Wuhan, China

January 25, 2008

No talk of global warming here, at least not this week. Supposedly to a “sub-tropical” clime, our trip to Wuhan happens to coincide with the coldest and snowiest spell here in decades. Icicle-bedraped palm trees, an odd sight. Polished marble sidewalks and porticos—no doubt elegant in more normal times, now ice-glazed and hazardous—reduce ambulation to a wall-clinging, shuffling adventure. Three-blanket nights in bone-chilling hotel rooms. Although the outdoor temperatures aren’t that far below freezing, most of the buildings lack central heating so everyone wears their coats all the time, indoors as well as outdoors. Ah, makes a Pittsburgher feel right at home.

Now on the last leg of my four-legged, four-week journey, I am in Wuhan, China, to evaluate and cultivate prospects for collaborations on global health. I have arranged for a small delegation of Pitt environmental health experts to meet me here. With me now is Bernie Goldstein, my predecessor as Dean of the Graduate School of Pubic Health (GSPH). Before coming to Pitt, Bernie had a distinguished career in environmental health research, including a stint as the Chief Scientist at the EPA. Bernie had a flight delay en route and missed a connection, so we had to proceed without him on the first day. Robbie Ali, an assistant professor and physician with an environmental and occupational health background—who already has strong ties to Wuhan through his wife and in-laws—is here from GSPH too. Robbie speaks Mandarin very well, almost fluently. He gets around Wuhan like a native and arranged most of our local agenda. I also invited Ken Olden, former Director of the National Institute of Environmental Health Sciences, to supplement our delegation. Ken’s expert insights have been invaluable. While in Wuhan I also took the opportunity to visit some virologists who worked on SARS during the epidemic a few years ago.

With Robbie and Ken at the entrance to Wuhan University Health Sciences Campus, in front of a statue of Chairman Mao.

Wuhan is the capital of Hubei Province, situated at the confluence of the Yangtze and Hanshui rivers, about 1,000 kilometers inland. The fourth largest city in China (population of about 10 million), Wuhan is the political, economic, and cultural hub of central China. Both Wuhan and Pittsburgh are located in their respective country’s industrial “heartland” well removed from the coasts, and both cites are situated at the confluence of major rivers, features that have had strong parallel influences their respective political, industrial, and environmental histories. The cities of Wuhan and Pittsburgh already have warm relations that should facilitate new cooperative projects on health. The two cities have been “sister cities” since 1982; city and county government leaders have exchanged visits on several occasions. Furthermore, last year Wuhan University and the University of Pittsburgh—with financial support from the Chinese government—jointly formed a Confucius Institute whose purpose is to foster intercultural understanding, to facilitate the exchange of faculty and students, and to promote academic collaborations between the two Universities.

This week I travelled quite a bit within the city of Wuhan itself, and found it to be—with the exception of the heating—a fully modern international metropolis. There are few bicycles on the streets anymore—they’re jammed with cars and buses—but this in part may reflect the cold weather. The roads, utilities, and buildings are modern and Western (but the toilets are not). Wuhan is much more similar to American cities than it is to cities in developing countries. That said, the weather precluded visits to rural areas outside Wuhan on this trip. On past trips elsewhere in China I have gone to rural regions where I have visited dirt-poor and technologically backward villages. I readily appreciate the growing urban-rural wealth disparities here.

Our Chinese university counterpart hosts have been very helpful. A team from the International Affairs Office of Wuhan University served as our primary point of contact and provided us with transportation. Importantly they also provided a translator. Of the four countries I have visited on this trip, communication has been most difficult here in China, by far. Essentially no one speaks English: not the smiling functionary at the airport information kiosk, not the hotel desk clerk, not even most professors. We Americans have become spoiled by the near universality of spoken English as the basal medium of international communication. Not here. China is very large, very autonomous, and very …. Chinese. I needed a translator by my side at every meeting. And of course, every conversation takes twice as long—at least—when conducted through a translator, so our meetings here all tended to be formal, frustrating, slow, and relatively uninformative for the effort expended. Of course, I expected this; communication has been no more or less difficult than elsewhere in my prior China experiences.

Our capable translator, Geng Jia—or Christina as she permitted herself to be called—was a shy 23-year-old masters student studying English translation at Wuhan University. She did a terrific job. I committed a minor faux pas when I asked her if she had any brothers or sisters. She responded that no, she didn’t, and that no else her age had any siblings, either. She was born during the mandatory “one child only” era in China.

