributed not only to solidifying the fact that women could be renowned physicians, but also brilliant physician scientists. 4 This brings me back to my first year lecture hall, where I look around and notice that there seems to be an equal amount of male and female faces. Actually, since the turn of the 21 st cen- tury, a great change has started to occur within the medical profession. In 2002, 25.2% of all U.S. physicians were women, almost double the 1980 figure 5 . Still, by far the biggest change is occurring now in medical schools across the country. According to the Association of Ameri- can Medical Colleges (AAMC), the total number of women entering medical schools has in- creased each year since 1982. Moreover, the percentage of women in medical school classes has increased from less than 31.4% in 1982-1983 to 49.6% in 2003-2004. In 2008-2009, women represented 48.8% of the students receiving M.D. degrees. This was the highest num- ber of female medical school graduates to date. 5 This increase in the number of women in medi- cal school is evident even here at New York Medical College where the class of 2010 is com- prised of 54% females and 46% males 2 . As I begin my own journey in medical education, I am very proud to attend a school such as New York Medical College that played such an important role in allowing women to pursue careers in medicine. Furthermore, I can’t help but pay hom- age to the brave trailblazers such as Dr. Blackwell and Dr. Lozier, who made it possible for women like me pursue a dream of becoming a physician. R E F E R E NC E S [1] Cazalet S.“History of the New York Medical College and Hospital for Women”.2001.Accessed 30 Dec. 2008.http://www.homeoint.org/cazalet/histo/newyork.htm [2] “About NYMC:History”.New York Medical College Website. 2009.Accessed 30 Dec. 2008.http:// www.nymc.edu/AboutNYMC/History.html [3] “Women’s History in America”.Women’s International Center. 1995.Accessed 30 Dec. 2008. http:// www.wic.org/misc/history.htm [4] “Women in Medicine: An AMA Timeline.”American Medical Association.2004.Accessed 30 Dec. 2008.http:// www.ama-assn.org/ama1/pub/upload/mm/19/wimtimeline.pdf [5] “U.S. Medical School Applicants and Students 1982-83 to 2009-2010”.Association of American Medical College. 2009.Accessed 30 Dec. 2008.http://www.aamc.org/data/facts/charts1982to2010.pdf Marissa Friedman: Women in Medicine 7 Planck Versus Poe: Scientific and Poetic Approaches Anita Kelkar The British theoretical physicist, Paul Adrien Maurice Dirac, wrote that "In science one tries to tell people, in such a way as to be understood by everyone, something that no one ever knew before. But in poetry, it’s the exact opposite." 1 This leads to the inevitable question: Do both approaches suggested in Dirac’s statement enjoy equal success in expanding human knowledge? 2 First it is necessary to explain the individual approaches of science and poetry. From there I hope to discover if an expansion of human knowledge actually occurs from these approaches. However, the phrase "human knowledge" is ambiguous and can mean different things. Human knowledge can refer to the knowledge obtained by humans about the world around them or it can represent knowledge about themselves. After taking into consideration every aspect of Dirac's statement, I hope to come to a conclusion of whether both approaches stated in the quotation enjoy equal success in expanding all aspects of human knowledge. "In science one tries to tell people, in such a way as to be understood by everyone, some- thing that no one ever knew before." According to Merriam-Webster science is defined as the "systematic acquisition of knowledge". This definition is the basis of the scientific method, which is the core of every researcher’s methodology. A researcher’s approach to a possible study begins with a review of background litera- ture that will ultimately culminate in a hypothe- sis. This is followed by a methods section and the actual experimentation, analysis, results and conclusions. Hence, when one is trying to relay scientific discoveries, one must provide data and statistical analyses to support one’s statement. This scientific approach has ultimately led to the evidence based medicine movement that dictates our approach to diagnoses and treatment today, Along with quantitative evidence of her discov- ery; the researcher must further prove that the conclusion is generalizable under all similar con- ditions. Generalizable information is an essential component for patient treatment. For example, if a certain cancer drug is proven to remain efficacious for all situations under all circumstances then the acceptance factor of that drug increases. Since there is no room for the statement to be denounced, it must be accepted. It is also important to explain this "systematically obtained knowledge" in such a way that it is understood precisely and unambiguously. The foremost goal of the scientific approach is for newly discovered information to be understood by all and accepted. The information must be easily understood by the audience, which requires the information to be worded in accordance to the ability level of the information receiver. This can be seen in the information dissemina- tion that occurs after a groundbreaking scientific discovery has occurred. When new discoveries are made in cancer research, the description of the discoveries written in JAMA will be more in 8 In the clinical sci- ences, lack of knowledge dissemination or accep- tance can have grave consequences" -depth and the language more technical than when the same discovery is relayed to AP Biology students in high school. The expressed information must be clear, precise and have no room for doubt or misinterpretation. It is only after the information has been conveyed in a precise man- ner, will the audience understand what is being said. The successful dissemination of scientific information requires the public to accept what is being said, for the public has gained knowledge only when the new information has been ac- cepted. In the clinical sciences, lack of knowledge dissemination or acceptance can have grave consequences. A prime example of this can be seen in the controversy regarding the supposed link between the MMR vaccine and autism. One of the authors of the Wakefield study that ini- tiated the link between vaccines and autism has recently stated “There is now unequivocal evi- dence that MMR is not a risk factor for autism -- this statement is not spin or medical conspir- acy, but reflects an unprecedented volume of medical study 3 .” Even before this statement, de- spite the volumes of data and scientific knowledge disproving the link between autism and vac- cines, millions of parents refused to accept this knowledge as true. Hence parents had been ulti- mately committing a harmful disservice to not only their children, but a disservice to the health of the public. The scientific approach for expanding human knowledge requires precision, clarity, evi- dence and generalizability of the information conveyed. Ultimately, regarding the expansion of the human knowledge, the strength of the scientific approach lies in the fact that information is presented in a clear, logical and unambiguous fashion, and is supported by analytical evidence. The second part Dirac’s statement requires the analysis of a poet's approach in extending human knowledge. Since poetry attempts to convey the poet’s ideas that may not be necessar- ily something new or unique or even easily understood, this method can be considered as al- most polar opposite of the scientific approach,. In po- etry instead of tangible and scientific facts, the "human knowledge" that is addressed, is the knowl- edge about human beings themselves. Poetry is de- fined as “writing that formulates a concentrated imaginative awareness of experience in language cho- sen and arranged to create a specific emotional re- sponse through meaning, sound, and rhythm.” 3 The poetic approach can be divided into two areas: one being how the poet states what she wants to say and the other is the content being of what she says. Each poet has his own unique style and is not required to conform. How then can one say that a poetic approach expands human knowledge? Unlike a scientist, a poet does not necessarily write for the purpose of disseminating new information. A poet writes to express his own emotions, describe an experience, provide inspiration; a poet’s intent is limit- less. Since the poet is not necessarily conveying a set message, the reader is free to interpret a poem in a way that appeals to himself. Unlike science where misinterpretation of conveyed in- formation can have serious consequences, poetry is open to many interpretations; interpreta- tions that the author may not have initially intended. One of the differences in interpretation can be due to the fact that it may be difficult for a person to understand an emotion they have yet to Anita Kelkar: Scientific and Poetic Approaches 9 A poet writes to express his own emo- tions, describe an ex- perience, provide in- spiration" experience. For example in Edgar Allan Poe's "A Dream" a heartbroken lover might see the plight of unrequited love, while a widower might see solitude and loneliness in it. A poet often makes a reader introspective and in doing so helps the reader explore the different facets of his being. Poetry has the ability to reveal to us, the reader, what is hidden and often what we refuse to see about ourselves. It may not be rash to say that poetry may be the mirror to one’s soul. Human knowledge is surely expanded by the poetic approach. The poetic method forces one to extend his imagination and enter the crevices of his own soul. Poetry evokes emotions and reactions, which subsequently give one insight into her thought processes. Not only does it rein- force feelings that may be already present, but poetry also provides a passage to emotions that one might not have yet experienced. It allows the reader to feel the poet's pain, loneliness, love or lust, or touch the tip of emotions that one has yet to embrace. The poetic approach expands human knowledge by ultimately developing or heightening one's self-awareness. If this method can expand this version of human knowledge, then this process to self-discovery is extremely critical as well. After discussing both approaches of two distinctly different fields it is clear that the each method is successful in its own right. The scientific, objective approach induces a growth of knowledge regarding the observable physical world of humans while the subjective poetic ap- proach focuses on self awareness. Both approaches are equally successful in expanding their angle of the already nebulous concept of human knowledge. Although the types of human knowledge ascertained are distinctly different, the approaches are not mutually exclusive. The scientific approach grants us information of our physical surroundings, and the interpretation of this knowledge helps us to gain insight about ourselves and our existence. Conversely, knowl- edge from self-discovery is necessary to discover our capacity and capability to deal with the outside world. Hence I must end here, for the only thing that remains certain can be summa- rized by the writer Samuel Coleridge, “During the act of knowledge itself, the objective and subjective are so instantly united, that we cannot determine to which of the two the priority be- longs." 4 R E F E R E NC E S [1] P.A.M. Dirac, H Eves Mathematical Circles Adieu (Boston 1977). [2] International Baccalaureate Theory of Knowledge Essay Topic [3] Merriam Webster Online Dictionary [4] P. Baker, D. Clements. “Does the MMR Vaccine cause Autism?” http://www.dukehealth.org/health_library/ advice_from_doctors/your_childs_health/mmr_vaccine_and_autism. (2007) [5] Samuel Coleridge., Chapter XII of Biographia Literaria (1817) Anita Kelkar: Scientific and Poetic Approaches 10 PEERS OF OUR PAST Outside of the basic sciences building (1975) Students were assigned an individual module desk where they would study, use their micro- scopes, and conduct experiments (1977) Grasslands housing complex (1980) 11 Antidepressants Misrepresented Steve Rockoff In the first week of 2010, a study performed by researchers at the University of Pennsyl- vania made waves as it circulated through every major national news outlet. The study, a meta- analysis of six independent studies conducted at various points in the past 20 years, was con- ducted in order to determine the relative benefit of antidepressant medications over a placebo, for depressed patients with a varied range of baseline symptom severities. 1 The results of the study led to the publication of articles in various medias with titles such as U.S. News & World Report’s “Do You Really Need That Antidepressant?” and USA Today’s “Study: Antidepres- sant lift may be all in your head.” 2, 3 Indeed, the conclusion that the researchers came to was that in cases of mild or moderate depression, some of those common antidepressants were no more useful than a mere sugar pill. I was fairly troubled when I perused through the various articles and stories that covered this study, seeing that in many cases, the media was up to its usual old tricks of sensationalizing and misrepresenting the most recent “hot medical study” of the week. Sending a message to the American people that trivializes the effects or usefulness of antidepressants is a very precarious game, and as I shall imminently elaborate, even more unfortunate when that message is based on a study with several inherent flaws. The class of drugs known as ‘antidepressant medications’ (ADMs) encompasses a multitude of compounds whose members are often pre- scribed for a wide variety of psychiatric disor- ders. One of these is major depressive disorder, a multi-factorial mood disorder that most likely arises due to a complex interaction of biological, psychological, and social factors including drug and substance abuse. Depression is a disorder that can range from having mildly intrusive to severely debilitating effects on a patient’s life. The most characteristic psychological symptoms of depression are low mood, low self-esteem, loss of interest & pleasure, excessive rumination, and feelings of worthlessness. These are more often than not accompanied by the physical symptoms of insomnia, drastically decreased appetite, weight loss, headaches, and fa- tigue. 4 The identification and treatment of depression is of great interest to the American peo- ple. While the lifetime prevalence of depression in most countries falls between 8-12%, the United States has roughly 17% of its population afflicted. 5 Antidepressants are the third-most widely prescribed class of drug in the US, with an estimated 10% of women and 4% of men taking them. 2 Unfortunately, it is widely agreed in the medical community that not only is de- pression under-diagnosed, but that diagnosed patients are often under-treated! The investiga- tors actually had a praiseworthy motive for the study at hand; their literature search revealed a 12 Not only is depression under-diagnosed… diag- nosed patients are often under-treated!" marked paucity of pharmacological studies in which participants had baseline scores below 23 on the Hamilton Depression Rating Scale (HDRS), the minimum score for “very severe depres- sion”. Bearing in mind that the majority of ADM patients may be considerably below a score of 23 (it was shown that 71% of participants in a recent survey had HDRS scores less than 22), the investigators’ task at hand of examining those who were “less” depressed would seem very worthwhile. 6 It is important to bear in mind that in the world of depression treatment, antidepressants share the throne with psychotherapy. Or at least, ideally they do. In the modern world’s quick- fix, medicated society, too often psychotherapy is overlooked or unwanted. Indeed, from 1996 to 2005, the use of ADM in the U.S. doubled, while the use of psychotherapy declined. 7 When in reality, the various forms of psychotherapy (which include cognitive behavioral therapy, group therapy, and psychoanalysis) may have just as much, if not more, to offer than ADMs in terms of treatment. This past summer, I worked in the Behavioral Health Center (BHC) of Westchester Medical Center under the supervision of B-2 inpatient unit physician Dr. Jay Draoua. I spent the bulk of my days observing or participating in the evaluations and treatments of the admitted patients, many of which had depression. As a rule, my current personal standpoint as an idealistic bur- geoning medical student is still one that prefers to avoid pharmacological treatment as much as possible, especially when other forms of treatment are available. This means that for psychiat- ric disorders such as depression, in addition to the helpful standbys of exercising, eating healthy, and pushing one’s self into socialization, I highly advocate psychotherapy as a thera- peutic tool. With the patients I have observed in the BHC, antidepressants have been highly useful in the stabilization of recently admitted patients; however, antidepressants are not sup- posed to be advertised as a long-term solution to for depression. As I have witnessed, to truly treat depression, one must examine the core of the patient, explore the roots of the underlying issues or events that triggered their pain, and have them come to an understanding with their illness. The patient has to approach an appreciation and respect for themselves. Only then can you put depression beyond the reaches of remission, something that antidepressants are not able to do. However, as I mentioned, antidepressants do have substantial merits of their own. The idea is to normalize certain neurotransmitters in the brain that are involved in regulating mood, thus potentially alleviating the altered levels which are sometimes associated with depression. This can provide immeasurable benefits for the patient on their road to recovery. Often, patients must be brought to a higher level of functioning before any meaningful psychotherapy can even begin. In other cases, they can stabilize a mildly – or moderately -– affected patient from re- lapsing into a severe episode. Perhaps most often, they can provide a subtle boost in function- ing for men and women going about their daily lives and work, without which they would be increasingly burdened by whichever depressive affliction haunts them. For these reasons, I feel somewhat offended by the way in which this study’s results are pre- sented by the authors and the media. As I perused the content of this meta-analysis, I built a list of several troubling concerns I had regarding the methods involved, and how the results were portrayed. Steve Rockoff: Antidepressants Misrepresented 13 To begin with, the literature search which was conducted by the investigators to find studies for their meta-analysis reached all the way back to 1980. Out of the over 2000 studies they searched, their exclusion criteria (for studies without placebo controls, or ones examining spe- cial subpopulations, etc.) narrowed the number of studies they included in their final meta- analysis down to just six. Of these six, three of them compared the ADM imipramine to pla- cebo, and three compared the ADM paroxetine to placebo. Imipramine belongs to an older class of drugs developed in the 1950’s, the tricyclics (TCAs), a highly effective group of antide- pressants which are still used for treatment-resistance depression when other drugs fail, though they can sometimes cause mania or hypomania on a maintained dosage. 8, 9 Today, the TCAs are less popular due to the advent of antidepres- sant drug classes with less severe side effects, such as the selective serotonin reuptake inhibi- tors (SSRIs). A 2007 ranking of the most com- monly prescribed ADMs in the U.S. put imipramine at thirteenth with 1.524 million, which is less than one-third of the twelfth- ranked nortriptyline and a mere fraction of the top four ranked ADMs (which all top 20 mil- lion on their own). 10 Using such a rarely- prescribed and antiquated drug to represent the whole range of ADMs and their supposed inef- fectiveness on mild depression is just poor practice, in my opinion. The investigators make note of several of their study’s limitations, but this is not one of them. It is quite a shame that they have allowed ADMs to be presented to the public this way, with half of their data coming from this particular drug. Paroxetine, a SSRI and the fifth-most prescribed ADM in the U.S. in 2007, was the other drug used in the studies. However, compared to the three SSRIs that were more popular (sertraline, escitalopram, and fluoxetine), paroxetine is associated with several concerning side effects such as weight gain, increased risk of suicidality, and high risk of withdrawal syn- drome. 11, 12, 13 Again, not a drug most representative of the antidepressants Americans would be likely to use. Neither one of the two ADMs used on patients in the meta-analsyis are popularly used as first-line agents for depression. Even if they were used as the first treatment, as they were in these studies, it is well known (and even taught to us in first year Behavioral Sciences in medical school) that very often the first-line of treatment is not effective, and that two or three classes of ADMs may be tried before finding one that the patient responds to. Another area of concern to me was that the investigators set a minimum criterion of a 6- week treatment duration period for symptom scores when selecting studies to include. In fact, the average treatment duration for the six studies was only a little over eight weeks, which seems to be an alarmingly short time to stop the recording data for a depression study. ADMs are renowned for their need to take several weeks in order to begin to take effect. Two to three weeks is usually the minimum standard, and for an ADM’s effect to take even longer than that is by no means rare. In particular, the rate of symptom improvement can greatly vary by drug and by person. Imipramine in particular has been shown to have a slower rate of symptom im- provement than other drugs in the treatment of depression, and even though it can lag behind its Steve Rockoff: Antidepressants Misrepresented 14 Often, patients must be brought to a higher level of functioning before any meaningful psychotherapy can even begin." peers after six weeks of treatment, its effect is by no means over – a continued improvement in symptom score is still observed beyond that six week mark. 14 The investigators’ findings seem to, unfortunately, only apply to acute treatment, not the continuous or maintenance ADM treat- ment that millions of Americans find themselves on. Further flaws in this recent study can be found in the types of patients who were chosen to be excluded from this meta-analysis. Almost 600 studies were stricken from inclusion because the depression patients were dysthymic or were from a special sub-population (i.e. a certain eth- nicity). Dysthymia is a mood disorder which is best described as chronic depression, but at a lesser intensity… the patient must have the symptoms of a depressed mood for at least two years, but without the presence of a major depressive episode. The very definition of dysthy- mia, which is to have a “less severe” depression, seems to suggest that its patients would suit perfectly for the present meta-analysis, which has a great interest in patients who score lower on a depressive symptom scale. If the proposed trend of less-severely depressed patients showed an equal response to placebo was also discovered in dysthymic patients, which would contrib- ute greatly to the investigator’s current conclusions. However, it has been well shown over the years that the three main classes of ADMs (SSRI, TCA, and monoamine oxidase inhibitors) have a noted pharmacological effect over placebo in the treatment of dysthymia patients, espe- cially in the short term. 15 It should also be noted that the results of this meta-analysis do not apply to inpatient populations or children, two sizable groups which were also excluded from the study. My last criticism of the meta-analysis at hand is the use of the depression symptom scoring criteria. All six studies involved used the Hamilton Depression Rating Scale (HDRS), in which patients scoring 8-13 have “mild” depression, 14-18 are “moderate”, 19-22 are “severe”, and greater than 23 are “very severe”. The results of the current analysis demonstrated that there was a small effective difference between ADM and placebo when the patients had a baseline below a score of 23. In addition, the National Institute for Clinical Excellence’s standard for significant difference between ADM and placebo (meaning the HDRS difference is 3 or greater) was not met until patients had a baseline of 25 or greater. Most media articles reporting this study emulate the claim that ADMs only work if one is “severely depressed,” i.e. has a HDRS score of 23 or greater. However, taking the ratings on the HDRS scale literally is very misleading. Resistance to the use of HRDS labels by mental health practitioners is nothing new. “The Hamilton concept of ‘severe’, I think many psychia- trists would think of as ‘moderate’,” said Dr. Mark Olfson, a professor of clinical psychiatry at Columbia University. 16 The Hamilton scale, developed in the 1960’s, is widely used because of tradition in the field, but in reality it suffers from a sort of “grade inflation” that can classify pa- tients in very misleading, and especially more severe, ways. The authors of this meta-analysis recognized some of the limitations of their study, particu- larly the caveat about the psychometric measuring properties of the HDRS. However, many of the items I noted above were not spoken for. I would agree with the author’s call for more stud- ies examining patients with a wide range of baseline depression severities, as their claim that there is relatively little data on lesser depressed patient’s responses to antidepressants appears to be valid. I would hope, though, that with future studies to be done, they could rectify some of my current critiques regarding the methods of analysis, and accurately present their conclusions to the public and media. Steve Rockoff: Antidepressants Misrepresented 15 R E F E R E NC E S [1] Fournier J, DeRubeis R, Hollon S, Dimidjian S, Amsterdam J, Shelton R, and Fawcett J. 2010. Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-Analysis. JAMA, 303[1]: 47-53. [2] Kotz, D. “Do You Really Need That Antidepressant?” USnews.com. 6 Jan 2010. Accessed 12 Jan 2010. http:// www.usnews.com/health/blogs/on-women/2010/01/06/do-you-really-need-that-antidepressant.html [3] Rubin, R. “Study: Antidepressant lift may be all in your head”. USAtoday.com. 5 Jan 2010. Accessed 12 Jan 2010. http://www.usatoday.com/news/health/2010-01-06-antidepressants06_ST_N.htm [4] “Depression”. 2008. National Institute of Mental Health. Accessed 12 Jan 2010. http://www.nimh.nih.gov/ health/publications/index.shtml [5] Andrade L, Caraveo-Anduaga JJ, Berglund P. 2003. The epidemiology of major depressive episodes: Results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys. Int J Methods Psychiatr Res, 12 [1]: 3–21. [6] Zimmerman M, Pasternak MA, and Chelminski I. 2002. Symptom severity and exclusion from antidepressant efficacy trials. J Clinical Psychopharmacology, 22[6]: 610-614. [7] Yan, J. 2009. Antidepressant Use Rises in 10-Year Period. Psychiatric News, 44[17]: 8. [8] Broquet K. 1999. Status of treatment of depression. South Med J, 92[9]: 846–56. [9] Bottlender R, Rudolf D, Strauss A, Möller HJ. 1998. Antidepressant-associated maniform states in acute treat- ment of patients with bipolar-I depression. European Archives of Psychiatry and Clinical Neuroscience, 248[6]: 296–300. [10] "Top 200 generic drugs by units in 2007."Drug Topics. 18 Feb 2008. Accessed 12 Jan 2010. http:// drugtopics.modernmedicine.com/drugtopics/Top200Drugs/ArticleStandard/article/detail/491194 [11] Papakostas, GI. 2008. Tolerability of modern antidepressants. J Clin Psychiatry, 69 Suppl E1: 8–13. [12] Barbui C, Furukawa TA, Cipriani A. 2008. Effectiveness of paroxetine in the treatment of acute major depression in adults: a systematic re-examination of published and unpublished data from randomized trials. CMAJ, 178[3]: 296–305. [13] Haddad P. 2001. Antidepressant discontinuation syndromes. Drug Safety, 24[3]: 183–97. [14] Feighner J, Aden G, Fabre L, Rickels K, and Smith W. 1983. Comparison of Alprazolam, Imipramine, and Placebo in the Treatment of Depression. JAMA, 249[22]: 3057-3064 [15] De Lima MS and Hotopf M. 2003. Benefits and risks of pharmacotherapy for dysthymia: a systematic ap- praisal of the evidence. Drug Safety, 26[1]: 55-64. [16] Spiegel, A. “Drug Studies Lean On Flawed Measure of Depression”. NPR. 6 Jan 2010. Accessed 16 Jan 2010. http://www.npr.org/blogs/health/2010/01/antidepressant_studies_lean_on_1.html Steve Rockoff: Antidepressants Misrepresented 16 Building the Westchester County Medical Center (1978) Early photograph of Sunshine Cottage Fifth Avenue Hospital, in Manhattan (1976), and home of New York Medical College. It was closed in 1979. Rear of Basic Sciences Building, 1979 yearbook (1966 on doors is not explained) 17 FUTURE FOUNDATIONS An Examination of Three Model Healthcare Delivery Systems Gavin Stern The United States is just now beginning its journey into a universal healthcare delivery sys- tem. On March 30, 2010, President Obama signed into law the “Health Care and Education Reconciliation Act of 2010” (H.R. 4872), which completed the work of the “Patient Protection and Affordable Care Act” (H.R. 3590) signed on March 23, 2010. The effects of this legislation are phased in over the course of this new decade, but the final product is far from certain. Im- plementation could be legislated away with one election cycle. This article examines three model healthcare delivery systems that the United States could look towards on its march to universal coverage: those of France, Germany, and the Netherlands. France: Government-run Universal Insurance In 2000, France had the best healthcare system in the world, according to the World Health Organization. 1 The basic French system - Sécurité Sociale - covers “Hospital care, ambulatory care and prescription drugs” along with “minimal coverage of outpatient eye and dental care” 2 and “nursing home benefits.” 1 This is a mandatory system. “Complementary insurance” covers individual cost sharing, and is usually provided by the employer. More recently, the Couverture Maladie Universelle (CMU) is provided to individuals who cannot afford the public system due to unemployment 2 , estimated at 0.4% of the population. Another system L’Aide Medicale d’Etat (AME) covers “Illegal residents.” In general, “poorer patients are exempt from cost-sharing.” 2 Therefore, one could infer that that none go without basic health insur- ance in France – even noncitizens. 1 The French medical system is not nearly as government-centralized as, for instance, the United Kingdom, which has a socialized system. Rather, the government of France finances basic healthcare via legislation “that creates the annual prospective global budget for the public health expenditures,” which “funds the Sécurité Sociale and CMU and is financed through na- tional income taxes and the General Social Tax – a supplementary income tax (7.5%) intro- duced in 1991 to help offset health care costs; 5.25% of which helps pay for the health care sys- tem.” Further, “Complementary insurance” reduces financial burden on individual cost sharing. Ninety-two percent of the population carries the complementary insurance, “roughly half of which is funded by employers.” 1 France controls healthcare costs with financial leverage. For instance, individual co- payment for a drug is linked to effectiveness. Drugs with proven therapeutic effects are basi- cally free, while those of dubious or limited use are cost-shared to a greater extent. While indi- viduals may visit any physician, reimbursements are better when one starts with a gatekeeper general practitioner: “Visits to the gatekeeping general practitioner are subject to a 30% co- insurance rate, while visits to other GPs are subject to a 50% co-insurance rate.” 2 This is a new 18 None go without health insurance in France—even nonciti- zens." concept, introduced via the Douste-Blazy law in order to reduce large budget deficits. Overall, the practice of medicine in France is a “self-regulating market.” A “reference price” determines what the public system will reimburse. Technology reduces paperwork and increases efficiency: “patients carry Sécurité Sociale cards containing microchips storing their comprehensive medi- cal information, allowing physicians immediate access to a patient’s record.” Physicians are private employees, “mostly self-employed and paid on a fee-for-service basis.” 1 Out of pocket spending for healthcare is still an issue in France, as “patients visiting physi- cians and dentists pay full price and are later reimbursed for costs by the public health insurance and complementary insurance.” Out of pocket expenses were 6.9% of total health expenditures in 2005. 1 However, some conditions are completely reimbursed, “including cancer, diabetes and other chronic conditions… includ[ing] all pharmaceuticals [and] experimental drugs.” Pricing and reimbursements are “negotiated between the health insurance funds and unions representing providers.” The supplemental insurance plans “are not allowed to compete by lowering health insurance premiums”, 1 which may have the effect of reducing competition but is done for the purposes of solidarity. To reduce the effects of moral hazard, there are additional co-payments per office visit, with an annual ceiling of 50 Euros. The French system in totality does not pro- vide the same level of expertise to all income levels, as “doctors and dentists may charge above this reference price based on their level of professional experience.” 2 The wealthy, then, can afford more skilled practitioners despite the French principle of solidarity. However, the ability for skilled physicians to set a higher price also provides an incentive to achieve that higher level of skill – a capitalist tenet. Is the French healthcare system a good deal? Healthcare spending in France was 11.1% of GDP in 2005, much lower than 15.3% in the United States. 3 Per capita spending in 2003 was $2903 in France compared to $5635 in the United States. There are proportionally more physi- cians in France: 3.4 to 2.3 per 1000. 4 French infant mortality was 4.3 deaths per 1000 births compared to 7.2 per 1000, and life expectancy at birth was 82.2/74.6 (female/male) compared to 79.4/73.9 in the United States. 5 Clearly, the French system performs better. However, US implementation of the French system would be difficult because it requires a strong central gov- ernment (France is arguably a single-payer system). A system of government-regulated insur- ance coverage (more like that of Germany or the Netherlands) might be a more reasonable long- term goal for the United Statess Germany: Social Insurance and Sickness Funds The healthcare system of Germany consists of governmentally independent sickness funds, along with a separate private insurance system. Sickness funds are “autonomous, not for profit, nongovernmental bodies regulated by law,” which act as “the collectors, purchasers, and payers in both health and long-term care insurance” in Germany. 6 This system of more than 200 sick- ness funds is “the oldest system of social insurance in the world.” 7 The notion is that these funds will compete against one another, encouraging greater efficiency and reduced cost. In 2006, 88% of Germans were covered by the sickness fund system. Only 0.22% of Ger- mans were uninsured. A “special state program” covered 9.7% as government employees, and 2% purchased private health insurance. 7 Individuals with income levels of less than ̀48,000 annually (75% of the German population) are required to enter into the public program. 75% of Gavin Stern: An Examination of Healthcare Systems 19 people with income above this level remain in the public system by choice. This helps to dem- onstrate that the public healthcare system of Germany is considered to be satisfactory even for those with greater income levels, as private insurance enrollment is very low. After 2009, “health insurance will be mandatory” in “either the social or private health insurance scheme.” 6 Before that, insurance was optional for individuals with yearly income over ̀ 48,000. The sickness funds are financed by employee and employer contributions of (on average) 8% and 7% of income, respectively. The unemployed are still expected to make a contribution. Patients may incur cost sharing or copayments of up to “2% of household income.” This figure is cut in half for those declared “chronically ill.” This system of contribution also changes in 2009, in that “all contributions will be centrally pooled by a new national health fund, which will allocate resources to each [sickness fund] based on an improved risk-adjusted capitation formula.” 6 This should help to evenly spread the risk of more ill, more needy, more expensive patients on particular sickness funds. However, this does show a trend towards more centralized control via the government. The sickness fund program is more comprehensive than other social health programs dis- cussed in this analysis – including, “dental, inpatient, and preventive care” along with “prescription drugs and rehabilitative treatments” and disability payments to those who cannot work.” 7 Patients receive incentives to utilize gen- eral practitioners in a “family physician care model.” The German system encourages cost ef- fectiveness as sickness funds and physicians col- laborate on price control. Physicians maintain their autonomy to practice and are generally “paid by a mixture of fees per time period and per medical procedure.” 6 Physicians are compensated “by sick- ness funds via their regional physician associa- tions.” 8 It should be noted that, unlike the United States system, physicians are encouraged to col- laborate and lobby, similar to the French system. Healthcare spending in Germany was 10.7% of GDP in 2005, lower than 15.3% in the United States and 11.1% for France. 3 Per capita spending in 2003 was $2996 in Germany, much lower than $5635 in the United States. Germany and France had the same per capita number of physi- cians at 3.4 per 1000, higher than 2.3 per 1000 in the United States. 4 German infant mortality was 4.6 deaths per 1000 births in 1999 (7.2 per 1000 in the US) while life expectancy at birth in 1998 was 80.5/74.5 (female/male) compared to 79.4/73.9 in the United States. 5 The German healthcare model receives generally good reviews, with 66% of Germans approving of the sys- tem in 1996, 5 and 11% disapproving. 8 The German system would be difficult to implement in the United States because it involves a large degree of government control. The sickness funds do not operate capitalistically (as in the Netherlands) but rather as a nonprofit, indirect exten- sion of government. The German healthcare system significantly outperforms that of the United States, with re- sults comparable to France but with less expenditure as a percentage of GDP. American imple- Gavin Stern: An Examination of Healthcare Systems 20 The notion is that these funds will compete against one another, en- couraging greater effi- ciency and lower cost." mentation of the German system is feasible because the sickness funds are analogous to private insurance companies. However, the German system requires these funds to be not-for-profit, and they now pay into a single national fund. Employers would have to contribute to the sys- tem, a policy that United States has been trending away from. While a system similar to that of Germany could practically evolve in the United States by capping insurance company profits, the political reality is that it would be attacked as anti-capitalist. The healthcare system of the Netherlands might be more palatable. The Netherlands: Multi-Payer Private Competition With Government Regulation The Dutch healthcare system has been referenced as a possible route to universal healthcare coverage in the United States. 9 The Health Insurance Act (2006) established a system of gov- ernment-regulated private insurance companies. As in the United States, insurers retain their for -profit status. However, in the Netherlands the Supervisory Board For Health regulates these companies. The emerging American model may benefit from the Dutch example of increased regulation. The Dutch government does not exert direct control over healthcare treatments (no rationing). Rather, insurance compa- nies are obligated to accept anyone who applies for the government-mandated standard insurance package. Each policy must include basic services: “medical care… hospitals and midwives, hospitali- zation… medical aids, medicines, mater- nity care, ambulance and patient transport services” as well as limited remedial, speech, and occupational therapy. Nurs- ing care, home care, chronic and mental illnesses are covered under the separate Exceptional Medical Expenses Act. All working adult citizens of the Netherlands are obligated to purchase a standard in- surance policy. The government pays for the health policies of children (under 18 years of age). The government also subsidizes indi- viduals who cannot afford such a policy, defined as greater than 5% of income, by providing an allowance proportionate to income. Nevertheless, an estimated 1.5% of Dutch citizens remained uninsured as of 2007. 10 The lack of 100% coverage remains a consequence of blunted govern- ment intervention, an issue that the United States will also be left with. Individuals, employers, and the government finance the Dutch system. Individuals pay “6.5% of the first ̀30,000 of annual taxable income.” The rate is reduced to 4.4% for the un- employed. Purchasers of these policies retain free choice, in that they may change policies once per year. Citizens also benefit from lowered prices as insurers compete for business. This com- petition-based model also forces increased efficiency and cost reduction. Physicians operate on a fee for service basis. General practitioners “receive a capitation payment for each patient on Gavin Stern: An Examination of Healthcare Systems 21 All working adult citizens of the Netherlands are obli- gated to purchase a standard insurance policy… Neverthe- less, 1.5% of Dutch citizens remained uninsured as of 2007." their practice list and a fee per consultation,” a vast improvement over American reimburse- ment for primary care services. Physicians maintain their autonomy, in that they are not em- ployees of the government. The billing process is simplified via Diagnosis Treatment Combina- tions (DTCs). DTCs incorporate all the costs of treatment and diagnosis, so that individuals do not receive billings for every minute detail in a single office visit. 10 Insurance companies charge a “flat rate premium,” which is based on the policy itself – not the risk of the insured as in the American system. The cost of these annual premiums was ̀1,050 on average in 2006. Government-mandated deductibles have been in effect since 2007, and the insured pay “the first ̀150 of any health care costs in a given year.” However, costs to the individual remain low, as “out of pocket payments as a proportion of total health expendi- ture are around 8%.” Payments “are collected centrally and distributed among insurers based on a risk-adjusted capitation formula” in order to equilibrate risk. 10 Healthcare spending in the Netherlands was 9.2% of GDP in 2004, lower than the United States, France, and Germany. 3 Per capita spending in 2003 was $2,976. The Netherlands em- ployed slightly fewer physicians per capita (3.1 per 1000) than Germany and France, but still outperformed the United States. 4 Dutch infant mortality was 4.3 deaths per 1000 births, and life expectancy at birth was 82.1 for females and 76.8 for males – rates almost unanimously equal or better than all countries compared in this analysis. 11 This system is far from perfect. Al- though the Dutch system encourages com- petition and free choice, “four insurers control 90% of the market.” Additionally, the basic healthcare package does not cover what Americans might consider to be essential services, such as dental care, eyeglasses, alternative therapies, and cos- metic surgery (in some cases of disfigure- ment). Citizens still have to pay extra for these services. Indeed, “90% [of citizens] buy supplemental packages.” The Future of The United States: Of the healthcare systems examined in this analysis – France, Germany, and the Nether- lands – the Dutch model is most compatible with the emerging healthcare system adopted by the United States in 2010. The Dutch model produces the best results at the lowest price, with a high degree of freedom and coverage while retaining capitalistic principles. The United States would do well to follow the path of mandated coverage and strong government regulation of insurance companies. There is some optimism that the United States may be moving in this di- rection. Those who support such a system and the benefits outlined herein will need to be vigi- lant of insurance companies that defend profit, of misplaced political accusations, and a politi- cal movement to repeal this reform or declare it unconstitutional. Gavin Stern: An Examination of Healthcare Systems 22 The United States would do well to follow the path of mandated coverage and strong government regulation of insurance companies." R E F E R E NC E S [1] International Health Systems: France. (2008, August 6). The Henry J. Kaiser Family Foundation. Retrieved April 22, 2009, from http://www.kaiseredu.org/topics_im_ihs.asp?imID=4&parentID=61 [2] Durand-Zeleski, I. (2008). The French Health Care System. Descriptions of Health Care Systems: Denmark, France, Germany, the Netherlands, Sweden, and the United Kingdom. Retrieved April 22, 2009, from http:// www.commonwealthfund.org/~/media/Files/Resources/2008/Health%20Care%20System%20Profiles/ LSE_Country_Profiles%20pdf.pdf [3] Anderson, G., & Frogner, B. (2008). Health Spending In OECD Countries: Obtaining Value Per Dollar. Health Affairs, 27(6), 1718-1727. Retrieved April 10, 2009, from http://content.healthaffairs.org/cgi/content/ abstract/27/6/1718 [4] Grol, R. (2006). Quality Development in Health Care in the Netherlands. The Commonwealth Fund, 21, np. Retrieved April 10, 2009, from http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2006/Mar/ Quality-Development-in-Health-Care-in-the-Netherlands.aspx [5] Rodwin (2003). The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States. American Journal Of Public Health, 93(1). [6] Busse, R. (2007). Descriptions of Health Care Systems: Germany. Retrieved April 10, 2009, from www.allhealth.org/briefingmaterials/CountryProfiles-FINAL-1163.pdf [7] The Century Foundation (2008). National health insurance: Lessons from abroad. New York City: The Cen- tury Foundation Press [8] Green, D., Irvine, B., & Cackett, B. (2005). Health care in Germany. Retrieved 4/17/2009, 2009, from http:// www.civitas.org.uk/pubs/bb3Germany.php [9] de Ven, W. v., & Shut, F. (2008). Universal Mandatory Health Insurance In The Netherlands: A Model For The United States?. Health Affairs, 27(3), 771-781 . Retrieved April 10, 2009, from http:// content.healthaffairs.org/cgi/content/abstract/27/3/771 [10] Klazinga, N. (2008). The Dutch Health Care System. Descriptions of Health Care Systems: Denmark, France, Germany, the Netherlands, Sweden, and the United Kingdom. Retrieved April 22, 2009, from http:// www.commonwealthfund.org/~/media/Files/Resources/2008/Health%20Care%20System%20Profiles/ LSE_Country_Profiles%20pdf.pdf [11] United States Central Intelligence Agency (2009). The Netherlands – CIA World Factbook. Retrieved April 9, 2009, from https://www.cia.gov/library/publications/the-world-factbook/geos/nl.html Gavin Stern: An Examination of Healthcare Systems 23 Homeopathy Charles Volk In 1860, the incoming class to the New York Homeopathic Medical College sat down to become specialists in their chosen form of medicine, homeopathy. At the time it was a com- pletely reputable form of medicine, equal to or better than the more conventional medicine of the day. Indeed, a homeopathic physician would often garner a larger salary in the western United States than a physician who used the strong laxatives and heavy metals that were used in conventional medicine of the time. The US was very welcoming of homeopathy, founding the American Institute of Homeopathy in 1844. The conventional physicians, in response to the ho- meopaths, made their own institute a couple of years later: The American Medical Association. The homeopaths gave conventional medicine a name to differentiate themselves and their form of medicine. They called conventional medicine “allopathy,” and although the term is an- tiquated, it seems to have stuck. This is actually a rivalry in medicine that has been going on since the time of Hippocrates. There’s an idea that if a person has a condition, a physician can do one of two things: 1) Give them a compound that causes an opposite problem. For example: If a per- son has diarrhea, give them something that causes constipation. You give them some- thing that would cause opposite suffering; allopathy. 2) Give them a compound that causes a similar problem. For example: If a person has diarrhea, give them an extremely small dose of something that causes diarrhea. Similar suffering; homeopathy. New York Homeopathic Medical College continued to churn out homeopathic physicians for many years. However, by the end of the 19 th century, new discoveries, an increasing trust in the scientific process, and disagreements among homeopathic practitioners were starting to sound a death knell for homeopathy in the United States. The curriculum at New York Homeo- pathic Medical College had integrated new discoveries in medicine and science since its charter class, and once medical education in the US became more homogenized around the turn of the 20 th century, its classes largely resembled those found at any contemporary Allopathic medical school. By 1910, as the popularity of homeopathy in the US dwindled and confidence in Allo- pathic medicine increased, New York Homeopathic Medical College changed its name to New York Medical College and the degree it offered to an Allopathic Medical Doctor. A little less than a century later, homeopathy enjoys a resurgence in the US, with a half dozen schools in the country. However, while the homeopathic medical education of the past encompassed new dis- coveries in its teaching, modern homeopathy has taken a completely different angle. 