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P&S Journal

P&S Journal: Spring 1997, Vol.17, No.2
Alumni News and Notes
Profile: Michael Iseman'65

Alumni News Editor:
MARIANNE WOLFF, M.D.
Alumni News Writer:
PETER WORTSMAN

Michael Iseman:

An All-Star on the Team Against TB

By Peter Wortsman

Michael Iseman '65  Remember TB, that turn-of-the-century scourge everyone thought was long since licked? Think again! It's almost the turn of another century and tuberculosis is back with a vengeance. The dread malady once dubbed "The White Death" and the "Captain of All These Men of Death" is mowing down humans at the rate of 2 million to 3 million a year, a rate that's on the rise. An infinitely resourceful culprit, the tubercle bacillus, identified in 1882 by Robert Koch as the cause of the disease, has succeeded by mutation in resisting and plowing through the front line of drugs once thought invincible in combating it. Never wholly vanquished, TB has re-emerged as the single most lethal infectious human affliction.

 For many years, Michael Iseman'65, a renowned expert on multi-drug-resistant (MDR) TB, a clinician, and a public health consultant with his eye on the big picture, has been predicting just that. Dr. Iseman is a committed team player and tactician in the international effort to control the spread of the disease.

 The National Jewish Center for Immunology and Respiratory Medicine in Denver, where Iseman holds the Girard and Madeline Beno Chair in Mycobacterial Diseases and officiates as chief of the clinical mycobacterial service, is the longest continuously running clinical facility for TB treatment in the United States. Currently, thanks to Iseman and colleagues, National Jewish, a medical mecca for the treatment of MDR-TB cases considered incurable elsewhere, has reclaimed leadership in the field. The tri-annual course Dr. Iseman holds in the clinical management and control of tuberculosis attracts health care professionals from around the country and the world. An official consultant to the World Health Organization, Iseman is also editor-in-chief of the prestigious publication, Tubercle and Lung Disease (the official journal of the International Union Against Tuberculosis and Lung Disease).

 After sending out urgent smoke signals for years, Dr. Iseman was gratified when the WHO, in 1995, finally declared tuberculosis a global emergency." Yet Iseman is too much of a realist to declare victory. "There are so many fires burning on our Earth, how do you decide where to direct the limited energy and resources?" he asks. A philosophical pragmatism has kept him from discouragement over the vastness of the problem. "Those of us who work in the field think of ourselves in a kind of missionary way as 'the voice of conscience,' if you will. But there are lots of Jiminy Crickets sitting on Pinocchio's shoulder trying to get his attention!"

 

A Lifelong Athlete Makes Medicine His Field

 A tiny cricket is not exactly the image to which one might liken Michael Iseman. Titan is more like it. His strength of character is matched by solid muscle. Every bit as fit and formidable of build today as when he helped trounce the opposition in football for Princeton and rugby for P&S, Iseman's stature would intimidate were it not for an open accessible smile. A gentle giant disguised by shirt and tie and a pair of tired eyes under reading glasses, this mild-mannered doctor for a great metropolitan medical center fights a never-ending battle against what Frank Ryan in his book, "The Forgotten Plague," termed "a superbug."

Wingback
Michael Iseman, wingback at Princeton University, circa 1960
 Dr. Iseman is endowed with the zest and energy of a lifelong athlete, the acumen and compassion of a dedicated clinician, and the insight and savvy of a public health specialist attuned to human foibles. Add to that a sense of history (his undergraduate major at Princeton) and a grudging respect for the wiles of his microscopic adversary, "a brilliantly adaptable and subtle species."

 Born in the small Midwestern city of Fremont, Neb., where his father was a local merchant and his mother a registered nurse, Iseman mastered every sport to which he ever applied his mind and body. He played baseball for Fremont High, varsity football and track at Princeton, and rugby and basketball at P&S. He surfed in the Navy and took up skiing with a passion as soon as he moved to Colorado-not to mention the handball tournaments he won and the gold medal he helped the YOFRA/New Haven Rowing Club earn at the 1984 World's Veterans Championships in Belgium.

 An All-American baseball player in high school, he received a personal phone call from the governor of the state asking him to stay home and play baseball for the University of Nebraska, a virtual stepping stone to the big leagues. But while Iseman would argue that sports is a wonderful training ground for the whole person, he had his eye on a wider field.

 The inspiration to go into medicine came from his hometown doc who "helped put me back together every time I tore myself apart with some sports injury" and, consequently, "opened my eyes to the amazing power of this healing art." At Princeton, while already firmly committed to a career in medicine, a wide-ranging intellectual curiosity led him to major in history. He took his pre-medical requirements in summer school before applying to P&S.