On our first day here we visited the Wuhan University School of Public Health, a small new school with strengths in the social and behavioral health sciences. The Dean, Zongfu Mao, was keen to develop collaborations with Pitt. Dean Mao and his predecessor Dean Bi had both spent time working at West Virginia University, with the National Institute of Occupational Safety and Health in Morgantown, and had briefly visited Pittsburgh. Later that day we met with Wuhan University Vice President Zhou Shuanbing, a civil engineer by training. He proposed that we draw up a memo of cooperation as soon as is reasonable.

Joining us for our visit to Wuhan University was the new US Consul General in Wuhan, Mrs. Wendy Lyle. She is the first CG in Wuhan and has been in residence for only two months; she points out that a new consulate is an important step up for Wuhan, and she promised to do whatever she could to facilitate our programs in Wuhan. She promptly re-organized her schedule to overlap twice more with ours after she expressed interest in visiting health institutions with us. She is an effusive and interesting character. Years ago Mrs. Lyle was the main English-speaking Voice of America broadcaster. Now, decades later, many of the English-speaking Chinese citizens we met greeted her as a celebrity and joyfully told her how she had influenced their lives. I have a renewed respect for the impact of VOA—and Mrs. Lyle.

Ken standing before the Wuhan University Library.

We spent Tuesday at the School of Public Health of the Tongji Medical College of the Huazhong University of Science and Technology. Unlike the small and young school at Wuhan University, the Tongji School of Public Health has 93 faculty with a full array of public health backgrounds and expertise and 150 graduate students. The school serves as home to the Hubei Key Laboratory of Environment and Health, the main environmental health lab serving a population of tens of millions. Joining us for the meeting at Tongji were Environmental Protection Agency officials from the national, state, and municipal levels. We had a good discussion (through translators, of course) about Chinese priorities and plans for environmental health.

Formal meeting with Senior Faculty of the Tongji School of Public Health and governmental EPA officials.

Our third day, Wednesday, was spent meeting with the leadership of the Wuhan Municipal Environmental Health Bureau. Again, we learned about priorities and plans. Two recent high-level developments in China should favor the creation of a new cooperative project on environmental health. On November 21, 2007, the Chinese government launched its first national environmental health action plan, the “National Environmental Health Action Plan for the Years 2007-2015.” This plan provides basic principles, goals, and action strategies to be implemented throughout China over the next eight years. The plan calls for establishment of surveillance networks, interagency cooperation, and collaborative international research. Local implementation plans in Wuhan are in development. In an unrelated but equally important step, on December 17 the Chinese government announced that a cluster of four cities in central China, one of them Wuhan, had been designated a national experimental zone to develop and evaluate new environmentally friendly programs. The National Development and Reform Commission has directed these cities to “as quickly as possible form systems and mechanisms beneficial to energy saving and environmental and ecological protection.” Again, local Wuhan implementation plans are now just under development. Environmental Health does seem to be a genuine priority here; they just moved into a beautiful new and well equipped 12-story building. We were shown impressive demonstrations of real time environmental ozone monitoring throughout the city.

Demonstration of the real time ozone monitoring system at the Wuhan Municipal Environmental Health Bureau.

While here we also called upon other health institutions. I already knew of, and had indirect contacts with, the excellent scientists at the Wuhan Institute of Virology (WIV) of the Chinese Academy of Sciences. Zhihong Hu, director of the institute, is the only woman director of a major Chinese agency we met. Her laboratories are modern, well equipped, and bustling with activity. I was invited to give a lecture at the Institute, which I did. On entry into the front lobby there was a large, 3-by-5-meter digital message board announcing my lecture. On this particular day in front of the message board there happened to be a group of a dozen young women, junior faculty and students, who were practicing a dance routine for performance at an upcoming festival. When I observed that it was the first time as a visiting lecturer that I had been greeted by dancing girls, Zhihong Hu burst out laughing. The WIV, under the direction of Shi Zhengli, is building the first level four BioSafety Lab (BSL-4) lab in China. Shi Zhengli, who did some excellent work on SARS, splits her time now between lab work and construction planning.