24 While homeopathic medi- cal education of the past en- compassed new discoveries in its teaching, modern home- opathy has taken a com- pletely different angle." My experiment with homeopathy started with a book on natural health for dogs and cats. In the book, the author introduced many “natural” ways to keeps pets healthy, but the one he es- poused the most was homeopathy. I started looking further into it and became fascinated with what I saw. After experimenting on myself and on willing family and friends (my dad still takes the homeopathic remedy I got him for his bursitis), I was hooked. I found out about a homeo- pathic medical school in Minneapolis, Minnesota, and after a year of college was accepted into the class of 2009. The first day of class started at 8AM on a frigid Minnesota January morning. The building I walked into was rented out to practitioners of the entire spectrum of complementary medicine. It felt like stepping back in time; herbs smoldering, strange esoteric compounds being displayed and archaic rituals being performed to heal diseases I didn’t even know existed. And there, at the end of the top floor hallway, was my homeopathic medical school classroom. It seemed like the room hadn’t changed much since the late 1800s: old woodwork, ancient blackboards, and colossal iron radiators. I took a front corner seat close to a power outlet (for my laptop) which had the unintended side effect of allowing me to see both the faces of my classmates and the professor at the same time. More on this later. The room eventually filled up with the other 30 students, and I noticed that I was the young- est person there by at least ten years. After some administrative stuff, we were all asked one-by- one to stand in front of the class and tell everyone how we were “called” to homeopathy. I was incredibly uncomfortable with this, as I didn’t feel “called” to anything. The term evokes a cer- tain amount of fait accompli of the universe; that my decision to study homeopathy could only be explained by supernatural means. What it really reminded me of was Catholic school. Once it was my turn, I just got up and explained how I thought homeopathy was very interesting, and how I thought I could really delve into the subject to come up with knowledge to make people better. I specifically left “God told me to” out of it. The first teacher brought my hopes up slightly, talking about what anyone in medicine could agree on, but the next teacher then started talking deeply about philosophy. He claimed that you have to be a philosopher to get homeopathy, and you could only be a great homeopath if you tweak your worldview. The phrase “tweak your worldview” was said to me dozens of times, and it grew old very quickly. I’m not really one for extended philosophical musings. Nights wiled away in a heated dis- cussion about our role in the universe just never really held too much interest for me. I always found that learning about the natural world was always far more interesting than debating on existentialism. I always felt that I existed because billions of years of evolution had by chance created me. If it hadn’t, I wouldn’t be around to think about it. So, I guess my worldview is that of “things exist that I can interact with or detect,” better known as “the materialistic world- view.” “The greatest problem with modern medicine and science is that it only believes in the ma- terialistic worldview,” the teacher says. Charles Volk: Homeopathy 25 So it begins. He claimed that homeopathy is spiritual energy. Later, another instructor claimed it was “energy medicine” somewhere in the realm of electromagnetism. Another invoked quantum mechanics (but couldn’t explain it, of course). If one read 100 authors books on homeopathy, one would get 100 different mechanisms for its action. It seems to be one of those disciplines that constantly lie in the gaps of scientific knowledge. If one gap is closed by legitimate re- search, it’ll move on to another. I think it behooves me here to take a little foray into exactly “what are homeopathics?” Homeopathic remedies are made by a certain process of dilution and shaking to “potentize” them. Let me take you through making one, step by step: First get your original product, for ex- ample, venom from the Bushmaster snake. Take one drop of the snake venom and put it in 99 drops of a water/ethanol mixture. Shake this mixture 40 times, then take one drop of that mixture and put it into 99 drops of water. Shake 40 times. Repeat with 28 more dilutions and shakes, and you have the remedy Lachesis 30C. The 30C means 30 1/100 dilutions. Now, you are probably thinking that there can’t be anything left of that snake venom. In fact, the mathematics of dilution (thanks, Avogadro!) state that there cannot be anything left of the original compound after twelve 1/100 dilutions, but the practitioners of home- opathy claim the more they dilute it, the better it seems to work. The basic idea is that it causes the opposite reaction of the toxin or herb in its full dose. For example, if one would take the belladonna herb and rub it on one’s skin, it would become very red, hot, and painful. The belladonna remedy helps remove afflictions with similar symptoms, like sunburn. Although occasionally, some herbs are used for the same con- ditions that their full strength counterparts are used for. It seems to be that if an herb has a large alternative medicine following, a homeopathic preparation of the herb does the exact same thing, just better. Homeopathics are prescribed in an extremely convoluted and seemingly contradictory fash- ion. Sometimes they operate in the opposite fashion from the large dose. Sometimes they have the same effect. Sometimes you are supposed to find the “constitutional type” a person is, and that remedy is the only thing that will heal them. I figured my confusion was only due to na- iveté, and would disappear when I had learned more about it. Luckily, they also offer combination remedies, which have a number of different homeo- pathic remedies in them that are commonly used for whatever disease. It takes much of the guesswork out of it (have the flu? Use flu!), though they are supposedly less effective than the Charles Volk: Homeopathy 26 There are currently no scientifically accepted tri- als that show homeopathy has any effectiveness be- yond placebo, and in fact, a general tendency towards placebo response." single remedies. No one could seem to explain why. My guess was that it would put homeo- paths out of a job. I should also mention that with the exception of some occasional small, poorly constructed drug efficacy studies, there are currently no scientifically accepted trials that show homeopathy has any effectiveness beyond placebo, and in fact, a general tendency towards the placebo re- sponse as methodological controls get more precise. There are individual trials that have shown the effectiveness of homeopathics, but none have been reproducible. However, there is some lab-based evidence that shows some cellular response to ultra-diluted compounds similar to ho- meopathics, as well as an immense amount of anecdotal evidence for its effectiveness. (A com- plete discussion of the evidence for and against homeopathy is beyond the scope of this essay. I would direct readers to the article on homeopathy in the Skeptic’s Dictionary at http:// www.skepdic.com/homeo.html) A little later into the discussion on that first day, I raised my hand, “What was all that about germs not causing disease?” “They don’t,” the teacher answers. My vantage point at the front corner meant I could see people’s faces and reactions whenever a barrage of ques- tionable information began. The sheer number of people in that class that had a look of “Well, of course they don’t. Everyone knows that” was disheartening in a way I can’t quite describe. The instructor backed it up by saying, “Viruses and bacteria are scavengers of diseased tissue. A miasm (literally meaning “evil spirit.” Seriously.) has to cause disease first, and only then can the microorganisms cause tissue damage.” If you roll this around in your head for a while, it makes a weird sort of sense, but then I re- member a man named Louis Pasteur proved that microor- ganisms, not miasms, caused disease over 150 years ago. We’re way past arguing the accuracy of the germ theory in the 21 st century. The lead instructor also said that homeopathics can cure bad luck. Another claim was that heredity is mostly energy (the teacher’s percentages were about 5% DNA and 95% energy). There was a point in there somewhere about rocks causing disease, which was then paralleled with the Christian idea of original sin. Again, my incredulousness was only matched by the agreeing nods of my classmates as they listened to his lecture. Soon enough, the very idea of the scientific method came under attack. He claimed that the entire idea of scientific theories was wrong. “The average life of a scientific theory is five years,” “All the scientists just go running from one theory to another,” and “You know, theory comes from the Greek word for theater.” Actually, theory comes from the Greek word for “spectator” or “observer.” I called him out on that after class and he claimed that, “spectator is Charles Volk: Homeopathy 27 Soon enough, the very idea of the scientific method came un- der attack." what I meant.” despite it completely changing the meaning of his damning appraisal of science. The teacher made an announcement (actually several) to those people who were perhaps having some trouble believing any of this (me). It was that we should “Put off our reasoning minds for awhile and make a space for homeopathy.” This is not something that I have much experience doing. It begs the question, “When is it okay to start thinking again?” I don’t know about most people’s minds, but I don’t “stop thinking.” My mind just doesn’t work that way. And why would I want it to anyway? So, homeopathy only makes sense only if you suspend any part of your brain that determines sense? What became the last straw for me was a student’s response to something the teacher said: “Yeah, that makes sense, because I can put a thought into a crystal and give that to some- one, and that will heal them.” Though I may be in the majority of people in the general population in thinking this is ut- terly ludicrous, I was in a definite minority in this room. I simply couldn’t take the barrage any- more. During a break, I went up to talk to the lead instructor. He could see that I was not com- fortable here and was having a hard time. He laid it out for me that he “could never prove that homeopathy was effective by my standards,” He also said that it “didn’t bother him if it wasn’t real” and that even if it was just by a placebo effect, he was “still helping.” There is definitely something to be said for the placebo effect, but I realized I have ethical issues with being in a profession that considers no real treatment just as worthy of charging for. And, I have a problem with a $20,000 tuition bill and spending four years of my time learning something that may not even be true. In the end, I spent 5 full days at the homeopathy academy. It was one of the most marginal- izing, confusing, degrading, and surreal experiences of my life. A few months after this experi- ence, I began allopathic pre-med studies and haven’t looked back. 28 Charles Volk: Homeopathy Homeopathy only makes sense if you sus- pend any part of your brain that determines sense?" Our Valhalla: Thirty-Eight Years of the ‘New’ NYMC Gavin Stern Just before 9:00a.m., first and second year medical students migrate from their on-campus apart- ments to class. Some sneak into the cafeteria to grab a bagel or coffee. Others were in the library the whole time, pre-studying under the glow of skylights. Along the way, the students pass snippets of his- tory that line the walls: paintings of founders and deans long gone, sketches of an old “homeopathic medical college” perched above a grocery store, the silvery names of honored graduates, and of course photographs of Flower Hospital – the very first built by a medical school in the United States. Arriving just a little late via the commuter lot, I pass under the Tree of Hippocrates – planted at Flower & Fifth Avenue Hospital in 1972 and then transplanted to Valhalla in 1979. I stop under the tree, which now towers over the rear entrance of the Basic Sciences Building, and consider – this Valhalla campus must have a history, as of yet untold. Indeed, the journey of New York Medical College is a testament to per- severance through difficult times, doing the best with what you have, and never giving up on doing bet- ter… The basic sciences building was completed in 1972, intended as temporary quarters for New York Medical College. At that time, the College operated two campuses (and trained two medi- cal school classes) while departments slowly transferred from Manhattan to Valhalla. Early stu- dents at the Valhalla campus would complete their training a year ahead of their Manhattan counterparts, as the “B” classes of 1975 and 1976 operated under an experimental three-year curriculum. Lectures, labs, and study modules were all located in the Basic Sciences Building – students and faculty alike crammed into clusters of rooms separated by “inter-labs.” Most stu- dents actually hailed from New York. In their yearbook tribute, the Class of 1975B “Pioneers” described the rigors of the transition period: unpaved roads, mountains of mud, a lack of fur- nishings, off-site faculty, a difficult housing situation, and one extraordinarily leaky roof. The modern Medical Education Center was only a dream. One cannot discuss the history of the Valhalla campus without explaining the circumstances surrounding the clo- sure of Flower & Fifth Avenue Hospi- tal. The move to Westchester occurred during a period of financial turmoil in New York City, as massive cuts in re- imbursement threatened the survival of many hospitals and medical schools in the 1970’s. Flower & Fifth Avenue Hospital and its owner, New York Medical College, were struck particu- larly hard. Seeking financial stability, New York Medical College signed an affiliation agreement with Pace College (now Pace University) in 1973, nearly merged with Metropolitan Hospital in 1977, and even considered a move to Queens. Ultimately, NYMC would affiliate with the Archdiocese of New York, at that time a major provider of healthcare in New York City. The Archdiocese guaran- We went to the brink—and came back.” Dr. John Connolly, the president of New York Medical College when interviewed by the New York Times in 1983 29 teed NYMC’s debt of $10 million (1978 dollars) and took over appointments to the College board, in a sponsorship arrangement that endured for nearly thirty years. In an extremely con- troversial move, the Archdiocese closed the storied Flower & Fifth Avenue Hospital and con- verted it into a continuing care facility, the Terrance Cardinal Cooke Health Center. By 1978, the School of Medicine transferred its main operations to the Val- halla campus. The Graduate School of Basic Medical Sciences followed suit, while control of the Graduate School of Nursing was relinquished to Pace, now a University due to its affiliation with the School of Medicine. New York Medical College maintained affiliations with many city hospitals, but it also gained a new one on campus – the Westchester County Medical Center. Due to a push by the American Medi- cal Association for all residency programs to have a university affiliation, and un- willingness for many physicians to practice without an academic appointment, Westchester County endeavored to bring a medical school to the suburbs. In 1968, the county offered New York Medical College land on the Grasslands Reservation along with favorable rental terms on former Grasslands Hospital buildings. The National Institute of Health provided much of the funding to build the Basic Sciences Building. The next step was to build an academic hospital. By 1977, the Westchester County Medical Center was completed on the site of an old apple or- chard, along with a new stretch of parkway to service it. The hospital went private in 1998 and was joined by the Maria Ferrari Children’s Hospital in 2005. Many of the current campus buildings were originally part of Grasslands Hospital Center, which predated Westchester Medical Center: Munger Pavilion, which now houses most clini- cal departments, was an adult tuberculosis hospi- tal while Sunshine Cottage was a pediatric hospi- tal. Animal imagery can still be seen in the archi- tecture of Sunshine Cottage, although most of the statues are gone. Elmwood Hall, another former Grasslands Hospital building, served as the ad- ministration building in the decade before Sun- shine Cottage was available. Vosburgh Pavilion has a previous life as a psychiatric facility (notice the fenced-in courtyard and small workrooms). New York Medical College owned the Mental Retardation Institute (Cedarwood Hall, now the Westchester Institute for Human Development) but sold it to the county government when it proved financially unsustainable. The “MRI” is Gavin Stern: Our Valhalla Flower and Fifth Avenue Hospital is no more. In its wake stands a new hospital, a new home. An era has ended only to mark a rebirth in Westchester.” 1979 yearbook, ‘Odyssey’ Compared to the way it was back then, the school is currently a thriving metropolis” Dr. Daniel Peters, Class of 1984 30 distinguished in holding the first lecture of the Valhalla campus, as outfitting of the BSB audi- toriums was behind schedule. Today, on-campus housing is considered a staple of the NYMC experience, but for two dec- ades Grasslands Housing was reserved primarily for second-year students. Private investors had planned to build 1,000 subsidized apartments, but protests from Westchester residents forced a substantial reduction, as reported by the New York Times in 1971. With few on-campus op- tions, many first-year students lived in dormitories at Manhattanville College, Briarcliff in Tarrytown. Vosburgh Pavilion doubled as temporary dormitory even as psychiatric patients were still being admitted nearby. In 1981, Vosburgh Pavilion changed its mission and instead housed new Graduate School of Health Sciences, later renamed the School of Public Health, and finally to the School of Health Sciences & Practice by 2008. Plans to replace the basic sciences building came and went over the decades. A 1984 “Master Plan” outlined the construction of a “Clinical Research and Education Center,” located between the Basic Sci- ences Building and the Institute for Human Develop- ment. The new building was to include a student cen- ter, five-hundred seat auditorium, library, dining fa- cilities, and laboratory space. Munger Pavilion was to be overhauled, while Vosburgh Pavilion would have become a permanent dormitory by renovating the rooms previously used for psychiatric admissions. The plan also called for administrative offices to move from Elmwood hall (near the prison) to the statelier Sunshine Cottage – which actually did occur. However, a projected cost of $50 million (1984 dollars) proved too ambi- tious to accomplish these goals all at once. Improvements to the College instead occurred incrementally over the ensuring decades: the Blue Auditorium stayed “blue,” but somewhere along the line Orange Auditorium was reno- vated into Terrance Cardinal Cooke. Courtyards that graced the center of each academic depart- ment were swallowed up to feed the BSB’s appetite for interior space (this explains why some offices have windows, but no view). Farmland occupied the rear of the College and was tended to by prisoners – this too disappeared – but a historic building on the estate was transformed into the Alumni House. The cafeteria expanded into the space once occupied by a much smaller bookstore, which in turn moved into the former instrument shop. A gargantuan, convex televi- sion fixture disappeared from the center lobby. Wall panels and bright red paint covered previ- ously exposed brick and steel. Slowly, private investment expanded the number of Grasslands apartments, with the final building completed in the mid-1990’s along with a student center (rededicated in 2008). Finally, medical students and their families could live, mingle, work out, and barbeque on campus. But one component of the modern NYMC was still missing. After nearly three decades of tinkering with the Basic Sciences Building, New York Medi- cal College finally built its elusive dream building in 2001, thanks to a massive fundraising ef- fort. The $32 million Medical Education Center included a proper lobby, the larger Nevins “When I came here in 1971, it was a little flowerpot. It has since grown into a beautiful garden” Delroy Chang, staff Gavin Stern: Our Valhalla 31 auditorium and updated study modules. The Health Sciences Library extended underneath the new structure and, capped with skylights, doubled in size. Previously segmented into ten small rooms, the anatomy lab moved into a single space on the top floor. Most of the old BSB class- rooms were renovated into laboratories and offices, but vestiges can still be found: cardiac simulators now occupy two of the old cadaver labs, as does the graduate school conference room. The physiology library remains virtually unchanged as a former classroom, while Blue Auditorium also provides a window into the past. Desks and microscopes once filled the open space now enjoyed as a student lounge. Previously trafficked by thirty years of medical students, the original entrance and lobby is difficult to find – but it’s there. Half of it houses the extended security station. The rest is hid- den behind a brick wall next to the MEC – but one can still find the marks where a doorframe and heaters were attached. Indeed, current students may never realize where their ancestors once toiled – but they were there, too. Thirty years after the odyssey began, the modern NYMC was born. It was now “our Valhalla.” Contributors: Dr. Elliot Perla Dr. Daniel Peters Delroy Chang Sean Manning Anonymous faculty Every yearbook staff since 1972 Gavin Stern: Our Valhalla 32 Ian Hovis A young Ghanian woman captured in a balancing act on the streets of Accra A Lesson from Iran: Improving Rural Primary Health Care in The United States Navid Shams Around the time of the Islamic Revolution (1979), 23 million of the total 60 million Iranians lived in extremely poor and underdeveloped rural areas. 1 Wide-spread poverty was the result of an imbalance of previous industrialization, modernization and economic development efforts that favored urban areas. 2 As a result, over 50% of the rural population had low health status. Recognizing this, the new Ministry of Health made rural health a priority in order to work to- ward the constitutionally-guaranteed right to health care for all citizens. 3 Before the Revolution Improving rural health posed a significant challenge due to the primitive infrastructure and lack of various types of resources. For instance, even though medical graduates were required to spend 2 years in the rural Health Corps, about 87% of the medical practitioners still worked in one of the 5 largest cities. This left very few physicians in the rural regions (physician:population ratio of 1:15,000). 4 Even the 400 Health Corps stations were only able to provide minimal care to 20,000 of the 55,000 villages. 4 Moreover, of the 700 doctors who graduated medical school every year, about half would leave to find work in other countries. 3 This led to importation of physicians from India, Pakistan and the Philippines, which was met with resistance by rural residents who preferred Iranian auxiliary health workers to non-Iranian physicians. 5 Also, the small health sector budget (about 3% of total government spending) was mostly used on expensive projects, such as building large city hospitals that the rural population didn’t have access to. These factors led to the poor health status in rural regions. Infant and child mortality rates were twice that of urban areas. Life expectancy was approximately 10 years lower in both the male and female rural population. Also, child malnutrition rates were high and important facili- ties such as sanitary drinking water were only present in 20% of rural homes. 3 An imbalanced distribution of economic resources also contributed to the difficulties. In 1977, 48% of the population lived in isolated villages with less than 1,000 inhabitants each. The government had not given financial support to provide these areas with roads, utilities, hospi- tals, or schools, 6 never mind the supporting facilities that physicians (Iranian or imported) would need to actually use their specialized skills in these rural areas. Building On Past Experience With social and economic considerations in mind, the government set out to establish a new rural primary health care (PHC) program. Fortunately, studies had recently been carried out in Iran that involved training local young people with primary education to become front line health workers (FLHW). 7 In each location, a male worker (Behdashtyar) was in charge of com- munity health (surveillance) and environmental sanitation, whereas the female worker 34 (Behvarz) was in charge of maternal and child health, family planning and general patient care. Because they were locals, the FLHW developed close relationships with community members, which allowed for accurate collection of health information that was recorded in individualized household log books. Implementation of the system led to significant declines in infant (IMR) and under 5 mortality rates (U5MR) before the revolution. 7 That success as well as the rela- tively inexpensive nature of the new primary care and prevention program led to the system’s expansion throughout rural and eventually urban areas during the 80’s and 90’s. The focal point of the new system is the “Health House” (khane behdasht). Each is staffed by the two FLHW, who serve about 1500 people. This number is large enough to give the Health House wall chart enough data to identify village level disparities and trends (in births/ deaths, marriage/divorce, disease, etc.) and small enough to allow monitoring of immunizations with household-specific active follow up. 1 The population is drawn from one main village and several “satellite” villages with similar culture and social structure. Satellite villages had to be within one hour walking distance of the main village. In addition to the Health Houses, mobile teams consisting of a doctor, lab technician and a Behvarz, make monthly visits to remote vil- lages to provide support and refer patients to Rural Health Centers (RHC). The RHC completes the network by supervising several Health Houses and mobile teams. Along with the doctor and technician, the RHC has a member from various specialties (i.e. environmental health, disease control, oral health, nurse, etc.). 3 An Ideal(istic) Solution? The Iranian government has identified and implemented an effective strategy to reach its rural health goals. The ease of access to a friendly and agreeable FLHW allows for constant and continuous interaction between the health system and the community. This has led to the pro- motion of healthy attitudes and behaviors, such as the encouragement of breastfeeding and awareness about environmental hygiene and sanitation improvements. 4 It has also catalyzed the movement toward universal immunization of children and correct treatment of children suffer- ing from diarrhea and acute respiratory infection. 8 These improvements were essential to the decrease in IMR and U5MR from 122 and 191 per 1,000 live births in 1970 to 28.6 and 35.6 per 1,000 live births in 2000. 9 Considering this success it is not surprising that groups in the United States have looked to the Iranian system in hopes of improving rural health. Recently, a group from Mississippi signed an agreement with Iran’s Shiraz University to form the Mississippi/Islamic Republic of Iran Rural Health Project. Despite having the 3 rd highest medical expenditure per capita, Missis- sippi has the highest level of childhood obesity, hypertension, and teenage pregnancy in the United States. 10 Furthermore, IMR among non-whites in the Mississippi Delta region are com- parable to that of third world countries. Ostensibly, a strong primary care network, which is sin- cerely lacking, can use the state’s pre-existing resources to improve these figures. However, the stigma against bringing in experts from a less than popular country, coupled with the already present distrust between the communities and public health officials, due to previous scandals (i.e. the Tuskegee Syphilis experiment), pose significant challenges. Despite these challenges, the concept of improving health has a way of opening doors. In fact, the first Mississippi “Health House” is set to open in January 2010 and 15 other communities have already ex- pressed interest in opening their own. The unique program has also caught the eye of Harvard’s Navid Shams: A Lesson from Iran 35 School of Public Health, which will assist in monitoring the project. The involvement and coop- eration among various groups is impressive and holds exciting potential for the project in the coming years. Conclusion With political commitment to a needs-driven development of the PHC program, Iran has made great strides towards minimizing health disparities between the rural and urban popula- tion. Several key aspects (i.e. access to health services, collection of data, community participa- tion and cooperation, unity and reach of the network, and a focus on prevention) cast a positive light on the system. Using these strengths, the implementation of similar programs can surely improve health statistics in various settings from Iran to Mississippi and beyond. R E F E R E N C E S [1] Couper I. Rural primary Health Care in Iran. South African Academy of Family Practice 2004 46(6):37-39 [2] Hooglund E. Land and revolution in Iran, 1960 – 1980. Middle East research and information projects reports. 1980, 87(1):3-6. [3] Aghajanian A. Mehryar AH. Ahmadnia S. Kazemipour S. Impact of rural health development programme in the Isalmic Republic of Iran on rural-urban disparities in health indicators. Eastern Mediteranian Health Jour- nal. 2007 13(6):1466-1475 [4] Ronaghy H. Najarzadeh E. Schwartz T. Russel S. Solter S. Zeighami B. The Front Line Health Worker: Selec- tion, Trainig, and Performance AJPH 1976 66(3):273-7 [5] Zeighami B. Zeighami E. Mehrabanpour J. Javidian I. Ronaghy H. Physician Importation – A Solution to De- veloping Countries’ Rural Health Care Problmes? AJPH 1978 68(8):739-742 [6] Amani M. Zandjani H. The Principles of population policy with special reference to Iran. Genus 1977 33(1-2) 141-150 [7] Barzegar M. Djazayery A. Evaluation of Rural Primary Health Care Services in Iran: Report on Vital Statis- tics in West Azarbaijan. American Journal of Public Health (AJPH) 1981 71(7):739-742 [8] LeBaron S. Schultz S. Family Medicine in Iran: The Birth of a New Specialty International Family Medicine 2005 37(7):502-5 [9] Unicef. At a glance: Iran (Islamic Republic of) http://www.unicef.org/infobycountry/iran.html [10] Lamb, Christina. Deep South calls in Iran to cure its health blues. The New York Times. December 20, 2009 Navid Shams: A Lesson from Iran 36 Social Networking Tools in the Modern Era of Human Rights Protection Odessa Balumbu, Richard Fazio, Mera Geis, and Michael Karsy Where after all do universal human rights begin? In small places, close to home - so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person; the neighborhood he lives in; the school or college he attends; the factory, farm or office where he works. Such are the places where every man, woman, and child seeks equal justice, equal opportunity, equal dignity without discrimination. Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world. Remarks by Eleanor Roosevelt at the United Nations, March 27, 1958 1 The technological advances employed during each major period of historical social change, whether it be the printing press or internet, have been at the forefront of organizing and foster- ing activism. From the drive of Eleanor Roosevelt in the passage of the United Nations Univer- sal Declaration of Human Rights on December 10 th , 1948, to the modern creation of online blogs and social networks championing a particular social cause, the field of human rights pro- tection has undergone vast change. Modern technologies have only supplemented the unremit- ting passion and drive that encourages social movements to improve the human condition worldwide. Social networks have become a mainstay used for an enormous variety of interest groups in the promotion of an ever increasing number of causes. Websites like Facebook, Myspace, Linkedin, and Wayn have grown from solely social networks used to connect individuals to be- coming tools used to raise awareness, organize activism and create a permanent constituency devoted to a particular cause. 2,3,4 In fact, specific applications have been designed and marketed for these networks to allow any user to raise funds for their favorite non-profit organization. 5 Other flavors of networking also exist, such as microblogging through Twitter, which allows individuals to rapidly dispatch very short messages to many others and has been successfully utilized in a variety of recent, real world cases. 6 Social bookmarking, such as Delicious, Stum- bleupon, and Reddit, allows individuals to quickly generate a public bookmark of websites geared towards any theme, thus being able to focus attention across the enormity of the web onto humanitarian issues and causes. Many other forms of social medial tools exist, including video-sharing (YouTube), photo-sharing (Flickr), podcasting (Blog Talk Radio), mapping (Google Maps), social voting (Digg), lifestreaming (Friendfeed), wikis (Wikipedia), and virtual worlds (Second Life), all with various capabilities and untapped potential. 7 Numerous organizations representing different platforms, from political parties and bio- medical research foundations to humanitarian agencies, utilize social networking tools to pro- mote their cause. A website such as Facebook boasts over 400 million members globally and serves as the largest social networking medium in the North America and Europe. 8 It is unclear how many distinct social causes exist within Facebook, but their impact on grassroots organiza- tion and fundraising has been importantly cited in political campaigning and voting patterns. 9,10 Despite the wide range of online tools for social networking, most large-scale organizations (e.g. Christopher and Dana Reeve Foundation, Michael J. Fox Foundation, Bill & Melinda 37 38 Gates Foundation) arguably utilize only a limited portion of available online resources. These mostly include tools to allow individuals to send general online petitions to congressmen, do- nate to the foundation or passively follow the activities of the organization. Furthermore, de- spite the immense potential of social networking tools in the biomedical sphere, most discus- sions involve the ethics of such tools and their misuses, such as medical students posting unpro- fessional content on social sites. 11,12,13,14 Instead, many grassroots organizations and humanitar- ian agencies (e.g. Genocide Intervention Network, STAND, Amnesty International) seem to have utilized the capabilities of online networking tools most effectively towards their respec- tive causes. These groups have generated tools to allow for local, self-organization in an effec- tive way. One of the first cases of online social networking arose serendipitously around U.S. citizen Eric Volz. 15 In 2006, Volz was falsely accused and imprisoned in Nicaragua under doctored charges of rape and murder. 16 Working in Nicaragua as the editor of the magazine El Puente, Volz was prosecuted under suspicious circumstances. Although eye-witness accounts, cell phone usage, and credit card receipts placed him two hours from the scene of the crime; never- theless, the government of Nicaragua proceeded to try him. The cause of his ordeal was later attributed to a strained geopolitical situation between Nicaragua and the U.S., in which Volz was entangled 15 . During Volz’s one-year ordeal, a website was created from his mother’s liv- ing room simply as a way to keep friends and family informed of his condition. 17 A phenome- nal world-wide movement emerged where the website received on average 140,000 visits a month with many asking how they could help 15 . A Spanish version of the site was also cre- ated. 18 These websites helped to organized numerous telephone calls to the U.S. State Depart- ment which implemented screening to direct calls to the Nicaraguan embassy and website, eventually resulting in a crash of the embassy webserver at one point. Volz’s ordeal was de- scribed in a video narrative posted on Youtube, the first cited event where the site was used to champion a human rights cause as oppose to solely entertainment 15,19 . In addition, this video also resulted in a propagandized video placed on the site by the Nicaraguan government vilify- ing Volz. 20 In fact, the story of Volz’s online support led to mainstream media stories on this situation, helping to garner further support and eventually aiding in Volz’s release and deporta- tion from Nicaragua. 21 Currently, the site is now used to generate support for other human rights abuses in Nicaragua and elsewhere. The Volz case highlights the first self-organized social movement supported by online tools. The power and widespread reach of social networking tools was illustrated quite clearly. How- ever, despite the great benefit of an online medium to support his cause, Volz cites several ex- amples where social networking acted detrimentally to his case in an unexpected way. The in- creasing publicity of Volz’s court case resulted in the case becoming extremely politicized and perilous in Nicaragua for any judge to overturn the decision. Furthermore, the Nicaraguan gov- ernment saw Volz as a more valuable bargaining chip when negotiating with the U.S. on diplo- matic and trade issues 15 . Misinterpretation of information generated from Volz’s site, Youtube video and online following was propagandized by the Nicaraguan media to vilify him often as wealthy American extorting the Nicaraguan justice system 20,22 . Additionally, during multiple instances throughout the ordeal, the Volz’s family was extorted by various individuals threaten- ing his life in exchange for money. In spite of these drawbacks, Volz still tours the country supporting the power of online social networks in organizing individuals towards a common Michael Karsy et al.: Social Networking Tools in the Modern Era of Human Rights Protection goal and using his site to raise awareness of ongoing human rights abuses in Nicaragua 15 . One of the most creative organizations to utilize the collective power of the internet and so- cial networking to advocate for humanitarian issues has been the Genocide Intervention Net- work (GI-Net). Formed in 2005 by Mark Hanis, a descendent of Holocaust survivors, GI-Net was designed to create a permanent anti-genocide constituency which could rapidly be mobi- lized. 23 Two key lessons Hanis learned from elder Holocaust survivors during his upbringing were to never forget and never let such a situation happen again 15 . GI-Net has been involved in a variety of activities through their website, including the creation of advocacy and divestment tools, and mobilizing constituents. Research by GI-Net in collaboration with genocide scholars have identified eight ongoing areas of genocide or ethnic cleansing occurring globally, namely Iraq, Sudan, Chad, Central Af- rican Republic, Democratic Republic of Congo, Somalia, Sri Lanka and Burma. 24 Educational tools remove any excuse for not knowing about genocide but beg the question: how can geno- cide still occur despite better global awareness? One possibility is that there is zero political cost to an absent Congressional vote against genocide. In response to this, GI-Net created Con- gressional report cards depending on how Congressmen voted for anti-genocide legislation. 25,26 The effect on Congress was dramatic and effective. Multiple members of Congress called im- mediately after the formation of the webtool and in response to a deluge of phone calls and e- mails from constituents, to inquire about how to improve their scores 19 . Some wrote op-ed pieces in their constituent’s districts. 27 The combined effort greatly improved the awareness of Congressmen and the public about the ongoing genocide. In addition, the lobbying was impor- tant in the passage of a variety of legislation to protect the people of Darfur, including the Su- dan Divestment and Accountability Act signed into law in December 2007. 28,29 In response to improving interaction with Congressmen during the passage of bills, GI-Net helped to establish the genocide hotline (1-800-GENOCIDE) where constituents could call, enter their zip code and automatically be transferred to the White House, their senators or representatives. 30 While Hanis states that GI-Net has been an important tool towards mobilizing activists in genocide intervention, he stresses that personal interaction with Congressmen still remains a key method of supporting one’s cause. These tools demonstrated the capability of online networks to foster rapid and widespread mobilization of constituents in order to allow individuals to collectively increase the power of their voice. In addition to advocacy, GI-Net and its student wing Student Anti-Genocide Coalition (STAND) have helped to organize targeted divestment against companies that do business in Sudan, which supports the ongoing genocide. While U.S. businesses are not allowed to operate in Sudan due to anti-terrorism legislation, stocks of companies operating in Sudan are ex- changed on the U.S. stock exchange and can receive investments from mutual fund companies. GI-Net and its collaborators helped to identify and publish an online list of companies involved in investments which funneled money into military equipment purchases while avoiding com- panies that were involved in infrastructure development and delivery of aid to the people of Darfur. Next, GI-Net and STAND provided online resources which encouraged the self- formation of student and grassroots groups that lobbied states, cities and universities to divest their pensions and funds from these companies. Harvard University and the UC Regents be- came two of the most publicized cases where divestment was successfully accomplished, al- though it was by no means simple. 31,32,33,34 Michael Karsy et al.: Social Networking Tools in the Modern Era of Human Rights Protection 39 Grassroots movements and student groups have also been able to expand from lobbying to broad fundraising campaigns using social networking tools. STAND helped to create and or- ganize the STANDFast Project through its website and student chapters, resulting in annual fundraising efforts by groups all over the country. These efforts have helped to raise more than $500,000 over the course of three years. 35 In fact, the Genocide Awareness and Prevention Group (GAAP) at New York Medical College (NYMC) has been involved in these efforts and has helped raise over $1500 in the past two years. 36 Recently, a new tool has been developed by social entrepreneurs involving the ability to donate via text messaging to a number of regis- tered charities. 37 Texting PROTECT to 90999 allows any person to donate $5 to GI-Net di- rectly from their cell phone bill. 38 In fact, this tool alone was cited for raising over $25 million dollars for Haiti after its 2010 earthquake. 39 These and other tools have helped to organize the fundraising of many small groups of interested people over a large area, which otherwise would have been impossible. New technology has rapidly changed the way that human rights issues are addressed both locally and globally. The benefits and negative effects of social networking on human rights protection and other important issues were not anticipated. In today’s era, where thousands of e -mails or Tweets can be fired off regarding one cause or another, there is an increased immunity to the impact of social networking due to the large volume of messages which can be sent on a daily basis. Despite this, online networking continues to play an important and developing role in social issues. These tools serve to supplement rather than replace organization on a face-to- face level. Social networking has allowed for greater participation on a variety of issues and has forever changed the landscape in the fight for social causes. R E F E R E N C E S [1] Roosevelt, E. “Quotations by Eleanor Roosevelt.” The Eleanor Roosevelt Papers. 28 June 2008. George Washington University. 25 February 2010. http://www.gwu.edu/~erpapers/abouteleanor/er-quotes/ [2] Watson, T. “Facebook Generation: Will social networks change the nature of philanthropy?” 18 June 2007. The Huffington Post. 25 February 2010. http://www.huffingtonpost.com/. [3] Guynn, J. “SOCIAL NETWORKING/ Changes in Facebook/ Web plan hopes to boost activism.” 25 May 2007. San Francisco Chronicle. 25 February 2010. http://articles.sfgate.com [4] Mansfield, H. “MySpace: Where pop culture meets social activism.” 26 February 2008. National Press Club. 25 February 2010. http://www.slideshare.net. [5] Causes on Facebook. 25 February 2010. http://apps.facebook.com/causes/about [6] DigiActive Team. “The DigiActive guide to Twitter for activism.” 13 April 2009. DigiActive. 25 February 2010. http://www.digiactive.org [7] Mishra, G. “Digital activism & the 4Cs social media framework.” 10 May 2009. DigiActive. 25 February 2010. http://www.digiactive.org [8] Facebook. 25 February 2010. http://www.facebook.com/press/info.php?statistics [9] Thewall, M. and Wilkinson, D. “Public dialogs in social network sites: What is their purpose?” Journal of the Ameri- can Society for Information Science and Technology 61:2 (2010): 392-404. [10] Zhang, W.W., Johnson, T.J., Seltzer, T. and Bichard, S.L. “The revolution will be networked the influence of social networking sites on political attitudes and behavior.” Social Science Computer Review 28:1 (2010): 75-92. [11] Guseh, J.S., Brendel, R.W., Brendel, D.H. “Medical professionalism in the age of online social networking.” Journal of Medical Ethics 35:9 (2009): 584-586. [12] Jain, S.H. “BECOMING A PHYSICIAN: Practicing medicine in the age of Facebook.” New England Journal of Michael Karsy et al.: Social Networking Tools in the Modern Era of Human Rights Protection 40 Medicine 361:7 (2009): 649-651. [13] Chretien, K.C., Greysen, S.R., Chretien, J.P., and Kind, T. “Online posting of unprofessional content by medical students.” Journal of the American Medical Association 302:12 (2009): 1309-1315. [14] Emery, C. “Medical students using Facebook and Twitter can get expelled.” 22 September 2009. MedPage Today. 25 February 2010. http://www.medpagetoday.com [15] The Human Rights Center – UC Berkeley. “Human rights on and off the internet: Social Networking.” 5 May 2009. UC Berkeley. 25 February 2010. http://fora.tv/ [16] Celizic, M. “Will Nicaragua ever set Eric Volz free?” 21 December 2007. MSNBC. 25 February 2010. http:// today.msnbc.msn.com [17] Friends of Eric Volz. 25 February 2010. http://www.friendsofericvolz.com [18] Amigos de Eric. 25 February 2010. http://www.amigosdeeric.com [19] “Am American wrongfully imprisoned in Nicaragua.” 21 March 2007. Friends of Eric Volz. 25 February 2010. http://www.youtube.com/watch?v=8YChhOHrFA4&feature=related [20] “Evidence against Eric Volz.” 30 March 2007. Nicaraguan Films. 25 February 2010. http://www.youtube.com/ watch?v=sSo3sb73CZY [21] “Details of release.” Friends of Eric Volz. 25 February 2010. http://www.friendsofericvolz.com/ Details_of_Release.html [22] Rogers, T. “Gringo justice in Nicaragua.” 18 December 2007. Time World. 25 February 2010. http://www.time.com/ time [23] “About us.” Genocide Intervention Network. 25 February 2010. http://www.genocideintervention.net/network [24] “Areas of Concern.” Genocide Intervention Network. 25 February 2010. http://www.genocideintervention.net/ areas_of_concern [25] Darfur Scores. 25 February 2010. http://www.darfurscores.org/ [26] Trageser, C. “OP-ED: Darfur: How do local reps stack up?” 24 November 2006. Willamette Week. 25 February 2010. http://blogs.wweek.com/ [27] Reichert, D. “OP-ED: U.S. must do more for people in Darfur.” 15 September 2006. Seattle Post-Intelligencer. 25 February 2010. http://seattlepi.nwsource.com/ [28] Stolberg, S.G. “Bush Signs Bill Allowing Sudan Divestment.” 1 January 2008. New York Times. 25 February 2010. http://www.times.com [29] S. 2271: Sudan Accountability and Divestment Act of 2007 [30] “Genocide Intervention Network’s advocacy hotline receives 25,000th caller.” 15 May 2009. Genocide Intervention Network. 25 February 2010. http://www.genocideintervention.net/press_release [31] Harvard Divest. 25 February 2010. http://www.harvarddivest.com/ [32] “Harvard’s Sort-of Divestment” 2 July 2007. Inside Higher Ed. 25 February 2010. http://www.insidehighered.com/ [33] UC Divest Sudan. 25 February 2010. http://www.ucdivestsudan.com [34] “UC Regents vote to divest from companies with business ties to Sudan government and acts of genocide.” 16 March 2006. UC Newsroom. 25 February 2010. http://www.universityofcalifornia.edu/news/ [35] STAND. 25 February 2010. http://www.standnow.org/campaigns/standfast [36] “Previous events.” 6 June 2009. Genocide Awareness and Prevention. 25 February 2010. http://www.nymc.edu/ Clubs/Gaap/index.htm [37] Mobile Accord. 25 February 2010. http://www.mobileaccord.com/ [38] Mgive. 25 February 2010. http://www.mgive.com/Partners.aspx [39] Dowd, K. “Text “Haiti” to “90999” Passes $25 Million.” 20 January 2010. DipNote - U.S. State Department Official Blog. 25 February 2010. http://blogs.state.gov Michael Karsy et al.: Social Networking Tools in the Modern Era of Human Rights Protection 41 Another Look: Medical Cooperation and the Israeli-Palestinian Conflict Danielle Masor The Controversy There has been much debate and controversy surrounding the war in Gaza of last year (December 28 2008- January 18, 2009), and it is often portrayed in a slanted, if not biased, manner. Indeed, I came across one such article in last year’s issue of Quill and Scope entitled “The Humanitarian Crisis in Gaza: A look at the health infrastructure before, during and imme- diately after the December-January attacks.” The article described the affects of last year’s con- flict on Gaza’s health care infrastructure and the health of its population. However, while doing so, it presented a highly politicized and biased view of the conflict, and critical facts about the events in Gaza were omitted. Critical Facts I would like to establish some key facts about the Gaza conflict that were not mentioned in last year’s article. Then, I hope to focus on a more uplifting aspect of the Israeli-Palestinian conflict: Israel’s medical aid to its Palestinian neighbors and the world beyond. In terms of critical facts, the article did not mention what precipitated the war in Gaza; it made no mention that Palestinians have fired over 12,000 rockets at southern Israel over the past eight years, terrorizing towns closest to Gaza, such as Sderot. 1,2 Over 90 percent of Sderot residents have experienced a Palestinian Kassam explosion at some point. 3 Over one million Israelis live within firing range of these deadly “homemade” rockets that are stuffed with shrap- nel and nails to inflict the maximum damage possible. 4 An entire generation of children in Sderot has grown up with the fear of constant rocket attacks. Thus, in order to protect its own citizens, Israel had no choice but to engage Gaza and root out its vast terrorist infrastructure. Moreover, while discussing the high death toll and injury rate in Gaza, the article omitted the fact that Hamas, the internationally recognized terrorist organization that runs Gaza, makes widespread use of human shields. Whereas the Israeli population hides in underground shelters when there is warning of a rocket attack, the authorities in Gaza have been known to hide guns in schools, mosques, or hospitals, and use human shields to protect themselves. 5 Alan Der- showitz, a professor at Harvard Law School, succinctly summarized the situation, “This is the Hamas dual strategy: to kill and injure as many Israeli civilians as possible by firing rockets in- discriminately at Israeli civilian targets, and to provoke Israel to kill as many Palestinian civil- ians as possible to garner world sympathy.” 6 In fact, the Israeli Defense Force (IDF) went to great lengths to avoid civilian casualties. The IDF announced exactly where it would strike with radio broadcasts, over two million leaflets, over 100,000 cell phone calls, and specific warnings before attacks. 8,9 In conclusion, the Gaza conflict is complex, and it is part of a broader Israeli-Palestinian conflict that is exquisitely complicated and multi-dimensional. Moving beyond the Gaza con- flict, now, I would like to show that there is more than strife between Israelis and Palestinians. Turning to the medical arena, I hope to show how Israel’s advanced medical system has bene- 42 fited its Palestinian neighbors, and how Israeli non-profit ventures have saved the lives of many Palestinians and others. The Reality Israel’s involvement in the administration of health care to Palestinians began over forty years ago. In 1967, Israel was attacked by its neighbors and after winning this brief, Six-Day War, Israel assumed control of the Golan Heights, West Bank and Gaza. Interestingly, it also assumed responsibility of the health of the Palestinians. As Dr. Theo Dov Golan, former Direc- tor General of Israel’s Ministry of Health notes, “During that period (1967-1994), Israel has presented annually dramatic documented achievements to the World Health Organization (WHO)…. This included the total eradication in the Palestinian population of poliomyelitis, neonatal-tetanus and measles. Also, Israel dramatically reduced the death rate of Palestinian newborns from over 60/1000 to 19/1000 within those 27 years of Israel's presence.” 9 To this very day, thousands of Palestinians are referred to Israeli hospitals for life-saving treatment. The Israel-based NGO, the Peres Center for Peace, has established the “Saving Chil- dren” project, facilitating referrals to and treatment of Palestinian infants and children in Israeli hospitals for sophisticated treatments and diagnostic procedures not available in the West Bank or Gaza. The costs are covered entirely by the Peres Center (which receives funding from pri- vate sources—including several regional Italian governments). Since its inception in 2003, “Saving Children” has received some 6,560 referrals from the West Bank and Gaza. 10 Outside the NGO circuit, Palestinians from the West Bank and Gaza are referred to several hospitals in Israel. Before the Gaza conflict, for example, Barzilai hospital, located only twelve miles from Gaza, received numerous Palestinian patients on a daily basis. As Dr. Ron Lobel, Barzilai’s deputy director noted in a 2008 interview: “We treat hundreds of Gazans here each year… Even if they're terrorists, they're treated like any other person being brought into the emergency room - we make no distinction between treating Israelis or Palestinians.” While the Palestinian Authority’s Health Department pays for a majority of the cases, Israel foots the bill for many others. Of course, it gets complicated, and many Gazans are stopped at the Erez secu- rity crossing before they can access Israeli health care. In 2004, a female suicide bomber who claimed she had surgical plates in her legs blew herself up at the crossing after bypassing the metal detector, killing four Israelis, prompting increased security measures. 11,12 Save A Child’s Heart (SACH) Perhaps the most uplifting of all the examples of the medical relationship between Israelis and Palestinians, is the Israeli-based humanitarian organization, Save a Child’s Heart (SACH), which was founded in 1995 by Dr. Ami Cohen. The goal of SACH is to provide and improve pediatric cardiac care for children from developing countries regardless of nationality, religion, color, gender or financial situation. To date, over 2,100 children (49% from the West Bank, Gaza, Iraq and Jordan, 40% from Africa, 7% from China, Sri Lanka, and Vietnam, and 4% from Moldova and Russia), ranging from early infancy to 18 years of age, have been success- fully treated. 13 Their cases include numerous congenital heart defects, such as tetralogy of Fal- lot, and acquired conditions, such as rheumatic heart disease. 43 Danielle Masor: Medical Cooperation and the Israeli-Palestinian Conflict SACH medical personnel travel throughout the Middle East, Africa, and beyond to evaluate potential patients with portable echocardiography technology and the cooperation of local cardi- ologists. If it is decided that an operation is necessary, SACH flies the child (and a family mem- ber, for younger children) to Israel for treatment. Surgery is performed at the Wolfson Center in Holon, Israel, not far from Tel Aviv. Children are hosted pre- and post-operatively at the nearby Children’s Home. SACH also runs teaching missions, sharing knowledge and expertise with colleagues in China, Ethiopia, and Mauritania, to name just a few. A total of 14 such teaching missions have been conducted to date. Moreover, SACH conducts training programs to foster more independent centers of competence in the developing world, and 50 visiting physicians have been trained under its auspices. 14 SACH is funded by private donors, including Christian charities, and its remarkable 70- person staff, including its chief surgeon, contribute their time without receiving any payment from SACH. What I find so uplifting about SACH is that it operates without regard to politics. SACH gives its all to save the life of any child—whether he or she is Palestinian or Iraqi. One particu- larly touching story, which emerged against the context of the war in Gaza, detailed how a little Palestinian girl, Noor, and her mother, Wafaa Huseini, managed to get out of Gaza and make it to the Wolfson Center for surgical correction of a debilitating patency between Noor’s right and left ventricles. The eleven person medical team included Jews, Christians, and Muslims. It did- n’t matter what was going on in the world outside, all that mattered was saving Noor’s life. I spent some time looking at the on-line photo gallery of children presently at the SACH Children’s Home either awaiting or recovering from heart surgery. 16 Yuquing, 13, is from China. Kinsley, 3.5 years, and Erica, age 5, are from Ghana. Hezhan and Rezhna, both smiling very broadly in their photos, are from Iraq. Salam, 9 months, is from the West Bank. Daria is Romanian, and Aisha, grinning to ear-to-ear, is from Zanzibar. These pictures concisely convey the humanitarian efforts of Israelis, and stand in sharp contrast to the often politicized, one- sided criticism of this small nation. Further research led me to similar ventures. Eye From Zion, for instance, is an Israel-based non-profit working to restore sight to hundreds throughout the developing world, mostly with the relatively simple removal of cataracts. 17 The Midwives Coexistence Project is a group of Palestinian and Israeli midwives who work together toward peace to assist pregnant Israeli and Palestinian mothers with safe and natural births. 18 In conclusion, it is easy to simplify the Israeli-Palestinian conflict and ignore the complex, subtle reality on the ground, of which Israeli-Palestinian medical involvement is but one dimen- sion. It is also easy to forget that Israel is a nation of only 7.2 million people, with a landmass the size of New Jersey. Despite its small populace, and vast security concerns, it remains the only democracy in the Middle East. And despite its small size, it sent one of the biggest interna- tional aid teams, 220 strong, to Haiti in the wake of the recent earthquake that claimed an esti- mated 200,000 to 250,000 lives. Israel set up a huge, makeshift hospital which could accommo- date up to 500 people, and included an operating room for complex surgeries. 19,20 Several Hai- tian children were born in the Israeli hospital. The first mother to deliver there told the doctor, Dr. Shir Dar, that she would name her son Israel. 20,21 Danielle Masor: Medical Cooperation and the Israeli-Palestinian Conflict 44 R E F E R E N C E S [1] “Gaza Facts.” The Israeli Ministry of Foreign Affairs. Accessed 12 Jan. 2009. http://www.mfa.gov.il/ GazaFacts [2] “Facing Rocket Attacks in Southern Israel (Video)” NY Times Online. 5 Jan. 2009. Accessed 17 Jan. 2010. http://video.nytimes.com/video/2009/01/05/world/middleeast/1194837360056/facing-rocket-attacks-in- southern-israel.html [3] Bedein D. “Trauma: The Unreported Casualty of War.” Therapy Today. Jun. 2009. Accessed 17 Jan. 2010. http://www.britannica.com/bps/additionalcontent/18/43444006/Trauma-the-unreported-casualty-of-war [4] “Gaza Facts.” The Israeli Ministry of Foreign Affairs. http://www.mfa.gov.il/GazaFacts [5] Montaner, C. “Gaza’s True Disproportion” Washington Post Global. 12 Jan. 2009. Accessed 17 Jan. 2010. http://newsweek.washingtonpost.com/postglobal/carlos_alberto_montaner/2009/01/ gazas_true_disproportion.html [6] Dershowitz, A. “Hamas’ War Crimes.” LA Times. 10 Jan. 2009. Accessed 17 Jan. 2010. http:// www.latimes.com/news/opinion/la-oe-dershowitz10-2009jan10,0,2587090.story [7] “UK Commander Challenges Goldstone Report.” UNWatch.org. 16 Oct. 2009. Accessed 15 Jan. 2010. http://www.unwatch.org/site/apps/nlnet/content2.aspx? c=bdKKISNqEmG&b=1313923&ct=7536409 [8] Cooper, A., Brackman, H. “The Threat of the Human Shield Strategy Hamas Uses Extends Beyond Israel, Gaza. US News & World Report. 19 Jan. 2009. Accessed 17 Jan. 2010. http://www.usnews.com/articles/ opinion/2009/01/09/the-threat-of-the-human-shield-strategy-hamas-uses-extends-beyond-israel-gaza.html [9] Golan, T. “The Big Why.” Israel21c.org 19 Sept. 2004. Accessed 17 Jan. 2010. http://www.israel21c.org/ opinion/the-big-why [10] The Peres Center For Peace http://www.peres-center.org/SectionProject.asp?cc=01140201 [11] Berg, R. “Israel’s Dilemma Over Sick Gazans.” BBC News. 30 Apr. 2008. Accessed 17 Jan. 2010 http:// news.bbc.co.uk/2/hi/middle_east/7375439.stm [12] Author’s Note: No current information found on Palestinian patients at Barzilai post Gaza operation. [13] Save A Child’s Heart http://www.saveachildsheart.org/89-en/Sach.aspx [14] Save A Child’s Heart http://www.saveachildsheart.org/89-en/Sach.aspx [15] Dyson, J. “Heart of Gold: Loving Hands Reach Out In the Nightmare of Mid-East Politics to Repair the Hearts of Dying Children.” Reader’s Digest. July 2009. Accessed 17 Jan. 2010. http:// www.saveachildsheart.org/sip_storage/FILES/2/1832.pdf [16] “Children Currently in Israel.” saveachildsheart.org Accessed 17 Jan. 2010. http:// www.saveachildsheart.org/265-2086-en/Sach.aspx?pos=1 [17] “Israel’s Eye From Zion Restores Sight in Developing Countries. Israel Ministry of Foreign Affairs. 