Building Medical Schools Around Social Missions: The Case of the University of California, Riverside.

Abstract-The University of California recently created the first new public medical school on the West Coast of the United States in nearly 50 years. It was built in a region of California with significant health challenges, including a marked physician shortage and very poor overall health outcomes. The region's population is racially and ethnically diverse and rapidly growing, with a particularly large population of Mexican American residents. It is also an area with high unemployment, low college-going rates compared to most other areas of California, and a large undocumented immigrant population. When the University of California Board of Regents authorized the creation of this new medical school, it charted unique social missions for the school that have particular relevance to the needs of its immediate region. This article presents a single case study of how the school was designed to accomplish these social missions and, ultimately, to improve the health of the people living in the region it serves. Many of the strategies used were adopted from developing countries that have far more serious workforce issues and health challenges. The authors believe these strategies and missions are unique among the 17 new medical schools created in the United States in the last decade. Furthermore, this model could have broader implications for the development of health policies and health system reform in other nations, such as Mexico.

Deworming the world.

Worms or helminths have historically infected more than half the world's population, but were largely neglected by medical science and public health interventions because they were considered non-fatal and of minimal clinical significance. During the 1980s, several oral drugs that were originally developed for veterinary use were discovered to cure, in a single dose, most human helminth infections. This allowed the first systematic population-based studies of the morbid sequelae of chronic worm infection and their potential reversibility after treatment. Based on these studies, we now know that almost all infected children and many adults, particularly pregnant and lactating women, suffer adverse effects from worms, including growth stunting, anemia, decreased cognitive development, and poor birth outcomes as well as poor school and work performance. Worm-infected people also respond less well to vaccinations and are more susceptible to several co-conditions such as HIV and cirrhosis. Based on these findings, several vertically organized national control programs were initiated in developing countries against schistosomiasis and the soil-transmitted helminths (hookworm, ascariasis, and whipworm). In 2005, the impact of helminth infections was redefined in terms of disability-adjusted life years (DALYs). All worm infections amenable to population-based mass chemotherapy are thought today to cause 30 million DALYs worldwide or very close to the worldwide impact of tuberculosis (TB) or malaria. In addition, almost all worm-induced DALYs are potentially reversible or preventable with periodic treatment. In 2001, the World Health Assembly advocated for mass deworming to reach 75% of the at-risk school-aged children of the world, but by 2011 only 13% had been reached. The recent large donations of anti-helminth drugs by major pharmaceutical companies linked to the inclusion of the "neglected tropical diseases" into current priorities for AIDS/TB and malaria now represent the best hope for closing this gap.

Schistosomiasis and pregnancy.

Currently, schistosomes infect approximately 40 million women of child-bearing age, yet little is known about schistosome-associated morbidity in pregnant women and their offspring. Animal models indicate a deleterious effect of schistosome infection on maternal, fetal and neonatal outcomes. Case reports have documented maternal infection in association with poor birth outcomes, and two observational studies indicate that maternal schistosome infection might be associated with decreased birth weight. Rigorously identifying and quantifying the impact of schistosome infection on pregnancy outcomes with well-designed observational and treatment studies are crucial for improving birth outcomes in schistosome-endemic areas. In addition, studies that address the safety of praziquantel during pregnancy could lead to further adoption of the recent informal recommendation by the World Health Organization to treat schistosome-infected pregnant and lactating women.

Katayama syndrome.

Katayama syndrome is an early clinical manifestation of schistosomiasis that occurs several weeks post-infection with Schistosoma spp (trematode) worms. Because of this temporal delay and its non-specific presentation, it is the form of schistosomiasis most likely to be misdiagnosed by travel medicine physicians and infectious disease specialists in non-endemic countries. Katayama syndrome appears between 14-84 days after non-immune individuals are exposed to first schistosome infection or heavy reinfection. Disease onset appears to be related to migrating schistosomula and egg deposition with individuals typically presenting with nocturnal fever, cough, myalgia, headache, and abdominal tenderness. Serum antibodies and schistosome egg excretion often substantiate infection if detected. Diffuse pulmonary infiltrates are found radiologically, and almost all cases have eosinophilia and a history of water contact 14-84 days before presentation of clinical symptoms; patients respond well to regimens of praziquantel with and without steroids. Artemisinin treatment given early after exposure may decrease the risk of the syndrome.

