Figure.
Figure.
Aerial view of the University of Virginia hospital
© 2003 University of Virginia Hospital
W Michael Scheld graduated from Cornell University Medical College in 1973. From 1973–1979 he completed his internship, residency, and fellowship in infectious diseases at the University of Virginia Medical Centre. He continued his academic career at the University of Virginia, where today he is the Wyeth Professor of Infectious Diseases and Professor of Medicine and Neurosurgery. His research interests include meningitis, central nervous infections, sepsis, septic shock, systemic mycoses, antimicrobial resistance, and HIV/AIDS.
Scheld has received numerous awards, is the author of more than 300 publications, and is the editor of the textbook Infections of the Central Nervous System as well as the section editor for The Cecil Textbook of Medicine. He sits on the editorial and advisory boards of many leading infectious disease journals, and is also the chair of the American Board of Internal Medicine subspecialty board on infectious diseases. He is active in several professional societies, most notably as the President of the Infectious Diseases Society of America (IDSA), President–elect of the National Foundation for Infectious Diseases, and is one of the founding members of the Academic Alliance for AIDS Care And Prevention in Africa.
TLID: What drew you into infectious diseases, and how did you become specifically interested in infections of the central nervous system?
WMS:Well, it started with my father who was a science teacher in the public school system in Connecticut, where I grew up. My father had a microscope and a telescope at home; he was a bit of a “rock hound” too, we would go out and collect fossils for example with our rock hammers. But as a result, it meant that before I went to junior high school, I was looking at pond water and knew the names of organisms such as Paramecium and Hydra, and others. I was fascinated by biology from the very beginning and I liked those courses in high school. But when I was accepted to medical school, my pre–conceived idea was that I would be a practitioner like Marcus Welby, who was a character in a television series in the 1950s and 1960s. He was a primary care provider and that was my role model. I had also spent a great deal of time with other family members who were in training to be veterinarians, and principally were private practitioners. So when I went to medical school I didn't have an academic career in mind at all, and I certainly didn't know what an academic physician did.
In my second year in medical school, I really enjoyed microbiology. I wrote a paper on infectious organisms as a cause of chronic conditions like cancer, an area of research which is very much in the limelight today. During my second year I took a course in parasitology that was taught predominantly by Benjamin Kean and Phillip Marsden. Both of them were phenomenal lecturers and instructors. The parasitology course at Cornell was spectacular and I really enjoyed it, and thought maybe I could make a career of studying and treating microorganisms and infectious disease. But then I liked internal medicine the most during my third year of training, so in my fourth year of medical school, I decided to do an elective in infectious diseases to test the waters. I was fortunate enough to do an elective at the Memorial Sloan–Kettering Cancer Center in New York. We did all the infectious disease consultations (approximately ten to 15 a day). My attending physician was Donald Armstrong who served as a previous president of IDSA. A conference held once a week called Inner City Rounds rotated from one hospital to another in New York and New Jersey where unknown cases were presented to the visiting attendants. It was very stimulating and a great conference, and at this stage I said, “I can do this, this is what I want to do”.
So when I applied for a residency, I chose a place that was already strong in infectious diseases, thinking I might be able to do a fellowship in infectious disease and residency at the same institution. This is primarily why I came to the University of Virginia. Edward Hook, another one of my mentors, had left Cornell as chief of infectious diseases and moved to the University of Virginia as the chairman of medicine, where he was developing an excellent division of infectious diseases under Gerald Mandell's leadership. And so I came to Virginia. My major mentor during that time was Merle Sande who also served as a past–president of the Infectious Diseases Society of America, as did Gerald Mandell. As a fellow, I was predominantly interested in bacterial pathogenesis, and the first experiments I did were related to bacterial endocarditis, but I quickly became interested in the pathogenesis and pathophysiology of bacterial meningitis. This came about, in part, because a fourth year medical student (Ralph Dacey) had worked the previous year with Merle in developing an model of meningitis in rabbits. Ralph and I were about the same age. Today he is the Chairman of neurosurgery at Washington University in St Louis. With the availability of the animal model to ask some clinically relevant questions in meningitis, I became interested in infections of the CNS. I also worked with Richard Winn who left Virginia to become the chairman of neurosurgery in Seattle, Washington, on developing a model of brain abscess in rats. Therefore, we did a lot of work on the pathogenesis of bacterial meningitis and other infections of the CNS, and it has peaked my interest ever since. Today my research is more focused on septic shock, which has a similar theme. We are interested in how the organism produces death in the host, and the influence of anti–inflammatory strategies, particularly adenosine A2A receptor agonists, on outcome.
TLID: Among the many positions you hold, you are the President of the IDSA. Can you tell us what that role involves?