17 Nov. 2009. Accessed 18 Jan 2010. http://www.mfa.gov.il/MFA/Israel+beyond+politics/ Eye_from_Zion_restores_sight_developing_countries_17-Nov-2009.htm?DisplayMode=print [18] Stein, H. “Giving Birth to Peace.” Israel21c.org. 6 Jan. 2010. Accessed 18 Jan. 2010. http:// www.israel21c.org/social-action/giving-birth-to-peace [19] Mozgovaya, N. “Israeli Team to Halt Haiti Search Efforts Monday.” Haaretz.com. 18 Jan. 2010. Accessed 18 Jan. 2010. http://www.haaretz.com/hasen/spages/1143165.html [20] Cohen, E. “Slow Medical Care is One More Thing For Quake Victims to Survive. CNN.com. 17 Jan. 2010. Accessed 18 Jan. 2010. http://cnn.mlogic.mobi/cnn/archive/archive/detail/432499/full/ frg;jsessionid=0C33EA7110AA24035D01EFE52DD36DBF.live7i [21] “Dr. Besser Assists in Haitian Baby’s Birth.” ABC News.18 Jan 2010. Accessed 18 Jan. 2010. http:// abcnews.go.com/Video/playerIndex?id=9591907 45 Danielle Masor: Medical Cooperation and the Israeli-Palestinian Conflict Njinga Stuart Mackenzie It’s been getting darker each day I wake, and the dawn’s chill is no motivation to leave the house. Yet the coffee soaks in, the Cape Dove chants, “Work harder, work harder,” and I know it’s time to leave. Outside, the 55-pound bulk of my Atlas bicycle sits, gently decaying into the morning’s mud. Its slowly leaking front tire is in need of a trip to the filling station. As I ease back the warped steel gate of our plot, the subdued quiet of home vanishes with the speeding black ex- haust of a passing sedan. Kabulonga is fully awake and scores of Zambians line the roadside, hoping for a lift from a passing vehicle or picking their way to work through the collected pud- dles. Few, if any, of these pedestrians are coming from the homes along Kudu Road, but that’s where they’re headed. Each morning, maids, guards, nannies and garden boys leave the ram- bling shantytown compound of Mtendere, warding off the cold with bright pieces of chitenge, and making their way to work in upscale Kabulonga. Sidewalks are not a luxury afforded to the poor, and the growing stream of cars forces these unseen labourers further into the mud. As I urge my cheap, over-built Indian bike further down the road, its bearings creak with each revolution, and the eyes that turn my way are a mixture of amusement and confusion. A white man, a mzungu, on a bicycle is an unusual sight around here, and few of these Zambians would believe that I actually prefer riding my bike to driving to work. You can be sure that not a single one of them would be caught dead in the street if they could afford anything with wheels. Cresting the hill towards Kalingalinga, a bike bell rings frantically and I look up from my bars to see a man speeding in the wrong direction. Without swerving, he brushes past a group of school children, the youngest of which is yanked backwards by the hand of an older sibling. There’s no apology from the cyclist, no indignation from the children, just another close call on a Tuesday. Pulling into the filling station, I wait by the air compressor as a taxi driver fills the tires of his robin-egg blue taxi. Both of the right wheels are small spare tires and the car leans percepti- bly to the passenger side. A small grey hatchback roars through the parking lot, scattering women selling bananas, and it pulls up next to the taxi. When the opportunity presents itself, this man goes to take the air hose, paying no attention to me or my bicycle, but the paleness of my skin makes him falter. He looks uncomfortable as I reinflate my front tire, and he brusquely takes the hose from me. As I leave the filling station and enter Kalingalinga Compound, a group of street kids run, chasing after the bike, screaming their only English at the top of their lungs, “Hello! How are you?” A passing bus conductor, passing literally six inches from my elbow, laughs from his perch on his bus’ window. He yells something in Nyanja, but it’s too fast for me to understand. 46 This stretch of road is what I love about starting each new day. The crowd of people, pro- duce, and vehicles, complete with swerving bicycles and the shouts of bus conductors, “Hospital, hospital!” are a heady reminder of the rich colour of Zambian life. This scene is also a stark reminder of the gross gradations in lifestyles that its participants enjoy. Those drivers of second-hand Chinese cars, the ones without a back window with the muffler held up by clothes hangers, will travel further this morning than the woman selling tomatoes will in a month. A hollering conductor packs those who can spare a few cents into a crowded mini-bus, although they’ll be back amongst the masses in just a few kilometres. Across from the bus stop, an old woman with a hammer and rheumy eyes bears hazy witness to this chaos as she pounds frag- ments of granite into stone dust and gravel. As a white foreigner, I am normally excluded from such everyday Zambian experiences, but on a bicycle, I manage to straddle the divide, if only for the fifteen-minute commute. Weaving through the bus stop, I’m careful not to take too much liberty with these testy drivers, and I dodge a weaving old man clutching his carton of maize beer. I’m quickly forced back into the mud by the swerve of a minibus that sees a potential cus- tomer on the side of the road. Coming too close to the refuse-choked ditch, I am furious and I yell at the perspiring driver as I pass. He stares back blankly, and I’m unable to tell if he just doesn’t understand me, or doesn’t care. Another passenger crammed aboard the minibus jumps out off the shoulder, and the bus flies 100 meters down the road before jamming on its brakes at a backup. Undeterred, the driver steers his vehicle onto the rutted shoulder and bumps along past the jam, honking incessantly at any pedestrian foolish enough to get in the way. The last stretch to my office is the least developed of the route, but it is the realm of paper- boys who chase the slow traffic with morning news. A big man in his Mercedes can’t consider slowing down for the teen chasing him, desperate to collect the money he’s owed. The closer I get to work, the thinner the pedestrian traffic becomes, and the potholes fade from the road sur- face. It’s not necessary to lock my bike, all the guards know who rides the big black Eagle, and I run in for my notebooks. Ten minutes later, I’m in the passenger seat of a brand new Land Cruiser, and the driver has the air conditioning on. It’s not hot, but we have air conditioning, so we use it. Pulling out onto the road, the driver turns back towards the compounds and our first clinic. Speeding through the potholes, he honks at a mother and child, reminding them to stay off the dry road. I was just here twenty minutes ago, but this time, I know there will be no chil- dren asking me how I am, and the conductors will mouth wordlessly as we pass. Stuart Mackenzie: Njinga 47 Katrina Bernardo If They Knew... Ava Asher Man Huddled (Top) Man Leaning (Bottom) Cancer Education And Awareness Program: Sukhpreet Singh "Time is a great teacher, but unfortunately it kills all its pupils." -- Hector Berlioz I remember this place, a high school auditorium filled with restless and inattentive teens. I was here last year to do a presentation on preventing skin cancer. These presentations had become mundane and rehearsed acts to an uneducated audience. To our surprise, the school principal asked us back to present again because the school was so impressed by our work and the impact that it left on the students. I guess mediocrity passes for excellence in some places. After our presentation, I was greeted with a familiar but awkward smile, “Hey, do you re- member me?” I replied, having no idea who he was, “Yes, of course, I do. How are you?” Without further guesswork, he reminded me how we had met, and I recalled his name, David. As we talked further, he said, “You know you saved my life right?” I replied amusingly, “How is that, David?” After I had given my presentation the year before, David noticed an odd spot on his back, and it fit the categorization of melanoma that we had taught. He saw a dermatologist, and he was told that he was lucky to have come in when he did. Based on pathology reports, the mole was start- ing to show signs of turning into an aggressive cancer. I realized that these seemingly mundane and rehearsed acts do have the ability to make a remarkable difference in people's lives. In medical school, we spend most of our time as students reading textbooks and memorizing minutiae for exams. The cost of this is that we lose perspective and awareness of our ability to make a difference right now, along with the impact we'll make in the future. Medicine is a privileged pro- fession. Even our slightest intervention carries long term significance. We manipulate the human body, and in our best attempts, we cure our patients. Even at our worst, we alleviate human suffer- ing. However, we forget the most amazing skill we have – to prevent disease before it afflicts our patients. We fight all sorts of ailments with interventions, but we minimize the importance of pre- vention through education. This galvanized my efforts of cancer prevention education. Cancer has been stigmatized over the years by most as an unpreventable death sentence. This reflects a lack of knowledge of behavioral contributions to cancer. It is this lack of understand- ing that not only causes an increase in morbidity and mortality, but also consequently makes the job of the physician harder. It is due to these reasons that we as physicians also have a significant roles as educators. We join the field of medicine because we believe in its ability to cure, but even more than that, to prevent disease. It was with that same philosophy that I started the Cancer Education and Awareness Program (CEAP) last year on campus. I had a vision, one that I hope to accomplish within the next few years at NYMC. With my organization, I aim to dispel the misconceptions about cancer, and to provide markers for early detection in the general community as tools for pre- vention. There have been similar programs started in foreign countries to reach populations that are impoverished in HIV/AIDS education. These programs found great success because they were able to approach their subjects through a story telling method, which is the model for our presentations. An article published by Mukoma et al. “Process evaluation of a school-based HIV/AIDS interven- Education And Its Role In The Prevention Of Cancer 50 tion in South Africa” outlines the specifics of their processes, including their successes and fail- ures. 1 When designing our program, I wanted it to not only incorporate a story telling approach, but to be able to address a much broader population. In his study of rural smokers of Illinois and popu- lations of urban cities, McLafferty et al. found that urban dwellers are more prone to cancers due to smoking. 2 It is nonetheless important to be able to disseminate information to every part of the population; disadvantaged, advantaged, rural or urban. Unfortunately, no programs in the United States have been able to reach an appreciable scale to do a publishable study. That is one of our goals. We want to be able to show that we are able to reach not only the students in our demographic, but also their parents by emphasizing the need for them to share this information. We aim to provide a comprehensible and scientific Power- Point presentation to kids between the ages of 14-18. This age group is easily accessible through high schools, and according to the American Lung Association, the average age of onset of smoking amongst teenagers is 13 years old. After we had defined our objectives and outlined a clear mission statement, we sought sup- port amongst the faculty and students. We knew we would not be able to launch this off the ground until we had other people sharing our vision. The success of the project owes itself to the support from faculty members, such as Dr. Wu, and the shared vision of my fellow classmates. It is with all of their help that we have taught nearly 800 students this year, nearly half my intended goal for the entire year. It is through these students that we reach their families and friends, thus, the real num- bers are forever growing as information always disseminates. I will have realized my greatest ac- complishment if I have been able to reach out to another David. As we continue to expand on the NYMC campus as a student club in the upcoming years, we aim to provide a curriculum for other cancers beyond our current lung cancer presentation. At the end of this year, we intend to incorporate a curriculum for skin cancer as well. I also intend on making CEAP an independent non-profit organization that will be incorporated into other graduate schools in the area. Our greatest strength is in our numbers. To recapitulate the words of Berlioz, the passage of time is a great teacher with its undeni- able consequence – death. As physicians, we bear the responsibility to not let our patients learn through time and to make their own mistakes, but to teach from the mistakes of others to allow them to live more fruitful lives. As long as we continue to believe that we have the ability to change the course of events by our own interventions, in this case to prolong life, we will make a difference without fail. That is why we must take on the roles of teachers and educate others before time does it for us. REF ERENCES [1] Mukoma, W., Flisher, A.J., Ahmed, N., Jansen, S., Mathews, C., Klepp, K.I., Schaalma, H. (2009): Process evaluation of a school-based HIV/AIDS intervention in South Africa. Scand J Public Health, June, 37, Suppl 2: 37-47. [2] McLafferty S., Wang F. (2009): Rural reversal? Rural-urban disparities in late-stage cancer risk in Illinois. Cancer, June 15, 115(12): 2755-64. Sukhpreet Singh: Cancer Education and Awareness Program 51 Anna Djougarian Transformation of the Medical Student Life Fuel Alanna Chait We are a people of loss. Umbilical cords sever like freshly cut grass; fluid evaporates as quickly as these words; hemorrhages pilfer life fuel; hemosiderin-laden ecchymoses burst like fallen sunsets; arteries and ardor retreat with each battle; leaky membranes displace ions like Adam from the garden; neoplasias obliterate self; bodies dwindle with each cut; disoriented immune systems cloud illusion and reality. We are a people of loss. We are a people of replenishment. Undying receptors cling like desperate lovers; protein transporters home as pigeons to their nests; bone springs from primordial roots; zymogens save us from ourselves; souls emerge from finely sculpted blastulas; ATP pumps birth energy and motion; liver cells replace defeated neighbors; vessels vitalize broken hearts; despair breeds strength and conviction. We are a people of replenishment. Within loss, gain; within death, birth. 53 For Only A Moment Daniel Waintraub Inspiration seems to only last a moment As if that’s all it’s worth Striking a chord, hitting the spot, enlightening the mind And once again back to the earth It only lasts for so long, before it leaves us again Like a quick lightning strike, or an uniquely caring friend Time and time again we encounter this “being” This thing they call inspiration, which allows us to “see” It’s too bad it only settles for a second, in our flashy, fleeting minds For if it would last a moment longer, it would be a moment longer to find… Some of those elements of life, which we all fail to perceive Those which are important or significant, before we are ready to leave Sadly though, it’s a fact and it is true That a free gift such as this is one taken for granted, one we tend to eschew Like a wave in the ocean, it comes and goes Where it will take us, only g-d really knows It may spur us into a mental frenzy of motion Lifting us to elated heights for a moment, like an effective potion However, we run from this moment, tend to close it out of our minds But we fail to realize, we only get such an opportunity so often, before we run out of time We could conquer this world, if we’d hold onto that spark Allow it to set in, lighten our minds, and eventually drag us out from the dark We could finally “see” that which is not seen, and “hear” that which is not heard if we grasp it so tight Amazing how the effect of one moment, could grant one the gift of “sight” But man is prone to escaping, from any moment of thought For he fears any sort of change, and this is what he has been taught That this world is for the benefit, of our kindly physical being that we own Ignore the open passageways, which permit us to look to the unknown Search for your body, and your heart and soul you shall ignore For they are not important, so they you will deplore So recognize the following, as a tool for the common man It will come upon you at some time, and it will not ever be planned 54 Daniel Waintraub: For Only A Moment A spark of inspiration, for the lost souls of our age A spark of inspiration, pushing you to finally turn the page To the next chapter of life, whichever one that may be But if you don’t hold on to that moment, that next page, you’ll never see Whatever it might be, that could cause such a flare in the mind Don’t neglect this sudden feeling, for you don’t know what you may find Failing to retain inspiration, is something we all have done We’ll continue to believe we have everything, when really all we have is…none It can only be to one’s avail, that sudden enlightenment which we feel And only if we hold onto it, and use it, will we be able to unveil that which is real So, the next time that you feel it, don’t let it go for naught For it might lead to something special, like that thing we call…thought 55 Linda DeMello Skull Rock Joshua Tree National Park Twentynine Palms, CA Resident Navid Shams Reminiscent, I close my eyes and think about us and our first years in the field of medicine. You, scarecrow, that sacred defender of its solidarity, ugly cousin of the man named malpractice. Those early days, surely that was the way it wasn’t going to be. So easy. So hopeful for a few days, as I entertained forged synapses, met a socialite threshold, burning diesel, then they arrived by email, all electric, and it all changed. Unlike memories, habits developed die hard. Now, while listening to you whine, me and a malbec drift away, rediscover simplicities, a couch and a convo, wondering about what could have been, dental school, anything really. Then I return to you, agitated and in need of advice, looking for the selfless few, escaping to tv and lethargy. Troubled. Test and toast, shot, shot, black out, we all open up. Passed out, cubbied, hunched over and lonely, coming home covered in an odor, pungent in the way only sterility can be. Wide-eyed, just to stare down a microscope. The multiple stresses of a traditional approach. A sacrificed anatomy but at least you made the mark. A slave now and when will I hear that canary sing? Maybe never, hopefully soon, probably tomorrow. Dates, another thing I learned not to share with reality. Either way I’m happy, like the only crow hidden in your shade, reaping the spoils others avoid. 56 Medamorphosis Andrei Kreutzberg Some call it a prison A locked in boxed in metal edge razor Cortisol crazy, relentless and furious Balancing on the edge of a knife from oblivion Wishing-hoping-pleading, Suffering one more day for mysterious reasons Sacrifice! sacrifice! Youth gives way to hunchback isolation and paper cuts The soul cries out for pleasure and repose But the narcissist longs for perfection, Perfection is beauty, perfection is joy, Only perfection can halt the millstone The mirror must shatter Striving-stomping-screaming, Giving up moon dreams and settling for safe ground But charity knows not mediocrity. A prison? Nay, a cocoon! A soul forged, fast paced, trial by fire frenzy A dark burning chrysalis: god spun, hope inspired, endurable The chalice of knowledge blisters and purifies What a beautiful metamorphosis: Earning each angel feather one wrong answer at a time 57 Vitality Poonam Kaushal He plays in the sun-sparkled sandbox each day, building small mounds of a castle along where his shovel and pail lay. With his mother watching fondly as the child giggles with pleasure, She looks at her son with ardor not made to measure. He plays in the sun without concern or care, His mother leisurely watches not realizing an unseen danger lurks somewhere. A sudden splash of something lands on his arm, He looks at it curiously without feeling a need to be alarmed. From its globular being, it drips and oozes without letting go of its hold, The child wonders what is of such a thing that is not so easy to mold. With great resistance, small drops evade the elastic splotch, Landing swiftly onto his delicate calf, he continues to watch. He doesn’t feel any different but suddenly becomes fatigued and lazy The oozing moving slowly down his arm starts to make him feel queasy. As he searches for a sign of meaning, his color starts to wane, He turns toward his mother who covers her face as she sobs in pain. The splotch that moved slowly to his hand causes him a new sensation of discomfort, He gently rests his head on his hand using the remaining energy he had to exert. He tugs and pulls and feels a little stuck, And after finally pulling free, he finds, sticking to the oozing splotch, a hair tuft. The sun is not bright, the clouds have it covered, A dark dismal gloom ensues making him wonder where he has faltered. The boy cries and sobs, Thinking all that was good has left, leaving nothing more than this blob. Just as abruptly as this blob came, while the boy shed almost all his tears, He suddenly felt his hand covered by another of younger years. Smaller eyes looked up at him curiously, filled with light He looked at them with wonder, forgetting momentarily about his plight. 58 Poonam Kaushal: Vitality Smiling happily, she held up his shovel and pail And as his eyes gazed over the baby he saw a tuft of hair no longer there. Confused and bewildered he sat and saw, that the despair and gloom that burdened was replaced by the light from her eyes filled with awe. It was not his mother’s worry or oncologist’s medicine that gave him strength, but a younger child reminding him that his own vitality will help him go the length. World Cancer Day is on February 4 th , 2010. A tribute to all of the children with cancer, and to those with cancer who help other children newly diagnosed with cancer each day. 59 Luke Selby Spring Break at Night The Shell Jordan Roth Here it is another day In the land where doctors roam. I’m in search of peace more than answers Because it’s been so long since I felt at home. Here comes the team Without a knock on the door. In their haste to save time I am left wanting more. No real connection I have come to expect. Trapped in this crumbling shell Their words are more direct. I hear my case retold each day But none of them knows my story. About when I ran, and laughed and played Lived and led, about my days of glory. Distant stares and scribbled notes Tell me more than they know. I wish I could tell them what I’ve learned about life And what’s most important at the end of this road. They funnel out in a line But one hesitates to leave. He best keep on moving or He is sure to face reprieve. The light filters in through the window And with it a smile greets me. And for a second I remember Life, love, humanity. His hand holding mine Our eyes meet with a glow. Perhaps for just this moment in time This place feels like home. 60 It’s Gonna Be All Right Linda DeMello She lost her job. After ten years, they told Marie they had to let her go. “The economy is bad,” they said. “We’ll compensate you for the rest of the month. We’re really sorry.” My God. What was she going to do now? The hospital’s sterile staircase ascended above her, leading to the gray door of the third floor. She held on to the cold railing so tightly that her knuckles were white. Panic clutched the strings of her heart, yanking them hard. Her husband died two years ago in a construction acci- dent, leaving her a mourning single mother of one. She tried her best, but no matter what she did, fate continued to mercilessly shove her down onto her knees. And now she had failed her son. She climbed the stairs and finally entered into the bright décor of the children’s unit. Drawings hung in picture frames – ferocious tigers, fire-breathing dragons, and princesses in pretty dresses. Christmas decorations covered the hallways, lights glowing and tinsel glittering as “Frosty the Snowman” hummed through the air. Conversation was abound, adults chatting and children laughing. The snake of dread constricted Marie’s throat as tears burned the back of her eyes. Everything was falling apart. Forcing herself onward, she winded through the lively hallways, feeling like a black shadow amidst the vibrant energy. Siblings chased each other as the staff dodged them, grin- ning in delight. As doctors and nurses passed her, their jovial faces faltered, recognizing that something was wrong. She wanted them to stop looking at her, to stop proving that she was weak and helpless, especially now that she had nothing left to give. Especially now that there was nothing more she could do for the most precious person in her life. Her hands began to shake. She clenched them into fists. She plowed onward towards room 309, ignoring the greetings and the smiles. Her eyes filled, and she lifted her head up in a vain attempt to prevent them from spilling. When she finally arrived, she opened the door to her five-year-old son’s room. He sat there, a beacon of light in the dark, wearing a Santa hat and playing with a fire truck. Machines surrounded him, sending out a cacophony of noise that had kept her up many nights. Joey looked up at her and his face lit like a ray of sunshine, for she had arrived earlier than usual. He wore his favorite pajamas, the ones with fire trucks all over them. He wanted to be a fireman when he grew up. And all Marie could think of was how his future had disappeared before her eyes, 61 chased away like chalk paintings in the rain. “Mommy!” Joey exclaimed, his fragile face filled with happiness. “You’re here!” “Yes, baby, I’m here,” Her voice cracked and she loathed the sound. She moved over to his bedside, trembling, regretting that she hadn’t picked up a gift for him, even if it was just a Hershey’s bar. Joey’s smile faded when he noticed her tears. “Mommy, what’s wrong?” She shook her head, managing a smile through the blur of misery. “Oh, nothing. Mommy is just being a silly girl.” He didn’t believe her. Like any child who knew far more than he should, she couldn’t fool him. He lifted the fire truck and placed it in her hands, his beautiful dark eyes filled with sympathy. “Here, mommy, you can have my truck. It’ll make you feel better.” Her walls came crashing down, crumbling apart at the sight of his favorite toy in her hand. “I’m sorry, honey,” she murmured hoarsely, apologizing for losing her job, for losing all hope of continued treatment, and for losing the battle against his cancer. “I’m so sorry.” Joey stood up, wobbly on his feet, and he wrapped his frail arms around her, showing her courage and strength beyond anything she could imagine. “It’s gonna be all right, mommy. It’s gonna be all right.” Linda DeMello: It’s Gonna Be All Right 62 Radeeb Akhtar Untitled Nude Telemedicine Management of Diabetics in an Underserved Community J. Paul Nielsen and Pranav Mehta, M.D. Introduction Information technology via telemedicine offers the potential for cost-effective and active management of type 2 diabetes mellitus for people in high-risk underserved communities such as Harlem, NY and the Bronx, NY. Adults with type 2 diabetes mellitus have heart disease death rates about 2 to 4 times higher than adults without diabetes, and the risk for stroke is 2 to 4 times higher among people with diabetes. 1 Telemedicine is the use of telecommunications technology for medical diagnostic, monitoring, and therapeutic purposes to communicate infor- mation instantaneously from one location to another, such as from a patients’ home to a hospi- tal. 2 Conventional diabetes management involves a patient diagnosed with type 2 diabetes melli- tus seeing a physician in an outpatient setting for monitoring, and meeting with a diabetes edu- cator who recommends lifestyle and dietary changes. If these lifestyle interventions are not adequate to bring the blood glucose levels under control, the physician may recommend phar- macological interventions such as treatment with metformin or another medication to increase insulin sensitivity and secretion. The New York City Health and Hospitals Corporation’s (NYC HCC) Housecalls program supplements conventional diabetes management by providing free tele-glucometers to patients diagnosed with type 2 diabetes mellitus. These glucometers transmit the patient’s daily blood glucose measurements back to the hospital and alert the medical staff to any needed changes in the treatment regimen. Utilizing only an existing phone line and a “tele-glucometer” rigged to plug into a phone line, clinicians have the opportunity to monitor the daily glycemic status of patients without having to see the patient in clinic. The use of telemedicine to assist residents of East Harlem with controlling their blood glu- cose levels can function in meeting the two main goals of Healthy People 2010: increase the quality and years of healthy life and to eliminate healthcare disparities. 3 A previous study on Army diabetics has indicated that telemedicine leads to better glycemic control and fewer com- plications than conventional treatment in controlling diabetes. 4 Using a home telemedicine sys- tem to deliver care to patients with type II diabetes resulted in a 16% reduction in Hemoglobin A1C levels (from 9.5 to 8.2%) and a 4% mean weight reduction (from 214.3 to 206.7 pounds) during a 3-month period of monitoring. 4 Our study aims to quantify the improvement experienced by NYC HCC diabetics treated at placed on the Housecalls telemedicine monitoring program and compares them to NYC HCC patients treated via the conventional approach of medication and lifestyle recommendations combined with regularly scheduled outpatient medical visits. Methods The patients analyzed were NYC HCC patients that were newly diagnosed with type 2 dia- 64 betes mellitus. Hemoglobin A1C levels from before the patient was enrolled in the Housecalls program served as baseline reference values. Hemoglobin A1C serves as a stable mean value of a patient’s constantly changing blood glucose levels averaged over a multi-week period. We compared the baseline Hemoglobin A1C levels to the levels recorded after the patient was en- rolled in Housecalls for at least 3 months. Results The initial results indicate that the Housecalls program is effective in improving compliance and management of diabetes. Of the patients with an HbA1c level measured within 3 months of start of program and 3 months after enrollment, 19 of 22 (86%) had a decrease in HbA1c, while the remaining 3 patients had no change in HbA1c. Discussion The initial success of the program is encouraging and demonstrates a great potential for the use of telemedicine in monitoring chronic disease. One of the largest problems in providing care to patients of underserved areas is loss to follow up, and telemedicine offers a cheap and effective solution to reduce such losses. The costs of providing the tele-glucometer would be largely offset by the reduced expenses of treating diabetes complications if this method is in- deed effective in improving long term glycemic status. The initial results are encouraging and certainly warrant more detailed and in-depth analysis of this simple tool. J. Paul Nielsen and Pranav Mehta, M.D.: Telemedicine Management of Diabetics 65 R E F E R E N C E S [1] “Improving Reproductive Health.” United Nations Population Fund. 2006. Accessed 1 Mar. 2007. http:// www.unfpa.org/rh/index.htm [2] Johri A. “Innovations at Work: Reaching Out with RCH Services.” State Innovations in Family Planning Ser- vices Project Agency, Uttar Pradesh. 1999. Accessed 2 Feb. 2007. http://www.policyproject.com/pubs/ countryreports/INDinnov.pdf [3] Claeson M, Bos ER, Mawji T and Pathmanathan I. 2000. Reducing Child Mortality in India in the New Mil- lennium. Bulletin of the World Health Organization, 78: 1192-1199. [4] Tewari J. “USAID/India Strategic Objective Close out Report.” Organization for Economic Co-operation and Development. 2005. Accessed 28 Jan. 2007. http://www.oecd.org/dataoecd/55/14/36104395.pdf [5] Gudipati D. “Healthcare Delivery Systems in Rural India: Meeting the Changing Needs of Rural Populations.” Carnegie Mellon Heinz School Review. 2006. Accessed 1 Mar. 2007. http://journal.heinz.cmu.edu/articles/ healthcare-delivery-systems-rural-india [6] Rosa FW. 1967. Impact of New Family Planning Approaches on Rural Maternal and Child Health Coverage in Developing Countries: India's Example. American Journal of Public Health and the Nation’s Health, 57[8]: 1327-1332. [7] Costello A, Osrin D and Manandhar D. 2004. Reducing Maternal and Neonatal Mortality in the Poorest Com- munities. British Medical Journal, 329: 1166-1168. J. Paul Nielsen and Pranav Mehta, M.D.: Telemedicine Management of Diabetics 66 Can Cycles of Neddylation and Deneddylation Provide Points for Possible Therapeutic Intervention? Nadia Nocera Introduction The process of ubiquitination serves as an important signaling mechanism in many biologi- cal processes such as protein trafficking, DNA repair, protein-protein interactions and proteoly- sis. 1 Ubiquitin is a small polypeptide that is covalently linked to the lysine residue of target pro- teins by a multienzymatic system consisting of E1 (ubiquitin-activating), E2 (ubiquitin- conjugating), and E3 (ubiquitin-ligating) enzymes. E3 ligases include cullin-based ubiquitin li- gases, in which the cullin acts as a scaffold for the assembly of a multisubunit ubiquitin ligase complex that contains a RING-box protein and a cullin-specific substrate adaptor protein. Cullin3 (Cul3) forms a complex, which controls cyclins, transcription factors, and cellular path- ways. 1 All cullins require an attachment of the ubiquitin homologue neural-precursor-cell- expressed and developmentally down regulated 8 (Nedd8) at a specific lysine residue near its C terminal end to activate its ubiquitin ligase function. After protein is tagged with ubiquitin, it is targeted to the proteosome, where it is degraded. Because these components in the cell cycle (E1, E2, E3, Cullins, Nedd8, etc.) are essential in controlling proteolysis, null function or increased production of any of these proteins may lead to unregulated cellular processes and possibly to tumorigenesis. Knowing the functional details of these interactions could lead to clues for therapeutic targeting. What is Nedd8 and what is its function? Cullin family proteins organize ubiquitin ligase (E3) complexes to target numerous cellular proteins, such as those involved in cell proliferation and proteasomal degradation. Cullins di- rectly interact with Roc1, a Ring finger protein. The Cullin-Roc1 complex comprises the core module of a series of ubiquitin E3 ligases, which confer substrate specificity and therefore regu- late the degradation process. 2 Cullin family proteins; Cul1, Cul2, Cul3, Cul4A, Cul4B, and Cul5, have been shown to be modified by Nedd8 (a ubiquitin-like protein) in mammalian cells. 3 Neddylation of cullins is critical to cullin function and is required to facilitate processive trans- fer of ubiquitin from E2 to E3 to the target protein. 4 Nedd8 is a highly conserved, 81- residue protein that is attached to cullins by a process termed neddylation. 1 Neddylation occurs through the action of a neddylation cascade similar to that used in the ubiquitin system. The first step in neddylation is the formation of a thiol-ester bond via the C-terminal glycine residue of Nedd8 with APP-BP1/Uba3, a heterodimeric E1- activating enzyme. 1 The process is completed by the formation of an isopeptide bond, linking the carboxyl-end of Nedd8 Gly-76 to the e-amino group of a conserved cullin lysine residue. 5 Neddylation results in mononeddylation of cullin substrates. Ubiquitination activities of cullin-RING ligases (CRLs) require neddylation to control their E3 ligase activity. Studies focusing on the relationship between neddylation and E3 ligase func- 67 tion 6, 7 suggest that Nedd8 plays a direct role in the activation of the E3 ligase function in ubiq- uitination. Inactivation of the CRL ligase activity requires the COP9 signalosome (CSN) that removes Nedd8 from cullins, a process called deneddylation. 8 Although the significance of Nedd8 in cullin complex activation has been established, it is not yet clear what the mechanism of Nedd8 action is. Neddylation and deneddylation provide means to maintain homeostasis It has been found that deneddylation by CSN protects cullins from degradation and that Nedd8-conjugated cullins are unstable and depleted in vivo. 8 CSN has been implicated in a wide range of biological processes including plant photomorphogenesis, yeast mating path- ways, signal transduction, the regulation of DNA repair, and cell cycle regulation. 9 CSN inhib- its ligase activity and negatively regulates the cell cycle by promoting deneddylation of cullins. The regulation of Cul1 and Cul3 by neddylation and deneddylation was examined by gener- ating CSN-null mutants of D. melanogaster. 8 Cul1 and Cul3 were found to be depleted, as shown in Western blots with lysates prepared from CSN-null larvae and CSN double-stranded RNA (dsRNA) treated S2 cells. The depletion was primarily due to the absence of unneddy- lated Cul1 and Cul3. 8 Although this study showed that neddylated cullins were degraded in the absence of CSN, the protective role of CSN remains debated. A different demonstrated that although the CSN complex was inactivated, both the percentage of neddylated cullins in cells, and the cullin substrates themselves, increased. 7 Further research is required to elucidate the role of cullins. Cul1 was found to accumulate in D. melanogaster, with the Nedd8-null allele present in the eye and wing discs—indicating that Nedd8 may have a role in down regulating the levels of Cul1 and Cul3 proteins. 8 This suggests the efficient degradation of neddylated cullins, unless the conjugated Nedd8 is removed by CSN. It therefore appears that neddylation and deneddyla- tion provide a means to maintain normal cellular levels of activated CRLs and prevent exces- sive ubiquitin ligase activity. 8 Neddylation and deneddylation may provide points for therapy Because of the apparent role of neddylation in the function of cullin, blocking this process may provide some real therapeutic benefit in cancer patients, by promoting cell death or cell cycle arrest in excessively proliferating cells. Furthermore, because of the requirement that cullins undergo deneddylation in addition to neddylation, blocking Nedd8 removal could se- verely interfere with cell viability. Specifically, the inhibition of cullin deneddylation through small molecule inhibitors would be expected to lead to defects in the cell’s ability to ubiquiti- nate numerous cullin-based E3 targets—ultimately leading to defects in cell proliferation. 10 However, it remains to be determined whether cancer cells have a greater rate of deneddylation, as compared to normally proliferating cells. If research reveals this to be the case, there could be a therapeutic window for small molecule inhibitors of the CSN protease. E1, E2 and Nedd8 form a complex Recently, a study conducted by Huang and colleagues 11 found a unique N-terminal se- quence on the E2 protein that helps form a complex to stabilize E1 and Nedd8. In this complex, Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? 68 three E1 domains pack to generate a large central groove, which cradles ATP, molecules of Nedd8, and E2 substrates together. E1 activates Nedd8 through adenylation and forms a bond with Nedd8, transferring the protein to E2. E2 then transfers Nedd8 to E3, which joins Nedd8 with Cul1. NEDD8 is in the center of the complex, with its C terminus tethered within a chan- nel focused on the thioester bond. 11 A network of charged and polar side-chains contacts E1’s catalytic cysteine and Nedd8’s C terminus. Mutational analyses showed that these residues con- tribute to E1, E2 and Nedd8 complex formation. 11 It was also demonstrated that deleting the tail from E2 significantly hinders the ability of E2 to transfer Nedd8 to E3, thereby decreasing the transfer of Nedd8 to Cul1. 12 Therefore, a decrease in the transfer of Nedd8 to Cul1 would lead to increased stability and negative regulation of the cell cycle. The discovery of this unique E2 tail is very intriguing for researchers because it may pro- vide one way to target the process of neddylation in cancer treatment. Scientists now know the exact shape and function of the E2 tail, and the E1 groove within which it fits. Novel drugs that are designed to disrupt the tail, the groove, or both might block the ability of the Nedd8 path- way to accelerate the replication of cancer cells. 12 Research reveals a new substrate for Nedd8 Although it is known that neddylation plays an important role in ubiquitin-mediated prote- olysis by modification of cullins, it was found that cullins are not the only substrates targeted for Nedd8 modification. In a study focusing on the neddylation of a breast cancer associated protein, it was found that BCA3 (breast cancer associated protein 3), a non-cullin protein, is also a Nedd8 substrate. 13 BCA3 has recently been found to be over-expressed in both breast and prostate cancers. Although BCA3 does not have an inherent relationship to cancer, it can act as a tumor suppressor when modified by Nedd8. 13 A yeast two-hybrid screen was performed in a human placental cDNA library using SENP8 (a Nedd8-specific protease) as bait—an interacting plasmid encoding BCA3 was identified. 13 BCA3 was tagged and was found to be modified by Nedd8. It thus appears that neddylation may occur through Nedd8’s association with eleven lysine residues on BCA3 because when these residues were replaced by arginine, neddylation did not occur. In the cell, BCA3 is localized within the nucleus. It has been reported to be a Kyo-T2 bind- ing protein, which was shown to regulate the DNA binding protein Recombination Signal Bind- ing Protein-Jk (RBPJk) and to participate in transcription regulation of NFkB (nuclear factor kappa B). 14 NFkB is a family of proteins that turn on genes involved in apoptosis and cell pro- liferation. When NFkB is over expressed, it can protect cells from undergoing apoptosis, so the more NFkB that is expressed, the more resistant a cell is to death. 15 In the study focusing on the neddylation of breast cancer associated protein, investigators examined whether BCA3 could act as a transcription regulator of NFkB, as well as whether the neddylation of BCA3 is required for its transcriptional inhibitory activity. 13 To investigate this, several lysine residues on BCA3 were “mutated”, whereby they were replaced with an arginine. One mutant had a single lysine mutated, while in two other mutants contained ten lysine re- placements. Of interest, researchers found that each of these mutants inhibited NFkB activation, with the exception of a BCA3 mutant in which all 11 lysine residues had been replaced. The Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? 69 latter mutant was also unable to undergo neddylation, demonstrating that BCA3 must be neddy- lated to inhibit NFkB activation. 13 The same study revealed that BCA3 binds to p65, one of the two proteins that make up NFkB, in order to regulate NFkB. Therefore, Nedd8-modified BCA3 binds to p65 and recruits a histone deacetylase (SITR1) to suppress NFkB-mediated transcrip- tion. 13 The aforementioned study describes a cancer-promoting (or demoting) pathway. 13 Interfer- ing with this pathway may provide a possible way to diminish the number of factors that pro- mote tumorigenesis. With further study, researchers may soon be able to design drugs that block the removal of Nedd8 from BCA3, or alternatively, promote the addition of Nedd8 to BCA3. By increasing the amount of Nedd8-modified BCA3, there would be a decrease in NFkB. Decreasing NFkB would render cancer cells less resistant to chemotherapy and more able to undergo apoptosis. Conclusion Through their control of cullins, cycles of neddylation and deneddylation have proven to be important processes in the cell cycle. Neddylation of cullins activates their ubiquitin ligase ac- tivity, subsequently allowing cullins to control the cell cycle via the ubiquitination of cellular proteins involved in cell proliferation. In contrast, the inactivation of cullins is achieved by deneddylation through the COP9 signalosome. Another substrate for Nedd8 is the BCA3 pro- tein, found to be a tumor suppressor when modified by Nedd8. When Nedd8 is removed from BCA3, oncogenes are no longer suppressed, resulting in resistance to apoptosis and excessive cell proliferation. Because of Nedd8’s critical roles in the cell cycle and modification of tumor suppressor genes, developing a way to control cycles of neddylation and deneddylation could prove to be an effective cancer therapy. R E F E R E N C E S [1] Wimuttisuk, W., Singer, J.D. The Cullin3 ubiquitin ligase functions as a Nedd8-bound heterodimer. Mol. Biol. Cell 18, 899–909. 2007 [2] Kamura, T.; Koepp, D. M.; Conrad, M. N.; Skowyra, D.; Moreland, R. J.; Iliopoulos, O.; Lane, W. S.; Kaelin, W. G., Jr.; Elledge, S. J.; Conaway, R. C.; Harper, J. W.; Conaway, J. W. Rbx1, a component of the VHL tumor suppressor complex and SCF ubiquitin ligase. Science 284: 657-661, 1999. [3] Osaka, F.; Kawasaki, H.; Aida, N.; Saeki, M.; Chiba, T.; Kawashima, S.; Tanaka, K.; Kato, S. A new NEDD8-ligating system for cullin-4A. Genes Dev. 12: 2263-2268, 1998. [4] Wu, K., Chen, A. and Pan, Z.Q., Conjugation of Nedd8 to CUL1 enhances the ability of the ROC1-CUL1 complex to promote ubiquitin polymerization. J. Biol. Chem. 275 41, pp. 32317–32324. 2000 [5] Pan, Z.Q., Kentsis, A., Dias, D.C., Yamoah, K., Wu, K. Nedd8 on cullin: building an expressway to protein destruction. Oncogene 23, 1985í1997. 2004 [6] Read, M.A. et al. Nedd8 modification of cul-1 activates SCF((TrCP))-dependent ubiquitination of IB. Mol. Cell. Biol. 20, 2326í2333. 2000 [7] Kawakami, T. et al. Nedd8 recruits E2 Ubiquitin to SCF E3 ligase. EMBO J 20, 4003-5012. 2001 [8] Wu et al. Neddylation and deneddylation regulate Cul1 and Cul3 protein accumulation Nature Cell Biology 7, 1014 - 1020 2005 Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? 70 [9] Bosu, D. R., Kipreos, E. T. Cullin-RING ubiquitin ligases: global regulation and activation cycles. Cell Di- vision, 3:7 doi:10.1186/1747-1028-3-7. 2008 [10] Nalepa, G., Harper, J. Therapeutic anti-cancer targets upstream of the proteasome. Cancer Treatment Re- views. Volume 29, Supplement 1, Pages 49-57. May 2003 [11] Huang DT, Hunt HW, Zhuang M, Ohi MD, Holton JM, Schulman BA: Basis for a ubiquitin-like protein thioester switch toggling E1–E2 affinity. Nature, 445(7126):394-398. 2007 [12] Structural Insights for Therapeutic Targeting of an E2 Function and Neddylation in Proliferation Control. Cancer Biology and Therapy. 10, 924-925. 2004 [13] Gao,F.; Cheng, J; Shi, T; Yeh E.T. H. Neddylation of a breast cancer-associated protein recruits a class III histone deacetylase that represses NFB-dependent transcription. Nature Cell Biology - 8, 1171 – 1177. 2006 [14] Oakley, F. et al. Basal expression of IB is controlled by the mammalian transcriptional repressor RBP-J (CBF1) and its activator Notch1. J. Biol. Chem. 278, 24359–24370. 2003 [15] MD Anderson Cancer Center News Release. New Path from Estrogen to Survival in Breast Cancer Cells Described. http://www.mdanderson.org/departments/newsroom/display.cfm?id=6C70D16C-C98D-4342- 9AE00B3BF82715AD&method=displayFull&pn=00c8a30f-c468-11d4-80fb00508b603a14 Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? 71 Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female Lea Alfi Symptoms “I feel so bloated.” The 67-year-old female could feel herself getting hot as she tried to ma- neuver herself into an upright position. She had gone through this 3 months prior, and won- dered why it was happening to her again. Her abdomen was now completely distended. She ex- plained that her ascites had been drained 3 months ago, and she promised that she had been so- ber. Exasperated, she brought herself to her feet. She had no one in the room with her, and looked apologetic as her eyes scanned the room, eventually resting on a distant roof gar- den. As her eyes fell to her legs, she explained how they had gradually ballooned over the past 12 weeks, despite her use of diuretics. With the swelling methodically moving up from her feet to her thighs, her slender frame was now completely hidden. She was exhausted; she said she had never felt so tired in her life. She could not get up quickly enough to reach the restroom, and the uneasy decision was made to place a Foley catheter. She looked down over her belly, unable even to see her feet, bewildered by her own condition. Investigation My resident assigned me this patient, emphasizing that it would be a great way to cement my understanding of hepatic pathophysiology, a textbook case of cirrhosis. My patient was a 67-year old female with a past medical history including cervical cancer (status post radiation) 15 years prior, with a resultant rectovaginal fistula, and a 40-year history of alcohol depend- ence. She was single, and gravida 0. She was a non-smoker, and denied any IV drug use in the past. Her labs revealed a normocytic anemia; she had started folate and multivitamins during her last admission. This explained some of her fatigue, but was there some underlying chronic dis- ease? The private attending following her planned a bone marrow biopsy. The medicine team did not work up the anemia right away, instead focusing their attention on the worsening ascites and lower extremity edema. Records from the patient’s last hospitalization included a CT scan demonstrating a cirrhotic liver. No liver biopsy had been performed. There was no documentation as to whether the cir- rhosis was of viral or toxic etiology, or possibly both. GI was consulted, and serology was sent for hepatitis panels. Her liver function tests were abnormal, as expected. My resident was fairly certain that this was another routine case of cirrhotic decompensation triggered by alcoholic hepatitis, but her AST: ALT ratio (aspartate aminotransferase: alanine aminotransferase) was not 2:1. Moreover, I felt the patient had no reason to lie about her sobriety, since she had been forthcoming about her alcohol history. Hepatitis B and C virology returned negative. The patient’s serum albumin was low, at 2.0 grams per deciliter (normal being 3.5-5 g/ 72 dl). She wasn’t spilling any protein into her urine, ruling out a nephrotic syndrome. Her low al- bumin was most likely due to a combination of chronic malnutrition and alcoholic hepatitis. Re- nal was consulted and SPA (serum poor albumin) treatment was initiated to pull the escaping fluid back into her intravascular space. SPA was of negligible benefit, with the patient still in overt pain and discomfort. My resident and intern performed a therapeutic tap. The paracentesis removed 3 liters of ascitic fluid, alleviating, but not resolving, the patient’s abdominal disten- tion. My resident assigned me with calculating the serum-ascites albumin gradient (SAAG), an- ticipating that it would support a cirrhotic etiology for the ascites. The SAAG was 1.0; by defi- nition, a SAAG greater than or equal to 1.1 would have suggested portal-hypertension related ascites. However, the patient’s SAAG was less than 1.1, meaning my patient’s ascites were possibly nonportal-hypertension related. My resident held firm to his belief that the ascites were portal-hypertension related, noting that a SAAG of 1.0 could be considered borderline. More- over, as cirrhosis was the cause of eighty-one percent of portal-hypertension related ascites, he reasoned that this was likely the case with our patient. However, because our patient had known cirrhosis, meaning an expected SAAG beyond 1.1, and her SAAG was still less than 1.1, I won- dered if we should spend more time considering other etiologies for her ascites. The physician’s aphorism played in my mind, “If you hear hoof-beats, look for horses, not zebras,” reminding me of the practice of pursuing more common, rather than exotic, diagnoses. However, as a medical student with a paucity of clinical experience and a relative excess of time, looking for zebras and following stringent SAAG cutoffs was more intuitive, and interest- ing, than looking for horses. Alternative diagnoses included peritonitis, pancreatitis, vasculitis, bowel obstruction or infarct, hypoalbuminemic states (nephrotic syndrome or a protein-losing enteropathy), or Meig’s syndrome. In the absence of any amylase or lipase elevations, I eliminated pancreatitis. Peritonitis did not fit, as the ascitic fluid showed PMNs, white blood cells indicative of acute infection, to be less than 250, and a white count less than 500. Moreover, she was afebrile, and had no abdomi- nal tenderness. There was no evidence of any vasculites or bowel obstruction. This left hypoal- buminemia or Meig’s syndrome. However, based on the failure of SPA treatment, it didn’t seem as if her ascites could have been solely due to a hypoalbuminemic state. Meig’s syn- drome typically presents as a triad: ascites, pleural effusion, and ovarian tumor. A possible two out of three seemed reasonable, so I texted my resident, “What about Meig’s?” Resolution Renal had re-initiated daily diuretics to drain the remaining fluid and lessen the patient’s lower extremity edema, the standard furosemide 40 and spironolactone 100. The patient’s pri- vate attending, an oncologist, had ordered a slew of tumor markers: AFP (alpha-fetoprotein), CEA (carcinoembryonic antigen), CA-125 (an antigen on nonmucinous ovarian cancers), and CA-19-9 (a monoclonal antibody against certain GI carcinomas). In reviewing her day’s labs, her CA-125 had returned; it was elevated. This threw weight behind Meig’s, or any gynecologic malignancy. As a transvaginal ultrasound was scheduled, I left the team for my next rotation. Lea Alfi: Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female 73 A few days later, I re-visited my patient. She told me how horrible the transvaginal ul- trasound had been, and said she had been told it was to test for ovarian cancer. She showed me the soaps and lotions a friend had brought her, sliding them under my nose, and pointed out the bouquet of cattails she had added to her windowsill garden of sunflowers. I reassured her, and wished her good luck. She kissed me on the cheek and thanked me. As I left her room, I did not know whether she had a benign fibroma or a malignant tumor, or whether the CA-125 was lead- ing us astray. I wondered whether our path to diagnosis had been achieved, not knowing ulti- mately to what the hoof-beats belonged. Five months later, I did a double take as I saw my former patient being admitted. From afar, I could see that her face had become unsettlingly gaunt, her belly more distended, and her legs unusually swollen juxtaposed against her twig-like arms. She was no longer my patient, and I was no longer on the medicine team. The medical record number that I had once typed by memory had receded from my mind. And unfortunately, I was unable to learn her final diagno- sis before she was moved to another floor. Lea Alfi: Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female 74 Sabrina Perrino Ocean Beach Pier . Resilience in the Third Year of Medical School: A Prospective Study of the Associations Between Stressful Events Occurring During Clinical Rotations and Student Well-Being Paul S. Nestadt, MS III; Margaret E.M. Haglund, M.D.; Marije aan het Rot, Ph.D.; Nicole S. Cooper, Ph.D.; David Muller, M.D.; Steven M. Southwick, M.D.; Dennis S. Charney, M.D. New York Medical College, Valhalla, New York; Columbia University, New York, New York; Mount Sinai School of Medicine, New York, New York; Yale University School of Medicine, New Haven, Connecticut. Purpose. The third year of medical school exposes students to many stressful and potentially traumatic events. These students witness patient suffering and death, personal mistreatment, and poor role modeling by physicians. Such experiences may explain increases in anxiety and de- pression during medical school, and could contribute to a decrease in future physician empathy. However, to date this has not been studied. Methods. The present study prospectively measured stressful clerkship events occurring during the 2006-2007 academic year in third-year medical students of the Mount Sinai School of Medicine (n = 125), using baseline measures and surveys completed monthly. Students labeled stressful events traumatic if they met the trauma criteria of the Diagnostic and Statistical Man- ual of Mental Disorders, fourth edition. The authors measured anxiety, depression, and post- traumatic stress symptoms at the beginning and end of the year and twice during the year. At year's end they also measured students' personal growth. Results. Class participation varied from 106 (85%) at baseline to 82 (66%) at endpoint. Most students (101; 81%) completed at least one monthly survey. Many students reported exposure to trauma as well as personal mistreatment and poor role modeling by superiors. Trauma expo- sure was positively associated with personal growth at year's end. In contrast, exposure to other stressful events was positively associated with endpoint levels of depression and other stress symptoms. Students who had experienced higher levels of childhood trauma were found to be more vulnerable to the psychopathogenic consequences of third year trauma, whereas students with higher levels of current social functioning were more resilient to these stresses. Conclusions. Trauma exposure was common but not associated with poor outcomes by year's end, which suggests that students were resilient. In fact, it appears that exposure to patient re- lated traumatic events throughout the third year may aid in student personal growth. However, unprofessional behavior by resident and attending physicians might have adverse effects on the well-being of students. CL I NI CA L S CI ENCE: F I RS T P L A CE 76 Wait List Death and Survival Benefit of Kidney Transplantation among Extra-renal Transplant Recipients James Cassuto 1 , MS II 4 ; Roy Bloom 2 , M.D.; Peter Reese 2 , M.D.; Matthew Levin 1 , M.D., Ph.D.; Seema Sonnad 3 , Ph.D.; Kim Olthoff 1 , M.D.; Abraham Shaked 1 , M.D., Ph.D.; Ali Naji 1 , M.D., Ph.D.; Peter Abt 1 , M.D. Hospital of the University of Pennsylvania, Philadelphia, PA 1 Division of Transplantation, 2 Renal Electrolyte and Hypertension, 3 Outcomes Research, 4 New York Medical College, Valhalla, NY Purpose. The number of surviving extra-renal transplant recipients who develop end stage renal disease is increasing, adding a drain on the limited pool of kidney grafts. With current interest in balancing equity and utility, we sought to evaluate kidney transplant benefit in extra-renal transplantation compared to primary isolated (KA1) or repeat primary kidney (KA2) trans- plants. Methods. Renal waitlist and transplant survival benefit for kidney after lung (KALu), kidney after heart (KAH), and kidney after liver (KALi) were compared to KA1 and KA2. Multivari- ate Cox regression models were constructed with UNOS data for patients listed and trans- planted between 1995 through 2008. Results. Deaths per 100 waitlist years were 8.9 for KA1, 5.8 for KA2, 26.5 for KALu, 19.6 for KAH, and 25.2 for KALi. The risk of death on the wait list for an extra-renal transplant was compared in an adjusted analysis to KA1: KA2 (p<0.001, HR=0.85, CI=0.82-0.88), KALu (p<0.001, HR=3.73, CI=3.06-4.54), KAH (p<0.001, HR=1.93, CI=1.68-2.21), and KALi (p<0.001, HR=3.02, CI=2.78-3.27). Compared to remaining on the waitlist, kidney transplanta- tion was associated with a five year survival benefit amongst all groups, with extra-renal trans- plant recipients demonstrating the largest survival benefit. Following transplant, patient sur- vival was greatest for KA1, but similar among KA2, KALi, and KAH, and inferior for KALu. Conclusions. Extra-renal transplant recipients with ESRD have an increased risk of wait list death and greater survival benefit from kidney transplantation compared to KA1 and KA2. These groups should be considered in the development of kidney allocation algorithms. CL I NI CA L S CI ENCE: S ECOND P L A CE 77 Racial Differences in Bronchopulmonary Dysplasia Severity for Neonates with Mitochon- drial Superoxide Dismutase Polymorphism Edward Hurley, MS II; Kristen Aland, B.A.; Johanna Calo, M.D.; Lance A Parton, M.D. Department of Pediatrics, New York Medical College, Valhalla, New York Purpose: Oxidative stress, along with genetic factors and mechanical ventilation, has been im- plicated in the susceptibility of preterm infants to bronchopulmonary dysplasia. Manganese su- peroxide dismutase is an important enzyme for quenching reactive oxygen species. It catalyzes the conversion of the superoxide anion to hydrogen peroxide in the mitochondria. The enzyme, which is coded by genomic DNA, requires a mitochondrial targeting sequence to gain entry. A well-studied single nucleotide polymorphism (SNP) in the mitochondrial targeting sequence causes a replacement of alanine by valine, resulting in less efficient transport into the mitochon- dria. For a subset of the subjects, we examined two other MnSOD SNPs. One SNP (rs11575993) causes a change in amino acid from a leucine to a phenylalanine and the other is an intronic SNP (rs2842958) that has been associated with other lung conditions such as COPD. Methods: We hypothesize that the MnSOD rs4880 SNP is associated with susceptibility to BPD. Infants (N=87) were enrolled who weighed <1 kg at birth and had no congenital or chro- mosomal abnormalities. DNA was isolated from buccal mucosal swabs and allelic discrimina- tion was performed using a specific probe with Real-time PCR. BPD is defined by the need for oxygen at 36 weeks PMA. Chi square analyses and ANOVA were performed with P<0.05 de- noting statistical significance. Results: There were significant differences in birth weights and gestational ages, but not in ra- cial distributions between BPD and Non-BPD infants. The genotype distributions were not sta- tistically different between BPD and Non-BPD infants (P=0.23). We found significant differ- ences between the genotype distributions of this SNP when we analyzed Caucasian (N=21, P=0.027), but not Hispanic or African-American infants. Significantly more intraventricular hemorrhage was found among infants with BPD compared to Non-BPD. Conclusions: Caucasian ELBW preterm infants who progress to BPD are more likely to con- tain the minor allele for the MnSOD rs4880 SNP, which results in less efficient transport of su- peroxide anion into the mitochondria. This association was not seen in Hispanics or African- Americans, and cannot be explained by differences in birth weight or gestational age. We ex- amined the two additional MnSOD SNPs (rs11575993 and rs2842958) in the Caucasian sub- jects but found no significance. CL I NI CA L S CI ENCE: THI RD P L A CE 78 Using Fluorescence in situ Hybridization (FISH) to Examine the Prevalence of ETS Gene Fusions in a Large Prostatectomy Cohort. Christopher J. LaFargue, MS I; Raquel Esgueva, M.D.; Sven Perner, M.D.; Veit Scheble, M.D.; Glen Kristiansen, M.D.; Mark A. Rubin, M.D. Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, NYC, NY. Department of Urology, University Hospital of Berlin, Berlin, Germany. Purpose: Approximately 40-60% of PSA screened prostate cancers harbor gene fusions between the 5’ region of the hormone regulated TMPRSS2 gene and the 3’ region of members of the ETS family of transcription factors, most commonly ERG. Prostate cancers possessing ERG rearrangements rep- resent a distinct sub-class of tumor based on previous studies reporting associations with histomor- phologic features, characteristic somatic copy number alterations, and gene expression signatures. More recently, additional 5’ fusion partners of ERG have been discovered; most notably SLC45A3 and NDRG1. The purpose of this study was to examine the frequency of these particular gene fu- sions in a large scale prostatectomy cohort and to determine whether any relationship existed with pathologic parameters or clinical outcome. Methods: A cohort of 614 prostate cancer patients who underwent radical prostatectomy was used. Various parameters such as age, preoperative PSA levels, PSA relapse (biochemical recurrence), Gleason grade, and tumor stage were recorded for each case. Tissue microarrays were constructed from the formalin-fixed paraffin-embedded tissue blocks from each patient. A break-apart FISH as- say was employed allowing an evaluator to determine whether or not a particular gene was disrupted. Two differently colored DNA probes flanking the gene of interest were simultaneously hybridized to 5 micron sections of each TMA and were evaluated using a fluorescence microscope. Four gene sets were used: ERG, TMPRSS2, SLC45A3, and NDRG1. A sample negative for rearrangement showed two green and red overlapping signals in each nucleus, with each overlapping pair corresponding to one allele. A sample harboring a rearranged gene showed a split, or break-apart, of the signals. In this case, each nucleus would contain a green-red overlapping signal (normal allele), and a single green and single red located apart from each other (disrupted allele). A case was considered positive for gene fusion if it possessed rearrangements of both ERG and the particular 5’ partner. Results: Of the 614 patients in the cohort, 540 could be evaluated by FISH. Similar to previous re- ports, ERG rearrangement occurred in 53% (254/540) of the cases. Of these 254 cases, 78% were shown to be fused with only TMPRSS2, 6% with only SLC45A3, 11% with both TMPRSS2 and SLC45A3, and 5% with an unknown partner. From these unknown cases, one was identified as be- ing fused to NDRG1, a novel 5’ partner recently discovered. Using various statistical methods, this study did not find any association with pathologic parameters or clinical outcome. Conclusions: While most studies have assumed that all ERG rearranged prostate cancers are fused with TMPRSS2, we showed that a significant percentage is SLC45A3-ERG. Additionally, the dis- covery of concurrent rearrangement of TMPRSS2 and SLC45A3 within the same case suggests that there must be additional molecular complexity which has been previously unappreciated. This study has important clinical implications for the development of diagnostic assays to detect ETS rearrange- ments in prostate cancer. Incorporation of these assays which detect the less common ERG rear- ranged fusions could further increase the sensitivity of the current PCR-based approaches. BA S I C S CI ENCE: F I RS T P L A CE 79 Use of EGFR Genetic Analysis to Potentially Expand Treatment Options for Patients With Vulvar Squamous Cell Carcinoma Susan L. Boisvert MS I, Whitfield B. Growdon MD, Sara Akhavanfard MD, Esther Oliva MD, Dora C. Dias- Santagata PhD, Sakiko Kojiro, Neil S. Horowitz MD, A. John Iafrate MD PhD, Darrell R. Borger PhD and Bo R. Rueda MD Massachusetts General Hospital, Boston, Massachusetts 02114, USA Purpose. Invasive vulvar cancer represents 5% of gynecologic cancers and it is estimated that 3,580 new cases and 900 deaths will be reported in the United States for 2009. Treatment for vulvar squamous cell carcinoma (VSCC) has changed little over the years and surgical incision and inguinal lymph node dissection remain the standard of care. This standard of care treatment is associated with significant morbidity and recurrence; therefore, understanding the molecular mechanisms of this malignancy has the potential to expand treatment to include targeted therapies. While it is clear that molecularly-targeted therapies play a major role in an adjuvant setting in other epithelial tumors, there is little understanding of the underlying etiology of vulvar carcinoma. Molecular alterations in a subset of patients leading to Epidermal Growth Factor Receptor (EGFR) gene activation have been shown to confer therapeutic response to targeted therapies in a number of cancers of epithelial origin. Therefore, the purpose of our study was to evaluate genetic alterations in the EGFR gene that could be used to expand clinical management of VSCC through the inclusion of molecular targeted thera- pies. Methods. A cohort of 51 patients seen at the Massachusetts General Hospital Cancer Center from 1994-2007 with primary VSCC was selected and represented all FIGO stages. Assessment of the following was completed: EGFR protein levels using immunohistochemistry (IHC), EGFR muta- tional analysis using PCR and EGFR gene amplification using fluorescence in situ hybridization (FISH). EGFR gene amplification and protein expression were correlated with a variety of clinical prognostic variables (age, stage, recurrence, lymph node status and survival). Results. A high level of EGFR protein expression was observed in 31% of VSCC patient samples. Common activating mutations in the tyrosine kinase domain of EGFR were not broadly identified in this cohort. Chromosomal analysis using FISH demonstrated amplification of the EGFR gene in 12% of patients. Decreased survival was observed in patients with additional copies of EGFR. Gene amplification was an independent prognostic variable, even when controlled for age, stage, grade, lymph node status and high-risk HPV status Conclusions. Our data demonstrates that a subset of patients with squamous cell carcinoma of the vulva present with EGFR gene amplification that is HPV-independent and associated with poor prognosis. Given the association of EGFR amplification with response to targeted therapies in other tumor types, EGFR amplification status in patients with VSCC may identify patients who will bene- fit from small molecule tyrosine kinase inhibitors that target the EGFR pathway. This investigation compliments an ongoing Dana Farber Harvard Cancer Center prospective clinical trial for patients with VSCC. Early correlative data from a patient on trial who exhibited a partial response to 6 weeks of therapy demonstrated EGFR gene amplification. This case reinforces the possible clinical implications of this translational investigation and the application of small molecule inhibitors in the treatment of vulvar squamous cell carcinoma. BA S I C S C I ENCE: S ECOND P L A CE 80 Arachidonate 5-Lipoxygenase Expression in Papillary Thyroid Carcinoma Correlates with Invasive Histopathology and Promotes Extracellular Matrix Degradation via MMP-9 Induction 1 Nicolas T Kummer MD-PhD Candidate Year VII (MS III) 2 Cordon Iacob MD, 2 Stimson Schantz MD, 1 Raj K Tiwari PhD, 1 Jan Geliebter PhD 1 NYMC, Department of Microbiology and Immunology, Valhalla, NY; 2 New York Eye and Ear, Ear Infirmary, New York, NY Purpose: Papillary thyroid carcinoma (PTC) is the most common thyroid and endocrine malignancy, accounting for ~80% of all thyroid cancer. Aggressive disease results in poor prognosis, however little is known about the pathogenesis of aggressive PTC. Evidence suggests arachidonate 5- lipoxygenase (ALOX5) promotes tumorigenesis of various carcinomas. Here we investigate the role of ALOX5 in the pathogenesis of aggressive PTC, with hopes of identifying new therapeutic targets and disease markers. Methods: To investigate the correlation between invasive PTC and ALOX5 expression, fold differ- ences in ALOX5 mRNA were calculated between pairs of matched PTC and normal thyroid tissue and correlated to a Tumor Invasive Score (TIS, based on histopathology). mRNA was quantified by real-time RT-PCR and significance was determined by Spearman correlation coefficient. To deter- mine the effects of ALOX5 on PTC pathogenesis; cell proliferation, MMP protein expression, and invasion were investigated in a PTC cell line transfected with an ALOX5 expression vector, or an empty vector control. In follow-up, ALOX5 induction of MMP-9 secretion was verified by western blot analysis of conditioned media from the transfected cells, and cells conditioned with 5-HETE (a metabolic product of arachidonic acid and ALOX5). To determine if ALOX5 enhances invasion via MMP-9 activity, invasion assays were repeated with the transfected cells and the addition of MMP-9 inhibitors. Results: Mean expression for ALOX5 in PTC and matched normal tissue were 3.39 (SE 2.09) and 0.27 (SE 0.10) copies/GAPDH (respectively P=0.002). The fold increase in ALOX5 mRNA expres- sion between matched samples significantly correlated with TIS (Spearman correlation coeffi- cient=0.74, P=0.0007). Transfection of an ALOX5 expression vector into the PTC cell line conferred a 3.12 fold increase in invasiveness compared to the empty vector control (P<0.001), and was re- versible by ALOX5 inhibition. Serum free conditioned media of the transfected cells demonstrated a 2.00 fold increase of MMP-9 (P=0.03) compared to the empty vector control, determined by MMP protein array, and confirmed by western blot analysis. Additionally, MMP-9 levels increased in a dose dependent manner in response to 5-HETE, determined by western blot analysis. Inhibition of MMP-9 activity, by either chemical inhibition or by an inhibitory antibody, abrogated the ALOX5 mediated increase in invasion. Conclusions: Current evidence characterizes ALOX5 primarily as anti-apoptotic in cancer. Here we demonstrate that ALOX5 correlates with tumor invasiveness and contributes to PTC pathogenesis by enhancing invasion via MMP-9 induction. These findings signify a new paradigm for ALOX5 in tumor pathogenesis which may be exploited for diagnostic and therapeutic advantages in aggressive PTC. BA S I C S C I ENCE: THI RD P L A CE 81 Julie Grimes Wendell Park Ann Tran Infinity Tribute to Generosity The editors and staff of the Quill & Scope would like to thank the generous donors whose financial and moral support have made this publication possible. -Jenny Lam & Edward Hurley Dr. Karl P. Adler Dr. Ralph A. O’Connell Dr. Gladys Ayala Dr. Norman Levine Dr. Muhammad Choudhury Dr. Sansar C. Sharma Diana Cunningham, MLS, MPH Department of Admissions Dr. Joseph T. English The Student Senate Weston Foundation Anonymous 84 Radeeb Akhtar ([email protected]); NYMC class of 2013, BA in Psychology from New York University. He is the inventor of the NYMC_ART club born 2009. He is pursuing international medicine through the MD/MPH program. A very active, introspective, and not-your-typical medical student. He enjoys creating art and hopes that he can continue it throughout a medical career. You'll often find him figuring out ways in which to save the world. Lea Alfi ([email protected]), class of 2011, graduated from Yale University in 2006 with a B.A. in Psychology and spent one year teaching the second grade in Manhattan before entering medical school. She is currently enjoying her clinical rotations, and she is looking forward to choosing a specialty. Ava Asher ([email protected]), class of 2012, graduated from University of Oregon in 2006. She is leaning toward family medicine, and is interested in health care reform. She originally wanted to be an art teacher, got lost and found herself in 2nd year of medical school. Katrina Bernardo ([email protected]), class of 2012, is a native of New York and can't wait for third year rotations to begin. Alanna Chait ([email protected]), class of 2012, is a 2004 graduate of Columbia University, where she majored in Psychology, English, and Comparative Literature. Before entering medical school, Alanna conducted research in child psychiatry and performed with several opera companies. Alanna is interested in psychiatry and pediatrics, and she plans to incorporate writing and singing into her medical career. Linda DeMello ([email protected]), class of 2013, is an executive board member of American Medical Women’s Association, a member of the Blood Drive Committee, and a managing editor for Quill & Scope. When she doesn’t have her head in the textbooks, she writes fiction and spends as much time as possible with her husband. She loves to run, drinks coffee by the gallon, and she still doesn’t know what kind of doctor she wants to be when she grows up. Anna Djougarian is a graduate of the Macaulay Honors College at CUNY Hunter with a BA in Psy- chology. She loves friends and family, sunny days, cooking, dancing, learning new things and frequent "The Office" study breaks. Marissa Friedman ([email protected]), class of 2013, graduated from New York Univer- sity in 2007 with a B.A. in psychology. She is expected to receive a Master’s in Health Administration from Hofstra University. She is also the first year representative for the NYMC chapter of the AMA, and is involved with the Medical Society of the State of New York, Medical Student section. Julie Grimes, class of 2012, graduated from Boston College in 2007 with a degree in Psychology. When she's not studying, she enjoys playing her trombone, being outdoors, and spreading Red Sox love in the heart of the evil empire. Ian Hovis, class of 2012 Michael Karsy ([email protected]) is a year four MD/PhD candidate in the Department of Ex- perimental Pathology. He is currently the treasurer of the Genocide Awareness and Prevention (GAAP) club at NYMC. He is a Leo, enjoys reading, and long walks on the beach. Poonam Kaushal ([email protected]), class of 2011, graduated from the University of Cali- fornia, Irvine with a B.S. in Neurobiology is interested in pediatrics and hopes to aid underserved chil- dren and influence health policy in the future. CONTRIBUTORS Anita Kelkar ([email protected]), M.D. class of 2011, received her Master of Public Health de- gree from Dartmouth College and her B.S. in Psychology from Virginia Commonwealth University. She is interested in cardiovascular medicine, and hopes to pursue a career in the field after finishing medical school. Andrei Kreutzberg ([email protected]) is a second year medical student. His interests include mu- sic, nutrition, running, and psychiatry. Eliott Lee, class of 2012, received his B.A. from Case Western Reserve University in 2003. After col- lege, he tried out numerous paths including stock broker, english teacher and law student before settling on medicine. He enjoys travel and photography and hopes he'll find more time for both in the future. W. G. Stuart Mackenzie ([email protected] ) class of 2013, was born and raised in Canada, and a graduate of both the University of Toronto and Boston University. Having spent time working in Internal Development and Infectious Disease, he is excited to read other NYMC students' perspectives on International Medicine. Danielle Masor ([email protected]), class of 2013, graduated from Swarthmore College with majors in French Literature and Economics. While slowly finding her way to the medical field, she has worked in the insurance and non-profit sectors, among others. Danielle loves kids and is considering pediatrics, although she has not yet done a rotation in this field. J. Paul Nielsen ([email protected]), MD/MPH, is proud to have contributed to the 3 rd edition of Quill and Scope. Paul is pursuing a career in radiology. In addition to writing about chronic and in- fectious diseases in NYC, Paul enjoys playing guitar, snowboarding, and basketball. Nadia Nocera ([email protected]), class of 2013, is a 2009 graduate of Brown University where she majored in biology. She is currently a member of AMSA, the surgery club, the blood drive commit- tee and the NSF foundation, which is a not-for-profit organization focused on providing health and edu- cation assistance to rural communities. Her current interest is to pursue reconstructive surgery. Sabrina Perrino, class of 2012, earned a B.S. and M.S. in Biology from the University of California, San Diego. She proudly participates on the executive boards of the NYMC Pediatrics Club, the Latino Medical Student Association, and La Casita de la Salud. After the sun goes down in Valhalla, she exe- cutes culinary masterpieces while listening to neo-soul, and plots how to get back to San Diego for resi- dency. Steve Rockoff ([email protected]), class of 2013, graduated from Northwestern University in Evanston, Illinois after studying psychology and biomedical engineering. He has developing interests in Internal Medicine and Psychiatry. Some of his favorite pastimes include watching baseball, eating sushi, and playing tennis. Jordan Roth ([email protected]) is an M.D. candidate for the class of 2010. He is looking for- ward to graduation and launching into an exciting career in Family Medicine. His passions in medicine include improving health care access and health education for the underserved, global health and mis- sion work, addiction medicine, and caring for families across the lifespan. As a native of the Pacific Northwest, he loves enjoying the outdoors with his beautiful wife Lauren. Luke Selby ([email protected]) is a third year student who, in his very limited free time, enjoys hiking, running, outdoor photography and SCUBA diving. These photos were taken on his honeymoon in Belize in April 2009. Navid Shams ([email protected]), class of 2013, is interested in Pediatrics and the Infectious Disease specialty. His passion for poetry began when reading and reciting Persian poems as a child in Iran. He has an undergraduate degree in Creative Writing and Biology from Carnegie Mellon Univer- sity. Prior to medical school, he attended Boston University for a Masters in Public Health, with concen- trations in International Health and Epidemiology. Gavin Stern ([email protected]) is a MD/MPH student in the Class of 2013, majoring in health policy and management. He studied English, biopsychology, and biology at the University of Michigan and is an alumnus of the Michigan Daily. Though a native of New York and alegal resident of Florida, he identifies most closely with Michiganders. His high school experience as an ice cream man has led him to choose the field of pediatrics. Sukhpreet Singh ([email protected]) attended the University of California, Irvine and re- ceived her B.S. in Developmental and Cell Biology with a minor in Chicano/Latino Studies. Having grown up in a country where medical care is hard to come by (and also at an expensive cost), she discov- ered the power of preventative medicine through the forum of teaching. Having worked with a similar project at her alma mater at UCI, she decided to organize a program based on the same principles, but with a more grand vision at New York Medical College. Ann Tran ([email protected]), class of 2012, graduated from Hunter College with a degree in An- thropology. She is involved with the pre-medical mentoring program at NYMC and is considering a ca- reer in Family Medicine. Charles Volk ([email protected]) is a first-year medical student. He is originally from Bis- marck, North Dakota and did his undergrad at the University of Minnesota - Twin Cities. He is the 2013 Scribe President, and is also active in PNHP, the NYMC community garden, and a med student blue- grass band. He is currently an officer under the Navy HPSP scholarship and lives on campus with his wife, Katrina. Daniel Waintraub ([email protected]), class of 2013, graduated from Yeshiva University in 2009 with a B.A. in Biology prior to embarking on his path through New York Medical College. His interests include writing, guitar, pretending to do work in the library (or elsewhere), mellow music, run- ning, fiction novels, day dreaming, and a well done mac’ and cheese. He is greatly looking forward to making it through medical school with his sanity intact. QUILL & SCOPE STAFF Humera Ahmed ([email protected]), class of 2012, received her B.A. in English from Boston College in 2007. In the intervening two years before medical school, she spent time researching the safety and efficacy of novel, catheter-based approaches to the treatment of cardiac arrhythmias. Follow- ing in the footsteps of her idols: Paul Farmer, MD and Sanjay Gupta, MD, Humera hopes to touch the world by avidly pursuing her passions for medicine, literature, social justice, and travel. Alanna Chait ([email protected]), class of 2012, received her B.A. in Psychology and English and Comparative Literature from Columbia University in 2004. Following graduation, she conducted research in the Department of Child Psychiatry at Columbia University, where she co-authored several papers and developed a music program for children with special needs. In addition to her Quill and Scope position, Alanna participates in PsychSIGN and is interested in pediatrics and psychiatry. Linda DeMello ([email protected]), class of 2013, is an executive board member of the American Medical Women’s Association, a member of the Blood Drive Committee, and a managing editor for Quill & Scope. She graduated magna cum laude from the University of Massachusetts Dart- mouth in 2007 with a BS in Biology and a minor in Biochemistry. She worked in clinical laboratories for six years in several hospitals across southern New England before her acceptance into NYMC. When she doesn’t have her head in the textbooks, she writes fiction and she spends as much time as possible with her husband. She loves to run, drinks coffee by the gallon, and she still doesn’t know what kind of doctor she wants to be when she grows up. Jonathan Drake ([email protected]), class of 2013, received his B.S. in Zoology from the University of Massachusetts Amherst in 1993. Following graduation, Jon worked for nine years in oph- thalmology research, including seven years at the University of California San Francisco, and two years at Miyata Eye Hospital in Japan. He then shifted to neuroscience research while receiving master’s de- grees at Boston University School of Medicine and at the University of Massachusetts Boston, and while working in neuropsychology and neuropathology at the Framingham Heart Study. Jon plans to pursue neurology as a specialty, and enjoys rock climbing, windsurfing, cooking, and traveling in his spare time. Loren Francis ([email protected]), class of 2013, received her B.S. in Applied Mathematics and Biology from Brown University in 2009. She is a member of the Pediatrics Interest Group and the soon- to-be famous flag football team Valhallabackers. When not studying, she enjoys reading, spending time outdoors, and baking anything chocolate. Marissa Friedman ([email protected]), class of 2013, graduated from New York Univer- sity in 2007 with a B.A. in psychology. She is expected to receive a Master’s in Health Administration from Hofstra University. She is also the first year representative for the NYMC chapter of the AMA, and is involved with the Medical Society of the State of New York, Medical Student section. Edward Hurley ([email protected]), class of 2012, graduated magna cum laude from the University of Massachusetts-Amherst with a dual major in Journalism and Philosophy. Prior to medical school, Edward spent nearly a decade as a journalist both in newspapers and in online media. When not studying, he enjoys spending time with his beautiful wife, Sarah. Edward is considering either pediatrics or geriatrics as he adores kids and older folks but is lukewarm about people in the middle. Jenny Lam ([email protected]), class of 2012, received her B.A. in Biological Sciences from Columbia in 2007. She is currently interested in a number of fields in internal medicine, namely endo- crinology, gastroenterology and hematology. She enjoys the performing arts, cooking, tennis, and bringing people together. Calley Levine ([email protected]), class of 2013, graduated from the University of Pennsyl- vania in 2009 with a B.S.E. in Computer Science & Graphics and a minor in Psychology. She is cur- rently a member of NYMC's Student Senate. Becky Lou , class of 2013. W.G. Stuart Mackenzie ([email protected]), class of 2013, was born and raised in Can- ada. He is a graduate of both the University of Toronto and Boston University. Having spent time working in International Development and Infectious Disease, he is excited to read other NYMC stu- dents' perspectives on International Medicine. Danielle Masor ([email protected]), class of 2013, graduated from Swarthmore College with majors in French Literature and Economics. While slowly finding her way to the medical field, she has worked in the insurance and non-profit sectors, among others. Danielle loves kids and is considering pediatrics, although she has not yet done a rotation in this field. James Naples ([email protected]), class of 2012, grew up in CT and graduated from Boston College in 2008 with a degree in Biology and Chemistry. He enjoys spending time outdoors, running, and being active. While he is keeping his options open for the future, he is very interested in oncology. He hopes to practice as a clinician and also stay in touch with laboratory research and academic medicine. Allison Navis ([email protected]), class of 2013, was born and raised in Los Angeles. She graduated from Boston University in 2007 with a BA in both Neuroscience and French. Upon gradua- tion, Allison moved to New York City where she worked in finance while also pursuing her interests in the arts. Allison currently lives in Brooklyn and is a first-year medical student at NYMC. Janet Nguyen ([email protected]), class of 2013, graduated from University of San Fran- cisco with a B.S. in Biology. Following graduation, she worked at Genentech Inc. in Quality Control Stability. After dabbling in the industry, Janet joined the Research Institute of California Pacific Medi- cal Center where she performed research on a novel gene therapy technique to treat monogenic dis- eases, such as Sickle Cell Disease. During her spare time, she enjoys cooking, watching TV and spend- ing time with her family and friends. Chris Ours ([email protected]), class of 2013, is just a city boy, born and raised in south detroit. He took the midnight train goin' to New York, class of 2013. He graduated from The College of William and Mary with a B.S. in Biology and Philosophy. In Williamsburg, Virginia, he did research on germline stem cells of Drosophila melanogaster and worked as an Emergency Room scribe for over two years. At NYMC, he serves on the 1st and 2nd year curriculum committee and has helped out on the SPAD fundraising committee. When not neck deep in notes, he enjoys cooking, mysteries, and ter- rible television medical drama. Sarah Pozniak ([email protected]), class of 2013, graduated from Boston University in 2006 with a B.A. in American Studies. After graduation she worked for three years as a medical assistant to a primary care physician in Cambridge, Mass. She likes pilates, running and reading The New Yorker. Sarah is interested in primary care. Rajdeep Pooni ([email protected]), class of 2013, is a graduate of UC Davis, where she stud- ied both biological sciences and English literature. Her diverse interests include healthcare, literature, and traveling. Aditya Sarvaria ([email protected]), class of 2012, is from Murfreesboro, TN. He received his B.A. in Biology from Wake Forest University. Navid Shams ([email protected]), class of 2013, is interested in Pediatrics and the Infectious Disease specialty. He has an undergraduate degree in Creative Writing and Biology from Carnegie Mellon University. Prior to medical school, he attended Boston University for a Masters in Public Health, with concentrations in International Health and Epidemiology. Mike Smith ([email protected]), class of 2012, graduated from Boston College in 2008 with a degree in Biology. In addition to his duties at Quill and Scope, he also designed the website for Student Physician Awareness Day. In his spare time, Mike enjoys sports, music, eating, and American Idol. Gavin Stern ([email protected]), class of 2013, is a MD/MPH student in the Class of 2013, ma- joring in health policy and management. He studied English, biopsychology, and biology at the Uni- versity of Michigan and is an alumnus of the Michigan Daily. Though a native of New York and a le- gal resident of Florida, he identifies most closely with Michiganders. His high school experience as an ice cream man has led him to choose the field of pediatrics. Annabelle Teng ([email protected]), class of 2012, graduated from University of California San Diego in 2005 with degrees in Anthropological Archaeology and Biochemistry/Cell Biology. Prior to medical school, she spent close to three years working on immunology and allergy research in Yokohama, Japan. She enjoys cooking/baking, salsa dancing, karate, oil painting, and learning foreign languages. Dennis Toy ([email protected]), class of 2012, graduated from University of Chicago in 2007 with an A.B. in Biological Sciences. As an undergraduate he worked for several years as a student docent at the Smart Museum of Art. In addition to art and medicine, his interests include paleontology, which has given him the opportunity to go on several excavations. His favorite dinosaur is the diplodocus. When not playing video games, Dennis enjoys running and playing tennis. Yin Tong ([email protected]), class of 2013, graduated with a BS in Human Development from Cornell University in 2008. She grew up in Beijing and Alaska as a misguided snowbird (summers in Beijing, winters in Alaska) and served as the executive editor of Cornell's Ivy Journal of Ethics. At NYMC, she is a first year coordinator for Big Sib Lil Sib, helps out on the SPAD PR committee and is a tour guide. She enjoys skiing, reading, sleeping and cultivating an irrational fear of birds, clowns and occasionally, the dark. Alex Trzebucki ([email protected]), class of 2013, graduated from Davidson College with a B.S. and biology and pursued graduate studies in Biomedical Science at Tufts University School of Medi- cine. Alex has conducted AIDS research at Albert Einstein College of Medicine, cardiothoracic re- search at Columbia University, and was a member of the Cardiothoracic Transplant Team at Colum- bia. Alex was the managing editor of a school newspaper and is an avid photographer, filmmaker, and urban explorer. Michael Weinreich ([email protected]), class of 2013, grew up in Poughkeepsie, NY. He received his undergraduate degree from Cornell University. LEND A HELPI NG HAND. . . Quill & Scope is a student driven journal containing reviews, commentaries, editorials, clinical experiences, poetry, and artwork. It is published annually by the students of New York Medical College. As with all endeavors, financial support is needed to improve, sustain, and distribute this work. Through sharing experiences confronting the personal, social, economic, and ethical issues of contemporary medicine today, we can contribute to professionalism and provide insight on the issues, which have begun to impact our professional judgment and clinical decision making. We invite you to join us in this endeavor and support this unique undertaking to take patient advocacy beyond the classroom. All patrons will be recognized in the journal and will receive a complimentary copy. We are grateful for your gifts and generosity. If you would like to give a tax-deductible financial gift to help with the publication costs, distri- bution, and continued improvement of Quill & Scope, visit our website http://www.nymc.edu/ Clubs/quill_and_scope/index.htm to pay by credit card. When donating, please be sure to direct your gift to Quill & Scope. Alternatively send the following with a check payable to: New York Medical College WITH the words “Quill & Scope” in the memo field. By designating “Quill & Scope” in the memo field, New York Medical College is required by law to use your donation for the sole purpose of the publication efforts of the Quill & Scope Student Medical Journal. We appreciate your support as we continue the tradition of literature in medicine. Tear off and Submit: Name: Address: City: State: Zip: I would like to donate the following amount: 50 100 200 300 500 Other: Please make your donation payable to New York Medical College with “Quill & Scope” in the memo field. Checks can be sent to: Quill & Scope New York Medical College Office of Student Affairs 40 Sunshine Cottage Road Valhalla, NY 10595 Quill & Scope Office of Student Affairs New York Medical College Administration Building 40 Sunshine Cottage Road Valhalla, New York 10595 www.nymc.edu/clubs/quill_and_scope QUILL & SCOPE PUBLISHED ANNUALLY BY THE STUDENTS OF NEW YORK MEDICAL COLLEGE VOLUME III. EDITORS IN CHIEF Edward Hurley Jenny Lam SENIOR GRAPHIC DESIGNERS Annabelle Teng Dennis Toy MANAGING EDITORS Linda DeMello Navid Shams Gavin Stern WEB COMMUNICATIONS Kevin Cummings SPRING 2010. SENIOR WEBMASTER Michael Smith EXECUTIVE FACULTY ADVISOR Gladys Ayala, MD EDITORIAL BOARD Gladys Ayala, MD Diana Cunningham, MLS Kenneth Lerea, PhD Stephen Moshman, MD Padmini Murthy, MD Sansar Sharma, PhD STAFF EDITORS Noorjahan Ali Debasree Banerjee Christine Capone Edward Hurley Sean Kivlehan Jenny Lam James Naples Annabelle Teng Dennis Toy Commentary Loren Francis Janet Nguyen Rajdeep Pooni Aditya Sarvaria Alex Trzebucki International Medicine Stuart Mackenzie Yin Tong Michael Weinreich Poetry & Fiction Alanna Chait Marissa Friedman Danielle Masor Community Health Chris Ours Sarah Pozniak Research Humera Ahmed Jonathan Drake ART EDITORS Becky Lou Allison Navis WEB DESIGN Calley Levine Quill & Scope is an annual NYMC student publication dedicated to promoting awareness of the personal, social, economic, and ethical issues con-fronting the modern physician. It was founded in 2008 by medical students Christine Capone and Sean Kivlehan. The articles selected for publication have been chosen for their literary or artistic merit. They do not necessarily represent the opinions or views of the editors, faculty, or New York Medical College. All rights reserved. No part of this publication may be reproduced, stored in electronic format, or transmitted in any form without the express permission of New York Medical College. Inquiries concerning reproduction should be directed to: Gladys M. Ayala, M.D., M.P.H. New York Medical College Administration Building/Office of Student Affairs 40 Sunshine Cottage Road Valhalla, NY 10595 [email protected] 1 ( : < 2 5 . 0 ( ' , & $ / 2)),&( 2) 7+( 35(6,'(17 & 2 / / ( * ( WZ ^/ & E z Ed ^ &KZ tKZ D t ^ D E z & E z D & K^ / D s , t d Y ^ ^ s ' > ^ d / / d E z D W t / < W W D K NEW YORK MEDICAL COLLEGE 40 SUNSHINE COTTAGE ROAD, VALHALLA, NEW YORK 10595 TEL 914-594-4500 FAX 914-594-4565 [email protected] PAUL M. WALLACH, M.D., F.A.C.P. VICE DEAN FOR MEDICAL EDUCATION “Hi HRU? K School? K Going to mall Have fun. ILY. LY2 TTYL” Our family represents the poster children for the family cell phone plan: five individuals, five phones…now with unlimited texting. That decision followed a month where I was charged for 1800 text messages made by one member of our family; that’s 60 a day! I still find it hard to believe that she is able to send that many texts, but without a doubt, text messaging is a part of today’s “communication” system. While text messaging is perfectly OK for the occasional message, I am concerned that relying on texting for a major amount of communication further erodes our ability to communicate effectively in the more formal written or spoken genres. Effective communication remains a central skill for physicians, health care practitioners, and health scientists. High quality written communication contributes extensively to our profession. In writing, we capture the clinical course of our patients so that other health care providers who come to see the same patient understand our thinking about the patient. In writing, we share scientific and other scholarly findings with colleagues so that our work can be evaluated by peers and so that others can benefit from the research. In writing, we share the stories of our field and contribute to the fabric of medicine. These stories add to the richness of medicine as an art, capture experiences that have moved us, and leave a legacy for those who follow. We speak about our successes and our failures, about our patients and our teachers, about our hopes and our fears, about what we learn when physicians become patients, about our relationships, about what it means to be a doctor. Similarly, the artistic expression in photography, drawing, and other visual arts also capture our experiences richly. I was honored to be asked to write a note of introduction for this issue of Quill & Scope. Herein, our students communicate beautifully about their experiences as physicians in training. They have written reviews, poetry, commentaries, essays, clinical experiences, and scientific papers. They have presented artwork that speaks thousands of words. I am proud of the work products of our students that are published here, acknowledge their efforts, and wish them great success in the future. I thank them for choosing to communicate so effectively through this venue and encourage others to similarly express themselves. We will all be richer for it. Congratulations to editors Jenny Lam and Edward Hurley, and Faculty Executive Advisor, Dr. Gladys Ayala. GTG. TTYL. My very best, Paul M. Wallach, MD Vice Dean for Medical Education 1860~2010 BUILDING ON THE EXCELLENCE OF OUR PAST Sir William Osler is regarded as the pre-eminent physician of the 20th century and ideal medical practitioner because of his humanism, his view that the practice of medicine is an art based on science, his thoughts on education, and his philosophy of life. Osler had a lifelong devotion to books and libraries. His influence and legacy, not only in the areas of clinical, educational, and literary spheres, remains strong and lives through his vast writings. Osler states that: "a library represents the mind of its collector, his fantasies and foibles, his strengths and weaknesses and preferences....The friendships of his life, the phases of his growth, the vagaries of his mind, all are represented.” As a foreword to this 3rd edition of the Quill and Scope, which coincides with NYMC’s Sesquicentennial Anniversary, I have chosen to highlight some of Sir William Osler quotes that contemplate the importance of culture, of reading literature and non-science books, and the value of studying the humanities to the lifelong study of medicine. Taken from “The Quotable Osler”, edited by Silverman, Murray, and Bryan, 2003: No. 25: Books influence character. Carefully studied, from such books come subtle influences which gives stability to character and help to give a man a sane outlook on the complex problems of life. No. 26. Culture is helpful to physicians. A physician may possess the science of Harvey in the art of Sydenham, and yet there may be lacking in him those finer qualities of heart and head which count for so much in life....medicine is seen at its best in men whose faculties have had the highest and most harmonious culture. No. 150. Cultivate your hearts and your heads. Be careful when you get into practice to cultivate equally well your hearts and your heads. No. 179. The practitioner also needs culture. One cannot practice medicine alone and practice it early and late, as so many of us have to do, and hope to escape the malign influences of her routine life. The incessant concentration of thought upon one subject, however interesting, then there's a man's mind in a narrow field. The practitioner needs culture as well as learning. No. 611. Without reading, a physician sinks to a low-level trade. A physician who does not use books and journals, who does not need a library, who does not read one or two of the best weeklies and monthlies, soon sinks to the level of the cross-counter prescriber, and not alone in practice, but in those mercenary feelings and habits which characterize a trade. No. 613. Reading benefits the mind. There is no such relaxation for a weary mind as that which is to be had from a good story, a good play or good essay. It is to the mind what sea breezes and the sunshine of the country are to the body -- a change of scene, a refreshment and a solace. No. 631. Expand your interest. Every day do some reading or work apart from your profession. I fully realize, no one more so, how absorbing is the profession of medicine; how applicable to it is what Michelangelo says "there are sciences which demand the whole of a man, without leaving the least portion of his spirit free for other distractions;" but you will be a better man and not a worse practitioner for avocation. With great pleasure and honor I introduce you to the third edition of the NYMC Student Journal, the Quill and Scope. This literary journal showcases the work of many students. Through these original articles, commentaries, poetry and artwork we can cultivate our hearts and minds as Osler still teaches us today, more than 150 years after his life. Congratulations to Jenny Lam and Edward Hurley for their dedication and hard work as editors-in-chief, they have taken this journal to the next level. Congratulations to the entire editorial staff, everyone that contributed their time and efforts in making this successful, and especially to the students that contributed a piece of themselves in their scholarly work. My sincerest good wishes to all the readers, new and old, of the NYMC Student Journal, Gladys M. Ayala, M.D., M.P.H. Senior Associate Dean for Student Affairs Executive Faculty Advisor Quill & Scope has served as a forum for the discussion of the personal. It showcases the wide range of literary. bioterrorism and international aid. faculty and the Board of Trustees. controversies of vaccination. and we hope to continue in the tradition of excellence first set by our predecessors many years ago. poetry. alumni. Since its founding in 2008. and a faculty review board. S The year 2010 marks New York Medical College’s 150th anniversary. and the belief in just and equitable healthcare. Ayala.500 copies to students. Weg. more than 25 contributors from all four classes. In honor of such a historical milestone. artistic and academic endeavors of burgeoning healthcare professionals as they reflect on today’s ever-evolving medical environment. The theme of Quill & Scope Volume 3 is as a retrospective on the transformations that have occurred over the years. the student medical journal has grown tremendously since its inception and established a presence at the College. humanistic desire to alleviate suffering. Quill & Scope dedicates this third volume to the faculty and alumni who tirelessly helped shape the College into the premier academic medical institution it is today. The Quill & Scope has an annual distribution of 1. Its old. the influence of social networking on human rights movements. Readers will also find timely articles on health-care policy and universal health care. and artwork. With a staff of 30 students. ethical. we hope to demonstrate that the practice of medicine continues to be founded on empathic and patient-centered care. offers a fascinating glimpse into the hallowed halls of the school founded on 20th Street and 3rd Avenue. as well as the impact of information technology on the management of diabetes. a distinguished alumnus trained at Flower Hospital. the student publication of then New York Homeopathic Medical College. time-worn pages reveal how the driving force of medical students has changed little: an insatiable appetite for knowledge. commentaries. essays. It is with great pride that we present to the New York Medical College community this collection of literary and artistic pieces by our fellow medical students. generous donors and the student body. our advisor Dr. Edward Hurley & Jenny Lam Editors-in-Chief . deans. beginning with the insights of Dr. Through editorials. political and socioeconomic facets of medicine that are not often discussed in the classroom or on the wards. Topics explored in the past two issues include healthcare disparities. to the advances of women in medicine and the construction of new buildings in the current campus location in Westchester. without whose support the journal would not have been possible. the editorial review board. We are grateful to our dedicated editors.EDITOR’S INTRODUCTION ifting through the 1880’s Chironian. military medicine. Despite small growth in the numbers of women physicians throughout most of the 20th century.R. impossibly diluted compounds. President Obama signed into law the “Health Care and Education Reconciliation Act of 2010” (H. but the final product is far from certain. it has powerful implications for the millions of Americans who are currently prescribed antidepressants. it’s the exact opposite. Dr. antidepressants have no measurable effect on depressive symptoms when compared to placebo. An Examination of Three Model Healthcare Delivery Systems 18 Gavin Stern The United States is just now beginning its journey into a universal healthcare delivery system. In a time when women did not receive the same rights as men. how the germ theory is wrong. Germany. 2010. women currently account for half of medical students in the United States. In 1918 this school became incorporated into the original New York Medical College. which completed the work of the “Patient Protection and Affordable Care Act” (H. John Weg. how science is incorrect.R. This resounding statement was widely circulated by every major national media outlet. John Weg: Pulmonary Medicine Pioneer 2 Recently. The effects of this legislation are phased in over the course of this new decade. Clemence Sophia Lozier. 2010. This article examines three model healthcare delivery systems that the United States could look towards on its march to universal coverage: those of France. 3590) signed on March 23. If true. But in poetry. and how miasms are at the core of all human suffering. the school taught a form of medicine called 'homeopathy'. founded the first women’s medical school in New York City. something that no one ever knew before. and the Netherlands. One of these women. What is this form of medicine and what would it be like to go to a homeopathic medical school? The author shares his experiences in the world of alternative medicine and the time he spent in a homeopathic academy learning about energy medicine. Homeopathy 24 Charles Volk For the first 50 years of NYMC's history. On March 30. a few courageous women pushed to open the field of medicine for all to study. COMMENTARY Women in Medicine 6 Marissa Friedman The 150th Anniversary of New York Medical College inspires a reflective look into the journey of women in medicine. the Quill & Scope’s Jenny Lam and Edward Hurley spoke with pulmonary medicine pioneer Dr.CONVERSATION Sitting Down with Dr. to become the co-ed school known today. 