The Medical College of Wisconsin's program to strengthen geriatrics education.

Medical care for geriatric patients requires physician training that promotes the acquisition of attitudes, knowledge and skills that will permit future practitioners to meet the health needs of increasing numbers of aged patients. MCW has strengthened its traditional curriculum by focusing on student attitudes in the early pre-clinical years through outreach and interest groups programs. Knowledge is integrated throughout the 4-year curriculum using our aging virtual patients. These patients are a teaching resource to the entire faculty. Attitudes, knowledge, and skills in geriatrics are further developed through an M3 geriatrics medicine option and the M4 Integrated Selective. Geriatric-specific skills are emphasized through the use of standardized patients and objective structured clinical examinations in the M4 Selective. It is anticipated that these students efforts will create interest in a novel residency experience (Med-Ger) that will ensure that upon successful completion of the program, residents are expert in geriatric medicine practice and meet criteria for board certification in geriatric medicine.

Administration of praziquantel to pregnant and lactating women.

Praziquantel (PZQ) is the safest of all anti-helminthics and now forms the backbone for all national control programs against schistosomiasis (Med. Res. Rev. 3 (1983) 147-200; Bull. WHO 57 (1979) 767-771; Wegner, D.H.G, Therapeutic Drugs (1991), Churchill Livingstone; Adv. Intern. Med. 32 (1987) 193-206; Drugs 42 (1991) 379-405; Pharmac. Ther. 68 (1995) 35-85; Ann. Intern. Med. 110 (1989) 290-296). Despite its lack of known toxicity, the drug was not tested on pregnant or lactating women prior to release. It is currently listed as Pregnancy Category B by the US FDA, which is a drug presumed safe based in animal studies. Unfortunately, this has been interpreted by most national control programs and WHO (1998) to exclude lactating and pregnant women from treatment. In fact, some experts advocate excluding adolescent girls from mass treatment campaigns over this issue. As a result, a large number of women living in endemic countries are currently left untreated or have treatment significantly delayed. A review of the current known toxicology of PZQ, combined with over two decades of clinical experience with this drug, suggest very low potential for adverse effects on either the mother or her unborn child. In contrast, significant animal and human data are presented in this review that suggest both the pregnant woman and her unborn fetus suffer morbid sequella from schistosomiasis. A double-blind placebo-controlled trial that could resolve this issue would require a very large and expensive study and in light of the above facts might not now be ethically appropriate. The author concludes that pregnant women should be treated with PZQ, that women of childbearing age should be included in all mass treatment programs and that lactating women are not systematically excluded from treatment.

New policies for using anthelmintics in high risk groups.

The 'Informal Consultation on the Use of Praziquantel during Pregnancy/Lactation, and Albendazole/Mebendazole in Children under 24 Months' was held 8-9 April 2002, in Geneva, Switzerland.

Genetic component to susceptibility to Trichuris trichiura: evidence from two Asian populations.

Trichuris trichiura is an helminthic infection with potentially severe health consequences. The hypothesis that host genetic factors can account for the distribution of Trichuris was tested using familial data on egg counts available for two populations, the Jirels of Nepal and the population of Jishan Island in Jiangxi Province of the People's Republic of China. Whipworm is highly prevalent in the Jishan Island population (86%), but occurs at a low rate in the Jirel population (14%). A quantitative genetic analysis was performed on each data set, using a variance component approach. Approximately 28% of the variation in Trichuris trichiura loads was attributable to genetic factors in both populations. Common household effects accounted for only 4% of the variation in the Jirels and none of the variation in the Jishan Island population. These concordant results from two separate populations provide strong evidence of the important role of genetics in determining differential susceptibility to whipworm infection.

Recent Advances in Schistosomiasis.

Schistosomiasis is a major parasitic disease, affecting nearly 200 million persons, worldwide. Major advances in our knowledge-in terms of pathogenesis, improved diagnosis, therapeutics (both drugs and strategies), and morbidity assessment-now make schistosomiasis a curable, often preventable disease. In contrast to most other illnesses, most schistosomiasis pathology appears to be reversible over time. For the future, several promising vaccine candidates are already in phase-I or phase-II testing. On the other hand, the range of this disease has been increasing, as water resources are developed in several newly industrialized countries and much of schistosomiasis in sub-Saharan Africa remains largely untreated.