Rowing Club
Michael Iseman, third from right, helps row YOFRA/New Haven Rowing Club to victory at World's Veterans Championships, Ghent, Belgium,1984
 Lacking the scientific grounding of other classmates, Iseman worked especially hard in his first two years of medical school and enjoyed the mutual support of a tight-knit group of friends. He relished the lectures of Harold Brown in parasitology, "who, in talking about the mechanisms of tropical infectious diseases, made us think outside the American model of medicine," and Harry Rose, "whose brilliant lectures in microbiology awakened all our curiosity."

 On his fourth-year sub-internship in medicine under Charles Ragan at Bellevue's First (Columbia) Medical Division, Iseman had an inkling of his future. He enjoyed the human dynamic of city-county medicine and found a great esprit among the house staff. Dr. Ragan subsequently offered him an internship. "It was indeed on the chest service at Bellevue," he says, "that I began my fascination with lung diseases and tuberculosis. Nothing else that I did interested me as much."

 Iseman made something of a name for himself early on when, with Dr. Ragan's support, he helped introduce fiber optic bronchoscopy to New York and taught others at Bellevue and elsewhere how to use the new diagnostic tool. Following a stint in the Navy, he returned to New York to find the Columbia Service had transferred to Harlem Hospital. After completing his second year of residency at Harlem, he pursued a fellowship in pulmonary medicine there under Julia Jones, "my mater, mentor, and quiet inspiration."

 

A Convincing Advocate for "Directly Observed Therapy"

 Moving to Denver in 1972, Dr. Iseman joined the faculty of the University of Colorado medical school (where he currently holds an appointment as professor of medicine) and took on the duties of associate director of the pulmonary service at Denver General Hospital. There he came under the influence of John Sbarbaro, head of the hospital's tuberculosis clinic. Already impressed by Dr. Sbarbaro's "Machiavellian sense of medical administration" and his deep understanding of human behavior and its impact on medicine, Iseman became a convinced "disciple" as soon as he saw Sbarbaro practice "directly observed therapy."

Jewish Hospital
One of the early structures of the National Jewish Hospital for Consumptives, circa 1915, and today the National Jewish Center For Immunology and Respiratory Medicine
 Sbarbaro realized as far back as the early 60s, in the wake of the closing of the major TB sanatoriums, that people inevitably stop taking their medicine when they start to feel well. And since tuberculosis is spread by casual contact, by sharing th

e same air as a patient with active TB, in p public health terms a person with communicable TB is not a free agent.

 When Iseman inherited the directorship of Denver General's TB clinic, he not only continued the practice of directly observed therapy, but also helped promote its virtues to public health authorities around the nation and the world.

 Finding the traditional seven-day regimen of TB treatment impractical and unenforceable in the long run, Iseman authored the first official statement of the American Thoracic Society, documenting the efficacy of short-course treatment restricted

to two times a week, making compliance a reasonable expectation. At Denver General and at National Jewish, where he joined the faculty in 1982, the TB clinics stay open all day six days a week, no appointment necessary, with a welcoming atmosphere, a nurs

e's listening ear, and a glass of juice to wash down the pills. Treatment is free and the actual consumption of the pills is supervised to assure compliance. Non-compliance leads to immediate legal action.

 The carrot-and-stick policy proved effective. In 1994, the American Thoracic Society and the Centers for Disease Control and Prevention officially accepted directly observed therapy as a model regimen. A year later, the World Health Organization

followed suit, embracing it as a global model.

 New York City, where public TB treatment programs were considered low priority and disbanded in the 70s, faced a public health crisis of catastrophic proportions by the early 80s with simultaneous emergence of AIDS, overcrowding in city hospitals

, and the prevalence of both diseases among the growing homeless population. HIV attacks the same T lymphocyte involved in controlling TB.

 Stripped of their natural defenses, AIDS patients with latent TB or those who subsequently contracted tthe disease died in a matter of weeks. The discovery of multi-drug-resistant strains of the disease among the fatalities sent a panic call that

was heard from City Hall to Albany to Washington, D.C. Rallying the support of federal, state, and city agencies, public health officials managed to turn the tide and cut the devastating losses by employing a strict regimen of directly observed therapy.<

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 Dr. Iseman views New York's success story with a mix of relief and dread. "What they were able to do in New York, thanks to the infusion of federal dollars," he points out, "they'll never be able to pull off in Kinshasa, Buenos Aires, Jakarta, or

Bangkok, where funds are lacking and AIDS and TB are far more prevalent than they ever were in New York."

 An active and vocal member of the American Thoracic Society, Dr. Iseman was appointed associate editor of the American Review of Respiratory Disease in 1984, in which capacity he produced a series of editorials warning against the spread of the d

eadly new drug-resistant strains. Iseman thus entered the international arena and became increasingly involved with tuberculosis in the Third World.