4872). investigators determined that for patients who had less than “very severe depression”. in an attempt to portray their findings in a less alarming and more realistic light." Dirac's quote confronts us with the question: Do both the scientific and poetic approaches ultimately enjoy equal success in expanding human knowledge? Antidepressants Misrepresented 12 Steve Rockoff In a January 2010 study conducted at the University of Pennsylvania. The commentary at hand highlights several glaring flaws in the design and conclusions of these researchers’ meta-analysis. about his career. in such a way as to be understood by everyone. medicine in general and his time at New York Medical College. Implementation could be legislated away with one election cycle. New York Medical College for Women. Class of 1959. . Planck Versus Poe: Scientific and Poetic Approaches 8 Anita Kelkar P A M Dirac wrote that "In science one tries to tell people. " Dirac's quote confronts us with the question: Do both the scientific and poetic approaches ultimately enjoy equal success in expanding human knowledge? Njinga 46 Stuart Mackenzie This piece is based upon my experiences over the course of 18 months in Lusaka. and much improved health status indicators. Consequently. it’s the exact opposite. there are many ways to make a difference. Promoting the awareness of and access to human rights is a job everyone can and should be a part of. including events leading to the closing of Flower & Fifth Avenue Hospital. coordinating community health initiatives and assisting in small business development for HIV support groups. Human rights promotion and international development have become popular philanthropic efforts and new technology is helping younger generations participate more easily. INTERNATIONAL MEDICINE A Lesson from Iran: Improving Rural Primary Health Care in The United States 34 Navid Shams In 1979. Iranian experts have recently begun aiding in the development of a similar program in Mississippi. something that no one ever knew before. In this setting. In the times of change that followed the revolution. safety and security. The article details how the campus evolved into its present form. . Photographs were collected from the Health Sciences Library and are interspersed throughout the issue. employment and education were stark and sobering.Our Valhalla: Thirty-Eight Years of the ’New’ NYMC 29 Gavin Stern “Our Valhalla” describes the history of the New York Medical College Valhalla campus. Zambia with the Center for Infectious Disease Research in Zambia (CIDRZ). in such a way as to be understood by everyone. Research for this article included consultation with faculty. I worked with patients in HIV/AIDS clinics across the country. But in poetry. My work and time in Zambia has impressed upon me the importance of understanding a patient’s life and context outside of the clinic. Richard Fazio. food security. such as the use of front line health workers. and Michael Karsy Human rights are fundamental liberties that should be guaranteed to all human beings. in order to treat them effectively within the clinic. Successful implementation of novel techniques. led to political commitment. Another Look: Medical Cooperation and the Israeli-Palestinian Conflict 42 Danielle Masor P A M Dirac wrote that "In science one tries to tell people. A simple commute to work was enough to see the effects of poverty and the threat of disease. the program’s expansion. fundraising or volunteering. about a third of Iran’s population was living in rural areas that were mostly out of contact with health services. a state with some of the worst health statistics in the country. but it wasn’t necessary to venture into the heart of a compound to witness the risk factors faced by most Zambians. the limits and discrepancies in access to health care. articles from the New York Times. The program is now considered the foremost example among rural primary care systems. Whether through activism. freedom from persecution and access to shelter. and archived yearbooks. nutrition. primitive infrastructure and lack of resources challenged the development of a rural primary health care program. Mera Geis. These include things such as access to education and health care. Social Networking Tools in the Modern Era of Human Rights Protection 37 Odessa Balumbu. now nearly 40 years old. this may disturb the proliferation of tumor and with further research. This allows them to be able to appreciate a more tangible aspect of disease that seems generally out of their reach.For Only A Moment Navid Shams . The initial results indicate that the Housecalls program is effective in improving compliance and management of diabetes.S. NY and the Bronx. The initial success of the program is encouraging and demonstrates a great potential for the use of telemedicine in monitoring chronic disease. such as from a patients’ home to a hospital. The cycle of neddylation and deneddylation is essential for cellular processes.Life Fuel Daniel Waintraub . This has. . NY. Information technology via telemedicine offers the potential for cost-effective and active management of type 2 diabetes mellitus for people in high-risk underserved communities such as Harlem.COMMUNITY HEALTH Cancer Education and Awareness Program: Education and Its Role in the Prevention of Cancer 50 Sukhpreet Singh As U. We do this by reaching out to high school students in the local community. CEAP has tried to bring back the role of the physician as an educator by taking this role straight into a high school classroom. We compared the baseline Hemoglobin A1C levels to the levels recorded after the patient was enrolled in the Housecalls telemedicine program for at least 3 months. unfortunately. we find that most diseases are treatable via technological intervention. Telemedicine is the use of telecommunications technology for medical diagnostic.Resident Andrei Kreutzberg .Medamorphosis Poonam Kaushal . Interfering with the process of neddylation and deneddylation could provide points of therapy by promoting cell death or cell cycle arrest in cells that are undergoing rapid proliferation. and through the method of storytelling. Paul Nielsen and Pranav Mehta. We hope this will allow our target audience to learn about the relevant consequences of their decisions now. and dispel the misconceptions the general population has about the prevention of disease. and therapeutic purposes to communicate information instantaneously from one location to another. we teach them the science behind the disease. The Cancer Education and Awareness Program attempts to tackle one of the worst diagnoses a patient can receive. M. reduced the role of the physician as the patient’s teacher and advocate in the clinical setting.Vitality Jordan Roth . healthcare accelerates into an era of science fiction. and if it is inhibited or amplified in some way.D. such as in tumors. monitoring.The Shell Linda DeMello . and to impact their health in the future. POETRY & FICTION Alanna Chait . it may be used as a target for cancer therapy.It’s Gonna Be All Right 53 54 56 57 58 60 61 ORIGINAL FINDINGS Telemedicine Management of Diabetics in an Underserved Community 64 J. Can Cycles of Neddylation and Deneddylation Provide Points for Possible Therapeutic Intervention? 67 Nadia Nocera Neddylation plays a critical role in proteosomal degradation and the progression of the cell cycle. a third year medical student explores what may be ailing a 67-year old woman with ascites and lower extremity edema. Boisvert et al. Using Fluorescence in situ Hybridization (FISH) to Examine the Prevalence of ETS Gene Fusions in a Large Prostatectomy Cohort. 79 Christopher J.Transformation of the Medical Student Linda DeMello .Spring Break at Night Radeeb Akhtar .If They Knew… Ava Asher . et al Wait List Death and Survival Benefit of Kidney Transplantation among Extra-renal Transplant Recipients 77 James Cassuto et al Racial Differences in Bronchopulmonary Dysplasia Severity for Neonates with Mitochondrial Superoxide Dismutase Polymorphism 78 Edward Hurley et al.Skull Rock Luke Selby .Man Huddled and Man Leaning Anna Djougarian .Administration Ian Hovis . LaFargue et al.Infinity 5 33 48 49 52 55 59 63 75 82 83 . Nestadt.Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female 72 Lea Alfi In this clinical vignette. ART AND PHOTOGRAPHY Eliott Lee .Wendell Park Ann Tran .Ocean Beach Pier Julie Grimes . MEDICAL STUDENT RESEARCH FORUM Resilience in the Third Year of Medical School: A Prospective Study of the Associations Between Stressful Events Occurring During Clinical Rotations and Student Well-Being 76 Paul S. Use of EGFR Genetic Analysis to Potentially Expand Treatment Options for Patients With Vulvar Squamous Cell Carcinoma 80 Susan L.Untitled Nude Sabrina Perrino .A young Ghanian woman captured in a balancing act on the streets of Accra Katrina Bernardo . Arachidonate 5-Lipoxygenase Expression in Papillary Thyroid Carcinoma Correlates with Invasive Histopathology and Promotes Extracellular Matrix Degradation via MMP-9 Induction 81 Nicolas T Kummer et al. An edited transcript follows: Q&S: What motivated you to go into medicine? Dr. where he is an emeritus professor in the Internal Medicine Department. It was phenomenal. which was a respiratory care unit. We had an iron lung. Weg about his career. research. Gas cost about 30 cents a gallon. to teaching nurses how to do things when they come in to see the patient on each of the trips. whether it be a diabetic coma or something else. tuberculosis was the major problem for pulmonary disease. and administration that you have done? Dr. It was an exciting time. Dr. Q&S: How has pulmonary medicine specifically changed since you started medicine? Dr. Even in grammar school I would tell my friends that I wanted to be a doctor some day. the more likely you are to require a ventilator. teaching. I liked that. which was great for polio because the person couldn’t fight against the machine. Then I worked at Jefferson Davis hospital in Houston. medicine in general and his time at NYMC. so we had to use pressure control ventilators which made you almost literally had to sit there and adjust the machine as their compliance and resistance changed in order for them to get an adequate breath. Dwight D. he is still involved in research and teaching at the University of Michigan. A pioneer in the field of pulmonary medicine. John Weg graduated from New York Medical College. John Weg: Pulmonary Medicine Pioneer In 1959. which is part of the Baylor Medical School and opened the intensive care unit there. I finished my training with the Air Force as head of the pulmonary and infectious disease unit. It was really wide spread. Recently. Q&S: Could you give us an overview of your career in terms of the mix of patient care. We started to try and ventilate people who had other kinds of lung disease like chronic obstructive pulmonary disease (COPD) and the machines we had were not really adequate.Sitting Down with Dr. 2 . but somebody with COPD or severe asthma would fight against that machine and you couldn’t adjust it. Weg received a Medal of Honor award from NYMC in 1990. only cost four cents for a stamp! That same year. So the sicker you are. Many people unfortunately were put inside the sanitarium for months if not years. That was interesting. After a five decade long career. which then became a critical care medicine unit. To mail a letter. Eisenhower was president. That was a subset of sick people. You didn’t have everything handed to you on a platter where the machine did everything automatically or almost automatically. the Quill & Scope’s Jenny Lam and Edward Hurley spoke with Dr. which was the first in Houston. We went from scratch. which people did in 1959. W: I’ve always been the type of person who wants to take care of people. Dr. W: When I started. W: How do I spend my time? Probably close to half of my time was spent taking care of patients and much more than half of that was spent in the intensive care unit (ICU). When people get very sick they almost always need a ventilator for whatever reason they get sick. but as it turns out none of those was very helpful because they were not specific. W: You made the diagnosis on the physical exam. We tried to open an ICU. Q&S: You have done extensive research in venous thrombo-embolism. Then in the late 1960’s we began using ventilation perfusion scans. I brought a nurse with a masters degree in pulmonary medicine from Houston. However. and looking at combinations of things that provide the most efficient diagnosis at the least cost and least invasiveness for the patient. John Weg: Pulmonary Medicine Pioneer And then when I came to the University of Michigan in 1971. it was the same study all over. Q&S: With all of these progressions and improvements in technology. It can only assure you that there was a pulmonary embolism or not in roughly a quarter of the patients. in real detail and take the time to do it. If you end up using the wrong test for the wrong patient then that usually leads to a wrong answer. I still am working on some of that. All these tests are good only after you get an adequate. And the same way.Sitting Down with Dr. and you expose some people that really aren’t going to benefit from the test. Ventilation perfusion scans got a new life. You don’t have to worry about the die causing problems with allergies but we found roughly a quarter of the studies were not good enough to be interpreted as to whether it was a PE or not. [she] provided a course for the nurses at the University of Michigan. And then from that we moved on to do CT Pulmonary Arteriography and that is very accurate and very specific. considerable radiation. Then another area that I spent a fair amount of time in was improving diagnosis of pulmonary embolism. Looking at different ways of diagnosing. EKG. do you think the quality of medicine has been hurt at all? For example. and blood gases. but I was the one in Michigan for over 25 years now. 3 . In the others it was not specific enough to say if it was a PE or not. We have been conducting studies in that area and I’m not the PI of it all. would people depend more on the ventilation perfusion scans and then miss something that could have been diagnosed in the physical diagnosis? Dr. as some people do. Most recently we looked up Magnetic Resonance Angiography. the chest X-ray. Your really have to start with the basics. If you go right to the test. Then one of the first multi-center studies I was involved in was trying to evaluate how good that was in making a diagnosis. Mixed into all of that would be the research on how to provide better care in the intensive care unit – what’s a better way to ventilate. we had the nurses assigned and I would come in on different shifts to make sure they were doing what was correct. what we realized there is a lot of radiation involved. W: I think that is always a concern. but more importantly to give them support so they would have it when they needed it. which has no radiation. It turns out it was not very good. We went back to look at the ventilation perfusion scans. accurate history of the patient in great detail. The most important thing is to get a very good history from the patient. The test was actually much better than we had thought. How would you describe the change in approach to this pathology since you started? Dr. you generate lots of costs. Select from that what’s most likely to be right and then move forward. Years ago we looked at a group of patients with sarcoid. In other areas. but an altered immunity to what – I don’t think we know. W: I think there have been many contributions to a whole variety of areas. I didn’t do any of those studies but we looked at multiple people that were going to do research. you were in a very low socioeconomic area with considerable rates of crime. So I commuted from the Bronx for a little while. I was on the NIH committee that looked at extensive studies. It seems to be an altered immunity. we just had two buildings: the hospital and the one building of the medical school that were hooked together as one. then I commuted from Flushing. but it didn’t go anywhere. I think they’ve made a major improvement in the diagnostic area. If you went more than a block east from there or less. to see whether they’re reactive to the atypical mycobacterium differently and they did all react.Sitting Down with Dr. With heparin. You can make a great case for the antibiotics. in the medical realm? Dr. at viral studies. The [Valhalla] campus is gorgeous. W: Flower Hospital [was] right in Central Park. The students would find housing in the neighborhood. some was not so nice – more was not so nice – and then others like myself commuted because I was married and we had children at the end of the first year. I started doing sarcoid when I actually went into the Air Force. It’s really expanded. and I assume you went to the Flower Hospital? Dr. and they didn’t find anything. our ability to diagnose without first deciding to do something like a laparotomy to find out whether someone has an intra-abdominal problem. bacterial. as well as part of the medical school. We really didn’t understand how to monitor the use of warfarin and we weren’t doing the right tests because we didn’t know what to do. Q&S: Can you compare and contrast the difference between the campus here. 4 . They really improve. whether it’s a chest X-ray or a CT or magnetic resonance. We postulated whether there was over-reaction to one of these atypical bugs. Q&S: What’s your theory behind sarcoidosis? Do you think it’s viral. There were no amenities. or purely autoimmune? Do you have a theory behind what causes sarcoidosis? Dr. if they’re selectively used. I don’t know. the need to adequately anti-coagulate patients with warfarin and then with heparin has improved greatly from when I first started. W: The short answer is I have no idea. some was nice. I think one large area is in visual images. John Weg: Pulmonary Medicine Pioneer Q&S: What do you think has been the greatest discovery or invention since you graduated from medical school. Now whether any of that would be the greatest. So we moved from just looking at a prothrombin time to looking at something called an international normalized ratio (INR). There was no campus. And I don’t think the ones I mentioned are at all inclusive. just speaking of the things that I’ve been talking about. we now have a short acting one. Eliott Lee Administration . Having a passion for helping others. where she graduated in 1853. and is credited with being the pioneer of women’s medical education. She did however continue with her teaching roots and desire to educate women by holding various health-related lectures out of her own home. at that time. despite the fact that she was a woman. Clemence Sofia Lozier. I am reminded of how lucky I am to be alive in this day and age. This was followed by the graduation of Dr. most hospitals did not permit women to obtain internships. As a matter of fact. These lectures on familiar medical fundamentals. In addition. the medical college in Geneva decided that one woman physician was enough. Eventually. such as anatomy and physiology became packed with women. Lozier first started as a teacher. the associated New York Medical College for Women was founded by Dr.2 This was undoubtedly amazing considering that this was going on far before women had not yet even received the right to vote. Lozier attended medical lectures at Central New York College at Rochester. as the first female physician to receive a medical education in New York City. she became inspired by the story of the first female medical doctor in the United States. and was finally admitted to Syracuse Eclectic College. Elizabeth Blackwell.1 When Lozier returned to New York City to practice medicine. New York Medical College has played an important role in promoting the presence of women in medicine. Lozier decided that she too wished to have a medical degree and tried to attend the same college. Dr. Blackwell graduated from Geneva Medical College in upstate New York in 1849. she became the first female physician in Canada. it was responsible for some remarkable accomplishments. Only three years after the founding of the original college in 1860. Especially as we begin to celebrate New York Medical College’s 150th anniversary. I cannot help but feel a sense of accomplishment and gratitude. opening a primary school for young women.Women in Medicine Marissa Friedman Looking across the rows of seats in the Cooke Auditorium at my fellow female medical students. It was also in 1918 that the New York Medical College for Women officially closed and transferred its students to the original 6 . when women actually have the opportunity to pursue a career as a physician. and that prompted her to eventually create the New York Medical College for Women. When Stowe returned to her native country. she was met with great success. the first school of its kind in New York City and the lower New York area. It was not until 1918 that other hospitals such as Bellevue opened up its doors to female medical students1. and thus the only hospital available to women for training was the Women’s hospital associated with New York Medical College. This includes the graduation of Elizabeth Stowe in 1867. After hearing this. Susan Mckinney in 1870 as the first African-American graduate in New York State and only the third in the nation. She was one of the first women in the United States to practice medicine. the American Medical Association did not allow female doctors to become members. and refused to admit Lozier as a student. However. Lozier realized that there was a strong desire by women to learn medicine. Although the College had an all-male faculty and only seven female students in its first class. Association of American Medical College. Around this time. 2009.wic. women represented 48.htm [2] “About NYMC:History”.org/ama1/pub/upload/mm/19/wimtimeline.Marissa Friedman: Women in Medicine and previously male-only New York Medical College.6% in 2003-2004. 2009. the AMA started to allow women to become members. Medical School Applicants and Students 1982-83 to 2009-2010”. She was the first woman to receive the Nobel Prize in Medicine in 1947.org/cazalet/histo/newyork.pdf 7 .ama-assn.http://www. since the turn of the 21st century. Dr.” women still made remarkable contributions to the medical field.nymc. According to the Association of American Medical Colleges (AAMC). In 2008-2009. physicians were women.Accessed 30 Dec. This only increased to approximately 17% during the 1980s. This act contributed not only to solidifying the fact that women could be renowned physicians. Furthermore.8% of the students receiving M. What many students might not realize is that Gerty Cori’s accomplishment goes far beyond just the discovery of the role of phosphorylase in glycogen metabolism.homeoint. 2008. This was the highest number of female medical school graduates to date.S.2% of all U.”American Medical Association. only 5% of physicians in the United States were women. In 2002. 25.org/misc/history.S.D. REFERENCES [1] Cazalet S. but also brilliant physician scientists.Accessed 30 Dec. Blackwell and Dr. almost double the 1980 figure5.Accessed 30 Dec.2001.Women’s International Center.5 This increase in the number of women in medical school is evident even here at New York Medical College where the class of 2010 is comprised of 54% females and 46% males2.org/data/facts/charts1982to2010. the percentage of women in medical school classes has increased from less than 31. by far the biggest change is occurring now in medical schools across the country. a great change has started to occur within the medical profession.http:// www.html [3] “Women’s History in America”. As I begin my own journey in medical education. Moreover. By 1890.http://www. Gerty Cori is a name that may sound familiar to first year students as one of many Nobel laureates thrown on the screen during a lecture for Biochemistry.edu/AboutNYMC/History. I am very proud to attend a school such as New York Medical College that played such an important role in allowing women to pursue careers in medicine.Accessed 30 Dec. Still. 2008.htm [4] “Women in Medicine: An AMA Timeline. the total number of women entering medical schools has increased each year since 1982. Actually.Accessed 30 Dec.pdf [5] “U. who made it possible for women like me pursue a dream of becoming a physician. the percentage of woman physicians remained low throughout most of the 20th century. I can’t help but pay homage to the brave trailblazers such as Dr. Despite the small numbers.2004.New York Medical College Website. http:// www. 2008. degrees. 2008. Lozier.http:// www.aamc. thus transforming it into a place for both men and women to receive a medical education. 1995.4 This brings me back to my first year lecture hall. 2008.3 Despite the groundbreaking headway that began at the end of the 19th century. where I look around and notice that there seems to be an equal amount of male and female faces. likely due to social constraints that categorized women as homemakers and a view that the medical profession was a “man’s job.4% in 1982-1983 to 49.“History of the New York Medical College and Hospital for Women”. it must be accepted."1 This leads to the inevitable question: Do both approaches suggested in Dirac’s statement enjoy equal success in expanding human knowledge?2 First it is necessary to explain the individual approaches of science and poetry. Paul Adrien Maurice Dirac. This scientific approach has ultimately led to the tance can have grave evidence based medicine movement that dictates consequences" our approach to diagnoses and treatment today. when one is trying to relay ences. Generalizable information is an essential component for patient treatment. which requires the information to be worded in accordance to the ability level of the information receiver. But in poetry. When new discoveries are made in cancer research. Hence. Human knowledge can refer to the knowledge obtained by humans about the world around them or it can represent knowledge about themselves. the phrase "human knowledge" is ambiguous and can mean different things. something that no one ever knew before. The information must be easily understood by the audience. lack of knowledge scientific discoveries. However. "In science one tries to tell people. This is followed by a methods section and In the clinical scithe actual experimentation. which is the core of every researcher’s methodology. Along with quantitative evidence of her discovery. one must provide data and dissemination or accepstatistical analyses to support one’s statement. After taking into consideration every aspect of Dirac's statement. the researcher must further prove that the conclusion is generalizable under all similar conditions. wrote that "In science one tries to tell people. A researcher’s approach to a possible study begins with a review of background literature that will ultimately culminate in a hypothesis." According to Merriam-Webster science is defined as the "systematic acquisition of knowledge". analysis. For example. The foremost goal of the scientific approach is for newly discovered information to be understood by all and accepted. From there I hope to discover if an expansion of human knowledge actually occurs from these approaches. This definition is the basis of the scientific method. It is also important to explain this "systematically obtained knowledge" in such a way that it is understood precisely and unambiguously.Planck Versus Poe: Scientific and Poetic Approaches Anita Kelkar The British theoretical physicist. it’s the exact opposite. This can be seen in the information dissemination that occurs after a groundbreaking scientific discovery has occurred. in such a way as to be understood by everyone. if a certain cancer drug is proven to remain efficacious for all situations under all circumstances then the acceptance factor of that drug increases. Since there is no room for the statement to be denounced. results and conclusions. I hope to come to a conclusion of whether both approaches stated in the quotation enjoy equal success in expanding all aspects of human knowledge. something that no one ever knew before. the description of the discoveries written in JAMA will be more in 8 . in such a way as to be understood by everyone. despite the volumes of data and scientific knowledge disproving the link between autism and vaccines. and is supported by analytical evidence. One of the authors of the Wakefield study that initiated the link between vaccines and autism has recently stated “There is now unequivocal evidence that MMR is not a risk factor for autism -. this method can be considered as almost polar opposite of the scientific approach. a poet’s intent is limitless. precise and have no room for doubt or misinterpretation. but a disservice to the health of the public. and rhythm. The expressed information must be clear. logical and unambiguous fashion. provide inpoetic approach can be divided into two areas: one being how the poet states what she wants to say and spiration" the other is the content being of what she says. The successful dissemination of scientific information requires the public to accept what is being said. The second part Dirac’s statement requires the analysis of a poet's approach in extending human knowledge. poetry is open to many interpretations. Each poet has his own unique style and is not required to conform. describe an exsponse through meaning. A prime example of this can be seen in the controversy regarding the supposed link between the MMR vaccine and autism. How then can one say that a poetic approach expands human knowledge? Unlike a scientist. Ultimately. describe an experience. but reflects an unprecedented volume of medical study3. the strength of the scientific approach lies in the fact that information is presented in a clear.”3 The perience. evidence and generalizability of the information conveyed. Since poetry attempts to convey the poet’s ideas that may not be necessarily something new or unique or even easily understood. interpretations that the author may not have initially intended. Unlike science where misinterpretation of conveyed information can have serious consequences. provide inspiration. the reader is free to interpret a poem in a way that appeals to himself. It is only after the information has been conveyed in a precise manner. Hence parents had been ultimately committing a harmful disservice to not only their children. Since the poet is not necessarily conveying a set message. millions of parents refused to accept this knowledge as true.this statement is not spin or medical conspiracy. regarding the expansion of the human knowledge. A poet writes to express his own emotions. Poetry is deA poet writes to fined as “writing that formulates a concentrated express his own emoimaginative awareness of experience in language chosen and arranged to create a specific emotional retions. lack of knowledge dissemination or acceptance can have grave consequences.Anita Kelkar: Scientific and Poetic Approaches -depth and the language more technical than when the same discovery is relayed to AP Biology students in high school. for the public has gained knowledge only when the new information has been accepted. One of the differences in interpretation can be due to the fact that it may be difficult for a person to understand an emotion they have yet to 9 . The scientific approach for expanding human knowledge requires precision.. will the audience understand what is being said. sound. clarity.” Even before this statement. is the knowledge about human beings themselves. In the clinical sciences. a poet does not necessarily write for the purpose of disseminating new information. In poetry instead of tangible and scientific facts. the "human knowledge" that is addressed. After discussing both approaches of two distinctly different fields it is clear that the each method is successful in its own right. what is hidden and often what we refuse to see about ourselves. which subsequently give one insight into her thought processes. and the interpretation of this knowledge helps us to gain insight about ourselves and our existence.Anita Kelkar: Scientific and Poetic Approaches experience.M. while a widower might see solitude and loneliness in it. the reader. or touch the tip of emotions that one has yet to embrace. If this method can expand this version of human knowledge. D. Poetry has the ability to reveal to us. knowledge from self-discovery is necessary to discover our capacity and capability to deal with the outside world. loneliness. Clements. Although the types of human knowledge ascertained are distinctly different. Hence I must end here. Chapter XII of Biographia Literaria (1817) 10 . The scientific approach grants us information of our physical surroundings.. A poet often makes a reader introspective and in doing so helps the reader explore the different facets of his being. The poetic method forces one to extend his imagination and enter the crevices of his own soul. Dirac. (2007) [5] Samuel Coleridge. then this process to self-discovery is extremely critical as well. the approaches are not mutually exclusive. It may not be rash to say that poetry may be the mirror to one’s soul. “Does the MMR Vaccine cause Autism?” http://www.A. Both approaches are equally successful in expanding their angle of the already nebulous concept of human knowledge. For example in Edgar Allan Poe's "A Dream" a heartbroken lover might see the plight of unrequited love. for the only thing that remains certain can be summarized by the writer Samuel Coleridge. love or lust. The poetic approach expands human knowledge by ultimately developing or heightening one's self-awareness."4 REFERENCES [1] P. “During the act of knowledge itself. It allows the reader to feel the poet's pain.org/health_library/ advice_from_doctors/your_childs_health/mmr_vaccine_and_autism. the objective and subjective are so instantly united. objective approach induces a growth of knowledge regarding the observable physical world of humans while the subjective poetic approach focuses on self awareness. [2] International Baccalaureate Theory of Knowledge Essay Topic [3] Merriam Webster Online Dictionary [4] P. but poetry also provides a passage to emotions that one might not have yet experienced.dukehealth. Human knowledge is surely expanded by the poetic approach. Conversely. H Eves Mathematical Circles Adieu (Boston 1977). Poetry evokes emotions and reactions. Baker. Not only does it reinforce feelings that may be already present. that we cannot determine to which of the two the priority belongs. The scientific. and conduct experiments (1977) Outside of the basic sciences building (1975) 11 .PEERS OF OUR PAST Grasslands housing complex (1980) Students were assigned an individual module desk where they would study. use their microscopes. The class of drugs known as ‘antidepressant medications’ (ADMs) encompasses a multitude Not only is depression of compounds whose members are often prescribed for a wide variety of psychiatric disorunder-diagnosed… diagders. it is widely agreed in the medical community that not only is depression under-diagnosed. and fatigue.”2. the media was up to its usual old tricks of sensationalizing and misrepresenting the most recent “hot medical study” of the week. weight loss. Depression is a disorder that can range from having mildly intrusive to severely debilitating effects on a patient’s life. a nosed patients are often multi-factorial mood disorder that most likely under-treated!" arises due to a complex interaction of biological. low self-esteem.1 The results of the study led to the publication of articles in various medias with titles such as U. The study. and as I shall imminently elaborate. One of these is major depressive disorder. Sending a message to the American people that trivializes the effects or usefulness of antidepressants is a very precarious game.2 Unfortunately. was conducted in order to determine the relative benefit of antidepressant medications over a placebo.5 Antidepressants are the third-most widely prescribed class of drug in the US. and social factors including drug and substance abuse. News & World Report’s “Do You Really Need That Antidepressant?” and USA Today’s “Study: Antidepressant lift may be all in your head. I was fairly troubled when I perused through the various articles and stories that covered this study.Antidepressants Misrepresented Steve Rockoff In the first week of 2010. seeing that in many cases. for depressed patients with a varied range of baseline symptom severities. psychological. While the lifetime prevalence of depression in most countries falls between 8-12%.S. with an estimated 10% of women and 4% of men taking them. the conclusion that the researchers came to was that in cases of mild or moderate depression. headaches. drastically decreased appetite. loss of interest & pleasure. and feelings of worthlessness. The most characteristic psychological symptoms of depression are low mood. These are more often than not accompanied by the physical symptoms of insomnia. a study performed by researchers at the University of Pennsylvania made waves as it circulated through every major national news outlet. excessive rumination. but that diagnosed patients are often under-treated! The investigators actually had a praiseworthy motive for the study at hand. 3 Indeed. a metaanalysis of six independent studies conducted at various points in the past 20 years. their literature search revealed a 12 .4 The identification and treatment of depression is of great interest to the American people. even more unfortunate when that message is based on a study with several inherent flaws. the United States has roughly 17% of its population afflicted. some of those common antidepressants were no more useful than a mere sugar pill. 13 . thus potentially alleviating the altered levels which are sometimes associated with depression. Jay Draoua. With the patients I have observed in the BHC. In other cases. the use of ADM in the U. too often psychotherapy is overlooked or unwanted. doubled. Bearing in mind that the majority of ADM patients may be considerably below a score of 23 (it was shown that 71% of participants in a recent survey had HDRS scores less than 22). I built a list of several troubling concerns I had regarding the methods involved. if not more. eating healthy. I feel somewhat offended by the way in which this study’s results are presented by the authors and the media. they can stabilize a mildly – or moderately -– affected patient from relapsing into a severe episode. while the use of psychotherapy declined. This can provide immeasurable benefits for the patient on their road to recovery. as I mentioned. medicated society. group therapy. from 1996 to 2005. Indeed. antidepressants are not supposed to be advertised as a long-term solution to for depression. in addition to the helpful standbys of exercising. antidepressants do have substantial merits of their own. many of which had depression.6 It is important to bear in mind that in the world of depression treatment. antidepressants share the throne with psychotherapy. As I perused the content of this meta-analysis. explore the roots of the underlying issues or events that triggered their pain. to truly treat depression. the minimum score for “very severe depression”. and psychoanalysis) may have just as much.7 When in reality. I worked in the Behavioral Health Center (BHC) of Westchester Medical Center under the supervision of B-2 inpatient unit physician Dr. For these reasons. ideally they do. This means that for psychiatric disorders such as depression. Or at least. something that antidepressants are not able to do. Often. The idea is to normalize certain neurotransmitters in the brain that are involved in regulating mood. I spent the bulk of my days observing or participating in the evaluations and treatments of the admitted patients. they can provide a subtle boost in functioning for men and women going about their daily lives and work. and pushing one’s self into socialization. Perhaps most often. As a rule. and how the results were portrayed. antidepressants have been highly useful in the stabilization of recently admitted patients. one must examine the core of the patient. the various forms of psychotherapy (which include cognitive behavioral therapy. without which they would be increasingly burdened by whichever depressive affliction haunts them. my current personal standpoint as an idealistic burgeoning medical student is still one that prefers to avoid pharmacological treatment as much as possible. Only then can you put depression beyond the reaches of remission. However. however. As I have witnessed. I highly advocate psychotherapy as a therapeutic tool. The patient has to approach an appreciation and respect for themselves.Steve Rockoff: Antidepressants Misrepresented marked paucity of pharmacological studies in which participants had baseline scores below 23 on the Hamilton Depression Rating Scale (HDRS). This past summer. especially when other forms of treatment are available. patients must be brought to a higher level of functioning before any meaningful psychotherapy can even begin. and have them come to an understanding with their illness. the investigators’ task at hand of examining those who were “less” depressed would seem very worthwhile. In the modern world’s quickfix.S. to offer than ADMs in terms of treatment. increased risk of suicidality.) narrowed the number of studies they included in their final metaanalysis down to just six. the tricyclics (TCAs). in 2007. though they can sometimes cause mania or hypomania on a maintained dosage. the literature search which was conducted by the investigators to find studies for their meta-analysis reached all the way back to 1980. patients must be tors (SSRIs). Imipramine belongs to an older class of drugs developed in the 1950’s. Out of the over 2000 studies they searched.S. and for an ADM’s effect to take even longer than that is by no means rare. The investigators make note of several of their study’s limitations. was the other drug used in the studies. Neither one of the two ADMs used on patients in the meta-analsyis are popularly used as first-line agents for depression. a SSRI and the fifth-most prescribed ADM in the U. ADMs are renowned for their need to take several weeks in order to begin to take effect. and high risk of withdrawal syndrome. and that two or three classes of ADMs may be tried before finding one that the patient responds to. and even though it can lag behind its 14 . 13 Again. Another area of concern to me was that the investigators set a minimum criterion of a 6week treatment duration period for symptom scores when selecting studies to include. and fluoxetine).524 million. with half of their data coming from this particular drug.S. and three compared the ADM paroxetine to placebo.10 Using such a rarelyprescribed and antiquated drug to represent the whole range of ADMs and their supposed ineffectiveness on mild depression is just poor practice.11. Paroxetine. it is well known (and even taught to us in first year Behavioral Sciences in medical school) that very often the first-line of treatment is not effective. functioning before any which is less than one-third of the twelfthranked nortriptyline and a mere fraction of the meaningful psychotherapy top four ranked ADMs (which all top 20 milcan even begin. not a drug most representative of the antidepressants Americans would be likely to use. However. Even if they were used as the first treatment. the rate of symptom improvement can greatly vary by drug and by person. a highly effective group of antidepressants which are still used for treatment-resistance depression when other drugs fail. such as the selective serotonin reuptake inhibiOften. In particular. which seems to be an alarmingly short time to stop the recording data for a depression study. the TCAs are less popular due to the advent of antidepressant drug classes with less severe side effects. paroxetine is associated with several concerning side effects such as weight gain.Steve Rockoff: Antidepressants Misrepresented To begin with. Of these six. escitalopram. the average treatment duration for the six studies was only a little over eight weeks. In fact. It is quite a shame that they have allowed ADMs to be presented to the public this way. but this is not one of them. etc.8. Imipramine in particular has been shown to have a slower rate of symptom improvement than other drugs in the treatment of depression. 12. in my opinion." lion on their own). as they were in these studies. or ones examining special subpopulations. put brought to a higher level of imipramine at thirteenth with 1. 9 Today. their exclusion criteria (for studies without placebo controls. compared to the three SSRIs that were more popular (sertraline. Two to three weeks is usually the minimum standard. A 2007 ranking of the most commonly prescribed ADMs in the U. three of them compared the ADM imipramine to placebo. However. many of the items I noted above were not spoken for. which is to have a “less severe” depression. Most media articles reporting this study emulate the claim that ADMs only work if one is “severely depressed. and monoamine oxidase inhibitors) have a noted pharmacological effect over placebo in the treatment of dysthymia patients. The very definition of dysthymia. but at a lesser intensity… the patient must have the symptoms of a depressed mood for at least two years. Mark Olfson. seems to suggest that its patients would suit perfectly for the present meta-analysis. I would hope. not the continuous or maintenance ADM treatment that millions of Americans find themselves on. All six studies involved used the Hamilton Depression Rating Scale (HDRS). TCA. In addition. unfortunately. 14-18 are “moderate”. its effect is by no means over – a continued improvement in symptom score is still observed beyond that six week mark. which has a great interest in patients who score lower on a depressive symptom scale. 19-22 are “severe”. I would agree with the author’s call for more studies examining patients with a wide range of baseline depression severities. it has been well shown over the years that the three main classes of ADMs (SSRI. The results of the current analysis demonstrated that there was a small effective difference between ADM and placebo when the patients had a baseline below a score of 23. in which patients scoring 8-13 have “mild” depression.15 It should also be noted that the results of this meta-analysis do not apply to inpatient populations or children. and accurately present their conclusions to the public and media. “The Hamilton concept of ‘severe’. especially in the short term. ways.e. they could rectify some of my current critiques regarding the methods of analysis. taking the ratings on the HDRS scale literally is very misleading. which would contribute greatly to the investigator’s current conclusions. and greater than 23 are “very severe”. and especially more severe. only apply to acute treatment. has a HDRS score of 23 or greater. as their claim that there is relatively little data on lesser depressed patient’s responses to antidepressants appears to be valid. two sizable groups which were also excluded from the study. The authors of this meta-analysis recognized some of the limitations of their study. Almost 600 studies were stricken from inclusion because the depression patients were dysthymic or were from a special sub-population (i. a professor of clinical psychiatry at Columbia University. If the proposed trend of less-severely depressed patients showed an equal response to placebo was also discovered in dysthymic patients. My last criticism of the meta-analysis at hand is the use of the depression symptom scoring criteria. I think many psychiatrists would think of as ‘moderate’. Resistance to the use of HRDS labels by mental health practitioners is nothing new. though. 15 . the National Institute for Clinical Excellence’s standard for significant difference between ADM and placebo (meaning the HDRS difference is 3 or greater) was not met until patients had a baseline of 25 or greater.Steve Rockoff: Antidepressants Misrepresented peers after six weeks of treatment.” i.e. but in reality it suffers from a sort of “grade inflation” that can classify patients in very misleading. that with future studies to be done. Further flaws in this recent study can be found in the types of patients who were chosen to be excluded from this meta-analysis. but without the presence of a major depressive episode. is widely used because of tradition in the field. developed in the 1960’s.16 The Hamilton scale. particularly the caveat about the psychometric measuring properties of the HDRS.14 The investigators’ findings seem to.” said Dr. However. However. a certain ethnicity). Dysthymia is a mood disorder which is best described as chronic depression. http:// drugtopics.npr. http://www. Comparison of Alprazolam. 178[3]: 296–305. Amsterdam J. Accessed 12 Jan 2010. and Fawcett J. Antidepressant discontinuation syndromes. 2002. Hollon S. 44[17]: 8. 24[3]: 183–97.com/news/health/2010-01-06-antidepressants06_ST_N. 1998. 92[9]: 846–56. 6 Jan 2010. National Institute of Mental Health. Imipramine. “Do You Really Need That Antidepressant?” USnews. Rickels K. “Study: Antidepressant lift may be all in your head”. Antidepressant-associated maniform states in acute treatment of patients with bipolar-I depression.nimh. DeRubeis R. Furukawa TA. R. 248[6]: 296–300. http://www. J Clinical Psychopharmacology. Symptom severity and exclusion from antidepressant efficacy trials. Status of treatment of depression. 2009. D. and Smith W. J Clin Psychiatry.html 16 . Accessed 16 Jan 2010. Int J Methods Psychiatr Res. Psychiatric News. 2008. Fabre L. [12] Barbui C. http:// www. 5 Jan 2010. CMAJ.htm [4] “Depression”.Steve Rockoff: Antidepressants Misrepresented REFERENCES [1] Fournier J. South Med J. 1983. 1999. 2003. Aden G. [13] Haddad P.modernmedicine. [7] Yan.com. 26[1]: 55-64. and Placebo in the Treatment of Depression.html [3] Rubin. [6] Zimmerman M. 12 [1]: 3–21. 2001. Accessed 12 Jan 2010. 303[1]: 47-53.usnews. Accessed 12 Jan 2010.com/drugtopics/Top200Drugs/ArticleStandard/article/detail/491194 [11] Papakostas. “Drug Studies Lean On Flawed Measure of Depression”. http://www. 2003. 2008. 2010. Drug Safety. [8] Broquet K. 69 Suppl E1: 8–13.usatoday. Antidepressant Use Rises in 10-Year Period.org/blogs/health/2010/01/antidepressant_studies_lean_on_1. European Archives of Psychiatry and Clinical Neuroscience. Berglund P. [16] Spiegel. [10] "Top 200 generic drugs by units in 2007. 249[22]: 3057-3064 [15] De Lima MS and Hotopf M. Rudolf D. USAtoday.com. Strauss A. [14] Feighner J. JAMA. J. Accessed 12 Jan 2010. Shelton R. and Chelminski I.nih. A. Dimidjian S. Tolerability of modern antidepressants. The epidemiology of major depressive episodes: Results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys. 6 Jan 2010. 22[6]: 610-614."Drug Topics. Cipriani A. Pasternak MA. Benefits and risks of pharmacotherapy for dysthymia: a systematic appraisal of the evidence. Möller HJ. NPR. GI. 2008. Effectiveness of paroxetine in the treatment of acute major depression in adults: a systematic re-examination of published and unpublished data from randomized trials. Drug Safety. Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-Analysis. 18 Feb 2008.shtml [5] Andrade L.com/health/blogs/on-women/2010/01/06/do-you-really-need-that-antidepressant.gov/ health/publications/index. [9] Bottlender R. Caraveo-Anduaga JJ. JAMA. [2] Kotz. 1979 yearbook (1966 on doors is not explained) Fifth Avenue Hospital. It was closed in 1979. Building the Westchester County Medical Center (1978) 17 Early photograph of Sunshine Cottage .FUTURE FOUNDATIONS Rear of Basic Sciences Building. in Manhattan (1976). and home of New York Medical College. one could infer that that none go without basic health insurance in France – even noncitizens. 3590) signed on March 23. This article examines three model healthcare delivery systems that the United States could look towards on its march to universal coverage: those of France. Ninety-two percent of the population carries the complementary insurance. “roughly half of which is funded by employers. 2010. Germany.” Further.”2 Therefore. For instance. which completed the work of the “Patient Protection and Affordable Care Act” (H. according to the World Health Organization. France had the best healthcare system in the world.1 The basic French system . While individuals may visit any physician. The effects of this legislation are phased in over the course of this new decade.” In general. Rather. the Couverture Maladie Universelle (CMU) is provided to individuals who cannot afford the public system due to unemployment2. but the final product is far from certain. 5. On March 30. Drugs with proven therapeutic effects are basically free.4% of the population. “Complementary insurance” covers individual cost sharing. France: Government-run Universal Insurance In 2000.25% of which helps pay for the health care system." The French medical system is not nearly as government-centralized as.” which “funds the Sécurité Sociale and CMU and is financed through national income taxes and the General Social Tax – a supplementary income tax (7. which has a socialized system. 2010.R.”2 This is a new 18 . the United Kingdom. and the Netherlands. “poorer patients are exempt from cost-sharing. while those of dubious or limited use are cost-shared to a greater extent.”1 France controls healthcare costs with financial leverage. More recently. Implementation could be legislated away with one election cycle. President Obama signed into law the “Health Care and Education Reconciliation Act of 2010” (H.R. and is usually provided by the employer. Another system L’Aide Medicale d’Etat (AME) covers “Illegal residents. individual copayment for a drug is linked to effectiveness. estimated at 0.Sécurité Sociale .”1 This is a mandatory system. “Complementary insurance” reduces financial burden on individual cost sharing. while visits to other GPs are subject to a 50% co-insurance rate. reimbursements are better when one starts with a gatekeeper general practitioner: “Visits to the gatekeeping general practitioner are subject to a 30% coinsurance rate. for instance. 4872).An Examination of Three Model Healthcare Delivery Systems Gavin Stern The United States is just now beginning its journey into a universal healthcare delivery system.1 None go without health insurance in France—even noncitizens.covers “Hospital care.5%) introduced in 1991 to help offset health care costs. the government of France finances basic healthcare via legislation “that creates the annual prospective global budget for the public health expenditures. ambulatory care and prescription drugs” along with “minimal coverage of outpatient eye and dental care” 2 and “nursing home benefits. Sickness funds are “autonomous. diabetes and other chronic conditions… includ[ing] all pharmaceuticals [and] experimental drugs. can afford more skilled practitioners despite the French principle of solidarity. A system of government-regulated insurance coverage (more like that of Germany or the Netherlands) might be a more reasonable longterm goal for the United Statess Germany: Social Insurance and Sickness Funds The healthcare system of Germany consists of governmentally independent sickness funds. nongovernmental bodies regulated by law. as “doctors and dentists may charge above this reference price based on their level of professional experience.” Physicians are private employees.” Pricing and reimbursements are “negotiated between the health insurance funds and unions representing providers. and 2% purchased private health insurance.Gavin Stern: An Examination of Healthcare Systems concept. To reduce the effects of moral hazard. Overall.” Out of pocket expenses were 6.” A “reference price” determines what the public system will reimburse. the practice of medicine in France is a “self-regulating market. “including cancer.9 in the United States.6 (female/male) compared to 79.2/74.1% of GDP in 2005. US implementation of the French system would be difficult because it requires a strong central government (France is arguably a single-payer system).7% as government employees. as “patients visiting physicians and dentists pay full price and are later reimbursed for costs by the public health insurance and complementary insurance.”7 The notion is that these funds will compete against one another.7 Individuals with income levels of less than 48.4 to 2. Is the French healthcare system a good deal? Healthcare spending in France was 11.5 Clearly. allowing physicians immediate access to a patient’s record.”2 The wealthy.9% of total health expenditures in 2005.3 deaths per 1000 births compared to 7. “mostly self-employed and paid on a fee-for-service basis. and payers in both health and long-term care insurance” in Germany.22% of Germans were uninsured. then. the ability for skilled physicians to set a higher price also provides an incentive to achieve that higher level of skill – a capitalist tenet. In 2006. Only 0. The French system in totality does not provide the same level of expertise to all income levels. not for profit. 75% of 19 .2 per 1000. much lower than 15. along with a separate private insurance system. 88% of Germans were covered by the sickness fund system.4/73. However.” The supplemental insurance plans “are not allowed to compete by lowering health insurance premiums”.1 However.3 Per capita spending in 2003 was $2903 in France compared to $5635 in the United States. purchasers. and life expectancy at birth was 82.1 which may have the effect of reducing competition but is done for the purposes of solidarity. Technology reduces paperwork and increases efficiency: “patients carry Sécurité Sociale cards containing microchips storing their comprehensive medical information. 