Young women faculty and students practicing a dance routine in the lobby of the Wuhan Institute of Virology

We were fortunate to fit in a visit to the ABSL-3 laboratory group at Wuhan University. They, like Joanne Flynn at Pitt, have received funding from the Gates Foundation to do tuberculosis vaccine testing. There are some excellent prospects for cooperation in infectious disease research in Wuhan, as well as environmental health research.

We also paid a call on some health institutions outside the pubic health field. The Wuhan University School of Nursing, supported by Project Hope, is headed by Dean Marcia Petrani, the only American faculty member we met at any of the institutions we visited. And we were given a tour of the magnificent new 2000 bed Wuhan Union hospital. Many of the physicians we met here had some training in America. The head of the Thoracic Surgery Unit, Professor Wang JinaJun, did his residency at Pitt over a decade ago, and expressed fond memories of Pittsburgh. As everywhere else in Wuhan, the reception we received was open and inviting. Indeed, I hope we can fulfill even some the potential collaborations that we found.

Touring the Wuhan Union Hospital Cardiac Intensive Care Unit. US Counsel General Wendy Lyle is the woman in the center. The red splotches on the gowns are not blood, they are Chinese ideographs.

Ken, Bernie, Robbie, and I all considered the prospects for collaboration here to be very good. There is an extraordinary confluence of favorable circumstances: a new Confucius Institute with Wuhan University, a new US consulate, a new National Plan, and a new Wuhan environmental enterprise zone. We discussed the possibility of creating a cooperative Environmental Health Indictors Project involving academic and local government institutions in Wuhan and Pittsburgh. Possible objectives of such a project could be to improve monitoring of environmental indicators for human health risks, to link environmental indicator monitoring data to local health outcomes data, and to develop cost-effective policies to mitigate the effects of environmental pollution on human health. The idea, just conceived, will have to gestate for a bit.

* * * * *

Today is the final day of my journey, a time to wrap up and write down some of my thoughts. It will be good to be home again.

Hyderabad, India

January 20, 2008

Whew. Catching my thoughts—and my breath—in the sweltering airport departure lounge after six frenzied days in this Southern India city … a week of brilliantly colored saris and filthy rags, fragrant cooking aromas and foul open sewers, Rolls-Royces and three wheelers, quiet meditation and continuous cacophony: Hyderabad assaults the senses. It’s wonderful!

My purpose here, as elsewhere on this trip, was to cultivate prospects for Pitt to strengthen its research and training relationships with academic health institutions. Larry Feick, Director of the University Center for International Studies (UCIS), accompanied me here in his role to build international relationships across the lower campus. Given Larry’s pre-UCIS background in the School of Business, we also paid special attention to Hyderabad academic business and management programs as well as health programs.

I came to Hyderabad to learn more about the small empire of health institutions built from scratch by Professor Pessara Sudekhar Reddy, better known simply as “P.S.” He was born in a district about 150 km north of here and completed his medical degree at the Gandhi Medical College in Hyderabad before coming to the United States where has been a successful Pitt School of Medicine academic cardiologist for more than 30 years. In the mid 1980s, P.S. and a nucleus of Indian-American physicians and friends launched project SHARE, a non-profit organization dedicated to improving medical training and care in the Hyderabad region. SHARE went on to successfully spawn a medical school, a nursing school, a tertiary city hospital, a large community hospital, a state-wide AIDS control program, and a district-wide maternal and child health program. P.S. led the creation of all these programs as he continuously shuttled back and forth between Pittsburgh and Hyderabad. Now trim and patrician as he approaches 70, P.S. speaks softly, never fretting or ruffling. He effortlessly and radiantly glides through Hyderabad’s chaos. Larry and I lodged together with P.S. at the SHARE apartment guest house for the week. P.S. accompanied us on all our meetings, and we ate every meal with him! Although gracious throughout, I’ll bet he was relieved to see us go.

Dr. P.S. Reddy, MediCity founder, looking out at the hospital from the balcony of the medical school.

Medical history hobbyist that I am, I recalled that it was in Secunderabad (the smaller half of the Hyderabad-Secunderabad twin cities) that Major Ronald Ross in 1897 discovered the role of mosquitoes in the transmission of malaria. So on the Sunday I arrived we promptly visited the site, a dilapidated but partially restored, musty, single-storied British military hospital, not much more than a shack. I lit metaphorical incense at this latter-day shrine to Ross’s Nobel Prize-winning work. Later, on Tuesday—an Indian festival holiday—I was given a tour of the India Institute of the History of Medicine. Their prize holdings are dozens of extraordinarily well preserved bound palm leaf Aruveydic texts, some four to five hundred years old. They are now digitizing many of their holdings for online display. In the helter-skelter of daily Hyderabad life, it can be easy to overlook the rich history here.