WMS: The president is an elected position. Individuals are elected to vice–president and they serve in that capacity for 1 year. They then serve as president–elect and then president, then past–president, and so it goes on. On election, it is understood that you give 4 more years of service to the organisation. The work load increases dramatically during the presidential year. The president, with the aid of the executive committee, and the governing council, sets the policy and the activities to benefit the membership of the entire society. We have three council meetings a year chaired by the president and a series of teleconferences once a month in between for the executive committee (president, vice–president, secretary, treasurer, president elect, and past president). We have matured from an organisation of about 2500 members in the early 1990s to about 7500 now, and we have grown from a staff of about three to over 20. But the size of the governing council and their responsibilities really hasn't changed. It is a very collegial organisation and because infectious diseases is not a huge discipline like cardiology, it's a very tight–knit group. Infectious diseases is the most international of all medical subspecialties, and this is a major focus of my current interests. In addition, the staff at IDSA headquarters, from Mark Leasure, our executive director, to all the others recruited by him, is fantastic, and an absolute pleasure to work with. The presidency is rotated based on the business meeting at the annual meeting of the society, so I will be stepping down and handing the baton to Joseph Dalovisio in October.
TLID: There are concerns about antimicrobial shortages and the disincentive of the pharmaceutical companies to develop new anti–infectives. Should we be worried, and how are we going to best overcome this shortage?
WMS: Yes we should be worried. But there are two separate issues here. Firstly antimicrobial shortages to some degree are caused by the pharmaceutical industry fostering a “justin–time” manufacturing technique, so there are never large stockpiles of antibiotics in warehouses. If a sudden demand for an antimicrobial agent develops, this [demand] leads to shortages very rapidly. We have seen this happen with penicillin, nafcillin, some of the aminoglycosides, and other antibiotics in recent years. Another problem is when a well—established antibiotic that is useful–eg, a cephalosporin that is used to treat gonorrhoea–is not manufactured by the drug company anymore due to cost/investment considerations.
The second problem is much more serious. The pipeline of new antibacterial drugs under development by the pharmaceutical industry is drying up. There have been only seven new antibacterials approved over the last 5 years by the Food and Drug Administration (FDA), with only one exploiting a unique target. We at the IDSA are concerned about that. I put together an antimicrobial availability task force on behalf of the IDSA, chaired by John Bartlett of the John Hopkins University. This group is challenged with studying the problem and coming up with some potential solutions to entice pharmaceutical companies into the antibacterial research and development arena. This group has made considerable progress, including meetings with senate and congressional staffers, others on Capitol Hill, Secretary Tommy Thompson, and leaders of the National Institute of Allergy and Infectious Diseases (NIAID), the FDA, and many others. The simple answer is that the pharmaceutical industry is going to need additional incentives to develop antibacterials. One major stumbling block has been that if you are the boss of a pharmaceutical company, you are more likely to put your resources into a drug that patients need to take for a lifetime rather than into a drug that patients take for 1 week to 10 days. Unfortunately, antibacterial development has slowed as a consequence of the success of these drugs, along with vaccinations, the greatest medical advance in the 20th century.
TLID: There is no doubt that 2 years on from the anthrax attacks after September 11, the attention infectious diseases has received has stepped up, with increased funding on the one hand, but with censorship and restrictions of who does research in the USA, on the other, and, more recently, the shift of NIAID research money to buy up 9 million doses of a new anthrax vaccine. Is there a danger of not getting the balance right between treating and preventing everyday infectious diseases and defending ourselves against a bioterroist attack?
WMS: In my judgement we do not have the balance right at the moment. We welcome the new funding (of course), as new and emerging infections are continuously in our midst, such as monkeypox and severe acute respiratory syndrome this year, and West Nile virus since 1999. But I believe there should be increased funding for new and emerging infections as well as problems related to antimicrobal resistance. There is a great deal of money being made available for “bioterrorist” threats. One example is project Bioshield, an administration proposal to develop new vaccines, diagnostics, biologicals, and treatments for agents that might be considered as a bioterrorist weapon. Our approach in the IDSA is to try to make congress realise that antimicrobial resistance is already here and is killing more Americans everyday than any of these “bioterrorist” threats. We have been somewhat successful, because in the final words of this proposal IDSA draws attention to the fact that antimicrobial resistance is here, getting worse, and needs to be addressed by additional funding through the National Institutes of Health (NIH) as well as the US Centres for Disease Control and Prevention. We at the IDSA do not feel that there should be a diversion of NIAID research money to procure a vaccine. We believe this a dangerous precedent. The NIH has never been asked to procure a vaccine before. Of course, the investigators funded by the NIH need enough vaccine to conduct their trials to test the immunogenicity, and establish the adverse event profile of the vaccine, but 9 million doses is excessive. The money to procure vaccines should come from the Department of Homeland Security, which was created to deal with these issues.
TLID: With regards to smallpox vaccination of US healthcare workers and others working on the front line, were you surprised that the first phase of the programme fell far short of its initial goal this year?