6 This system of more than 200 sickness funds is “the oldest system of social insurance in the world. there are additional co-payments per office visit. A “special state program” covered 9. with an annual ceiling of 50 Euros.3 per 1000. some conditions are completely reimbursed. There are proportionally more physicians in France: 3.4 French infant mortality was 4.3% in the United States.000 annually (75% of the German population) are required to enter into the public program. introduced via the Douste-Blazy law in order to reduce large budget deficits. However. encouraging greater efficiency and reduced cost.”1 Out of pocket spending for healthcare is still an issue in France. the French system performs better.” which act as “the collectors. much lower than $5635 in the United States.7% of GDP in 2005. American imple20 . more needy. which will allocate resources to each [sickness fund] based on an improved risk-adjusted capitation formula.3 per 1000 in the United States. in that “all contributions will be centrally pooled by a new national health fund.5/74. However. After 2009. enmixture of fees per time period and per medical procedure.” The German system encourages cost effectiveness as sickness funds and physicians colThe notion is that laborate on price control. Physicians maintain their these funds will compete autonomy to practice and are generally “paid by a against one another. more expensive patients on particular sickness funds. The German healthcare system significantly outperforms that of the United States. The sickness funds do not operate capitalistically (as in the Netherlands) but rather as a nonprofit. This helps to demonstrate that the public healthcare system of Germany is considered to be satisfactory even for those with greater income levels.8 The German system would be difficult to implement in the United States because it involves a large degree of government control. physicians are encouraged to collaborate and lobby. The unemployed are still expected to make a contribution.5 (female/male) compared to 79." tions. with results comparable to France but with less expenditure as a percentage of GDP.Gavin Stern: An Examination of Healthcare Systems people with income above this level remain in the public system by choice.000.4/73.9 in the United States.” This system of contribution also changes in 2009. and preventive care” along with “prescription drugs and rehabilitative treatments” and disability payments to those who cannot work.1% for France.”6 Before that. Per capita spending in 2003 was $2996 in Germany.” This figure is cut in half for those declared “chronically ill. indirect extension of government. The sickness funds are financed by employee and employer contributions of (on average) 8% and 7% of income.4 German infant mortality was 4.”6 This should help to evenly spread the risk of more ill.”6 Physicians are compensated “by sickcouraging greater effiness funds via their regional physician associaciency and lower cost. unlike the United States system.5 and 11% disapproving. Patients may incur cost sharing or copayments of up to “2% of household income.3% in the United 3 States and 11.2 per 1000 in the US) while life expectancy at birth in 1998 was 80.6 deaths per 1000 births in 1999 (7. Germany and France had the same per capita number of physicians at 3. “dental.”8 It should be noted that. “health insurance will be mandatory” in “either the social or private health insurance scheme. this does show a trend towards more centralized control via the government. respectively.4 per 1000.”7 Patients receive incentives to utilize general practitioners in a “family physician care model. The sickness fund program is more comprehensive than other social health programs discussed in this analysis – including. inpatient. higher than 2. lower than 15. insurance was optional for individuals with yearly income over 48. Healthcare spending in Germany was 10. as private insurance enrollment is very low. with 66% of Germans approving of the system in 1996.5 The German healthcare model receives generally good reviews. similar to the French system. Gavin Stern: An Examination of Healthcare Systems mentation of the German system is feasible because the sickness funds are analogous to private insurance companies. and occupational therapy.” The rate is reduced to 4. by providing an allowance proportionate to income. The healthcare system of the Netherlands might be more palatable. As in the United States. Nevertheless. While a system similar to that of Germany could practically evolve in the United States by capping insurance company profits. hospitaliinsurance policy… Neverthezation… medical aids. All working adult citizens of the Netherlands are obligated to purchase a standard insurance policy. a policy that United States has been trending away from. Physicians operate on a fee for service basis. Purchasers of these policies retain free choice. chronic and mental illnesses are covered under the separate Exceptional Medical Expenses Act. and the government finance the Dutch system. and they now pay into a single national fund. The Dutch government does not exert direct control over healthcare treatments (no rationing).5% of Dutch citizens remained uninsured as of 2007. home care. employers. Citizens also benefit from lowered prices as insurers compete for business. The government pays for the health policies of children (under 18 years of age). an estimated 1. remained uninsured as of speech. insurers retain their for -profit status. Employers would have to contribute to the system. defined as greater than 5% of income.5% of Dutch citizens nity care. in the Netherlands the Supervisory Board For Health regulates these companies. insurance companies are obligated to accept anyone who All working adult citizens applies for the government-mandated of the Netherlands are oblistandard insurance package. The Netherlands: Multi-Payer Private Competition With Government Regulation The Dutch healthcare system has been referenced as a possible route to universal healthcare coverage in the United States." ing care. medicines.4% for the unemployed. materless.9 The Health Insurance Act (2006) established a system of government-regulated private insurance companies. the political reality is that it would be attacked as anti-capitalist. 1. This competition-based model also forces increased efficiency and cost reduction. the German system requires these funds to be not-for-profit. an issue that the United States will also be left with.10 The lack of 100% coverage remains a consequence of blunted government intervention. ambulance and patient transport services” as well as limited remedial.5% of the first 30.000 of annual taxable income. Individuals. The emerging American model may benefit from the Dutch example of increased regulation. Individuals pay “6. Rather. However. in that they may change policies once per year. The government also subsidizes individuals who cannot afford such a policy. Each policy must include basic services: “medical gated to purchase a standard care… hospitals and midwives. General practitioners “receive a capitation payment for each patient on 21 . Nurs2007. However. 3 deaths per 1000 births. so that individuals do not receive billings for every minute detail in a single office visit. Government-mandated deductibles have been in effect since 2007.” The Future of The United States: Of the healthcare systems examined in this analysis – France. alternative therapies. with a high degree of freedom and coverage while retaining capitalistic principles. There is some optimism that the United States may be moving in this direction." .976.4 Dutch infant mortality was 4.” a vast improvement over American reimbursement for primary care services. The billing process is simplified via Diagnosis Treatment Combinations (DTCs). Those who support such a system and the benefits outlined herein will need to be vigilant of insurance companies that defend profit.1 per 1000) than Germany and France.2% of GDP in 2004. of misplaced political accusations.” Payments “are collected centrally and distributed among insurers based on a risk-adjusted capitation formula” in order to equilibrate risk. The United States would do well to follow the path of mandated coverage and strong government regulation of insurance companies. 10 Insurance companies charge a “flat rate premium.Gavin Stern: An Examination of Healthcare Systems their practice list and a fee per consultation. “four insurers control 90% of the market.” Additionally. The cost of these annual premiums was 1. Germany. and the insured pay “the first 150 of any health care costs in a given year. in that they are not employees of the government. eyeglasses. and the Netherlands – the Dutch model is most compatible with the emerging healthcare system adopted by the United States in 2010. as “out of pocket payments as a proportion of total health expenditure are around 8%. The Dutch model produces the best results at the lowest price. Physicians maintain their autonomy. 22 The United States would do well to follow the path of mandated coverage and strong government regulation of insurance companies.3 Per capita spending in 2003 was $2.1 for females and 76.050 on average in 2006. and a political movement to repeal this reform or declare it unconstitutional.11 This system is far from perfect. lower than the United States. Citizens still have to pay extra for these services.8 for males – rates almost unanimously equal or better than all countries compared in this analysis. “90% [of citizens] buy supplemental packages. The Netherlands employed slightly fewer physicians per capita (3. DTCs incorporate all the costs of treatment and diagnosis. but still outperformed the United States. 10 Healthcare spending in the Netherlands was 9. such as dental care. Indeed. costs to the individual remain low. and life expectancy at birth was 82. and Germany. Although the Dutch system encourages competition and free choice. and cosmetic surgery (in some cases of disfigurement).” However.” which is based on the policy itself – not the risk of the insured as in the American system. France. the basic healthcare package does not cover what Americans might consider to be essential services. . Health Spending In OECD Countries: Obtaining Value Per Dollar. from http:// content.aspx [5] Rodwin (2003). & Shut. from http:// www. 2009. National health insurance: Lessons from abroad.gov/library/publications/the-world-factbook/geos/nl. the Netherlands.. Health Affairs. Kaiser Family Foundation. The Dutch Health Care System. D. Universal Mandatory Health Insurance In The Netherlands: A Model For The United States?. B. (2008). Retrieved April 10. Germany. 2009. 2009. 2009. American Journal Of Public Health. R. from https://www. August 6).php [9] de Ven. The Commonwealth Fund..kaiseredu. 1718-1727.org/topics_im_ihs.org/Content/Publications/Fund-Reports/2006/Mar/ Quality-Development-in-Health-Care-in-the-Netherlands. 27(6). Retrieved April 22. (2006). from http:// www. from http://content.healthaffairs. W. Health care in Germany. (2007).pdf [3] Anderson. Sweden. France.asp?imID=4&parentID=61 [2] Durand-Zeleski.org/cgi/content/ abstract/27/6/1718 [4] Grol.healthaffairs. Retrieved April 10.Gavin Stern: An Examination of Healthcare Systems REFERENCES [1] International Health Systems: France. G. The French Health Care System. 2009.pdf [11] United States Central Intelligence Agency (2009). Descriptions of Health Care Systems: Denmark. and the United Kingdom. France.pdf [7] The Century Foundation (2008). & Cackett. Retrieved April 9.commonwealthfund. B. and the United Kingdom.org/cgi/content/abstract/27/3/771 [10] Klazinga. from http://www. [6] Busse. The Netherlands – CIA World Factbook. I.allhealth. The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States. R.org/briefingmaterials/CountryProfiles-FINAL-1163. (2008). 2009. Health Affairs. N.org/~/media/Files/Resources/2008/Health%20Care%20System%20Profiles/ LSE_Country_Profiles%20pdf. the Netherlands. np. v. B.org. from http:// www. 771-781 . F. (2008).org/~/media/Files/Resources/2008/Health%20Care%20System%20Profiles/ LSE_Country_Profiles%20pdf. Retrieved April 10. from http://www.. 27(3). New York City: The Century Foundation Press [8] Green. Retrieved April 10. (2008.html 23 . 21. & Frogner. Germany.commonwealthfund. Descriptions of Health Care Systems: Germany. from www.cia.uk/pubs/bb3Germany. Retrieved April 22.civitas. Sweden. 2009. 2009. The Henry J. Retrieved April 22.commonwealthfund. (2005). Descriptions of Health Care Systems: Denmark. (2008). 2009. 93(1). Irvine. Quality Development in Health Care in the Netherlands. Retrieved 4/17/2009. equal to or better than the more conventional medicine of the day. its classes largely resembled those found at any contemporary Allopathic medical school. Indeed. New York Homeopathic Medical College changed its name to New York Medical College and the degree it offered to an Allopathic Medical Doctor. allopathy. However.Homeopathy Charles Volk In 1860. For example: If a person has diarrhea. While homeopathic medical education of the past encompassed new discoveries in its teaching. However. Similar suffering. homeopathy enjoys a resurgence in the US. For example: If a person has diarrhea.” and although the term is antiquated. while the homeopathic medical education of the past encompassed new discoveries in its teaching. in response to the homeopaths. and disagreements among homeopathic practitioners were starting to sound a death knell for homeopathy in the United States. The US was very welcoming of homeopathy. There’s an idea that if a person has a condition. 2) Give them a compound that causes a similar problem. homeopathy. made their own institute a couple of years later: The American Medical Association. with a half dozen schools in the country. as the popularity of homeopathy in the US dwindled and confidence in Allopathic medicine increased. an increasing trust in the scientific process." New York Homeopathic Medical College continued to churn out homeopathic physicians for many years. modern homeopathy has taken a completely different angle. a physician can do one of two things: 1) Give them a compound that causes an opposite problem. The conventional physicians. founding the American Institute of Homeopathy in 1844. At the time it was a completely reputable form of medicine. it seems to have stuck. They called conventional medicine “allopathy. by the end of the 19th century. new discoveries. A little less than a century later. This is actually a rivalry in medicine that has been going on since the time of Hippocrates. the incoming class to the New York Homeopathic Medical College sat down to become specialists in their chosen form of medicine. 24 . The homeopaths gave conventional medicine a name to differentiate themselves and their form of medicine. You give them something that would cause opposite suffering. The curriculum at New York Homeopathic Medical College had integrated new discoveries in medicine and science since its charter class. and once medical education in the US became more homogenized around the turn of the 20th century. give them something that causes constipation. give them an extremely small dose of something that causes diarrhea. modern homeopathy has taken a completely different angle. By 1910. a homeopathic physician would often garner a larger salary in the western United States than a physician who used the strong laxatives and heavy metals that were used in conventional medicine of the time. homeopathy. as I didn’t feel “called” to anything. I guess my worldview is that of “things exist that I can interact with or detect. The term evokes a certain amount of fait accompli of the universe. In the book. but the next teacher then started talking deeply about philosophy. So. I specifically left “God told me to” out of it. The phrase “tweak your worldview” was said to me dozens of times. The first teacher brought my hopes up slightly. Once it was my turn. we were all asked one-byone to stand in front of the class and tell everyone how we were “called” to homeopathy.” better known as “the materialistic worldview. The room eventually filled up with the other 30 students. I always felt that I existed because billions of years of evolution had by chance created me. What it really reminded me of was Catholic school. and after a year of college was accepted into the class of 2009. and you could only be a great homeopath if you tweak your worldview. but the one he espoused the most was homeopathy. and colossal iron radiators. After experimenting on myself and on willing family and friends (my dad still takes the homeopathic remedy I got him for his bursitis). He claimed that you have to be a philosopher to get homeopathy. 25 .” the teacher says. The building I walked into was rented out to practitioners of the entire spectrum of complementary medicine. herbs smoldering. Minnesota. ancient blackboards.Charles Volk: Homeopathy My experiment with homeopathy started with a book on natural health for dogs and cats. I’m not really one for extended philosophical musings.” “The greatest problem with modern medicine and science is that it only believes in the materialistic worldview. I always found that learning about the natural world was always far more interesting than debating on existentialism. After some administrative stuff. and how I thought I could really delve into the subject to come up with knowledge to make people better. I just got up and explained how I thought homeopathy was very interesting. I started looking further into it and became fascinated with what I saw. at the end of the top floor hallway. strange esoteric compounds being displayed and archaic rituals being performed to heal diseases I didn’t even know existed. I was hooked. Nights wiled away in a heated discussion about our role in the universe just never really held too much interest for me. I was incredibly uncomfortable with this. And there. the author introduced many “natural” ways to keeps pets healthy. I took a front corner seat close to a power outlet (for my laptop) which had the unintended side effect of allowing me to see both the faces of my classmates and the professor at the same time. I wouldn’t be around to think about it. was my homeopathic medical school classroom. I found out about a homeopathic medical school in Minneapolis. and I noticed that I was the youngest person there by at least ten years. If it hadn’t. that my decision to study homeopathy could only be explained by supernatural means. It felt like stepping back in time. More on this later. It seemed like the room hadn’t changed much since the late 1800s: old woodwork. The first day of class started at 8AM on a frigid Minnesota January morning. talking about what anyone in medicine could agree on. and it grew old very quickly. a homeopathic preparation of the herb does the exact same thing. which have a number of different homeopathic remedies in them that are commonly used for whatever disease. I think it behooves me here to take a little foray into exactly “what are homeopathics?” Homeopathic remedies are made by a certain process of dilution and shaking to “potentize” them. If one gap is closed by legitimate research. though they are supposedly less effective than the 26 als that show homeopathy has any effectiveness beyond placebo. It seems to be that if an herb has a large alternative medicine following. but the practitioners of homeopathy claim the more they dilute it. Avogadro!) state that there cannot be anything left of the original compound after twelve 1/100 dilutions. Let me take you through making one. If one read 100 authors books on homeopathy. Sometimes they operate in the opposite fashion from the large dose. Take one drop of the snake venom and put it in 99 drops of a water/ethanol mixture. the mathematics of dilution (thanks. For example. It takes much of the guesswork out of it (have the flu? Use flu!). and would disappear when I had learned more about it.Charles Volk: Homeopathy So it begins. they also offer combination remedies. one would get 100 different mechanisms for its action. Luckily. Shake this mixture 40 times. it would become very red. Sometimes you are supposed to find the “constitutional type” a person is. a general tendency towards placebo response. Now. In fact. and painful." . He claimed that homeopathy is spiritual energy. and you have the remedy Lachesis 30C. it’ll move on to another. Although occasionally. you are probably thinking that there can’t be anything left of that snake venom. Later. the better it seems to work. Another invoked quantum mechanics (but couldn’t explain it. another instructor claimed it was “energy medicine” somewhere in the realm of electromagnetism. hot. then take one drop of that mixture and put it into 99 drops of water. Shake There are currently no 40 times. if one would take the belladonna herb and rub it on one’s skin. and that remedy is the only thing that will heal them. Homeopathics are prescribed in an extremely convoluted and seemingly contradictory fashion. venom from the Bushmaster snake. It seems to be one of those disciplines that constantly lie in the gaps of scientific knowledge. Repeat with 28 more dilutions and shakes. of course). and in fact. The basic idea is that it causes the opposite reaction of the toxin or herb in its full dose. for example. step by step: First get your original product. Sometimes they have the same effect. just better. like sunburn. scientifically accepted triThe 30C means 30 1/100 dilutions. I figured my confusion was only due to naiveté. The belladonna remedy helps remove afflictions with similar symptoms. some herbs are used for the same conditions that their full strength counterparts are used for. However. my incredulousness was only matched by the agreeing nods of my classmates as they listened to his lecture. there is some lab-based evidence that shows some cellular response to ultra-diluted compounds similar to homeopathics. and only then can the microorganisms cause tissue damage. there are currently no scientifically accepted trials that show homeopathy has any effectiveness beyond placebo. “What was all that about germs not causing disease?” “They don’t. theory comes from the Greek word for “spectator” or “observer. a general tendency towards the placebo response as methodological controls get more precise." The lead instructor also said that homeopathics can cure bad luck. My guess was that it would put homeopaths out of a job. There are individual trials that have shown the effectiveness of homeopathics. My vantage point at the front corner meant I could see people’s faces and reactions whenever a barrage of questionable information began.” “All the scientists just go running from one theory to another.) has to cause disease first. which was then paralleled with the Christian idea of original sin.” the teacher answers. He claimed that the entire idea of scientific theories was wrong.” I called him out on that after class and he claimed that.skepdic. “Viruses and bacteria are scavengers of diseased tissue. “spectator is 27 . it makes a weird sort of sense. I would direct readers to the article on homeopathy in the Skeptic’s Dictionary at http:// www.” Actually.Charles Volk: Homeopathy single remedies. but none have been reproducible.” If you roll this around in your head for a while. We’re way past arguing the accuracy of the germ theory in the 21st century. not miasms. the very idea of the scientific method came under attack. I should also mention that with the exception of some occasional small. The instructor backed it up by saying. Everyone knows that” was disheartening in a way I can’t quite describe. and in fact. I raised my hand. of course they don’t. Soon enough. A miasm (literally meaning “evil spirit. Another claim was that heredity is mostly energy (the teacher’s percentages were about 5% DNA and 95% energy). Again.” and “You know. Soon enough. (A complete discussion of the evidence for and against homeopathy is beyond the scope of this essay. but then I remember a man named Louis Pasteur proved that microorganisms. There was a point in there somewhere about rocks causing disease.” Seriously. caused disease over 150 years ago.com/homeo. The sheer number of people in that class that had a look of “Well. the very idea of the scientific method came under attack. theory comes from the Greek word for theater. as well as an immense amount of anecdotal evidence for its effectiveness.html) A little later into the discussion on that first day. “The average life of a scientific theory is five years. poorly constructed drug efficacy studies. No one could seem to explain why. The teacher made an announcement (actually several) to those people who were perhaps having some trouble believing any of this (me). homeopathy only makes sense only if you suspend any part of your brain that determines sense? What became the last straw for me was a student’s response to something the teacher said: “Yeah.” My mind just doesn’t work that way. that makes sense. A few months after this experience. And. because I can put a thought into a crystal and give that to someone.” There is definitely something to be said for the placebo effect. I have a problem with a $20. “When is it okay to start thinking again?” I don’t know about most people’s minds. It was one of the most marginalizing. And why would I want it to anyway? So. Homeopathy only makes sense if you suspend any part of your brain that determines sense?" 28 . During a break. It begs the question.” Though I may be in the majority of people in the general population in thinking this is utterly ludicrous. he was “still helping.” He also said that it “didn’t bother him if it wasn’t real” and that even if it was just by a placebo effect. I went up to talk to the lead instructor. I began allopathic pre-med studies and haven’t looked back. degrading.” despite it completely changing the meaning of his damning appraisal of science. It was that we should “Put off our reasoning minds for awhile and make a space for homeopathy.000 tuition bill and spending four years of my time learning something that may not even be true. and surreal experiences of my life. He could see that I was not comfortable here and was having a hard time.” This is not something that I have much experience doing. and that will heal them. He laid it out for me that he “could never prove that homeopathy was effective by my standards. but I realized I have ethical issues with being in a profession that considers no real treatment just as worthy of charging for. I spent 5 full days at the homeopathy academy. but I don’t “stop thinking. confusing. I simply couldn’t take the barrage anymore.Charles Volk: Homeopathy what I meant. I was in a definite minority in this room. In the end. Seeking financial stability. I stop under the tree. off-site faculty. New York Medical College signed an affiliation agreement with Pace College (now Pace University) in 1973. Along the way. the New York City.. and study modules were all located in the Basic Sciences Building – students and faculty alike crammed into clusters of rooms separated by “inter-labs. and never giving up on doing better… Our Valhalla: Thirty-Eight Years of the ‘New’ NYMC Gavin Stern The basic sciences building was completed in 1972. pre-studying under the glow of skylights. One cannot discuss the history of the Valhalla campus without explaining the circumstances surrounding the cloWe went to the brink—and sure of Flower & Fifth Avenue Hospicame back. first and second year medical students migrate from their on-campus apartments to class. New York Medical College. Flower & Fifth Avenue the New York Times in 1983 Hospital and its owner. the silvery names of honored graduates.” tal. which now towers over the rear entrance of the Basic Sciences Building. as of yet untold. sketches of an old “homeopathic medical college” perched above a grocery store. Some sneak into the cafeteria to grab a bagel or coffee. the Class of 1975B “Pioneers” described the rigors of the transition period: unpaved roads. a difficult housing situation. intended as temporary quarters for New York Medical College.m. at that time a major provider of healthcare in New York City. Others were in the library the whole time. The Archdiocese guaran29 . were struck particularly hard. and of course photographs of Flower Hospital – the very first built by a medical school in the United States. The move to Westchester occurred during a period of financial turmoil in Dr. I pass under the Tree of Hippocrates – planted at Flower & Fifth Avenue Hospital in 1972 and then transplanted to Valhalla in 1979. mountains of mud. the journey of New York Medical College is a testament to perseverance through difficult times. and one extraordinarily leaky roof. John Connolly. In their yearbook tribute. NYMC would affiliate with the Archdiocese of New York. The modern Medical Education Center was only a dream. a lack of furnishings. At that time. nearly merged with Metropolitan Hospital in 1977. the College operated two campuses (and trained two medical school classes) while departments slowly transferred from Manhattan to Valhalla.” Most students actually hailed from New York. the students pass snippets of history that line the walls: paintings of founders and deans long gone.Just before 9:00a. Indeed. Lectures. Early students at the Valhalla campus would complete their training a year ahead of their Manhattan counterparts. and consider – this Valhalla campus must have a history. as massive cuts in represident of New York Medical imbursement threatened the survival of many hospitals and medical schools in College when interviewed by the 1970’s. labs. doing the best with what you have. and even considered a move to Queens. Ultimately. Arriving just a little late via the commuter lot. as the “B” classes of 1975 and 1976 operated under an experimental three-year curriculum. another former Grasslands Hospital building. By 1977. the cal departments. along with a new stretch of parkway to service it. the Archdiocese closed the storied Flower & Fifth Avenue Hospital and converted it into a continuing care facility. Elmwood Hall. New York Medical College maintained affiliations with many city hospitals. In an extremely controversial move. a new home. Vosburgh Pavilion has a previous life as a psychiatric facility (notice the fenced-in courtyard and small workrooms). ‘Odyssey’ Due to a push by the American Medical Association for all residency programs to have a university affiliation. although most of the Dr. the Terrance Cardinal Cooke Health Center.” 1979 yearbook. while control of the Graduate School of Nursing was relinquished to Pace. An era has ended only to mark a rebirth in Westchester. In 1968. and unwillingness for many physicians to practice without an academic appointment. but it also gained a new one on campus – the Westchester County Medical Center. New York Medical College owned the Mental Retardation Institute (Cedarwood Hall. the Westchester County Medical Center was completed on the site of an old apple orchard. In its wake stands a new hospital. The Graduate School of Basic Medical Sciences followed suit. now a University due to its affiliation with the School of Medicine.Gavin Stern: Our Valhalla teed NYMC’s debt of $10 million (1978 dollars) and took over appointments to the College board. Many of the current campus buildings were originally part of Grasslands Hospital Center. Daniel Peters. The “MRI” is 30 . By 1978. The hospital went private in 1998 and was joined by the Maria Ferrari Children’s Hospital in 2005. Westchester County endeavored to bring a medical school to the suburbs. now the Westchester Institute for Human Development) but sold it to the county government when it proved financially unsustainable. The next step was to build an academic hospital. Animal imagery can still be seen in the archithriving metropolis” tecture of Sunshine Cottage. Flower and Fifth Avenue Hospital is no more. The National Institute of Health provided much of the funding to build the Basic Sciences Building. in a sponsorship arrangement that endured for nearly thirty years. the county offered New York Medical College land on the Grasslands Reservation along with favorable rental terms on former Grasslands Hospital buildings. served as the adClass of 1984 ministration building in the decade before Sunshine Cottage was available. the School of Medicine transferred its main operations to the Valhalla campus. which now houses most cliniit was back then. statues are gone. which predated Westchester Medical Center: Compared to the way Munger Pavilion. was an adult tuberculosis hospischool is currently a tal while Sunshine Cottage was a pediatric hospital. But one component of the modern NYMC was still missing. which in turn moved into the former instrument shop. Slowly. dining facilities. while Vosburgh Pavilion would have become a permanent dormitory by renovating the rooms previously used for psychiatric admissions. Private investors had planned to build 1. Vosburgh Pavilion doubled as temporary dormitory even as psychiatric patients were still being admitted nearby. In 1981.” located between the Basic Sciences Building and the Institute for Human Development. Munger Pavilion was to be overhauled. Improvements to the College instead occurred incrementally over the ensuring decades: the Blue Auditorium stayed “blue. on-campus housing is considered a staple of the NYMC experience. with the final building completed in the mid-1990’s along with a student center (rededicated in 2008). Wall panels and bright red paint covered previously exposed brick and steel. A 1984 “Master Plan” outlined the construction of a “Clinical Research and Education Center. Courtyards that graced the center of each academic department were swallowed up to feed the BSB’s appetite for interior space (this explains why some offices have windows. many first-year students lived in dormitories at Manhattanville College. New York Medical College finally built its elusive dream building in 2001. later renamed the School of Public Health. and barbeque on campus. as outfitting of the BSB auditoriums was behind schedule. medical students and their families could live. thanks to a massive fundraising effort. However. a projected cost of $50 million (1984 dollars) proved too ambitious to accomplish these goals all at once. With few on-campus options.000 subsidized apartments. but protests from Westchester residents forced a substantial reduction. The cafeteria expanded into the space once occupied by a much smaller bookstore. the larger Nevins 31 1971.Gavin Stern: Our Valhalla distinguished in holding the first lecture of the Valhalla campus. Vosburgh Pavilion changed its mission and instead housed new Graduate School of Health Sciences. It has since grown into a beautiful garden” . work out. but for two decades Grasslands Housing was reserved primarily for second-year students. convex television fixture disappeared from the center lobby. The plan also called for administrative offices to move from Elmwood hall (near the prison) to the statelier Sunshine Cottage – which actually did occur. Briarcliff in Tarrytown. staff ter. it was a little flowerpot. Today. Plans to replace the basic sciences building came and went over the decades. After nearly three decades of tinkering with the Basic Sciences Building.” but somewhere along the line Orange Auditorium was renovated into Terrance Cardinal Cooke. private investment expanded the number of Grasslands apartments. mingle. but no view). The $32 million Medical Education Center included a proper lobby. A gargantuan. five-hundred seat auditorium. Finally. The new building was to include a student cenDelroy Chang. and laboratory space. as reported by the New York Times in 1971. Farmland occupied the rear of the College and was tended to by prisoners – this too disappeared – but a historic building on the estate was transformed into the Alumni House. and finally to the School “When I came here in of Health Sciences & Practice by 2008. library. but vestiges can still be found: cardiac simulators now occupy two of the old cadaver labs. the anatomy lab moved into a single space on the top floor. Half of it houses the extended security station.Gavin Stern: Our Valhalla auditorium and updated study modules. the original entrance and lobby is difficult to find – but it’s there. Indeed. the modern NYMC was born. doubled in size. Desks and microscopes once filled the open space now enjoyed as a student lounge. Elliot Perla Dr. too. The physiology library remains virtually unchanged as a former classroom. Previously segmented into ten small rooms. Thirty years after the odyssey began.” Contributors: Dr. It was now “our Valhalla. as does the graduate school conference room. capped with skylights. The Health Sciences Library extended underneath the new structure and. Daniel Peters Delroy Chang Sean Manning Anonymous faculty Every yearbook staff since 1972 32 . current students may never realize where their ancestors once toiled – but they were there. while Blue Auditorium also provides a window into the past. Previously trafficked by thirty years of medical students. Most of the old BSB classrooms were renovated into laboratories and offices. The rest is hidden behind a brick wall next to the MEC – but one can still find the marks where a doorframe and heaters were attached. Ian Hovis A young Ghanian woman captured in a balancing act on the streets of Accra . A Lesson from Iran: Improving Rural Primary Health Care in The United States Navid Shams Around the time of the Islamic Revolution (1979). studies had recently been carried out in Iran that involved training local young people with primary education to become front line health workers (FLHW).6 never mind the supporting facilities that physicians (Iranian or imported) would need to actually use their specialized skills in these rural areas. which was met with resistance by rural residents who preferred Iranian auxiliary health workers to non-Iranian physicians.5 Also. This left very few physicians in the rural regions (physician:population ratio of 1:15. over 50% of the rural population had low health status. modernization and economic development efforts that favored urban areas. such as building large city hospitals that the rural population didn’t have access to.2 As a result. Pakistan and the Philippines. about 87% of the medical practitioners still worked in one of the 5 largest cities. the government set out to establish a new rural primary health care (PHC) program. Building On Past Experience With social and economic considerations in mind. 48% of the population lived in isolated villages with less than 1. hospitals.000). child malnutrition rates were high and important facilities such as sanitary drinking water were only present in 20% of rural homes. 23 million of the total 60 million Iranians lived in extremely poor and underdeveloped rural areas.3 Before the Revolution Improving rural health posed a significant challenge due to the primitive infrastructure and lack of various types of resources. a male worker (Behdashtyar) was in charge of community health (surveillance) and environmental sanitation. 3 This led to importation of physicians from India. the small health sector budget (about 3% of total government spending) was mostly used on expensive projects. Fortunately. Also.000 villages. of the 700 doctors who graduated medical school every year. In 1977.4 Even the 400 Health Corps stations were only able to provide minimal care to 20. Infant and child mortality rates were twice that of urban areas. about half would leave to find work in other countries.7 In each location. or schools. 4 Moreover. whereas the female worker 34 . Recognizing this.1 Wide-spread poverty was the result of an imbalance of previous industrialization.000 of the 55.000 inhabitants each. Life expectancy was approximately 10 years lower in both the male and female rural population. the new Ministry of Health made rural health a priority in order to work toward the constitutionally-guaranteed right to health care for all citizens. utilities. 3 An imbalanced distribution of economic resources also contributed to the difficulties. For instance. The government had not given financial support to provide these areas with roads. even though medical graduates were required to spend 2 years in the rural Health Corps. These factors led to the poor health status in rural regions. and teenage pregnancy in the United States. The unique program has also caught the eye of Harvard’s 35 .1 The population is drawn from one main village and several “satellite” villages with similar culture and social structure. such as the encouragement of breastfeeding and awareness about environmental hygiene and sanitation improvements. Satellite villages had to be within one hour walking distance of the main village.000 live births in 2000. In fact.) and small enough to allow monitoring of immunizations with household-specific active follow up.6 per 1. who serve about 1500 people. Despite these challenges. The ease of access to a friendly and agreeable FLHW allows for constant and continuous interaction between the health system and the community.8 These improvements were essential to the decrease in IMR and U5MR from 122 and 191 per 1. The focal point of the new system is the “Health House” (khane behdasht). etc. Implementation of the system led to significant declines in infant (IMR) and under 5 mortality rates (U5MR) before the revolution.Navid Shams: A Lesson from Iran (Behvarz) was in charge of maternal and child health. However. oral health. Recently. the RHC has a member from various specialties (i. Along with the doctor and technician.000 live births in 1970 to 28. 3 An Ideal(istic) Solution? The Iranian government has identified and implemented an effective strategy to reach its rural health goals. 4 It has also catalyzed the movement toward universal immunization of children and correct treatment of children suffering from diarrhea and acute respiratory infection.e. which is sincerely lacking. 7 That success as well as the relatively inexpensive nature of the new primary care and prevention program led to the system’s expansion throughout rural and eventually urban areas during the 80’s and 90’s. mobile teams consisting of a doctor. disease control. the concept of improving health has a way of opening doors. marriage/divorce. pose significant challenges.9 Considering this success it is not surprising that groups in the United States have looked to the Iranian system in hopes of improving rural health. Because they were locals. can use the state’s pre-existing resources to improve these figures. family planning and general patient care. which allowed for accurate collection of health information that was recorded in individualized household log books. etc. make monthly visits to remote villages to provide support and refer patients to Rural Health Centers (RHC). the FLHW developed close relationships with community members.e. coupled with the already present distrust between the communities and public health officials. This has led to the promotion of healthy attitudes and behaviors. hypertension. nurse. a strong primary care network. the stigma against bringing in experts from a less than popular country. the Tuskegee Syphilis experiment). The RHC completes the network by supervising several Health Houses and mobile teams. Ostensibly. environmental health. Mississippi has the highest level of childhood obesity. the first Mississippi “Health House” is set to open in January 2010 and 15 other communities have already expressed interest in opening their own. lab technician and a Behvarz. IMR among non-whites in the Mississippi Delta region are comparable to that of third world countries. due to previous scandals (i.6 and 35. disease. In addition to the Health Houses. a group from Mississippi signed an agreement with Iran’s Shiraz University to form the Mississippi/Islamic Republic of Iran Rural Health Project.). Each is staffed by the two FLHW. Despite having the 3rd highest medical expenditure per capita. This number is large enough to give the Health House wall chart enough data to identify village level disparities and trends (in births/ deaths.10 Furthermore. and Performance AJPH 1976 66(3):273-7 [5] Zeighami B. Schwartz T. Deep South calls in Iran to cure its health blues. and a focus on prevention) cast a positive light on the system. Several key aspects (i. Najarzadeh E. Schultz S. 2009 36 . Russel S. REFERENCES [1] Couper I. Christina. South African Academy of Family Practice 2004 46(6):37-39 [2] Hooglund E. which will assist in monitoring the project. Iran has made great strides towards minimizing health disparities between the rural and urban population. 1960 – 1980. collection of data. Javidian I. Kazemipour S. American Journal of Public Health (AJPH) 1981 71(7):739-742 [8] LeBaron S. Mehrabanpour J. Rural primary Health Care in Iran. Evaluation of Rural Primary Health Care Services in Iran: Report on Vital Statistics in West Azarbaijan. community participation and cooperation. The Front Line Health Worker: Selection. Zeighami E. 1980. Physician Importation – A Solution to Developing Countries’ Rural Health Care Problmes? AJPH 1978 68(8):739-742 [6] Amani M. Solter S. At a glance: Iran (Islamic Republic of) http://www.Navid Shams: A Lesson from Iran School of Public Health.unicef. [3] Aghajanian A. Trainig. Genus 1977 33(1-2) 141-150 [7] Barzegar M.html [10] Lamb. Zandjani H. Impact of rural health development programme in the Isalmic Republic of Iran on rural-urban disparities in health indicators. Middle East research and information projects reports. Mehryar AH. Conclusion With political commitment to a needs-driven development of the PHC program. The New York Times. 87(1):3-6. December 20. the implementation of similar programs can surely improve health statistics in various settings from Iran to Mississippi and beyond. Ronaghy H. unity and reach of the network. The Principles of population policy with special reference to Iran. Ahmadnia S. Djazayery A. Eastern Mediteranian Health Journal. Zeighami B. Family Medicine in Iran: The Birth of a New Specialty International Family Medicine 2005 37(7):502-5 [9] Unicef. 2007 13(6):1466-1475 [4] Ronaghy H. access to health services. Using these strengths. Land and revolution in Iran.e. The involvement and cooperation among various groups is impressive and holds exciting potential for the project in the coming years.org/infobycountry/iran. farm or office where he works. including video-sharing (YouTube). Linkedin.4 In fact.5 Other flavors of networking also exist. which allows individuals to rapidly dispatch very short messages to many others and has been successfully utilized in a variety of recent. Stumbleupon.8 It is unclear how many distinct social causes exist within Facebook. and Michael Karsy Where after all do universal human rights begin? In small places. podcasting (Blog Talk Radio). the school or college he attends. Bill & Melinda 37 . wikis (Wikipedia).9. Christopher and Dana Reeve Foundation. lifestreaming (Friendfeed). social voting (Digg). we shall look in vain for progress in the larger world. and Wayn have grown from solely social networks used to connect individuals to becoming tools used to raise awareness. mapping (Google Maps). most large-scale organizations (e. Unless these rights have meaning there. thus being able to focus attention across the enormity of the web onto humanitarian issues and causes.3. Mera Geis.g. March 27. but their impact on grassroots organization and fundraising has been importantly cited in political campaigning and voting patterns. Such are the places where every man.Social Networking Tools in the Modern Era of Human Rights Protection Odessa Balumbu. Websites like Facebook. and child seeks equal justice. From the drive of Eleanor Roosevelt in the passage of the United Nations Universal Declaration of Human Rights on December 10th. they have little meaning anywhere. and virtual worlds (Second Life). Myspace. such as microblogging through Twitter. woman. Yet they are the world of the individual person.2. the field of human rights protection has undergone vast change. A website such as Facebook boasts over 400 million members globally and serves as the largest social networking medium in the North America and Europe. photo-sharing (Flickr). the neighborhood he lives in. real world cases. 19581 The technological advances employed during each major period of historical social change. specific applications have been designed and marketed for these networks to allow any user to raise funds for their favorite non-profit organization.6 Social bookmarking. such as Delicious.7 Numerous organizations representing different platforms. allows individuals to quickly generate a public bookmark of websites geared towards any theme. close to home . equal dignity without discrimination. all with various capabilities and untapped potential. the factory. from political parties and biomedical research foundations to humanitarian agencies. Remarks by Eleanor Roosevelt at the United Nations. Social networks have become a mainstay used for an enormous variety of interest groups in the promotion of an ever increasing number of causes. Richard Fazio.so close and so small that they cannot be seen on any map of the world. to the modern creation of online blogs and social networks championing a particular social cause. Michael J. Fox Foundation. 1948. and Reddit. equal opportunity.10 Despite the wide range of online tools for social networking. utilize social networking tools to promote their cause. Without concerted citizen action to uphold them close to home. organize activism and create a permanent constituency devoted to a particular cause. Many other forms of social medial tools exist. whether it be the printing press or internet. have been at the forefront of organizing and fostering activism. Modern technologies have only supplemented the unremitting passion and drive that encourages social movements to improve the human condition worldwide. 15 In 2006. During Volz’s one-year ordeal.20 In fact.S. Although eye-witness accounts.Michael Karsy et al. One of the first cases of online social networking arose serendipitously around U.S.g. In spite of these drawbacks. Volz cites several examples where social networking acted detrimentally to his case in an unexpected way. These groups have generated tools to allow for local. most discussions involve the ethics of such tools and their misuses. during multiple instances throughout the ordeal. Furthermore. The power and widespread reach of social networking tools was illustrated quite clearly. the site is now used to generate support for other human rights abuses in Nicaragua and elsewhere. such as medical students posting unprofessional content on social sites.18 These websites helped to organized numerous telephone calls to the U.. the government of Nicaragua proceeded to try him. Genocide Intervention Network.S. citizen Eric Volz.11. Youtube video and online following was propagandized by the Nicaraguan media to vilify him often as wealthy American extorting the Nicaraguan justice system20. the first cited event where the site was used to champion a human rights cause as oppose to solely entertainment15. in which Volz was entangled15. Additionally. Misinterpretation of information generated from Volz’s site. STAND. this video also resulted in a propagandized video placed on the site by the Nicaraguan government vilifying Volz. Volz still tours the country supporting the power of online social networks in organizing individuals towards a common 38 . nevertheless. Volz was falsely accused and imprisoned in Nicaragua under doctored charges of rape and murder. self-organization in an effective way. The increasing publicity of Volz’s court case resulted in the case becoming extremely politicized and perilous in Nicaragua for any judge to overturn the decision. despite the great benefit of an online medium to support his cause. on diplomatic and trade issues15. eventually resulting in a crash of the embassy webserver at one point. In addition. cell phone usage. Furthermore.17 A phenomenal world-wide movement emerged where the website received on average 140. helping to garner further support and eventually aiding in Volz’s release and deportation from Nicaragua.14 Instead. Volz was prosecuted under suspicious circumstances.19. Amnesty International) seem to have utilized the capabilities of online networking tools most effectively towards their respective causes. A Spanish version of the site was also created. despite the immense potential of social networking tools in the biomedical sphere. State Department which implemented screening to direct calls to the Nicaraguan embassy and website.22. However.: Social Networking Tools in the Modern Era of Human Rights Protection Gates Foundation) arguably utilize only a limited portion of available online resources.21 Currently.13. The Volz case highlights the first self-organized social movement supported by online tools. the story of Volz’s online support led to mainstream media stories on this situation. the Volz’s family was extorted by various individuals threatening his life in exchange for money. These mostly include tools to allow individuals to send general online petitions to congressmen. the Nicaraguan government saw Volz as a more valuable bargaining chip when negotiating with the U. The cause of his ordeal was later attributed to a strained geopolitical situation between Nicaragua and the U. donate to the foundation or passively follow the activities of the organization. and credit card receipts placed him two hours from the scene of the crime. many grassroots organizations and humanitarian agencies (e.12.000 visits a month with many asking how they could help15.S.16 Working in Nicaragua as the editor of the magazine El Puente. a website was created from his mother’s living room simply as a way to keep friends and family informed of his condition. Volz’s ordeal was described in a video narrative posted on Youtube. 32. stocks of companies operating in Sudan are exchanged on the U.27 The combined effort greatly improved the awareness of Congressmen and the public about the ongoing genocide. GI-Net was designed to create a permanent anti-genocide constituency which could rapidly be mobilized. Chad. which supports the ongoing genocide. although it was by no means simple.S. to inquire about how to improve their scores19. While U. cities and universities to divest their pensions and funds from these companies. including the creation of advocacy and divestment tools.30 While Hanis states that GI-Net has been an important tool towards mobilizing activists in genocide intervention. Somalia. Formed in 2005 by Mark Hanis. GI-Net and its collaborators helped to identify and publish an online list of companies involved in investments which funneled money into military equipment purchases while avoiding companies that were involved in infrastructure development and delivery of aid to the people of Darfur. namely Iraq. and mobilizing constituents. Multiple members of Congress called immediately after the formation of the webtool and in response to a deluge of phone calls and emails from constituents. GI-Net and its student wing Student Anti-Genocide Coalition (STAND) have helped to organize targeted divestment against companies that do business in Sudan. In response to this.S. Democratic Republic of Congo. a descendent of Holocaust survivors.Michael Karsy et al.23 Two key lessons Hanis learned from elder Holocaust survivors during his upbringing were to never forget and never let such a situation happen again15.26 The effect on Congress was dramatic and effective.33. stock exchange and can receive investments from mutual fund companies. GI-Net has been involved in a variety of activities through their website. GI-Net created Congressional report cards depending on how Congressmen voted for anti-genocide legislation. Sri Lanka and Burma. Research by GI-Net in collaboration with genocide scholars have identified eight ongoing areas of genocide or ethnic cleansing occurring globally. In addition to advocacy. enter their zip code and automatically be transferred to the White House.31. One of the most creative organizations to utilize the collective power of the internet and social networking to advocate for humanitarian issues has been the Genocide Intervention Network (GI-Net). businesses are not allowed to operate in Sudan due to anti-terrorism legislation. Some wrote op-ed pieces in their constituent’s districts. These tools demonstrated the capability of online networks to foster rapid and widespread mobilization of constituents in order to allow individuals to collectively increase the power of their voice. Harvard University and the UC Regents became two of the most publicized cases where divestment was successfully accomplished.34 39 . GI-Net and STAND provided online resources which encouraged the selfformation of student and grassroots groups that lobbied states. In addition. Sudan.25. Next.: Social Networking Tools in the Modern Era of Human Rights Protection goal and using his site to raise awareness of ongoing human rights abuses in Nicaragua15. he stresses that personal interaction with Congressmen still remains a key method of supporting one’s cause. GI-Net helped to establish the genocide hotline (1-800-GENOCIDE) where constituents could call. including the Sudan Divestment and Accountability Act signed into law in December 2007.29 In response to improving interaction with Congressmen during the passage of bills. the lobbying was important in the passage of a variety of legislation to protect the people of Darfur.28.24 Educational tools remove any excuse for not knowing about genocide but beg the question: how can genocide still occur despite better global awareness? One possibility is that there is zero political cost to an absent Congressional vote against genocide. their senators or representatives. Central African Republic. D. DigiActive. 25 February 2010.com/. E.” The Eleanor Roosevelt Papers. which otherwise would have been impossible.. National Press Club. These tools serve to supplement rather than replace organization on a face-toface level. “SOCIAL NETWORKING/ Changes in Facebook/ Web plan hopes to boost activism. Despite this. Causes on Facebook. 25 February 2010. 25 February 2010. Brendel.org Facebook. online networking continues to play an important and developing role in social issues.. http://www. 28 June 2008.facebook. G. “Medical professionalism in the age of online social networking.gwu. 25 February 2010. New technology has rapidly changed the way that human rights issues are addressed both locally and globally.digiactive.php?statistics Thewall.com/press/info. http://articles. and Wilkinson.” Social Science Computer Review 28:1 (2010): 75-92. 25 February 2010. http://apps. George Washington University.W. this tool alone was cited for raising over $25 million dollars for Haiti after its 2010 earthquake.000 over the course of three years. The Huffington Post.” Journal of Medical Ethics 35:9 (2009): 584-586.37 Texting PROTECT to 90999 allows any person to donate $5 to GI-Net directly from their cell phone bill. These efforts have helped to raise more than $500.. J.” 26 February 2008.slideshare.L. “Facebook Generation: Will social networks change the nature of philanthropy?” 