Overall, I found the potential for medical research and training collaborations here to be terrific. The MediCiti hospital in Medchal district is a 500-bed facility situated on a rock-strewn, 600-acre rural campus (Medchal is the name of the district; the “Med” in Medchal has local language roots, and nothing to do with medicine). The hospital consists of six spartan but clean and adequately equipped four-story buildings. Sixty physicians covering all the major specialties treat inpatients, see about 500 outpatients daily, and teach at the medical college better known as the MediCiti Institute of Medical Sciences (MIMS). Although there is a hospital laboratory, most patients are diagnosed and managed on clinical grounds. The MIMS medical and nursing colleges are also “no-frills.” Each medical school class has about 100 students who are awarded an MBBS and each nursing school class has 60 students who take a three year course leading to a diploma.

Now that the schools are established, P.S. is trying to create an academic culture at MIMS. He has a marketer’s knack for acronyms; the major research projects are named REACH (Rural Effective Affordable Comprehensive Healthcare) and CATCH (Community Access to Cervical Health).

The goal of the REACH project is to provide universal quality health care in Medchal, which has a population of about 48,000. The centerpiece is a program to measure and reduce infant and maternal mortality rates. This is carried out by a cadre of 45 semi-educated women who serve as community health volunteers (CHVs), one per village. The women, who know their village neighbors well, record all pregnancies, births, and deaths. They monitor the health and vaccination status of every infant. All these data, along with GIS mapping of households, kinships, and socio-economic data are regularly reported to the REACH data system. When a vaccination is missed, the local community health volunteer arranges for an on-site immunization. The percent of children who are completely immunized rose in Medchal from the national rural average of less than 50 percent to its current level of more than 90 percent.

Community Health Volunteers assembled to meet with me (they really are much warmer and friendlier than comes through in this photo).

Vaccination in an infant's bum

Moms and their small children awaiting vaccination

The women also conduct a program to provide half-day preschool activities, and a nutritious lunch, for all 2-to-6-year-olds. The children sat on the floor, answering their teacher in unison, then clapping and singing tunes together. Outside, an elderly grandma prepared upma, a bland but nutritious semolinia gruel that the kids seemed to relish. It was orderly, efficient, and loving. I was moved.

Healthy kids in project REACH day care, awaiting lunch

The CATCH program, carried out in collaboration with my old colleague Dr. Patty Gravitt at Johns Hopkins, is a program on HPV and cervical cancer in Medchal women older than 25. More than 2,000 study participants have been screened for human papillomavirus, had a pelvic exam, and a biopsy and treatment whenever necessary. The genius of the CATCH program is that builds directly off the extraordinary REACH data system. The difficulties are those expected in any population, including gaining participation and informed consent, and compliance. The CATCH project has clearly demonstrated that sophisticated and detailed studies can be done in this rural population. This message was clear to me.

Back at the hospital, P.S. and the MediCiti group gave me the honor of cutting the ribbon at the opening ceremony for a modern 6,000-square-foot Research Center that should provide a valuable core facility for MIMS investigators and their foreign collaborators. Ever the promoter, P.S. had an office in his new center ready for me, complete with a “University of Pittsburgh” sign on the door. After the ceremony the entire hospital staff celebrated with a luncheon of kabobs and curries.

Another major SHARE program in Hyderabad is the Andhra Pradesh AIDS Consortium Project (APAIDSCON), a state-wide HIV/AIDS education, prevention, and treatment program at 15 medical colleges. The program is well funded by the US PEPFAR (President’s Emergency Program for AIDS Relief) and has emerged as one of the largest providers of AIDS services, public or private, in the state. SHARE has just constructed a new building that will house APAIDSCON together with an AIDS outpatient treatment ward and a full-service diagnostic laboratory. The doctors I met were young, bright, and enthusiastic.

It so happens that several of India’s largest new biotech companies are in Hyderabad, so I took the opportunity to visit two, Shanta Biotech and Bharat Biotech. Both are modern WHO-approved, state-of-the-art manufacturing plants that market vaccines worldwide, mostly through UNICEF to developing countries. We were taken on a full tour of Shanta Biotech’s diphtheria vaccine manufacturing building, which I found to be scrupulously clean, well run, and compliant with the highest standards.