WMS: I was somewhat surprised, but not totally. When we heard that the administration was planning to announce a smallpox vaccine initiative in December 2002, I, on behalf of IDSA, wrote to the president and provided a statement of support for a limited smallpox vaccine initiative among health–care workers but strongly opposed vaccinating the entire population. Even so, the first phase of this vaccine programme fell short and I believe some of the public—health officials were surprised. In my view, there were many reasons for this outcome. From the beginning, there was no legislation that dealt with the potential adverse events that might befall a health–care provider receiving the vaccine. That legislation was not signed into law until late spring this year, well after the beginning of the campaign to vaccinate health–care workers. Many people declined vaccination due to the uncertainty of compensation if they had any adverse effects or ended up being hospitalised. Secondly, about the time that the campaign might have broadened because the compensation issue had finally been established, the cases of myocarditis or myocardial infarction occurred. In essence, these events brought the vaccine campaign to an absolute screeching halt in many hospitals and institutions in the USA. Approximately 45 000 health–care workers have been vaccinated in the first phase, about one–tenth of what was anticipated. Of course, they have done much better with vaccination in the military.
But we must put things in perspective. This vaccine is the most dangerous vaccine available. Vaccinating people in a situation where the disease no longer exists in nature is unprecedented.
TLID: You are a founding member of the Academic Alliance for AIDS Care and Prevention in Africa. Can you tell us more about this initiative?
WMS: The Academic Alliance for AIDS Care and Prevention in Africa is justly credited to Merle Sande and Professor Nelson Sewankambo, Dean of the Faculty of Medicine, of Makerere University in Kampala, Uganda. It arose as a partnership between some prominent North American physicians (of which I am proud to be a part), and nine faculty members from Makerere University to deliver enhanced HIV and AIDS care and prevention in a setting where we were also addressing operational research, and training of physicians and other health–care providers in the care of patients with HIV and AIDS. We are grateful for the support of Pfizer who provided us with a seed grant of US$ 11·5 million over 2·5 years. This funding enabled us to start building programmes in Uganda. My main role in the Academic Alliance has been, with Moses Kamya, coordinating the training programme that we now offer to physicians (and in 2004, nurses and other health—care providers). The training programme is very intense. It is 1 month in length, 4 weeks of instruction, about half in a classroom, the other 50% at a clinic, at the bedside, or in the hospital. We have to date had about 100 physicians from 11 African countries graduate from this programme; our training programme in Uganda is truly a regional centre. The Academic Alliance with the help of Pfizer and our colleagues in Kampala is constructing a new building, the Infectious Diseases Institute, which is the first new building on the campus of Makerere University Medical School in 36 years. It will be a magnet centre for clinic operations that care for patients with HIV and other infectious disorders, as well as providing a state of the art laboratory, and a training centre for the entire region. We have done this in cooperation with IDSA as the instrument for trainer identification. Since the Academic Alliance was formed we have raised more than $10 million in additional funding (and gifts in kind) from various agencies, including the Gates Foundation, World Bank, NIH, industry, and other agencies. It's a beginning and it can be used as a model of public—private partnerships to enhance the building of health–care infrastructures as antiretrovirals are introduced in greater quantities into Africa in the future.
TLID: What have been your biggest achievements in medicine and the most memorable moments for you in your career so far?
WMS: This is a very difficult question. But the first memorable moment that occurred in my career was when I graduated from medical school. I received an award called the “Good Physician” award at Cornell University Medical College. It is an award given to a graduating physician for “best exemplifying the qualities of the good physician”. The award is chosen by the vote of one's classmates and to have my classmates feel that way about me was extremely gratifying and a humbling honour at the time. The other thing to mention is the recognition of my teaching abilities over the years. I received the Attending of the Year award from my house staff several times, the Department of Medicine, and the Deans School of Medicine awards on several occasions. It is not about the pieces of paper or the awards. What is important is that teaching is recognised. I put a lot of effort into it and enjoy it. These are the things that I would like to be remembered for–an influence on the next generation of physicians through teaching.
TLID: Have there been any unexpected changes or events in the infectious–disease specialty that you never thought you'd live to see?
WMS: I can say that when I entered the field of infectious diseases, at the beginning of my fellowship back in the late 1970s, I was rather naive with regard to the use of an infectious agent as a weapon of terror. The deliberate release of an agent like anthrax would have surprised me. But as I matured, I realised that this was a definite risk. When I was on the Interscience Conference on Antimicrobial Agents and Chemotherapy programme committee in 1991, I put together the first symposium on bioterrorism in the history of the meeting. After that I became more realistic but it still comes as a shock. The other thing that I probably wouldn't have expected was that we would be using a vaccine that is as dangerous as smallpox in a time when the disease is no longer present.
Another achievement that I wouldn't have predicted when I was beginning my infectious disease career was the eradication of a disease from the world. The eradication of smallpox occurred about then, but now we are very close to eradicating poliomyelitis. I would not have expected these advancements when I was starting my fellowship. I would not have expected us to get to a point where there was so much antimicrobial resistance in some bacteria. There is almost nothing left to treat some multiresistant pathogens.
TLID: How do you unwind at the end of the day? Do you have any hobbies?
WMS: The things I enjoy are outdoor activities that bring you in contact with nature. My favourite hobby is fly fishing, but I like hiking, biking, canoeing, and kayaking. I also enjoy amateur photography. I used to do a lot of black and white photography in my own dark room and with the encouragement of my daughter, Sarah, I am hoping to get back into it again.