18 June 2007. REFERENCES [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] Roosevelt. The benefits and negative effects of social networking on human rights protection and other important issues were not anticipated. http://www. Johnson. S. Zhang.net. J. T.com/causes/about DigiActive Team. Seltzer.Michael Karsy et al.: Social Networking Tools in the Modern Era of Human Rights Protection Grassroots movements and student groups have also been able to expand from lobbying to broad fundraising campaigns using social networking tools. R.38 In fact. http://www. “The DigiActive guide to Twitter for activism. Guseh.S. “The revolution will be networked the influence of social networking sites on political attitudes and behavior. W. Brendel. In today’s era.” 13 April 2009. “Digital activism & the 4Cs social media framework.sfgate.. a new tool has been developed by social entrepreneurs involving the ability to donate via text messaging to a number of registered charities. “Quotations by Eleanor Roosevelt. http://www. and Bichard. STAND helped to create and organize the STANDFast Project through its website and student chapters.org Mishra.W. H. 25 February 2010. D.huffingtonpost.H. S. there is an increased immunity to the impact of social networking due to the large volume of messages which can be sent on a daily basis. Social networking has allowed for greater participation on a variety of issues and has forever changed the landscape in the fight for social causes. 25 February 2010. Jain. the Genocide Awareness and Prevention Group (GAAP) at New York Medical College (NYMC) has been involved in these efforts and has helped raise over $1500 in the past two years. San Francisco Chronicle.35 In fact.H.” 10 May 2009.” New England Journal of 40 . http://www. http://www. T. where thousands of e -mails or Tweets can be fired off regarding one cause or another. 25 February 2010.J. T.facebook.39 These and other tools have helped to organize the fundraising of many small groups of interested people over a large area.digiactive. “MySpace: Where pop culture meets social activism. “Public dialogs in social network sites: What is their purpose?” Journal of the American Society for Information Science and Technology 61:2 (2010): 392-404. M. DigiActive.edu/~erpapers/abouteleanor/er-quotes/ Watson.36 Recently. “BECOMING A PHYSICIAN: Practicing medicine in the age of Facebook.com Mansfield. resulting in annual fundraising efforts by groups all over the country.” 25 May 2007. Guynn. http://www. http://www. 25 February 2010. 25 February 2010.org/ Trageser. K.insidehighered. must do more for people in Darfur.msnbc. http://www. http://www. 25 February 2010.genocideintervention. T. http://blogs. 25 February 2010. http://www.Michael Karsy et al.com/ “Harvard’s Sort-of Divestment” 2 July 2007.edu/news/ STAND.P. http://www. Nicaraguan Films.genocideintervention. 25 February 2010.nwsource.” Genocide Intervention Network.aspx Dowd. 25 February 2010. T. “Text “Haiti” to “90999” Passes $25 Million. http://www.: Social Networking Tools in the Modern Era of Human Rights Protection Medicine 361:7 (2009): 649-651. “Human rights on and off the internet: Social Networking.com/ watch?v=sSo3sb73CZY “Details of release.com Friends of Eric Volz.standnow. Inside Higher Ed. Friends of Eric Volz.edu/ Clubs/Gaap/index.S.” Friends of Eric Volz. MedPage Today.youtube. 2271: Sudan Accountability and Divestment Act of 2007 “Genocide Intervention Network’s advocacy hotline receives 25. “Bush Signs Bill Allowing Sudan Divestment. M. UC Berkeley.htm Mobile Accord. http://www. http://www. “Gringo justice in Nicaragua.” 20 January 2010.net/ areas_of_concern Darfur Scores. 25 February 2010. Chretien.” 15 May 2009. Time World. Greysen. Emery.” 5 May 2009.U.mgive. http://www.state.com The Human Rights Center – UC Berkeley. New York Times. C. DipNote . 25 February 2010.tv/ Celizic.S. S. S.com Amigos de Eric. 25 February 2010. Genocide Intervention Network.” 16 March 2006.friendsofericvolz. 25 February 2010.youtube. 25 February 2010.times. D.net/network “Areas of Concern.G. Genocide Awareness and Prevention.” 18 December 2007. 25 February 2010.” 22 September 2009. http://www.ucdivestsudan.harvarddivest.” 15 September 2006. http://www.R. http://www.wweek. http://blogs.time. MSNBC. 25 February 2010. “OP-ED: Darfur: How do local reps stack up?” 24 November 2006. “Medical students using Facebook and Twitter can get expelled. C..universityofcalifornia.com/Partners. 25 February 2010. 25 February 2010. 25 February 2010.com/ Reichert.genocideintervention. and Kind. 25 February 2010..com/watch?v=8YChhOHrFA4&feature=related “Evidence against Eric Volz.friendsofericvolz. http://seattlepi. 25 February 2010.com/ Stolberg. 25 February 2010.amigosdeeric.org/campaigns/standfast “Previous events.msn.mobileaccord. State Department Official Blog.. 25 February 2010. “OP-ED: U. http://www.” Genocide Intervention Network. http:// today.darfurscores. [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] Chretien.” Journal of the American Medical Association 302:12 (2009): 1309-1315.” 30 March 2007.com “UC Regents vote to divest from companies with business ties to Sudan government and acts of genocide.html Rogers.000th caller.medpagetoday.com/ Details_of_Release. K.net/press_release Harvard Divest. J. 25 February 2010. http://www. 25 February 2010. http://www.com S.C. 25 February 2010. http://www. Willamette Week. http://www. 25 February 2010.” 6 June 2009.com/ UC Divest Sudan. http://www. “Will Nicaragua ever set Eric Volz free?” 21 December 2007.” 21 March 2007. “Online posting of unprofessional content by medical students.nymc. http://www.” 1 January 2008.com “Am American wrongfully imprisoned in Nicaragua.com/ time “About us.com/ Mgive. 25 February 2010.gov 41 . Seattle Post-Intelligencer. UC Newsroom. http://fora. the Israeli Defense Force (IDF) went to great lengths to avoid civilian casualties. during and immediately after the December-January attacks. Turning to the medical arena. or hospitals.9 In conclusion. I came across one such article in last year’s issue of Quill and Scope entitled “The Humanitarian Crisis in Gaza: A look at the health infrastructure before.8. the Gaza conflict is complex. it made no mention that Palestinians have fired over 12. 2009). I would like to show that there is more than strife between Israelis and Palestinians. Then. I hope to show how Israel’s advanced medical system has bene42 . and specific warnings before attacks. and critical facts about the events in Gaza were omitted. Whereas the Israeli population hides in underground shelters when there is warning of a rocket attack. “This is the Hamas dual strategy: to kill and injure as many Israeli civilians as possible by firing rockets indiscriminately at Israeli civilian targets. Critical Facts I would like to establish some key facts about the Gaza conflict that were not mentioned in last year’s article. over two million leaflets. and to provoke Israel to kill as many Palestinian civilians as possible to garner world sympathy. Moreover. while discussing the high death toll and injury rate in Gaza.2 Over 90 percent of Sderot residents have experienced a Palestinian Kassam explosion at some point. Israel had no choice but to engage Gaza and root out its vast terrorist infrastructure.January 18. now. over 100. the article omitted the fact that Hamas. and use human shields to protect themselves.Another Look: Medical Cooperation and the Israeli-Palestinian Conflict Danielle Masor The Controversy There has been much debate and controversy surrounding the war in Gaza of last year (December 28 2008. However. Moving beyond the Gaza conflict. while doing so. if not biased. it presented a highly politicized and biased view of the conflict.000 rockets at southern Israel over the past eight years. the article did not mention what precipitated the war in Gaza.” The article described the affects of last year’s conflict on Gaza’s health care infrastructure and the health of its population. makes widespread use of human shields. Indeed.000 cell phone calls. in order to protect its own citizens.5 Alan Dershowitz. mosques. In terms of critical facts. succinctly summarized the situation.” 6 In fact. a professor at Harvard Law School. I hope to focus on a more uplifting aspect of the Israeli-Palestinian conflict: Israel’s medical aid to its Palestinian neighbors and the world beyond. such as Sderot. The IDF announced exactly where it would strike with radio broadcasts. and it is often portrayed in a slanted. terrorizing towns closest to Gaza. Thus.1.4 An entire generation of children in Sderot has grown up with the fear of constant rocket attacks. manner.3 Over one million Israelis live within firing range of these deadly “homemade” rockets that are stuffed with shrapnel and nails to inflict the maximum damage possible. the internationally recognized terrorist organization that runs Gaza. the authorities in Gaza have been known to hide guns in schools. and it is part of a broader Israeli-Palestinian conflict that is exquisitely complicated and multi-dimensional. and Vietnam. Interestingly. and many Gazans are stopped at the Erez security crossing before they can access Israeli health care. and 4% from Moldova and Russia). Barzilai hospital. Israel was attacked by its neighbors and after winning this brief. which was founded in 1995 by Dr. former Director General of Israel’s Ministry of Health notes. Of course. for example.Danielle Masor: Medical Cooperation and the Israeli-Palestinian Conflict fited its Palestinian neighbors. religion.” While the Palestinian Authority’s Health Department pays for a majority of the cases. Iraq and Jordan. such as tetralogy of Fallot. The Reality Israel’s involvement in the administration of health care to Palestinians began over forty years ago. thousands of Palestinians are referred to Israeli hospitals for life-saving treatment. The Israel-based NGO. In 2004. Before the Gaza conflict. 43 . gender or financial situation. has established the “Saving Children” project.12 Save A Child’s Heart (SACH) Perhaps the most uplifting of all the examples of the medical relationship between Israelis and Palestinians. As Dr. color. killing four Israelis. 7% from China. Israel foots the bill for many others. Ami Cohen. The costs are covered entirely by the Peres Center (which receives funding from private sources—including several regional Italian governments). neonatal-tetanus and measles. it also assumed responsibility of the health of the Palestinians. the Peres Center for Peace. is the Israeli-based humanitarian organization. Palestinians from the West Bank and Gaza are referred to several hospitals in Israel. received numerous Palestinian patients on a daily basis.560 referrals from the West Bank and Gaza. To date. a female suicide bomber who claimed she had surgical plates in her legs blew herself up at the crossing after bypassing the metal detector. and acquired conditions. Israel has presented annually dramatic documented achievements to the World Health Organization (WHO)…. such as rheumatic heart disease. Israel dramatically reduced the death rate of Palestinian newborns from over 60/1000 to 19/1000 within those 27 years of Israel's presence. The goal of SACH is to provide and improve pediatric cardiac care for children from developing countries regardless of nationality. This included the total eradication in the Palestinian population of poliomyelitis. over 2.we make no distinction between treating Israelis or Palestinians. ranging from early infancy to 18 years of age. Barzilai’s deputy director noted in a 2008 interview: “We treat hundreds of Gazans here each year… Even if they're terrorists. it gets complicated.” 9 To this very day. Save a Child’s Heart (SACH). 40% from Africa.13 Their cases include numerous congenital heart defects. “Saving Children” has received some 6. facilitating referrals to and treatment of Palestinian infants and children in Israeli hospitals for sophisticated treatments and diagnostic procedures not available in the West Bank or Gaza. and how Israeli non-profit ventures have saved the lives of many Palestinians and others. Since its inception in 2003. located only twelve miles from Gaza. Israel assumed control of the Golan Heights. have been successfully treated.11. Also. Gaza. West Bank and Gaza. As Dr. they're treated like any other person being brought into the emergency room . “During that period (1967-1994). Sri Lanka. prompting increased security measures. Theo Dov Golan.100 children (49% from the West Bank. In 1967. Six-Day War. 10 Outside the NGO circuit. Ron Lobel. Africa. to name just a few. SACH gives its all to save the life of any child—whether he or she is Palestinian or Iraqi. and 50 visiting physicians have been trained under its auspices. 220 strong. The first mother to deliver there told the doctor. Christians. and her mother. It is also easy to forget that Israel is a nation of only 7. and stand in sharp contrast to the often politicized. These pictures concisely convey the humanitarian efforts of Israelis. is an Israel-based non-profit working to restore sight to hundreds throughout the developing world.000 to 250. SACH conducts training programs to foster more independent centers of competence in the developing world. that she would name her son Israel. contribute their time without receiving any payment from SACH. for younger children) to Israel for treatment. and vast security concerns. Eye From Zion. are from Iraq.and post-operatively at the nearby Children’s Home. it is easy to simplify the Israeli-Palestinian conflict and ignore the complex. SACH also runs teaching missions. One particularly touching story.16 Yuquing. detailed how a little Palestinian girl. Dr. is from the West Bank. and Muslims. Children are hosted pre. which emerged against the context of the war in Gaza. it remains the only democracy in the Middle East. is from China.000 lives. and Erica. I spent some time looking at the on-line photo gallery of children presently at the SACH Children’s Home either awaiting or recovering from heart surgery.18 In conclusion. A total of 14 such teaching missions have been conducted to date. SACH flies the child (and a family member. 20. sharing knowledge and expertise with colleagues in China. and beyond to evaluate potential patients with portable echocardiography technology and the cooperation of local cardiologists. managed to get out of Gaza and make it to the Wolfson Center for surgical correction of a debilitating patency between Noor’s right and left ventricles. makeshift hospital which could accommodate up to 500 people. onesided criticism of this small nation.2 million people. age 5.Danielle Masor: Medical Cooperation and the Israeli-Palestinian Conflict SACH medical personnel travel throughout the Middle East.19. Shir Dar.5 years. 9 months. subtle reality on the ground. including its chief surgeon. grinning to ear-to-ear. for instance. 13. Ethiopia. are from Ghana. all that mattered was saving Noor’s life. The eleven person medical team included Jews. It didn’t matter what was going on in the world outside. Daria is Romanian. and included an operating room for complex surgeries. What I find so uplifting about SACH is that it operates without regard to politics. and Aisha.20 Several Haitian children were born in the Israeli hospital. including Christian charities. and its remarkable 70person staff. to Haiti in the wake of the recent earthquake that claimed an estimated 200. Hezhan and Rezhna.17 The Midwives Coexistence Project is a group of Palestinian and Israeli midwives who work together toward peace to assist pregnant Israeli and Palestinian mothers with safe and natural births. Despite its small populace. Israel set up a huge. Salam.21 44 . it sent one of the biggest international aid teams. Kinsley. both smiling very broadly in their photos. with a landmass the size of New Jersey. is from Zanzibar. If it is decided that an operation is necessary.14 SACH is funded by private donors. of which Israeli-Palestinian medical involvement is but one dimension. not far from Tel Aviv. mostly with the relatively simple removal of cataracts. Israel. Moreover. Surgery is performed at the Wolfson Center in Holon. And despite its small size. 3. and Mauritania. Further research led me to similar ventures. Noor. Wafaa Huseini. org/ opinion/the-big-why [9] [10] The Peres Center For Peace http://www. http://www.saveachildsheart. Accessed 17 Jan. 2010.com/bps/additionalcontent/18/43444006/Trauma-the-unreported-casualty-of-war “Gaza Facts.nytimes. 2010.org/sip_storage/FILES/2/1832. http:// www. http://www.mfa. Jun.usnews.0.uk/2/hi/middle_east/7375439.” UNWatch. 2009. Accessed 18 Jan.jsessionid=0C33EA7110AA24035D01EFE52DD36DBF. 2009. 2009. Accessed 18 Jan.org. 2010.com/hasen/spages/1143165. 2010. 12 Jan.org/89-en/Sach. H.israel21c. http:// www.com/news/opinion/la-oe-dershowitz10-2009jan10. CNN. Accessed 15 Jan. 2010.il/GazaFacts Montaner.mobi/cnn/archive/archive/detail/432499/full/ frg.Danielle Masor: Medical Cooperation and the Israeli-Palestinian Conflict REFERENCES [1] [2] “Gaza Facts. Accessed 17 Jan..peres-center.” Israel21c. 19 Jan.” Israel21c. Israel Ministry of Foreign Affairs.html Bedein D. 2010.” saveachildsheart.com/video/2009/01/05/world/middleeast/1194837360056/facing-rocket-attacks-insouthern-israel.org. N.org/SectionProject. 2009. 2010.html Golan.com.mfa.israel21c.stm [12] Author’s Note: No current information found on Palestinian patients at Barzilai post Gaza operation. 16 Oct. Accessed 17 Jan. J. “Israel’s Dilemma Over Sick Gazans. http://www.aspx?pos=1 [17] “Israel’s Eye From Zion Restores Sight in Developing Countries. http://www.com/Video/playerIndex?id=9591907 45 . Besser Assists in Haitian Baby’s Birth. http://www. Accessed 18 Jan 2010. US News & World Report. “Israeli Team to Halt Haiti Search Efforts Monday.saveachildsheart.gov. “The Threat of the Human Shield Strategy Hamas Uses Extends Beyond Israel. 2010. 2010. 18 Jan.haaretz. July 2009. http://cnn.org/89-en/Sach. “Trauma: The Unreported Casualty of War.washingtonpost. 2010.live7i [21] “Dr. http:// abcnews.co. www. Accessed 17 Jan. 6 Jan.” Haaretz.org/social-action/giving-birth-to-peace [19] Mozgovaya. 2009. Gaza. A.com.2587090.org/265-2086-en/Sach.” The Israeli Ministry of Foreign Affairs.pdf [16] “Children Currently in Israel. 2010.saveachildsheart.gov.mfa.story http:// [3] [4] [5] [6] [7] [8] “UK Commander Challenges Goldstone Report. “Hamas’ War Crimes.unwatch.gov.” Reader’s Digest.org/site/apps/nlnet/content2.” BBC News.htm?DisplayMode=print [18] Stein. 17 Jan. “Gaza’s True Disproportion” Washington Post Global. 2004. E.” LA Times. “Slow Medical Care is One More Thing For Quake Victims to Survive. http://www. “Heart of Gold: Loving Hands Reach Out In the Nightmare of Mid-East Politics to Repair the Hearts of Dying Children.18 Jan 2010. http://www. Brackman. 10 Jan.html Dershowitz. “Giving Birth to Peace. 2008. 2009. 2010 http:// news.” Therapy Today.” ABC News.il/ GazaFacts “Facing Rocket Attacks in Southern Israel (Video)” NY Times Online. Accessed 18 Jan. 2010. 2010.saveachildsheart. Accessed 17 Jan.go.org Accessed 17 Jan.bbc.aspx [15] Dyson. “The Big Why. 2009. A. Accessed 12 Jan. http://newsweek. 2009. 2010. http://www. C. Accessed 17 Jan.org 19 Sept. [13] Save A Child’s Heart http://www. Accessed 18 Jan.html [20] Cohen. Accessed 17 Jan.com/articles/ opinion/2009/01/09/the-threat-of-the-human-shield-strategy-hamas-uses-extends-beyond-israel-gaza.aspx [14] Save A Child’s Heart http://www. Accessed 17 Jan. H.com/postglobal/carlos_alberto_montaner/2009/01/ gazas_true_disproportion. 5 Jan. 2010. http://video.latimes.” The Israeli Ministry of Foreign Affairs. R. http:// www.asp?cc=01140201 [11] Berg. 17 Nov. 30 Apr. T. 2010.britannica.il/MFA/Israel+beyond+politics/ Eye_from_Zion_restores_sight_developing_countries_17-Nov-2009.mlogic.aspx? c=bdKKISNqEmG&b=1313923&ct=7536409 Cooper. chasing after the bike. Sidewalks are not a luxury afforded to the poor. Its slowly leaking front tire is in need of a trip to the filling station. laughs from his perch on his bus’ window. You can be sure that not a single one of them would be caught dead in the street if they could afford anything with wheels. and making their way to work in upscale Kabulonga. the 55-pound bulk of my Atlas bicycle sits. Pulling into the filling station. but the paleness of my skin makes him falter. on a bicycle is an unusual sight around here. Both of the right wheels are small spare tires and the car leans perceptibly to the passenger side. “Hello! How are you?” A passing bus conductor. Each morning. gently decaying into the morning’s mud. Cresting the hill towards Kalingalinga. and the eyes that turn my way are a mixture of amusement and confusion. passing literally six inches from my elbow. screaming their only English at the top of their lungs. As I leave the filling station and enter Kalingalinga Compound. work harder. Few. this man goes to take the air hose. the Cape Dove chants. maids. and few of these Zambians would believe that I actually prefer riding my bike to driving to work. scattering women selling bananas. A white man. Yet the coffee soaks in. He yells something in Nyanja. a group of street kids run. 46 . Kabulonga is fully awake and scores of Zambians line the roadside. I wait by the air compressor as a taxi driver fills the tires of his robin-egg blue taxi. He looks uncomfortable as I reinflate my front tire. no indignation from the children. As I ease back the warped steel gate of our plot. of these pedestrians are coming from the homes along Kudu Road. the youngest of which is yanked backwards by the hand of an older sibling. but that’s where they’re headed. if any.Njinga Stuart Mackenzie It’s been getting darker each day I wake. just another close call on a Tuesday. Outside. and he brusquely takes the hose from me. When the opportunity presents itself. hoping for a lift from a passing vehicle or picking their way to work through the collected puddles. he brushes past a group of school children. the subdued quiet of home vanishes with the speeding black exhaust of a passing sedan. guards. a mzungu. its bearings creak with each revolution. As I urge my cheap. warding off the cold with bright pieces of chitenge. paying no attention to me or my bicycle. over-built Indian bike further down the road. and the growing stream of cars forces these unseen labourers further into the mud. nannies and garden boys leave the rambling shantytown compound of Mtendere. There’s no apology from the cyclist. and the dawn’s chill is no motivation to leave the house. A small grey hatchback roars through the parking lot.” and I know it’s time to leave. “Work harder. but it’s too fast for me to understand. a bike bell rings frantically and I look up from my bars to see a man speeding in the wrong direction. and it pulls up next to the taxi. Without swerving. and the driver has the air conditioning on. and I’m unable to tell if he just doesn’t understand me. or doesn’t care. although they’ll be back amongst the masses in just a few kilometres. the thinner the pedestrian traffic becomes. “Hospital. and vehicles. I am furious and I yell at the perspiring driver as I pass. and the potholes fade from the road surface. if only for the fifteen-minute commute. Across from the bus stop. Ten minutes later. an old woman with a hammer and rheumy eyes bears hazy witness to this chaos as she pounds fragments of granite into stone dust and gravel. Those drivers of second-hand Chinese cars. all the guards know who rides the big black Eagle. desperate to collect the money he’s owed. Undeterred. I was just here twenty minutes ago. I know there will be no children asking me how I am.Stuart Mackenzie: Njinga This stretch of road is what I love about starting each new day. The closer I get to work. The crowd of people. produce. I’m careful not to take too much liberty with these testy drivers. but this time. Weaving through the bus stop. I manage to straddle the divide. I am normally excluded from such everyday Zambian experiences. A big man in his Mercedes can’t consider slowing down for the teen chasing him. It’s not necessary to lock my bike. reminding them to stay off the dry road. 47 . It’s not hot. Another passenger crammed aboard the minibus jumps out off the shoulder. the driver steers his vehicle onto the rutted shoulder and bumps along past the jam. This scene is also a stark reminder of the gross gradations in lifestyles that its participants enjoy. He stares back blankly. the driver turns back towards the compounds and our first clinic. I’m in the passenger seat of a brand new Land Cruiser. As a white foreigner. I’m quickly forced back into the mud by the swerve of a minibus that sees a potential customer on the side of the road. honking incessantly at any pedestrian foolish enough to get in the way. and I dodge a weaving old man clutching his carton of maize beer. hospital!” are a heady reminder of the rich colour of Zambian life. he honks at a mother and child. but it is the realm of paperboys who chase the slow traffic with morning news. complete with swerving bicycles and the shouts of bus conductors. The last stretch to my office is the least developed of the route. Speeding through the potholes. Pulling out onto the road. the ones without a back window with the muffler held up by clothes hangers. and I run in for my notebooks. so we use it. and the conductors will mouth wordlessly as we pass. and the bus flies 100 meters down the road before jamming on its brakes at a backup. but we have air conditioning. but on a bicycle. A hollering conductor packs those who can spare a few cents into a crowded mini-bus. Coming too close to the refuse-choked ditch. will travel further this morning than the woman selling tomatoes will in a month. . .Katrina Bernardo If They Knew.. Ava Asher Man Huddled (Top) Man Leaning (Bottom) . which is the model for our presentations. David noticed an odd spot on his back. we spend most of our time as students reading textbooks and memorizing minutiae for exams. The cost of this is that we lose perspective and awareness of our ability to make a difference right now. I realized that these seemingly mundane and rehearsed acts do have the ability to make a remarkable difference in people's lives. We fight all sorts of ailments with interventions. With my organization. I guess mediocrity passes for excellence in some places. he reminded me how we had met. We manipulate the human body. but even more than that. There have been similar programs started in foreign countries to reach populations that are impoverished in HIV/AIDS education. These presentations had become mundane and rehearsed acts to an uneducated audience. and to provide markers for early detection in the general community as tools for prevention. I aim to dispel the misconceptions about cancer. and it fit the categorization of melanoma that we had taught. Medicine is a privileged profession. “How is that. the mole was starting to show signs of turning into an aggressive cancer. I was greeted with a familiar but awkward smile. but also consequently makes the job of the physician harder. Even our slightest intervention carries long term significance. the school principal asked us back to present again because the school was so impressed by our work and the impact that it left on the students. “Yes. He saw a dermatologist. but we minimize the importance of prevention through education. How are you?” Without further guesswork. of course. In medical school. After our presentation. and in our best attempts. As we talked further. To our surprise. and I recalled his name. one that I hope to accomplish within the next few years at NYMC. We join the field of medicine because we believe in its ability to cure. An article published by Mukoma et al. and he was told that he was lucky to have come in when he did. “Process evaluation of a school-based HIV/AIDS interven50 . but unfortunately it kills all its pupils. I do. having no idea who he was. “You know you saved my life right?” I replied amusingly. along with the impact we'll make in the future.Cancer Education And Awareness Program: Education And Its Role In The Prevention Of Cancer Sukhpreet Singh "Time is a great teacher. It is this lack of understanding that not only causes an increase in morbidity and mortality. Based on pathology reports. we forget the most amazing skill we have – to prevent disease before it afflicts our patients. David?” After I had given my presentation the year before. This galvanized my efforts of cancer prevention education. I was here last year to do a presentation on preventing skin cancer. we cure our patients. These programs found great success because they were able to approach their subjects through a story telling method." -. Cancer has been stigmatized over the years by most as an unpreventable death sentence. It was with that same philosophy that I started the Cancer Education and Awareness Program (CEAP) last year on campus. to prevent disease. he said. David. “Hey. we alleviate human suffering. do you remember me?” I replied. However. It is due to these reasons that we as physicians also have a significant roles as educators. Even at our worst. This reflects a lack of knowledge of behavioral contributions to cancer. I had a vision. a high school auditorium filled with restless and inattentive teens.Hector Berlioz I remember this place. we will make a difference without fail. Schaalma. I will have realized my greatest accomplishment if I have been able to reach out to another David. S.. Suppl 2: 37-47. That is one of our goals. I also intend on making CEAP an independent non-profit organization that will be incorporated into other graduate schools in the area. we aim to provide a curriculum for other cancers beyond our current lung cancer presentation. A. Scand J Public Health. (2009): Process evaluation of a school-based HIV/AIDS intervention in South Africa. Jansen. we intend to incorporate a curriculum for skin cancer as well. [2] McLafferty S. C. I wanted it to not only incorporate a story telling approach. nearly half my intended goal for the entire year. As we continue to expand on the NYMC campus as a student club in the upcoming years. McLafferty et al.. in this case to prolong life. found that urban dwellers are more prone to cancers due to smoking. and according to the American Lung Association.I. Cancer. the passage of time is a great teacher with its undeniable consequence – death. It is with all of their help that we have taught nearly 800 students this year. including their successes and failures. June 15. We knew we would not be able to launch this off the ground until we had other people sharing our vision. N. but to teach from the mistakes of others to allow them to live more fruitful lives.J. the average age of onset of smoking amongst teenagers is 13 years old. Our greatest strength is in our numbers. That is why we must take on the roles of teachers and educate others before time does it for us. 37. June. Klepp.. we bear the responsibility to not let our patients learn through time and to make their own mistakes. disadvantaged. Wang F. It is through these students that we reach their families and friends. This age group is easily accessible through high schools. no programs in the United States have been able to reach an appreciable scale to do a publishable study... Wu. rural or urban. W.2 It is nonetheless important to be able to disseminate information to every part of the population. At the end of this year. but to be able to address a much broader population.. (2009): Rural reversal? Rural-urban disparities in late-stage cancer risk in Illinois.Sukhpreet Singh: Cancer Education and Awareness Program tion in South Africa” outlines the specifics of their processes. and the shared vision of my fellow classmates. we sought support amongst the faculty and students. advantaged. As long as we continue to believe that we have the ability to change the course of events by our own interventions. As physicians. thus. Unfortunately. Flisher. To recapitulate the words of Berlioz. We want to be able to show that we are able to reach not only the students in our demographic. Mathews. REFERENCES [1] Mukoma. We aim to provide a comprehensible and scientific PowerPoint presentation to kids between the ages of 14-18. 51 .1 When designing our program. H. but also their parents by emphasizing the need for them to share this information. The success of the project owes itself to the support from faculty members. such as Dr. the real numbers are forever growing as information always disseminates. In his study of rural smokers of Illinois and populations of urban cities. K. After we had defined our objectives and outlined a clear mission statement.. 115(12): 2755-64. Ahmed. Anna Djougarian Transformation of the Medical Student . protein transporters home as pigeons to their nests.Life Fuel Alanna Chait We are a people of loss. fluid evaporates as quickly as these words. liver cells replace defeated neighbors. Within loss. disoriented immune systems cloud illusion and reality. Undying receptors cling like desperate lovers. We are a people of replenishment. leaky membranes displace ions like Adam from the garden. despair breeds strength and conviction. zymogens save us from ourselves. We are a people of loss. bodies dwindle with each cut. We are a people of replenishment. souls emerge from finely sculpted blastulas. ATP pumps birth energy and motion. bone springs from primordial roots. arteries and ardor retreat with each battle. birth. Umbilical cords sever like freshly cut grass. hemorrhages pilfer life fuel. vessels vitalize broken hearts. within death. hemosiderin-laden ecchymoses burst like fallen sunsets. gain. neoplasias obliterate self. 53 . enlightening the mind And once again back to the earth It only lasts for so long. and your heart and soul you shall ignore For they are not important. if we’d hold onto that spark Allow it to set in. before we are ready to leave Sadly though. one we tend to eschew Like a wave in the ocean. before it leaves us again Like a quick lightning strike. of our kindly physical being that we own Ignore the open passageways. which permit us to look to the unknown Search for your body. and “hear” that which is not heard if we grasp it so tight Amazing how the effect of one moment. before we run out of time We could conquer this world. and it will not ever be planned 54 . we run from this moment. in our flashy. tend to close it out of our minds But we fail to realize. so they you will deplore So recognize the following. it’s a fact and it is true That a free gift such as this is one taken for granted. lighten our minds. as a tool for the common man It will come upon you at some time. hitting the spot. fleeting minds For if it would last a moment longer. we only get such an opportunity so often. it comes and goes Where it will take us.For Only A Moment Daniel Waintraub Inspiration seems to only last a moment As if that’s all it’s worth Striking a chord. from any moment of thought For he fears any sort of change. like an effective potion However. and this is what he has been taught That this world is for the benefit. which we all fail to perceive Those which are important or significant. only g-d really knows It may spur us into a mental frenzy of motion Lifting us to elated heights for a moment. and eventually drag us out from the dark We could finally “see” that which is not seen. or an uniquely caring friend Time and time again we encounter this “being” This thing they call inspiration. which allows us to “see” It’s too bad it only settles for a second. could grant one the gift of “sight” But man is prone to escaping. it would be a moment longer to find… Some of those elements of life. that sudden enlightenment which we feel And only if we hold onto it. whichever one that may be But if you don’t hold on to that moment. that next page. you’ll never see Whatever it might be. CA 55 . is something we all have done We’ll continue to believe we have everything. pushing you to finally turn the page To the next chapter of life.Daniel Waintraub: For Only A Moment A spark of inspiration. and use it. that could cause such a flare in the mind Don’t neglect this sudden feeling. like that thing we call…thought Linda DeMello Skull Rock Joshua Tree National Park Twentynine Palms. don’t let it go for naught For it might lead to something special. when really all we have is…none It can only be to one’s avail. for the lost souls of our age A spark of inspiration. for you don’t know what you may find Failing to retain inspiration. the next time that you feel it. will we be able to unveil that which is real So. So easy. coming home covered in an odor. 56 . pungent in the way only sterility can be. ugly cousin of the man named malpractice. hunched over and lonely. looking for the selfless few. Then I return to you. Now. rediscover simplicities. and it all changed. anything really. as I entertained forged synapses. me and a malbec drift away. Passed out. shot. reaping the spoils others avoid. while listening to you whine. a couch and a convo. scarecrow. another thing I learned not to share with reality. Troubled. met a socialite threshold.Resident Navid Shams Reminiscent. habits developed die hard. Wide-eyed. wondering about what could have been. we all open up. dental school. hopefully soon. then they arrived by email. black out. surely that was the way it wasn’t going to be. Those early days. The multiple stresses of a traditional approach. cubbied. So hopeful for a few days. escaping to tv and lethargy. shot. I close my eyes and think about us and our first years in the field of medicine. just to stare down a microscope. Dates. probably tomorrow. that sacred defender of its solidarity. A sacrificed anatomy but at least you made the mark. agitated and in need of advice. burning diesel. Test and toast. Either way I’m happy. Unlike memories. like the only crow hidden in your shade. all electric. You. A slave now and when will I hear that canary sing? Maybe never. perfection is joy.Medamorphosis Andrei Kreutzberg Some call it a prison A locked in boxed in metal edge razor Cortisol crazy. fast paced. Perfection is beauty. Giving up moon dreams and settling for safe ground But charity knows not mediocrity. Only perfection can halt the millstone The mirror must shatter Striving-stomping-screaming. endurable The chalice of knowledge blisters and purifies What a beautiful metamorphosis: Earning each angel feather one wrong answer at a time 57 . Suffering one more day for mysterious reasons Sacrifice! sacrifice! Youth gives way to hunchback isolation and paper cuts The soul cries out for pleasure and repose But the narcissist longs for perfection. relentless and furious Balancing on the edge of a knife from oblivion Wishing-hoping-pleading. a cocoon! A soul forged. trial by fire frenzy A dark burning chrysalis: god spun. hope inspired. A prison? Nay. He gently rests his head on his hand using the remaining energy he had to exert. he finds. He looks at it curiously without feeling a need to be alarmed. As he searches for a sign of meaning. building small mounds of a castle along where his shovel and pail lay. He suddenly felt his hand covered by another of younger years. Just as abruptly as this blob came. A dark dismal gloom ensues making him wonder where he has faltered. The child wonders what is of such a thing that is not so easy to mold. his color starts to wane. filled with light He looked at them with wonder. he continues to watch. The splotch that moved slowly to his hand causes him a new sensation of discomfort. The sun is not bright. 58 . With his mother watching fondly as the child giggles with pleasure. while the boy shed almost all his tears. leaving nothing more than this blob. Thinking all that was good has left. Smaller eyes looked up at him curiously. A sudden splash of something lands on his arm. The boy cries and sobs. He plays in the sun without concern or care. small drops evade the elastic splotch.Vitality Poonam Kaushal He plays in the sun-sparkled sandbox each day. With great resistance. sticking to the oozing splotch. a hair tuft. His mother leisurely watches not realizing an unseen danger lurks somewhere. the clouds have it covered. And after finally pulling free. it drips and oozes without letting go of its hold. He turns toward his mother who covers her face as she sobs in pain. She looks at her son with ardor not made to measure. He tugs and pulls and feels a little stuck. From its globular being. Landing swiftly onto his delicate calf. forgetting momentarily about his plight. He doesn’t feel any different but suddenly becomes fatigued and lazy The oozing moving slowly down his arm starts to make him feel queasy. but a younger child reminding him that his own vitality will help him go the length. and to those with cancer who help other children newly diagnosed with cancer each day. Luke Selby Spring Break at Night 59 . she held up his shovel and pail And as his eyes gazed over the baby he saw a tuft of hair no longer there. It was not his mother’s worry or oncologist’s medicine that gave him strength. that the despair and gloom that burdened was replaced by the light from her eyes filled with awe. Confused and bewildered he sat and saw. 2010. World Cancer Day is on February 4th.Poonam Kaushal: Vitality Smiling happily. A tribute to all of the children with cancer. His hand holding mine Our eyes meet with a glow. They funnel out in a line But one hesitates to leave. And for a second I remember Life. about my days of glory. Distant stares and scribbled notes Tell me more than they know. In their haste to save time I am left wanting more. Here comes the team Without a knock on the door.The Shell Jordan Roth Here it is another day In the land where doctors roam. 60 . About when I ran. The light filters in through the window And with it a smile greets me. I hear my case retold each day But none of them knows my story. and laughed and played Lived and led. I wish I could tell them what I’ve learned about life And what’s most important at the end of this road. Trapped in this crumbling shell Their words are more direct. love. He best keep on moving or He is sure to face reprieve. Perhaps for just this moment in time This place feels like home. humanity. I’m in search of peace more than answers Because it’s been so long since I felt at home. No real connection I have come to expect. adults chatting and children laughing. Her eyes filled.” My God. She climbed the stairs and finally entered into the bright décor of the children’s unit. When she finally arrived. and princesses in pretty dresses. Siblings chased each other as the staff dodged them. sending out a cacophony of noise that had kept her up many nights. Her hands began to shake.It’s Gonna Be All Right Linda DeMello She lost her job. And all Marie could think of was how his future had disappeared before her eyes. “We’ll compensate you for the rest of the month. He wore his favorite pajamas. After ten years. She clenched them into fists. they told Marie they had to let her go. And now she had failed her son. Christmas decorations covered the hallways. Drawings hung in picture frames – ferocious tigers. yanking them hard. What was she going to do now? The hospital’s sterile staircase ascended above her. fire-breathing dragons. grinning in delight. Especially now that there was nothing more she could do for the most precious person in her life. especially now that she had nothing left to give. to stop proving that she was weak and helpless. but no matter what she did. 61 . She held on to the cold railing so tightly that her knuckles were white. Machines surrounded him. recognizing that something was wrong. Conversation was abound. ignoring the greetings and the smiles. Forcing herself onward. The snake of dread constricted Marie’s throat as tears burned the back of her eyes. Joey looked up at her and his face lit like a ray of sunshine. Her husband died two years ago in a construction accident. she opened the door to her five-year-old son’s room. their jovial faces faltered. As doctors and nurses passed her. He sat there. Everything was falling apart. She wanted them to stop looking at her. leaving her a mourning single mother of one. for she had arrived earlier than usual. Panic clutched the strings of her heart. leading to the gray door of the third floor. wearing a Santa hat and playing with a fire truck. She tried her best. and she lifted her head up in a vain attempt to prevent them from spilling. We’re really sorry. He wanted to be a fireman when he grew up. feeling like a black shadow amidst the vibrant energy. lights glowing and tinsel glittering as “Frosty the Snowman” hummed through the air.” they said. She plowed onward towards room 309. she winded through the lively hallways. the ones with fire trucks all over them. a beacon of light in the dark. fate continued to mercilessly shove her down onto her knees. “The economy is bad. “Mommy!” Joey exclaimed. and he wrapped his frail arms around her. and for losing the battle against his cancer. his fragile face filled with happiness. “Here. nothing. “I’m sorry. trembling. his beautiful dark eyes filled with sympathy. I’m here. regretting that she hadn’t picked up a gift for him. she couldn’t fool him. baby. for losing all hope of continued treatment. mommy. Mommy is just being a silly girl. apologizing for losing her job. “It’s gonna be all right. showing her courage and strength beyond anything she could imagine. even if it was just a Hershey’s bar.” Joey stood up. She moved over to his bedside. “I’m so sorry. crumbling apart at the sight of his favorite toy in her hand.” Her walls came crashing down. It’s gonna be all right. what’s wrong?” She shook her head.” 62 . It’ll make you feel better. mommy. “You’re here!” “Yes. managing a smile through the blur of misery.” Her voice cracked and she loathed the sound.” she murmured hoarsely. He lifted the fire truck and placed it in her hands.Linda DeMello: It’s Gonna Be All Right chased away like chalk paintings in the rain. “Mommy. you can have my truck. wobbly on his feet.” He didn’t believe her. Like any child who knew far more than he should. “Oh. honey. Joey’s smile faded when he noticed her tears. Radeeb Akhtar Untitled Nude . 2 Conventional diabetes management involves a patient diagnosed with type 2 diabetes mellitus seeing a physician in an outpatient setting for monitoring.5 to 8. monitoring. clinicians have the opportunity to monitor the daily glycemic status of patients without having to see the patient in clinic. The use of telemedicine to assist residents of East Harlem with controlling their blood glucose levels can function in meeting the two main goals of Healthy People 2010: increase the quality and years of healthy life and to eliminate healthcare disparities. M.3 to 206.3 A previous study on Army diabetics has indicated that telemedicine leads to better glycemic control and fewer complications than conventional treatment in controlling diabetes. NY. These glucometers transmit the patient’s daily blood glucose measurements back to the hospital and alert the medical staff to any needed changes in the treatment regimen.2%) and a 4% mean weight reduction (from 214.Telemedicine Management of Diabetics in an Underserved Community J. and therapeutic purposes to communicate information instantaneously from one location to another.D.1Telemedicine is the use of telecommunications technology for medical diagnostic. and meeting with a diabetes educator who recommends lifestyle and dietary changes. The New York City Health and Hospitals Corporation’s (NYC HCC) Housecalls program supplements conventional diabetes management by providing free tele-glucometers to patients diagnosed with type 2 diabetes mellitus. Methods The patients analyzed were NYC HCC patients that were newly diagnosed with type 2 dia64 . such as from a patients’ home to a hospital. Introduction Information technology via telemedicine offers the potential for cost-effective and active management of type 2 diabetes mellitus for people in high-risk underserved communities such as Harlem. Paul Nielsen and Pranav Mehta. Utilizing only an existing phone line and a “tele-glucometer” rigged to plug into a phone line. Adults with type 2 diabetes mellitus have heart disease death rates about 2 to 4 times higher than adults without diabetes.4 Using a home telemedicine system to deliver care to patients with type II diabetes resulted in a 16% reduction in Hemoglobin A1C levels (from 9. the physician may recommend pharmacological interventions such as treatment with metformin or another medication to increase insulin sensitivity and secretion.7 pounds) during a 3-month period of monitoring. and the risk for stroke is 2 to 4 times higher among people with diabetes. NY and the Bronx. If these lifestyle interventions are not adequate to bring the blood glucose levels under control.4 Our study aims to quantify the improvement experienced by NYC HCC diabetics treated at placed on the Housecalls telemedicine monitoring program and compares them to NYC HCC patients treated via the conventional approach of medication and lifestyle recommendations combined with regularly scheduled outpatient medical visits. M.J. We compared the baseline Hemoglobin A1C levels to the levels recorded after the patient was enrolled in Housecalls for at least 3 months. 65 . 19 of 22 (86%) had a decrease in HbA1c. Results The initial results indicate that the Housecalls program is effective in improving compliance and management of diabetes. while the remaining 3 patients had no change in HbA1c. and telemedicine offers a cheap and effective solution to reduce such losses. The costs of providing the tele-glucometer would be largely offset by the reduced expenses of treating diabetes complications if this method is indeed effective in improving long term glycemic status. Hemoglobin A1C levels from before the patient was enrolled in the Housecalls program served as baseline reference values. One of the largest problems in providing care to patients of underserved areas is loss to follow up. Paul Nielsen and Pranav Mehta. Discussion The initial success of the program is encouraging and demonstrates a great potential for the use of telemedicine in monitoring chronic disease.D.: Telemedicine Management of Diabetics betes mellitus. The initial results are encouraging and certainly warrant more detailed and in-depth analysis of this simple tool. Of the patients with an HbA1c level measured within 3 months of start of program and 3 months after enrollment. Hemoglobin A1C serves as a stable mean value of a patient’s constantly changing blood glucose levels averaged over a multi-week period. 2004. 1999. “USAID/India Strategic Objective Close out Report. Bos ER. British Medical Journal. “Innovations at Work: Reaching Out with RCH Services. American Journal of Public Health and the Nation’s Health. 2000. Osrin D and Manandhar D. [7] Costello A. Mawji T and Pathmanathan I. 2007.: Telemedicine Management of Diabetics REFERENCES [1] “Improving Reproductive Health. Accessed 1 Mar. http://www. http://journal.htm [2] Johri A.” United Nations Population Fund. Accessed 28 Jan. 2007.” State Innovations in Family Planning Services Project Agency. http:// www. 2007. “Healthcare Delivery Systems in Rural India: Meeting the Changing Needs of Rural Populations. http://www. Reducing Child Mortality in India in the New Millennium.edu/articles/ healthcare-delivery-systems-rural-india [6] Rosa FW. Paul Nielsen and Pranav Mehta. 2006. [4] Tewari J. 66 . Impact of New Family Planning Approaches on Rural Maternal and Child Health Coverage in Developing Countries: India's Example.cmu.pdf [5] Gudipati D. Accessed 2 Feb. M. Accessed 1 Mar.” Carnegie Mellon Heinz School Review.oecd. 2007.com/pubs/ countryreports/INDinnov. 329: 1166-1168. Reducing Maternal and Neonatal Mortality in the Poorest Communities. 2006. Uttar Pradesh. 2005.heinz. 57[8]: 1327-1332.org/rh/index.D.pdf [3] Claeson M. 78: 1192-1199.J. 1967.” Organization for Economic Co-operation and Development.org/dataoecd/55/14/36104395.unfpa.policyproject. Bulletin of the World Health Organization. Knowing the functional details of these interactions could lead to clues for therapeutic targeting. null function or increased production of any of these proteins may lead to unregulated cellular processes and possibly to tumorigenesis. a Ring finger protein.1 All cullins require an attachment of the ubiquitin homologue neural-precursor-cellexpressed and developmentally down regulated 8 (Nedd8) at a specific lysine residue near its C terminal end to activate its ubiquitin ligase function. E3. E3 ligases include cullin-based ubiquitin ligases.5 Neddylation results in mononeddylation of cullin substrates. which controls cyclins.3 Neddylation of cullins is critical to cullin function and is required to facilitate processive transfer of ubiquitin from E2 to E3 to the target protein. where it is degraded. Ubiquitination activities of cullin-RING ligases (CRLs) require neddylation to control their E3 ligase activity. linking the carboxyl-end of Nedd8 Gly-76 to the e-amino group of a conserved cullin lysine residue.1 The process is completed by the formation of an isopeptide bond. Because these components in the cell cycle (E1.) are essential in controlling proteolysis.Can Cycles of Neddylation and Deneddylation Provide Points for Possible Therapeutic Intervention? Nadia Nocera Introduction The process of ubiquitination serves as an important signaling mechanism in many biological processes such as protein trafficking.1 Neddylation occurs through the action of a neddylation cascade similar to that used in the ubiquitin system. Cullin3 (Cul3) forms a complex. Cullins. The Cullin-Roc1 complex comprises the core module of a series of ubiquitin E3 ligases. in which the cullin acts as a scaffold for the assembly of a multisubunit ubiquitin ligase complex that contains a RING-box protein and a cullin-specific substrate adaptor protein. What is Nedd8 and what is its function? Cullin family proteins organize ubiquitin ligase (E3) complexes to target numerous cellular proteins. transcription factors. Cul4A. etc. Nedd8. protein-protein interactions and proteolysis. DNA repair. Studies focusing on the relationship between neddylation and E3 ligase func67 .1 Ubiquitin is a small polypeptide that is covalently linked to the lysine residue of target proteins by a multienzymatic system consisting of E1 (ubiquitin-activating). 81. E2 (ubiquitinconjugating). Cullins directly interact with Roc1. it is targeted to the proteosome. The first step in neddylation is the formation of a thiol-ester bond via the C-terminal glycine residue of Nedd8 with APP-BP1/Uba3. such as those involved in cell proliferation and proteasomal degradation. and Cul5. have been shown to be modified by Nedd8 (a ubiquitin-like protein) in mammalian cells. Cul2. Cul3. After protein is tagged with ubiquitin. E2. a heterodimeric E1activating enzyme. Cul1. which confer substrate specificity and therefore regulate the degradation process.2 Cullin family proteins. and cellular pathways.residue protein that is attached to cullins by a process termed neddylation. and E3 (ubiquitin-ligating) enzymes.4 Nedd8 is a highly conserved. Cul4B. by promoting cell death or cell cycle arrest in excessively proliferating cells. because of the requirement that cullins undergo deneddylation in addition to neddylation. The depletion was primarily due to the absence of unneddylated Cul1 and Cul3. blocking this process may provide some real therapeutic benefit in cancer patients. it is not yet clear what the mechanism of Nedd8 action is. as shown in Western blots with lysates prepared from CSN-null larvae and CSN double-stranded RNA (dsRNA) treated S2 cells.9 CSN inhibits ligase activity and negatively regulates the cell cycle by promoting deneddylation of cullins. Neddylation and deneddylation provide means to maintain homeostasis It has been found that deneddylation by CSN protects cullins from degradation and that Nedd8-conjugated cullins are unstable and depleted in vivo. the regulation of DNA repair. The regulation of Cul1 and Cul3 by neddylation and deneddylation was examined by generating CSN-null mutants of D. It therefore appears that neddylation and deneddylation provide a means to maintain normal cellular levels of activated CRLs and prevent excessive ubiquitin ligase activity. Specifically. yeast mating pathways.8 Although this study showed that neddylated cullins were degraded in the absence of CSN. If research reveals this to be the case. the inhibition of cullin deneddylation through small molecule inhibitors would be expected to lead to defects in the cell’s ability to ubiquitinate numerous cullin-based E3 targets—ultimately leading to defects in cell proliferation. unless the conjugated Nedd8 is removed by CSN. melanogaster. and the cullin substrates themselves. 