Shanta Biotech Vaccine manufacturing facility in Hyderabad.

Several other academic institutions in Hyderabad that could be valuable partners:
The University of Hyderabad already provides a home to the Pitt in India program, so we called upon them. The University is led by Chancellor Seyed Hasnain, a brilliant and dynamic microbiologist with a special interest in tuberculosis. He revealed his plans to launch a new Center for Medical Sciences with a focus on human diseases including tuberculosis. Here too there were obvious opportunities for collaboration. However, when I suggested to Professor Hasnain that he should visit Pittsburgh, he candidly proclaimed that he had stopped travelling to the United States for several years now because the hassles of obtaining visas and clearances were simply too great. Instead he travels to Europe for scientific meetings.

Another important new institution for Pitt’s plans in India is the Public Health Foundation of India. The Foundation, headed by Professor Srinath Reddy (not a direct relative of P.S.’s) aims to build, equip, staff, and support 11 new schools of public health all across India. The furthest along is the school in Hyderabad. Land has been acquired, plans approved, and construction is to begin next month. GSPH is already training one Indian physician who is in the MPH program in preparation for his taking up a position as one of the first faculty members at the school of public health in Hyderabad.

At the site of the future Hyderabad School of Public Health (with the project director and the site manager).

Along with Larry Feick, we called upon Pitt Business School Professor Kuldeep Shastri who was in Hyderabad to teach at the private Indian School of Business. The ISB facilities are gorgeous. Kuldeep will teach his course on risk management for just six weeks then return to Pitt. He, like many Indian-American expats who return to India to teach at ISB, uses his time in India to visit with family, in his case his elderly mother.

I am very enthusiastic about the potential for Hyderabad and especially the SHARE as an excellent partner for Pitt global health activities. A whole host of projects could be done on childhood nutrition, tuberculosis, or vaccine-preventable diseases. When I asked the Community Health Volunteers to suggest a top priority, they almost unanimously wanted an effort on motor vehicle accidents. Hair-raising incident after hair-raising incident on the Hyderabad roads left me unsurprised that they answered that way. However, the most productive new studies would be those built upon the currently existing and highly successful REACH maternal-infant cohort. P.S. and I decided to move ahead full speed with a pilot project aimed at creating in Hyderabad a project parallel to the National Children’s Study; Roberta Ness and Clare Bunker have already begun drawing up plans for it.

Now I’m off for Wuhan, China.

Hyderabad Rocks

An odd feature of the terrain around Hyderabad is its rocks. The city and countryside are strewn with boulders and mounds. All are rounded or ovoid, ranging in size from hundreds of meters across to single stones of a few tons and on down. It is commonplace to find a 10-ton boulder perched precariously atop another boulder of only slightly larger size, defying logic – and gravity. Here and there you can spot a formation with yet a third boulder atop. Although I’m sure there’s a rational geological explanation, my own theory is that that such quirky formations must have been placed by an ancient race of giants. No other explanation seemed adequate. The photo above is not mine, but is from a New York Times article that you can read here.

Doha, Qatar

I arrived in Doha late last Tuesday night (January 7). Fridays and Saturdays are the official weekend here in Qatar, so I had just two full work days to conduct my business. Accompanying me on this leg of my trip to Qatar is Dr. Cliff Brubaker, Dean of Pitt’s School of Health and Rehabilitation Sciences. We also linked up with Mr. George Fechter, formerly Pitt’s Health Sciences Associate Vice Chancellor for External Relations, who is in Doha as a visiting lecturer.

For almost two years now UPMC has had a contract with the Hamad Medical Corporation, through the Qatar government, to provide education, training and services to Qatar’s emergency medical system for the entire country. UPMC Project Director Dr. Walt Stoy and his team of 20 mostly American expatriates have been terrific hosts for our visit. Walt is Professor of Emergency Medicine at Pitt, in Cliff’s School of Health and Rehabilitation Sciences. A long time Pittsburgher, he received his PhD in Education, specializing in instructional design and technology. Like many on his team, Walt shuttles back and forth between Pittsburgh and Doha at least once a month. He works and talks at a frenetic pace, pausing every few seconds to peer over his salt and pepper walrus moustache to check his blackberry. At dinner his physician colleagues grab for their hand-held radios 24/7 to reply to field teams of emergency medical technicians calling in to seek management advice about this or that horrific calamity. A cardiac arrest case, then a broken skull, then a tension pneumothorax, and on it goes. What a pace!

Qatar, on the Southwest shore of the Persian Gulf, is an Arab Emirate with a total population of about 1 million, of whom only about 200,000 are citizens. Most of the population are expatriate guest workers, supported by Qatar’s extraordinary income from natural gas. Because so many of the guest workers are male, the gender ratio is almost 2 to 1 males to females, the most skewed in the world. Most of the expatriate men come from India, the Philippines, or other Asian countries to work as construction laborers. The citizenry is 90% Sunni and 10% Shiite Muslims. Although Qatar is liberal compared to many Islamic Arab countries, Qatari women typically wear a full black traditional dress with head cover and face cover. It is not acceptable to photograph Muslim women here, so I have been very careful not to include them in my snapshots. Nor does a man put forth a hand to shake hands with a woman, western style. One merely nods his head and touches his chest.

That said, the Qataris are friendly people who readily exchange greetings and smiles with strangers, even on the street. In conversation, Qataris can be quite direct, a refreshing difference from other cultures where determining if you have just been told “yes” or “no” can be difficult. Perhaps the most striking feature of modern Qatar society is the infrastructure: the roads are paved, the air is clear, and hospitals are spotless. Of course, this reflects huge investments by the Qatar government over the past few years. The real problem faced by Qatar is trained and educated professional workforce. Although Qataris hold the highest positions in government and business, essentially all of the technocrats are foreigners. One good example of this is the UPMC team. Outside of natural gas, Qatar has few natural resources to support its economy, so an educated citizenry will be essential to sustained national well-being when the gas reserves become depleted in a few decades.

Qatar’s solution has been the creation of “Education City,” a unique 2,500-acre campus on the outskirts of Doha which hosts branch campuses of leading universities from around the world, mostly from North America. Our Pittsburgh colleagues from Carnegie Mellon University run two programs, one in computer science and one in business. Others include the Weil Cornell Medical School; the University of Calgary School of Nursing; the Georgetown School of Foreign Service, and five other programs. Each matriculates around 50 students per year, largely from nearby counties, with a sizable fraction from Qatar itself. We met with Weil Cornell Dean Daniel Alonso, a gracious and gentlemanly pathologist who has led the Cornell program since its inception six years ago. He is justifiably proud of his first crop of graduates this year (theirs is a “2+4” or six year curriculum).

A sincere public thank you to our CMU brothers and sisters; the Carnegie Mellon team was especially open and helpful. CMU-Q Dean Chuck Thorpe, Strategic Initiatives Director Anqi Qian, and Associate Dean Mohamed Dobashi all provided experienced insights into Qatar practices and politics. And through its long-term excellent relations with the Qatar Foundation, the Pittsburgh CMU President’s office provided us with some important Qatari contacts.

The Hamad General Hospital, where Walt Stoy and his team are headquartered, is an active modern general hospital. The Emergency Department is incredibly busy, averaging about 1,000 new patient visits each day. Yes, that’s 1,000 per day, almost one every minute! It is probably the busiest ED in the world. Physically the Emergency Department is divided into two separate and equal services, one for males and one for females. Most of the visits are by guest workers (laborers) so 80% of the patients are males. Layout, logistics, staffing, and training are all potential nightmares, but the place seems under control, even efficient, in no small part thanks to the improvements instituted by the UPMC team. Like the workforce at large, most of the ED physicians are expats from Egypt, Jordan/Palestine, India, Iraq, and other countries in the region; a substantial portion of the nurses are from the Philippines. ED data and statistical records are improving in quantity and quality, and a new electronic medical record is being implemented.

Outside Hamad General Hospital, there are five more hospitals in the Hamad Medical Corporation system. On the weekend (Friday), on a trip to the countryside, we unannounced dropped in on a visit to the ED at Al Khor Hospital, about 50 km north of Doha. The intervening roadside landscape had been flat, bleak, and uninhabited, interspersed with frequent “warning - camel crossing” signs. I expected a grim, dirty, marginally functional health unit, much as I had seen upcountry in many other provincial hospitals in other countries. I was shocked to find a modern, computerized, well equipped, well staffed, and clean facility. Everyone wore “UPMC – HMC” name tags, Purell hand sanitizers dotted the walls, and prominent posters reminded the ED staff to treat patients with respect, introduce themselves, and explain what was going on to the patients. Hallways, waiting rooms, and public restrooms were spotless! I would have been confident to have myself or my family treated there (or at least, substantially less concerned than at most comparable locations elsewhere in the world).