68 . blocking Nedd8 removal could severely interfere with cell viability. a study conducted by Huang and colleagues11 found a unique N-terminal sequence on the E2 protein that helps form a complex to stabilize E1 and Nedd8. melanogaster. and cell cycle regulation. A different demonstrated that although the CSN complex was inactivated. 7 suggest that Nedd8 plays a direct role in the activation of the E3 ligase function in ubiquitination. signal transduction.8 Although the significance of Nedd8 in cullin complex activation has been established.7 Further research is required to elucidate the role of cullins. Inactivation of the CRL ligase activity requires the COP9 signalosome (CSN) that removes Nedd8 from cullins. Cul1 was found to accumulate in D.8 This suggests the efficient degradation of neddylated cullins. as compared to normally proliferating cells. E2 and Nedd8 form a complex Recently. the protective role of CSN remains debated. In this complex. with the Nedd8-null allele present in the eye and wing discs—indicating that Nedd8 may have a role in down regulating the levels of Cul1 and Cul3 proteins. Furthermore. E1. a process called deneddylation.8 Neddylation and deneddylation may provide points for therapy Because of the apparent role of neddylation in the function of cullin. increased.8 CSN has been implicated in a wide range of biological processes including plant photomorphogenesis. it remains to be determined whether cancer cells have a greater rate of deneddylation.10 However. both the percentage of neddylated cullins in cells.Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? tion6.8 Cul1 and Cul3 were found to be depleted. there could be a therapeutic window for small molecule inhibitors of the CSN protease. Of interest. and the E1 groove within which it fits. the more resistant a cell is to death.11 A network of charged and polar side-chains contacts E1’s catalytic cysteine and Nedd8’s C terminus. as well as whether the neddylation of BCA3 is required for its transcriptional inhibitory activity. Scientists now know the exact shape and function of the E2 tail. transferring the protein to E2. BCA3 is localized within the nucleus. Mutational analyses showed that these residues contribute to E1. The discovery of this unique E2 tail is very intriguing for researchers because it may provide one way to target the process of neddylation in cancer treatment. In the cell. which cradles ATP. E1 activates Nedd8 through adenylation and forms a bond with Nedd8.13 BCA3 was tagged and was found to be modified by Nedd8.13 A yeast two-hybrid screen was performed in a human placental cDNA library using SENP8 (a Nedd8-specific protease) as bait—an interacting plasmid encoding BCA3 was identified.12 Research reveals a new substrate for Nedd8 Although it is known that neddylation plays an important role in ubiquitin-mediated proteolysis by modification of cullins. it can act as a tumor suppressor when modified by Nedd8. and E2 substrates together.15 In the study focusing on the neddylation of breast cancer associated protein. with the exception of a BCA3 mutant in which all 11 lysine residues had been replaced. It thus appears that neddylation may occur through Nedd8’s association with eleven lysine residues on BCA3 because when these residues were replaced by arginine.11 It was also demonstrated that deleting the tail from E2 significantly hinders the ability of E2 to transfer Nedd8 to E3.12 Therefore. thereby decreasing the transfer of Nedd8 to Cul1. investigators examined whether BCA3 could act as a transcription regulator of NFkB. a non-cullin protein. while in two other mutants contained ten lysine replacements. E2 and Nedd8 complex formation. the groove. several lysine residues on BCA3 were “mutated”.13 BCA3 has recently been found to be over-expressed in both breast and prostate cancers. which joins Nedd8 with Cul1. E2 then transfers Nedd8 to E3. Novel drugs that are designed to disrupt the tail.14 NFkB is a family of proteins that turn on genes involved in apoptosis and cell proliferation. it was found that BCA3 (breast cancer associated protein 3). with its C terminus tethered within a channel focused on the thioester bond. so the more NFkB that is expressed. it was found that cullins are not the only substrates targeted for Nedd8 modification.13 To investigate this. In a study focusing on the neddylation of a breast cancer associated protein. researchers found that each of these mutants inhibited NFkB activation. whereby they were replaced with an arginine. NEDD8 is in the center of the complex. is also a Nedd8 substrate. The 69 . When NFkB is over expressed. molecules of Nedd8. a decrease in the transfer of Nedd8 to Cul1 would lead to increased stability and negative regulation of the cell cycle. One mutant had a single lysine mutated. It has been reported to be a Kyo-T2 binding protein. or both might block the ability of the Nedd8 pathway to accelerate the replication of cancer cells.Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? three E1 domains pack to generate a large central groove. it can protect cells from undergoing apoptosis. which was shown to regulate the DNA binding protein Recombination Signal Binding Protein-Jk (RBPJk) and to participate in transcription regulation of NFkB (nuclear factor kappa B). neddylation did not occur. Although BCA3 does not have an inherent relationship to cancer. . K. Nedd8 modification of cul-1 activates SCF((TrCP))-dependent ubiquitination of IB. pp. M. and Pan. Moreland. or alternatively. Saeki. Nedd8 recruits E2 Ubiquitin to SCF E3 ligase.. in order to regulate NFkB. K. Kaelin. Harper. Kawashima. J.. K. M.D.13 The same study revealed that BCA3 binds to p65. one of the two proteins that make up NFkB... H. Dias.. D. Z. Lane. REFERENCES [1] [2] Wimuttisuk.. Tanaka. N. A.13 Interfering with this pathway may provide a possible way to diminish the number of factors that promote tumorigenesis. R. subsequently allowing cullins to control the cell cycle via the ubiquitination of cellular proteins involved in cell proliferation. Nedd8 on cullin: building an expressway to protein destruction. a component of the VHL tumor suppressor complex and SCF ubiquitin ligase. 2007 Kamura. the inactivation of cullins is achieved by deneddylation through the COP9 signalosome.. Neddylation of cullins activates their ubiquitin ligase activity. Singer. Kentsis. K. Chen. F. Mol. there would be a decrease in NFkB.Q. 1999. T. Conjugation of Nedd8 to CUL1 enhances the ability of the ROC1-CUL1 complex to promote ubiquitin polymerization.Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? latter mutant was also unable to undergo neddylation.. Wu. Cell. 2326í2333... 4003-5012. 1998. et al. Z. 2004 Read. S. S. Science 284: 657-661. 2000 Pan. G. 275 41.. 32317–32324.. D.. Conclusion Through their control of cullins..A. Because of Nedd8’s critical roles in the cell cycle and modification of tumor suppressor genes. Osaka. In contrast.. cycles of neddylation and deneddylation have proven to be important processes in the cell cycle.. J. EMBO J 20. When Nedd8 is removed from BCA3. demonstrating that BCA3 must be neddylated to inhibit NFkB activation. Biol. Chem. C. researchers may soon be able to design drugs that block the removal of Nedd8 from BCA3. Biol. W. Cell 18. Kato. Kawasaki. With further study. M. Genes Dev. Elledge. Rbx1. 1985í1997.Q. found to be a tumor suppressor when modified by Nedd8. Aida.13 The aforementioned study describes a cancer-promoting (or demoting) pathway... Nedd8-modified BCA3 binds to p65 and recruits a histone deacetylase (SITR1) to suppress NFkB-mediated transcription. Wu. et al. resulting in resistance to apoptosis and excessive cell proliferation. 2001 Wu et al. W. 20. R. Decreasing NFkB would render cancer cells less resistant to chemotherapy and more able to undergo apoptosis.. Skowyra. The Cullin3 ubiquitin ligase functions as a Nedd8-bound heterodimer.C. J. J. Another substrate for Nedd8 is the BCA3 protein. Chiba. S. Neddylation and deneddylation regulate Cul1 and Cul3 protein accumulation Nature Cell Biology 7. N. Conaway. 12: 2263-2268. Therefore. Jr. W. W. Koepp. O.1020 2005 70 [3] [4] [5] [6] [7] [8] . W. 1014 . A. By increasing the amount of Nedd8-modified BCA3. 2000 Kawakami. T. 899–909.. A new NEDD8-ligating system for cullin-4A... J. D. developing a way to control cycles of neddylation and deneddylation could prove to be an effective cancer therapy. T. oncogenes are no longer suppressed. Yamoah. S. Iliopoulos. M. Conaway... promote the addition of Nedd8 to BCA3. J. Conrad. Mol.. Biol. Oncogene 23. Nature Cell Biology . 2008 [10] Nalepa. T. Schulman BA: Basis for a ubiquitin-like protein thioester switch toggling E1–E2 affinity. 445(7126):394-398. 10.cfm?id=6C70D16C-C98D-43429AE00B3BF82715AD&method=displayFull&pn=00c8a30f-c468-11d4-80fb00508b603a14 71 . 2007 [12] Structural Insights for Therapeutic Targeting of an E2 Function and Neddylation in Proliferation Control. G.T. http://www. 24359–24370. 3:7 doi:10. J. New Path from Estrogen to Survival in Breast Cancer Cells Described. J. 1171 – 1177. Basal expression of IB is controlled by the mammalian transcriptional repressor RBP-J (CBF1) and its activator Notch1. Harper. Supplement 1.mdanderson. Cell Division. R.1186/1747-1028-3-7. Nature. Chem. H. T. Therapeutic anti-cancer targets upstream of the proteasome. Kipreos. Cancer Treatment Reviews. Pages 49-57.. 2006 [14] Oakley.8. Cullin-RING ubiquitin ligases: global regulation and activation cycles. Cancer Biology and Therapy. Hunt HW. et al.Nadia Nocera: Cycles of Neddylation and Deneddylation As Possible Therapeutic Intervention? [9] Bosu. E.org/departments/newsroom/display. Yeh E. Zhuang M.. F. 924-925. J. Ohi MD. May 2003 [11] Huang DT. Volume 29. Shi. 278. D. 2003 [15] MD Anderson Cancer Center News Release. Biol. 2004 [13] Gao.F.. Cheng. Holton JM. Neddylation of a breast cancer-associated protein recruits a class III histone deacetylase that represses NFB-dependent transcription. Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female Lea Alfi Symptoms “I feel so bloated.” The 67-year-old female could feel herself getting hot as she tried to maneuver herself into an upright position. She had gone through this 3 months prior, and wondered why it was happening to her again. Her abdomen was now completely distended. She explained that her ascites had been drained 3 months ago, and she promised that she had been sober. Exasperated, she brought herself to her feet. She had no one in the room with her, and looked apologetic as her eyes scanned the room, eventually resting on a distant roof garden. As her eyes fell to her legs, she explained how they had gradually ballooned over the past 12 weeks, despite her use of diuretics. With the swelling methodically moving up from her feet to her thighs, her slender frame was now completely hidden. She was exhausted; she said she had never felt so tired in her life. She could not get up quickly enough to reach the restroom, and the uneasy decision was made to place a Foley catheter. She looked down over her belly, unable even to see her feet, bewildered by her own condition. Investigation My resident assigned me this patient, emphasizing that it would be a great way to cement my understanding of hepatic pathophysiology, a textbook case of cirrhosis. My patient was a 67-year old female with a past medical history including cervical cancer (status post radiation) 15 years prior, with a resultant rectovaginal fistula, and a 40-year history of alcohol dependence. She was single, and gravida 0. She was a non-smoker, and denied any IV drug use in the past. Her labs revealed a normocytic anemia; she had started folate and multivitamins during her last admission. This explained some of her fatigue, but was there some underlying chronic disease? The private attending following her planned a bone marrow biopsy. The medicine team did not work up the anemia right away, instead focusing their attention on the worsening ascites and lower extremity edema. Records from the patient’s last hospitalization included a CT scan demonstrating a cirrhotic liver. No liver biopsy had been performed. There was no documentation as to whether the cirrhosis was of viral or toxic etiology, or possibly both. GI was consulted, and serology was sent for hepatitis panels. Her liver function tests were abnormal, as expected. My resident was fairly certain that this was another routine case of cirrhotic decompensation triggered by alcoholic hepatitis, but her AST: ALT ratio (aspartate aminotransferase: alanine aminotransferase) was not 2:1. Moreover, I felt the patient had no reason to lie about her sobriety, since she had been forthcoming about her alcohol history. Hepatitis B and C virology returned negative. The patient’s serum albumin was low, at 2.0 grams per deciliter (normal being 3.5-5 g/ 72 Lea Alfi: Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female dl). She wasn’t spilling any protein into her urine, ruling out a nephrotic syndrome. Her low albumin was most likely due to a combination of chronic malnutrition and alcoholic hepatitis. Renal was consulted and SPA (serum poor albumin) treatment was initiated to pull the escaping fluid back into her intravascular space. SPA was of negligible benefit, with the patient still in overt pain and discomfort. My resident and intern performed a therapeutic tap. The paracentesis removed 3 liters of ascitic fluid, alleviating, but not resolving, the patient’s abdominal distention. My resident assigned me with calculating the serum-ascites albumin gradient (SAAG), anticipating that it would support a cirrhotic etiology for the ascites. The SAAG was 1.0; by definition, a SAAG greater than or equal to 1.1 would have suggested portal-hypertension related ascites. However, the patient’s SAAG was less than 1.1, meaning my patient’s ascites were possibly nonportal-hypertension related. My resident held firm to his belief that the ascites were portal-hypertension related, noting that a SAAG of 1.0 could be considered borderline. Moreover, as cirrhosis was the cause of eighty-one percent of portal-hypertension related ascites, he reasoned that this was likely the case with our patient. However, because our patient had known cirrhosis, meaning an expected SAAG beyond 1.1, and her SAAG was still less than 1.1, I wondered if we should spend more time considering other etiologies for her ascites. The physician’s aphorism played in my mind, “If you hear hoof-beats, look for horses, not zebras,” reminding me of the practice of pursuing more common, rather than exotic, diagnoses. However, as a medical student with a paucity of clinical experience and a relative excess of time, looking for zebras and following stringent SAAG cutoffs was more intuitive, and interesting, than looking for horses. Alternative diagnoses included peritonitis, pancreatitis, vasculitis, bowel obstruction or infarct, hypoalbuminemic states (nephrotic syndrome or a protein-losing enteropathy), or Meig’s syndrome. In the absence of any amylase or lipase elevations, I eliminated pancreatitis. Peritonitis did not fit, as the ascitic fluid showed PMNs, white blood cells indicative of acute infection, to be less than 250, and a white count less than 500. Moreover, she was afebrile, and had no abdominal tenderness. There was no evidence of any vasculites or bowel obstruction. This left hypoalbuminemia or Meig’s syndrome. However, based on the failure of SPA treatment, it didn’t seem as if her ascites could have been solely due to a hypoalbuminemic state. Meig’s syndrome typically presents as a triad: ascites, pleural effusion, and ovarian tumor. A possible two out of three seemed reasonable, so I texted my resident, “What about Meig’s?” Resolution Renal had re-initiated daily diuretics to drain the remaining fluid and lessen the patient’s lower extremity edema, the standard furosemide 40 and spironolactone 100. The patient’s private attending, an oncologist, had ordered a slew of tumor markers: AFP (alpha-fetoprotein), CEA (carcinoembryonic antigen), CA-125 (an antigen on nonmucinous ovarian cancers), and CA-19-9 (a monoclonal antibody against certain GI carcinomas). In reviewing her day’s labs, her CA-125 had returned; it was elevated. This threw weight behind Meig’s, or any gynecologic malignancy. As a transvaginal ultrasound was scheduled, I left the team for my next rotation. 73 Lea Alfi: Diagnosis: Recurrent Ascites and Lower Extremity Edema in a 67-year old Female A few days later, I re-visited my patient. She told me how horrible the transvaginal ultrasound had been, and said she had been told it was to test for ovarian cancer. She showed me the soaps and lotions a friend had brought her, sliding them under my nose, and pointed out the bouquet of cattails she had added to her windowsill garden of sunflowers. I reassured her, and wished her good luck. She kissed me on the cheek and thanked me. As I left her room, I did not know whether she had a benign fibroma or a malignant tumor, or whether the CA-125 was leading us astray. I wondered whether our path to diagnosis had been achieved, not knowing ultimately to what the hoof-beats belonged. Five months later, I did a double take as I saw my former patient being admitted. From afar, I could see that her face had become unsettlingly gaunt, her belly more distended, and her legs unusually swollen juxtaposed against her twig-like arms. She was no longer my patient, and I was no longer on the medicine team. The medical record number that I had once typed by memory had receded from my mind. And unfortunately, I was unable to learn her final diagnosis before she was moved to another floor. 74 .Sabrina Perrino Ocean Beach Pier . . Nestadt. Ph. The present study prospectively measured stressful clerkship events occurring during the 2006-2007 academic year in third-year medical students of the Mount Sinai School of Medicine (n = 125).D. Connecticut.. Conclusions.CLINICAL SCIENCE: FIRST PLACE Resilience in the Third Year of Medical School: A Prospective Study of the Associations Between Stressful Events Occurring During Clinical Rotations and Student Well-Being Paul S. Purpose. Most students (101. depression. The authors measured anxiety. Cooper. M. New York Medical College. Results. and could contribute to a decrease in future physician empathy. unprofessional behavior by resident and attending physicians might have adverse effects on the well-being of students. New York. Mount Sinai School of Medicine. Nicole S. New Haven. M. New York. to date this has not been studied.D. Class participation varied from 106 (85%) at baseline to 82 (66%) at endpoint. The third year of medical school exposes students to many stressful and potentially traumatic events.D. which suggests that students were resilient. Steven M. and poor role modeling by physicians. New York. Trauma exposure was common but not associated with poor outcomes by year's end. personal mistreatment.M. Charney.. New York. fourth edition.. Marije aan het Rot. Such experiences may explain increases in anxiety and depression during medical school. Columbia University. Methods. 81%) completed at least one monthly survey. and posttraumatic stress symptoms at the beginning and end of the year and twice during the year. MS III. it appears that exposure to patient related traumatic events throughout the third year may aid in student personal growth.D.. M. However. David Muller. Yale University School of Medicine. However. using baseline measures and surveys completed monthly. Students labeled stressful events traumatic if they met the trauma criteria of the Diagnostic and Statistical Manual of Mental Disorders. whereas students with higher levels of current social functioning were more resilient to these stresses. Valhalla. Many students reported exposure to trauma as well as personal mistreatment and poor role modeling by superiors.D. Dennis S. These students witness patient suffering and death. Trauma exposure was positively associated with personal growth at year's end. 76 . Haglund. Margaret E.D. Southwick. At year's end they also measured students' personal growth. New York. M. exposure to other stressful events was positively associated with endpoint levels of depression and other stress symptoms. In contrast. Ph. Students who had experienced higher levels of childhood trauma were found to be more vulnerable to the psychopathogenic consequences of third year trauma. In fact. 85..D. M.5 for KALu. Hospital of the University of Pennsylvania. 77 .9 for KA1. Peter Reese2. 4 New York Medical College.. HR=3. HR=3.D. Methods. Renal waitlist and transplant survival benefit for kidney after lung (KALu). and kidney after liver (KALi) were compared to KA1 and KA2. M. and inferior for KALu. Ph. KALi.. Following transplant. adding a drain on the limited pool of kidney grafts.88).. kidney after heart (KAH). and 25. Results... and KAH.93. M.02. HR=1. The risk of death on the wait list for an extra-renal transplant was compared in an adjusted analysis to KA1: KA2 (p<0.2 for KALi. M. 26. Ph. with extra-renal transplant recipients demonstrating the largest survival benefit.27). Matthew Levin1.2 Renal Electrolyte and Hypertension. PA1 Division of Transplantation. M. HR=0.001.001. Peter Abt1. Kim Olthoff1. Roy Bloom2. 5. we sought to evaluate kidney transplant benefit in extra-renal transplantation compared to primary isolated (KA1) or repeat primary kidney (KA2) transplants. CI=3.D.D.D. The number of surviving extra-renal transplant recipients who develop end stage renal disease is increasing.. Ph.54). MS II4.06-4. kidney transplantation was associated with a five year survival benefit amongst all groups. NY Purpose. 19.D. Philadelphia. 3 Outcomes Research. Abraham Shaked1.8 for KA2. Valhalla. and KALi (p<0. Deaths per 100 waitlist years were 8.D. Ali Naji1. CI=2..001. M.D.73. Extra-renal transplant recipients with ESRD have an increased risk of wait list death and greater survival benefit from kidney transplantation compared to KA1 and KA2. KALu (p<0. CI=1. KAH (p<0.78-3.D. Seema Sonnad3. These groups should be considered in the development of kidney allocation algorithms.CLINICAL SCIENCE: SECOND PLACE Wait List Death and Survival Benefit of Kidney Transplantation among Extra-renal Transplant Recipients James Cassuto1.68-2.82-0. Multivariate Cox regression models were constructed with UNOS data for patients listed and transplanted between 1995 through 2008. CI=0.6 for KAH. M. With current interest in balancing equity and utility..001. Compared to remaining on the waitlist.. patient survival was greatest for KA1. Ph.D.D.21). but similar among KA2. Conclusions. 05 denoting statistical significance. we examined two other MnSOD SNPs. Department of Pediatrics. Manganese superoxide dismutase is an important enzyme for quenching reactive oxygen species. Johanna Calo. Results: There were significant differences in birth weights and gestational ages. For a subset of the subjects. Conclusions: Caucasian ELBW preterm infants who progress to BPD are more likely to contain the minor allele for the MnSOD rs4880 SNP. but not Hispanic or African-American infants. Valhalla. New York Purpose: Oxidative stress. M. BPD is defined by the need for oxygen at 36 weeks PMA. Kristen Aland. It catalyzes the conversion of the superoxide anion to hydrogen peroxide in the mitochondria. This association was not seen in Hispanics or AfricanAmericans.D. resulting in less efficient transport into the mitochondria.CLINICAL SCIENCE: THIRD PLACE Racial Differences in Bronchopulmonary Dysplasia Severity for Neonates with Mitochondrial Superoxide Dismutase Polymorphism Edward Hurley. M. and cannot be explained by differences in birth weight or gestational age. Significantly more intraventricular hemorrhage was found among infants with BPD compared to Non-BPD. which results in less efficient transport of superoxide anion into the mitochondria. MS II. We examined the two additional MnSOD SNPs (rs11575993 and rs2842958) in the Caucasian subjects but found no significance. has been implicated in the susceptibility of preterm infants to bronchopulmonary dysplasia. We found significant differences between the genotype distributions of this SNP when we analyzed Caucasian (N=21. but not in racial distributions between BPD and Non-BPD infants.. P=0..D.23). Chi square analyses and ANOVA were performed with P<0. requires a mitochondrial targeting sequence to gain entry. along with genetic factors and mechanical ventilation. which is coded by genomic DNA. Lance A Parton. DNA was isolated from buccal mucosal swabs and allelic discrimination was performed using a specific probe with Real-time PCR. Methods: We hypothesize that the MnSOD rs4880 SNP is associated with susceptibility to BPD. Infants (N=87) were enrolled who weighed <1 kg at birth and had no congenital or chromosomal abnormalities. The enzyme. The genotype distributions were not statistically different between BPD and Non-BPD infants (P=0. New York Medical College.027). One SNP (rs11575993) causes a change in amino acid from a leucine to a phenylalanine and the other is an intronic SNP (rs2842958) that has been associated with other lung conditions such as COPD. A well-studied single nucleotide polymorphism (SNP) in the mitochondrial targeting sequence causes a replacement of alanine by valine.A. 78 . B. and 5% with an unknown partner. and gene expression signatures. M. PSA relapse (biochemical recurrence). Conclusions: While most studies have assumed that all ERG rearranged prostate cancers are fused with TMPRSS2. we showed that a significant percentage is SLC45A3-ERG. a novel 5’ partner recently discovered. Using various statistical methods. Department of Pathology and Laboratory Medicine. In this case. This study has important clinical implications for the development of diagnostic assays to detect ETS rearrangements in prostate cancer. Gleason grade. Two differently colored DNA probes flanking the gene of interest were simultaneously hybridized to 5 micron sections of each TMA and were evaluated using a fluorescence microscope. Department of Urology. A sample harboring a rearranged gene showed a split. or break-apart.D. TMPRSS2. 11% with both TMPRSS2 and SLC45A3. LaFargue.BASIC SCIENCE: FIRST PLACE Using Fluorescence in situ Hybridization (FISH) to Examine the Prevalence of ETS Gene Fusions in a Large Prostatectomy Cohort. most notably SLC45A3 and NDRG1.. with each overlapping pair corresponding to one allele. A break-apart FISH assay was employed allowing an evaluator to determine whether or not a particular gene was disrupted. NYC. Additionally.D. preoperative PSA levels. Similar to previous reports. and a single green and single red located apart from each other (disrupted allele). ERG rearrangement occurred in 53% (254/540) of the cases. 78% were shown to be fused with only TMPRSS2. and NDRG1. each nucleus would contain a green-red overlapping signal (normal allele).. Rubin. Four gene sets were used: ERG. M. Results: Of the 614 patients in the cohort. Germany. The purpose of this study was to examine the frequency of these particular gene fusions in a large scale prostatectomy cohort and to determine whether any relationship existed with pathologic parameters or clinical outcome. Of these 254 cases.. Methods: A cohort of 614 prostate cancer patients who underwent radical prostatectomy was used. Purpose: Approximately 40-60% of PSA screened prostate cancers harbor gene fusions between the 5’ region of the hormone regulated TMPRSS2 gene and the 3’ region of members of the ETS family of transcription factors. Prostate cancers possessing ERG rearrangements represent a distinct sub-class of tumor based on previous studies reporting associations with histomorphologic features. additional 5’ fusion partners of ERG have been discovered. Incorporation of these assays which detect the less common ERG rearranged fusions could further increase the sensitivity of the current PCR-based approaches. the discovery of concurrent rearrangement of TMPRSS2 and SLC45A3 within the same case suggests that there must be additional molecular complexity which has been previously unappreciated.D. one was identified as being fused to NDRG1. this study did not find any association with pathologic parameters or clinical outcome. characteristic somatic copy number alterations. 79 . M. Glen Kristiansen. Sven Perner. most commonly ERG. University Hospital of Berlin. MS I.D. A case was considered positive for gene fusion if it possessed rearrangements of both ERG and the particular 5’ partner.D. Berlin. From these unknown cases. M. NY. Mark A. 540 could be evaluated by FISH. Weill Cornell Medical College. M.. 6% with only SLC45A3. Christopher J. Veit Scheble. of the signals. Tissue microarrays were constructed from the formalin-fixed paraffin-embedded tissue blocks from each patient. A sample negative for rearrangement showed two green and red overlapping signals in each nucleus. More recently. Various parameters such as age. SLC45A3. Raquel Esgueva. and tumor stage were recorded for each case. Chromosomal analysis using FISH demonstrated amplification of the EGFR gene in 12% of patients. This investigation compliments an ongoing Dana Farber Harvard Cancer Center prospective clinical trial for patients with VSCC. Invasive vulvar cancer represents 5% of gynecologic cancers and it is estimated that 3. Growdon MD. Borger PhD and Bo R. DiasSantagata PhD. Darrell R. lymph node status and high-risk HPV status Conclusions. Common activating mutations in the tyrosine kinase domain of EGFR were not broadly identified in this cohort.580 new cases and 900 deaths will be reported in the United States for 2009. therefore. A high level of EGFR protein expression was observed in 31% of VSCC patient samples. Sara Akhavanfard MD. A cohort of 51 patients seen at the Massachusetts General Hospital Cancer Center from 1994-2007 with primary VSCC was selected and represented all FIGO stages. John Iafrate MD PhD. Esther Oliva MD. grade. Boston. EGFR amplification status in patients with VSCC may identify patients who will benefit from small molecule tyrosine kinase inhibitors that target the EGFR pathway. Given the association of EGFR amplification with response to targeted therapies in other tumor types. Massachusetts 02114. lymph node status and survival). This standard of care treatment is associated with significant morbidity and recurrence. Sakiko Kojiro. Neil S. While it is clear that molecularly-targeted therapies play a major role in an adjuvant setting in other epithelial tumors. Methods. Horowitz MD. Therefore. stage. Assessment of the following was completed: EGFR protein levels using immunohistochemistry (IHC). 80 . Boisvert MS I. Dora C. A. Rueda MD Massachusetts General Hospital. recurrence. even when controlled for age.BASIC SCIENCE: SECOND PLACE Use of EGFR Genetic Analysis to Potentially Expand Treatment Options for Patients With Vulvar Squamous Cell Carcinoma Susan L. Our data demonstrates that a subset of patients with squamous cell carcinoma of the vulva present with EGFR gene amplification that is HPV-independent and associated with poor prognosis. Whitfield B. there is little understanding of the underlying etiology of vulvar carcinoma. Molecular alterations in a subset of patients leading to Epidermal Growth Factor Receptor (EGFR) gene activation have been shown to confer therapeutic response to targeted therapies in a number of cancers of epithelial origin. Early correlative data from a patient on trial who exhibited a partial response to 6 weeks of therapy demonstrated EGFR gene amplification. understanding the molecular mechanisms of this malignancy has the potential to expand treatment to include targeted therapies. Treatment for vulvar squamous cell carcinoma (VSCC) has changed little over the years and surgical incision and inguinal lymph node dissection remain the standard of care. Results. Gene amplification was an independent prognostic variable. stage. This case reinforces the possible clinical implications of this translational investigation and the application of small molecule inhibitors in the treatment of vulvar squamous cell carcinoma. the purpose of our study was to evaluate genetic alterations in the EGFR gene that could be used to expand clinical management of VSCC through the inclusion of molecular targeted therapies. Decreased survival was observed in patients with additional copies of EGFR. USA Purpose. EGFR mutational analysis using PCR and EGFR gene amplification using fluorescence in situ hybridization (FISH). EGFR gene amplification and protein expression were correlated with a variety of clinical prognostic variables (age. To determine if ALOX5 enhances invasion via MMP-9 activity. NY New York Eye and Ear. 1Raj K Tiwari PhD. Ear Infirmary. or an empty vector control.09) and 0. and invasion were investigated in a PTC cell line transfected with an ALOX5 expression vector. Methods: To investigate the correlation between invasive PTC and ALOX5 expression. To determine the effects of ALOX5 on PTC pathogenesis. Department of Microbiology and Immunology. Results: Mean expression for ALOX5 in PTC and matched normal tissue were 3.74. Inhibition of MMP-9 activity. Aggressive disease results in poor prognosis.001). invasion assays were repeated with the transfected cells and the addition of MMP-9 inhibitors. cell proliferation. and was reversible by ALOX5 inhibition. with hopes of identifying new therapeutic targets and disease markers. Here we demonstrate that ALOX5 correlates with tumor invasiveness and contributes to PTC pathogenesis by enhancing invasion via MMP-9 induction. abrogated the ALOX5 mediated increase in invasion. The fold increase in ALOX5 mRNA expression between matched samples significantly correlated with TIS (Spearman correlation coefficient=0. 2Stimson Schantz MD. by either chemical inhibition or by an inhibitory antibody. ALOX5 induction of MMP-9 secretion was verified by western blot analysis of conditioned media from the transfected cells.002). 81 . P=0.27 (SE 0. 1Jan Geliebter PhD 2 1 NYMC. MMP-9 levels increased in a dose dependent manner in response to 5-HETE. and cells conditioned with 5-HETE (a metabolic product of arachidonic acid and ALOX5).BASIC SCIENCE: THIRD PLACE Arachidonate 5-Lipoxygenase Expression in Papillary Thyroid Carcinoma Correlates with Invasive Histopathology and Promotes Extracellular Matrix Degradation via MMP-9 Induction 1 Nicolas T Kummer MD-PhD Candidate Year VII (MS III) 2Cordon Iacob MD. Serum free conditioned media of the transfected cells demonstrated a 2.00 fold increase of MMP-9 (P=0. determined by western blot analysis. based on histopathology). MMP protein expression. mRNA was quantified by real-time RT-PCR and significance was determined by Spearman correlation coefficient.10) copies/GAPDH (respectively P=0.39 (SE 2. Transfection of an ALOX5 expression vector into the PTC cell line conferred a 3. accounting for ~80% of all thyroid cancer.0007). fold differences in ALOX5 mRNA were calculated between pairs of matched PTC and normal thyroid tissue and correlated to a Tumor Invasive Score (TIS. In follow-up. Evidence suggests arachidonate 5lipoxygenase (ALOX5) promotes tumorigenesis of various carcinomas. determined by MMP protein array.12 fold increase in invasiveness compared to the empty vector control (P<0. New Purpose: Papillary thyroid carcinoma (PTC) is the most common thyroid and endocrine malignancy. Valhalla. Here we investigate the role of ALOX5 in the pathogenesis of aggressive PTC. NY. however little is known about the pathogenesis of aggressive PTC. Additionally. These findings signify a new paradigm for ALOX5 in tumor pathogenesis which may be exploited for diagnostic and therapeutic advantages in aggressive PTC. York. Conclusions: Current evidence characterizes ALOX5 primarily as anti-apoptotic in cancer.03) compared to the empty vector control. and confirmed by western blot analysis. Julie Grimes Wendell Park . Ann Tran Infinity . Norman Levine Dr. Gladys Ayala Dr. Karl P. Muhammad Choudhury Diana Cunningham. O’Connell Dr. MPH Dr. Adler Dr. Sansar C. English Weston Foundation Dr. Ralph A. Sharma Department of Admissions The Student Senate Anonymous 84 . Joseph T. -Jenny Lam & Edward Hurley Dr.Tribute to Generosity The editors and staff of the Quill & Scope would like to thank the generous donors whose financial and moral support have made this publication possible. MLS. edu). Alanna Chait (Alanna_Chait@nymc. class of 2012 Michael Karsy (Michael_karsy@nymc. she enjoys playing her trombone. Alanna is interested in psychiatry and pediatrics. She is leaning toward family medicine. She loves friends and family. class of 2013. He enjoys creating art and hopes that he can continue it throughout a medical career. He is pursuing international medicine through the MD/MPH program. graduated from the University of California. English. Alanna conducted research in child psychiatry and performed with several opera companies. class of 2013. Katrina Bernardo (katrina_bernardo@nymc. A very active. and she plans to incorporate writing and singing into her medical career. She loves to run. Ian Hovis. class of 2011. Poonam Kaushal (poonam_kaushal@nymc. and she still doesn’t know what kind of doctor she wants to be when she grows up. class of 2012.edu). is an executive board member of American Medical Women’s Association. She is also the first year representative for the NYMC chapter of the AMA. and she is looking forward to choosing a specialty.CONTRIBUTORS Radeeb Akhtar (radeeb_akhtar@nymc. drinks coffee by the gallon. in Neurobiology is interested in pediatrics and hopes to aid underserved children and influence health policy in the future. class of 2012.S. sunny days. Before entering medical school. graduated from New York University in 2007 with a B. where she majored in Psychology. learning new things and frequent "The Office" study breaks. She is currently enjoying her clinical rotations. dancing. Irvine with a B. being outdoors. is a 2004 graduate of Columbia University. graduated from Boston College in 2007 with a degree in Psychology.edu). class of 2012. class of 2012. and is interested in health care reform. got lost and found herself in 2nd year of medical school. and a managing editor for Quill & Scope.edu). She is expected to receive a Master’s in Health Administration from Hofstra University. in psychology. and is involved with the Medical Society of the State of New York.edu) is a year four MD/PhD candidate in the Department of Experimental Pathology. in Psychology and spent one year teaching the second grade in Manhattan before entering medical school. BA in Psychology from New York University.A. NYMC class of 2013.edu).com). and spreading Red Sox love in the heart of the evil empire. introspective. He is the inventor of the NYMC_ART club born 2009. She originally wanted to be an art teacher. is a native of New York and can't wait for third year rotations to begin. enjoys reading. graduated from University of Oregon in 2006. and Comparative Literature. Julie Grimes. a member of the Blood Drive Committee.edu). He is a Leo. Anna Djougarian is a graduate of the Macaulay Honors College at CUNY Hunter with a BA in Psychology. and not-your-typical medical student. Marissa Friedman (marissa_friedman@nymc. Medical Student section. Linda DeMello (linda_demello@nymc. she writes fiction and spends as much time as possible with her husband.edu). Ava Asher (ava_asher@nymc. When she's not studying. class of 2011. cooking.A. You'll often find him figuring out ways in which to save the world. and long walks on the beach. graduated from Yale University in 2006 with a B. . Lea Alfi (leaalfi@gmail. He is currently the treasurer of the Genocide Awareness and Prevention (GAAP) club at NYMC. When she doesn’t have her head in the textbooks. Steve Rockoff (steve. is proud to have contributed to the 3rd edition of Quill and Scope. graduated from Northwestern University in Evanston. addiction medicine. and M. the blood drive committee and the NSF foundation. class of 2013. class of 2012. She is interested in cardiovascular medicine. class of 2013.edu) is a third year student who. He enjoys travel and photography and hopes he'll find more time for both in the future. and La Casita de la Salud. class of 2013. running. He is looking forward to graduation and launching into an exciting career in Family Medicine.edu). and basketball. and a graduate of both the University of Toronto and Boston University. These photos were taken on his honeymoon in Belize in April 2009. and playing tennis. in Psychology from Virginia Commonwealth University. Luke Selby (Luke_Selby@nymc. Paul is pursuing a career in radiology. the Latino Medical Student Association. Stuart Mackenzie (stuart. After the sun goes down in Valhalla. She proudly participates on the executive boards of the NYMC Pediatrics Club. he tried out numerous paths including stock broker. the surgery club. His passions in medicine include improving health care access and health education for the underserved.rockoff@gmail. among others. Her current interest is to pursue reconstructive surgery. Danielle Masor (danielle_masor@nymc. although she has not yet done a rotation in this field. which is a not-for-profit organization focused on providing health and education assistance to rural communities. Andrei Kreutzberg (akreutzb@gmail. Some of his favorite pastimes include watching baseball. he loves enjoying the outdoors with his beautiful wife Lauren.Anita Kelkar (anita_kelkar@nymc. J. While slowly finding her way to the medical field. In addition to writing about chronic and infectious diseases in NYC.A. and plots how to get back to San Diego for residency. eating sushi.S. Danielle loves kids and is considering pediatrics. His interests include music. graduated from Swarthmore College with majors in French Literature and Economics. Paul enjoys playing guitar.edu) is an M. and caring for families across the lifespan. Nadia Nocera (nadia_nocera@nymc. global health and mission work.com) is a second year medical student. received his B. San Diego.com). and psychiatry.edu). He has developing interests in Internal Medicine and Psychiatry. candidate for the class of 2010. M. class of 2011. .edu).edu).mackenzie@gmail. She is currently a member of AMSA. Illinois after studying psychology and biomedical engineering.D. she has worked in the insurance and non-profit sectors. MD/MPH. running. outdoor photography and SCUBA diving. and hopes to pursue a career in the field after finishing medical school.com ) class of 2013. G.D. Sabrina Perrino. in his very limited free time. After college. class of 2012. Paul Nielsen (jonpaul_nielsen@nymc. was born and raised in Canada. in Biology from the University of California. english teacher and law student before settling on medicine. enjoys hiking.S. W. Eliott Lee. Jordan Roth (Jordan_roth@nymc. she executes culinary masterpieces while listening to neo-soul. nutrition. As a native of the Pacific Northwest. Having spent time working in Internal Development and Infectious Disease. is a 2009 graduate of Brown University where she majored in biology. he is excited to read other NYMC students' perspectives on International Medicine. earned a B.S. from Case Western Reserve University in 2003. snowboarding. received her Master of Public Health degree from Dartmouth College and her B. edu) is a first-year medical student. He is greatly looking forward to making it through medical school with his sanity intact. class of 2013. He is currently an officer under the Navy HPSP scholarship and lives on campus with his wife. Katrina. She is involved with the pre-medical mentoring program at NYMC and is considering a career in Family Medicine. Though a native of New York and alegal resident of Florida.S.Navid Shams (Navid_Shams@nymc. pretending to do work in the library (or elsewhere). the NYMC community garden. Charles Volk (charles_volk@nymc. she decided to organize a program based on the same principles. His interests include writing. graduated from Yeshiva University in 2009 with a B. He is the 2013 Scribe President. biopsychology. running. guitar. and a well done mac’ and cheese. Having grown up in a country where medical care is hard to come by (and also at an expensive cost). in Developmental and Cell Biology with a minor in Chicano/Latino Studies. North Dakota and did his undergrad at the University of Minnesota . Daniel Waintraub (daniel_waintraub@nymc. she discovered the power of preventative medicine through the forum of teaching.edu) is a MD/MPH student in the Class of 2013. class of 2013. majoring in health policy and management. Prior to medical school. His passion for poetry began when reading and reciting Persian poems as a child in Iran. but with a more grand vision at New York Medical College. mellow music.edu). and biology at the University of Michigan and is an alumnus of the Michigan Daily. He is originally from Bismarck. with concentrations in International Health and Epidemiology. fiction novels. in Biology prior to embarking on his path through New York Medical College. graduated from Hunter College with a degree in Anthropology. he identifies most closely with Michiganders.edu). He studied English.A. he attended Boston University for a Masters in Public Health. and is also active in PNHP. . Having worked with a similar project at her alma mater at UCI. Gavin Stern ([email protected]) attended the University of California. day dreaming. Ann Tran (ann_tran@nymc. His high school experience as an ice cream man has led him to choose the field of pediatrics. is interested in Pediatrics and the Infectious Disease specialty. class of 2012. He has an undergraduate degree in Creative Writing and Biology from Carnegie Mellon University. Sukhpreet Singh (Sukhpreet_Singh@nymc. and a med student bluegrass band.edu).Twin Cities. Irvine and received her B. a member of the Blood Drive Committee. graduated from New York University in 2007 with a B. Prior to medical school. . and while working in neuropsychology and neuropathology at the Framingham Heart Study.S. received her B. spending time outdoors. he enjoys spending time with his beautiful wife. When not studying. class of 2012.A.edu). in Psychology and English and Comparative Literature from Columbia University in 2004. class of 2012. Linda DeMello (lindardemello@gmail. and traveling in his spare time. gastroenterology and hematology. windsurfing. in English from Boston College in 2007. class of 2012. and a managing editor for Quill & Scope. class of 2013.edu). and baking anything chocolate. catheter-based approaches to the treatment of cardiac arrhythmias. cooking. in Applied Mathematics and Biology from Brown University in 2009. namely endocrinology. literature. Edward spent nearly a decade as a journalist both in newspapers and in online media. Alanna Chait (alanna_chait@nymc. she conducted research in the Department of Child Psychiatry at Columbia University. and she still doesn’t know what kind of doctor she wants to be when she grows up. where she co-authored several papers and developed a music program for children with special needs. in Biological Sciences from Columbia in 2007. class of 2013. She worked in clinical laboratories for six years in several hospitals across southern New England before her acceptance into NYMC. graduated magna cum laude from the University of Massachusetts-Amherst with a dual major in Journalism and Philosophy. He then shifted to neuroscience research while receiving master’s degrees at Boston University School of Medicine and at the University of Massachusetts Boston. and is involved with the Medical Society of the State of New York. class of 2013. class of 2012. She is a member of the Pediatrics Interest Group and the soonto-be famous flag football team Valhallabackers.A. drinks coffee by the gallon.A.com). and bringing people together. Sarah.edu). She graduated magna cum laude from the University of Massachusetts Dartmouth in 2007 with a BS in Biology and a minor in Biochemistry. Medical Student section. In the intervening two years before medical school. MD and Sanjay Gupta. Loren Francis (loren_francis@nymc. including seven years at the University of California San Francisco. Humera hopes to touch the world by avidly pursuing her passions for medicine. received her B. is an executive board member of the American Medical Women’s Association. Jon plans to pursue neurology as a specialty. Following graduation. She loves to run. in psychology. received his B. received her B. Jenny Lam (jenny_lam@nymc. she writes fiction and she spends as much time as possible with her husband. Jon worked for nine years in ophthalmology research. In addition to her Quill and Scope position.S. She is currently interested in a number of fields in internal [email protected]). tennis. received her B. When she doesn’t have her head in the textbooks.A. Marissa Friedman (marissa_friedman@nymc. and two years at Miyata Eye Hospital in Japan. in Zoology from the University of Massachusetts Amherst in 1993.edu). Following in the footsteps of her idols: Paul Farmer. and enjoys rock climbing. Jonathan Drake (jonathan_drake@nymc. MD. cooking. class of 2013. She is expected to receive a Master’s in Health Administration from Hofstra University. She is also the first year representative for the NYMC chapter of the AMA. she spent time researching the safety and efficacy of novel. Following graduation. Alanna participates in PsychSIGN and is interested in pediatrics and psychiatry. Edward is considering either pediatrics or geriatrics as he adores kids and older folks but is lukewarm about people in the middle.QUILL & SCOPE STAFF Humera Ahmed (humera. Edward Hurley ([email protected]). she enjoys reading. When not studying.edu). social justice. She enjoys the performing arts. and travel. After graduation she worked for three years as a medical assistant to a primary care physician in Cambridge. Following graduation. He graduated from The College of William and Mary with a B. class of 2012. class of 2013. Danielle loves kids and is considering pediatrics. was born and raised in Los Angeles. in Quality Control Stability. Stuart Mackenzie (stuart.edu). Danielle Masor (danielle_masor@nymc. Mass. born and raised in south detroit. graduated from Boston University in 2006 with a B. literature. he did research on germline stem cells of Drosophila melanogaster and worked as an Emergency Room scribe for over two years. class of 2013. He is a graduate of both the University of Toronto and Boston University. graduated from the University of Pennsylvania in 2009 with a B. among others. in Biology and Philosophy. class of 2013. When not neck deep in notes. She graduated from Boston University in 2007 with a BA in both Neuroscience and French. Chris Ours ([email protected]). In Williamsburg. running and reading The New Yorker. class of 2013. Virginia. While slowly finding her way to the medical field. . He took the midnight train goin' to New York. Rajdeep Pooni (rajdeep. Janet Nguyen (janetnguyen14@yahoo. Sarah is interested in primary care. graduated from Swarthmore College with majors in French Literature and Economics. class of 2013. Upon graduation.pooni@gmail. Allison Navis ([email protected]. is a graduate of UC Davis. After dabbling in the industry. James Naples ([email protected]. such as Sickle Cell Disease. and traveling.Calley Levine (calley_levine@nymc. She is currently a member of NYMC's Student Senate. is just a city boy. he is excited to read other NYMC students' perspectives on International Medicine. she enjoys cooking. and terrible television medical drama.G.com). graduated from University of San Francisco with a B. where she studied both biological sciences and English literature. mysteries. Having spent time working in International Development and Infectious Disease.edu). She likes pilates. in American Studies. class of 2013. While he is keeping his options open for the future.com). Becky Lou . Her diverse interests include healthcare. Sarah Pozniak (sarah_pozniak@nymc. class of 2013.com). and being active. he is very interested in oncology. he serves on the 1st and 2nd year curriculum committee and has helped out on the SPAD fundraising committee. class of 2013. class of 2013. At NYMC. in Biology. he enjoys cooking. He hopes to practice as a clinician and also stay in touch with laboratory research and academic medicine. class of 2013. was born and raised in Canada.edu). He enjoys spending time outdoors.mackenzie@gmail. she worked at Genentech Inc. Allison currently lives in Brooklyn and is a first-year medical student at NYMC.com). Allison moved to New York City where she worked in finance while also pursuing her interests in the arts. grew up in CT and graduated from Boston College in 2008 with a degree in Biology and Chemistry. although she has not yet done a rotation in this field.edu). in Computer Science & Graphics and a minor in Psychology. watching TV and spending time with her family and friends. During her spare time. Janet joined the Research Institute of California Pacific Medical Center where she performed research on a novel gene therapy technique to treat monogenic diseases. she has worked in the insurance and non-profit sectors. W. running. clowns and occasionally. in Biological Sciences. Alex Trzebucki (trzebucki@gmail. Navid Shams (navid_shams@nymc. Prior to medical school. She enjoys skiing.edu). graduated from Davidson College with a B. He received his undergraduate degree from Cornell University. In addition to his duties at Quill and Scope. Mike Smith (smithixy@gmail. karate. in Biology from Wake Forest University. she spent close to three years working on immunology and allergy research in Yokohama. At NYMC. helps out on the SPAD PR committee and is a tour guide.edu). Gavin Stern ([email protected]). Prior to medical school. class of 2013. Annabelle Teng (annabelle_teng@nymc. graduated from University of California San Diego in 2005 with degrees in Anthropological Archaeology and Biochemistry/Cell Biology.Aditya Sarvaria ([email protected]). class of 2013. Though a native of New York and a legal resident of Florida. He received his B. oil painting. which has given him the opportunity to go on several excavations. graduated from University of Chicago in 2007 with an A. majoring in health policy and management. Michael Weinreich (michael_weinreich@nymc. In addition to art and medicine. class of 2012. In his spare time. salsa dancing.edu). Japan. and was a member of the Cardiothoracic Transplant Team at Columbia.S. class of 2013. graduated from Boston College in 2008 with a degree in Biology. and biology at the University of Michigan and is an alumnus of the Michigan Daily. eating. She grew up in Beijing and Alaska as a misguided snowbird (summers in Beijing. music. As an undergraduate he worked for several years as a student docent at the Smart Museum of Art. is a MD/MPH student in the Class of 2013. is from Murfreesboro. He studied English. NY. TN. the dark. Yin Tong (yin. is interested in Pediatrics and the Infectious Disease specialty. and learning foreign languages. class of 2012. cardiothoracic research at Columbia University. and urban explorer. and biology and pursued graduate studies in Biomedical Science at Tufts University School of Medicine. class of 2012.com).B. .A. class of 2012. When not playing video games.tong. Alex has conducted AIDS research at Albert Einstein College of Medicine. reading. sleeping and cultivating an irrational fear of birds. biopsychology. he identifies most closely with Michiganders. his interests include paleontology. with concentrations in International Health and Epidemiology. His high school experience as an ice cream man has led him to choose the field of pediatrics. she is a first year coordinator for Big Sib Lil Sib. graduated with a BS in Human Development from Cornell University in 2008. winters in Alaska) and served as the executive editor of Cornell's Ivy Journal of Ethics. class of 2013. Mike enjoys sports. grew up in Poughkeepsie. filmmaker. Dennis Toy ([email protected]).ak@gmail. She enjoys cooking/baking. he also designed the website for Student Physician Awareness Day. Dennis enjoys running and playing tennis. He has an undergraduate degree in Creative Writing and Biology from Carnegie Mellon University. Alex was the managing editor of a school newspaper and is an avid photographer. he attended Boston University for a Masters in Public Health. His favorite dinosaur is the diplodocus. class of 2013. and American Idol.edu).edu). Quill & Scope is a student driven journal containing reviews. It is published annually by the students of New York Medical College. Checks can be sent to: Quill & Scope New York Medical College Office of Student Affairs 40 Sunshine Cottage Road Valhalla. which have begun to impact our professional judgment and clinical decision making. We appreciate your support as we continue the tradition of literature in medicine. economic. and artwork. distribution.nymc. Tear off and Submit: Name: City: Address: State: Zip: 200 Other: I would like to donate the following amount: 50 100 300 500 Please make your donation payable to New York Medical College with “Quill & Scope” in the memo field. financial support is needed to improve. social. 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