There could be real training opportunities for University of Pittsburgh health sciences students and residents in a number of capacities in emergency medicine, especially in recording and analyzing the impact of newly implemented policies during such a time of change.

I can also see several global health opportunities here. The first is in the area of rehabilitation. The program directors Cliff and I met were quite interested in training opportunities for their own faculty and professional staff, as well as trainees. Because Qatar usually does not send expatriates abroad for training, yet most faculty and professional staff are not Qatari, we were advised that the greatest demand would be in on-line and in-country short courses that awarded a completion certificate or similar non-degree recognition of achievement. Cliff and I came away encouraged about the prospects. We also met with directors of pharmacy, nursing, and other health specialties, who echoed these perceptions of training requirements.

Of course, I also looked into the prospects for research and training in public health. Currently there is no School of Public Health in the country. Most of the reliable health statistics are compiled from analysis of hospital records of the Hamad Medical Corporation; although there is an extensive primary care system throughout the country, record keeping is minimal and data are lacking. Professor Abdulbari Bener, Head of the Departement of Epidemiology and Medical Statistics, puts out a fine national Annual Health Report. He recognizes needs for training and support for public health programs. Importantly, just three months ago an expat (American) Gail Fraser Chanpong was appointed Director of Public Health for the National Health Authority, with a mandate for action and a budget to match. Gail is a DrPH with substantial international experience in Trinidad, Indonesia, and Tanzania. It’s a good bet that she will be able to help substantially strengthen Public Health programs in Qatar.

Qatar rightly sees itself as a model progressive Islamic Arab state. The Qataris are justifiably proud of their global TV news station Al Jazeera (the very term Al Jazeera means “the peninsula,” referring to the Peninsula of Qatar) The Qatari’s are making some bold and visionary moves to modernize their infrastructure and education systems. It strikes me that as the USA strategically moves to restore its relationships with the Islamic world, Qatar, and especially health initiatives with Qatar, could serve as a keystone for such a strategy.

Construction cranes are everywhere in Doha.

Modern, well equipped, and staffed Emergency Department at Hamad General Hospital

Camel-crossing warning highway sign

Chuck Thorpe, Dean of CMU-Qatar

Palermo, Italy, ISMETT visit

Early AM, 7 January 2008

We arrived in Palermo on schedule on Thursday morning. Accompanying me on this leg of my trip is Chuck Rinaldo, Chairman of Infectious Diseases and Microbiology at GSPH. I invited Chuck for his expertise in viral infections in transplantation.

My purpose here is to explore collaborative research and training opportunities between the University of Pittsburgh and ISMETT, the Italian acronym for the Mediterranean Institute for Transplantation and Specialized Therapies. ISMETT is an exciting joint venture between UPMC and the Italian and Sicilian governments to create a state-of-the-art transplant hospital in Palermo. In years past Sicilian patients requiring transplants were typically sent to centers outside Italy, at great expense to the government. The idea was to create a joint public-private (with UPMC) center of transplantation excellence that would build up local Sicilian medical and scientific infrastructure and at the same time keep money in the country. By most measures the ISMETT experiment is a runaway success. ISMETT has rapidly become a leading Italian center, both in number of transplants performed and the vitality of the scientific program. ISMETT emphasizes liver transplants, but also performs a large number heart, lung, and other organ transplants.

Although transplantation is the central procedure, for every transplant patient ISMETT provides the medical care for dozens of other severely ill patients who are awaiting transplantation. Because of this, ISMETT is essentially a full-service hospital, with more than 70 full time physicians, 300 nurses, and a large staff.

ISMETT is directed by Dr. Bruno Gridelli, a transplant surgeon whose youthful appearance and soft spoken manner conceal ferocious drive, energy, and intelligence. Originally from the North of Italy, Bruno trained in Pittsburgh and has strong Pitt/UPMC connections. He met his charming American wife Melanie in Pittsburgh, where she worked at Mellon bank.

Dr. Gridelli arranged a full schedule for us to meet with ISMETT physicians and scientists, ranging from transplant surgeons to cardiologists to infectious disease specialists to regulatory compliance experts. Most spoke English well, only a few required translators. We also toured the facility.

The main ISMETT building, constructed only four years ago, is a surprisingly large, completely modern hospital with a state of the art ICU, sophisticated radiology and imaging, comfortable patient areas, and an efficient staff. Implementation of a new comprehensive Electronic Medical Record is essentially complete for all patient-related data.

Now that the clinical program is successfully launched, attention at ISMETT is turning toward developing a research program, with a strong emphasis on transplantation. A second major public–private partnership with UPMC has recently been announced, this one aiming to create a research institute in Palermo, and to train post doctoral research scientists who will return to Palermo to staff the institute. The new research institute will be physically and administratively distinct from ISMETT, but closely linked scientifically. Based on my initial discussions, I can foresee a wealth of opportunities where Pitt and ISMETT could develop important and productive collaborations.

Most ISMETT liver transplants are done for liver failure or liver cancer caused by hepatitis C virus, a common infection in Sicily as it is throughout the Mediterranean region. Because some virus remains in patients’ bodies after transplantation with a new liver, the virus infects the new liver and causes recurrence of hepatitis and destruction of the new liver. Methods are needed to prevent this terrible but very common occurrence. Would it be possible to cure a patient of hepatitis C at the time of transplant? Chuck Rinaldo is already working on defining T-lymphocyte activity against hepatitis C virus infected cells. One possible project would be to grow large quantities of anti-hepatitis C lymphocytes in the new ISMETT GMP “cell factory” facility and infuse these cells into a patient at the time of transplant. The large bulk of hepatitis C virus will be removed with the diseased liver, and such immunotherapy could contain or even eliminate residual virus. Alternatively, anti-hepatitis C drugs might be added to lymphocyte infusions, in an all-out effort to cure the patient.

Another chronic virus that causes transplant problems is the Human Herpes Virus Type 8 (HHV-8), also known as the Kaposi’s Sarcoma Herpes Virus (KSHV). Prevalences of this virus are about 7% in ISMETT transplant patients and donors, and recurrent or acute KSHV infections are a serious problem in transplant recipients here. Pat Moore and Yuan Chang, the discoverers of KSHV are professors at Pitt (UPCI). Pat and Yuan could provide outstanding expertise in research into improved diagnostics and therapeutics for KSHV. I plan to ask them to visit ISMETT soon.

ISMETT has growing training needs. For example, transplant patients require unusually intensive and complex nursing care, but trained nurses are in short supply in Sicily. The University of Palermo has a solid three-year nurses training program, yet an additional training period beyond three years is necessary for most ISMETT nurses. This would seem to be a good area of opportunity for the Pitt School of Nursing and ISMETT. Another need is in health administration, where a program could be developed through the Pitt Health Policy and Management Department at the School of Public Health.

One exciting opportunity would be to create a Mediterranean center of health research excellence, headquartered in Palermo. Located smack in the center of the Mediterranean Sea, only a short distance from Northern Africa, Sicily serves as a bridge between Arab and European cultures. These dual influences permeate every aspect of Sicilian life, from art and religion to language and food. Nowhere is this fusion of cultures more evident than in the spectacular Monreal Cathedral here just outside Palermo. Within this Norman Christian Church the life of Jesus is shown in spectacular mosaic tiled murals, bordered with classic interwoven Arabian patterns. The nearby cloisters are similarly decorated with an Arabian flair. ISMETT has already struck agreements on transplantation with Tunisia, Libya, and Egypt. This could provide a creative opportunity for the USA to mend its dangerously frayed relationships with the Islamic world! ISMETT could become a lead partner in growing cooperation on health research with the moderate north African Islamic states. Tempting as such grand visions may be, we of course will want to proceed stepwise. Perhaps we could start by co-sponsoring a small multi-country conference at ISMETT.

I’ve been up for a couple of hours now, and its time for breakfast. Another full day at ISMETT today, then off to Doha, Qatar, tomorrow morning.
















With ISMETT leadership (L to R): Giovanni Vinzzini, Ugo Palazzo, Bruno Gridelli, Don Burke, Gabriele Cappelletti, Chuck Rinaldo
















Small child who received a liver transplant in the ISMETT ICU

Robotic cell culture chamber in the ISMETT Good Manufacturing Practices “Cell Factory” facility

Columns in the Cloisters of the Monreal Cathedral showing Arab artistic influence.