 His career in TB, as he described it in a talk at the P&S Alumni Reunion Weekend in 1995, "is like an inverted pyramid." From his early work dealing with individual patients at Harlem Hospital and later at Denver General, he became increasing

ly aware of the public health dimension. At National Jewish, he perceived a nationwide referral pattern of multi-drug-resistant cases in the 80s. His international consultation led him to consider global patterns of the disease.

 

TB, Still With Us and Fatal After All These Years

 A descendent of microorganisms in the primordial soil, the TB bacillus sprouted with the grass, spread to ruminant animals, was passed on to the first herders at the dawn of civilization, and has been with us ever since. Traces have been found in

ancient human remains from the equator to the polar circle. The disease continues to plague people old and young, men, women, and children on every continent.

 "How can it be," asks Iseman, "that an illness for which we have a vaccine and a curative therapy is still rampant in the world today?"

 Though the development of such wonder drugs as streptomycin, isoniazid, and para-aminosalicylic acid (PAS) surely constitute "one of the modern miracles of medicine," he argues, "the bacillus outwitted us, defeating the current level of our techn

ology to combat it." The BCG vaccination has been proved flawed, offering at best a partial protection.

 In 1990, WHO estimated 7.54 million cases of TB worldwide. With rampant HIV, Africa's incidence of TB is soaring. And in Southeast Asia and Latin America, where access to medical care has been fragmentary and chaotic, as many as 25 percent to 40

percent of the cases are estimated to be drug-resistant.

 The consequences of these statistics are already spilling across the border into the United States, where the majority of MDR-TB is detected among foreign-born persons.

 

New Therapies and Old Outmoded Treatments Reappraised

 At National Jewish, Dr. Iseman and his colleagues, undaunted by the odds, specialize in the treatment of patients who have failed therapy elsewhere and are referred there as a last hope. He and his team currently experiment with 13 drugs that hav

e demonstrated a degree of effectiveness against TB. In 1983, they also rediscovered an outdated mode of treatment: surgery. Removing all or part of a damaged lung, careful to expunge all of the bacilli, their successes have exceeded their own expectation

s. "We're now taking and curing patients who are sick to a degree I never could have imagined any regimen able to treat. That's very gratifying," says Iseman.

 "I've come a long way from Fremont, Nebraska!" he beams. "Medicine has meant everything to me. It still feels kind of magical to be able to do something so worthwhile, to impart knowledge, facilitate healing, diminish suffering-what better way to

spend a life!"

 A few years ago, the two-time winner of the Kaiser Permanente Award for Excellence in Teaching at the University of Colorado medical school and recipient in 1995 of the P&S Alumni Gold Medal for Excellence in Clinical Medicine, among many oth

er honors, enjoyed a physician's ultimate affirmation. His son Matthew'98, who accompanied him on a medical mission to Africa, turned to him and asked: "Hey, Dad, how do I become a doctor?"

 

Saranac Laboratory
Edward Livingston Trudeau at the Saranac Laboratory

The Trudeau Heritage at P&S

By Peter Wortsman

 When Edward Livingston Trudeau entered P&S in the 1880s, tuberculosis was taught as a non-contagious, incurable disease, a consequence of peculiarities, perverted humors, and various types of inflammation." When as a medical student he contra

cted the disease himself, believing his fate was sealed, he traveled to the Adirondacks, in upstate New York, for a last taste of the outdoor life he loved. There, to his surprise and delight, he began to get well. Reading of TB sanitoriums in Europe, he

became convinced of the therapeutic benefit of rest and fresh air.

 In 1884, Edward Livingston Trudeau, who received three degrees from P&S (M.D. in 1871, M.S. in 1899, and Hon. D. in 1913), founded the Adirondack Cottage Sanitorium at Saranac Lake. Among his best-known patients was author Robert Louis Steven

son. Another famous convalescent at Saranac Lake in later years was author Walker Percy'41.

 In 1885, three years after the discovery by Robert Koch of the tubercle bacillus, Dr. Trudeau, who later founded the Saranac Laboratory, was the first scientist in America to grow TB bacilli in artificial culture. When his laboratory was destroye

d by a fire in 1893, old friends from the P&S faculty presented him with a new microscope to continue his work. A note accompanying the gift added, "...don't think we have decided whether we want to do this most because we appreciate the good work you

are always doing...or because you have had more pluck than anybody we know..." In 1905 he was elected first president of the National Association for the Study and Prevention of Tuberculosis, today the National Lung Association. Its medical section was l

ater named the American Trudeau Society. Alas, his oldest son, Edward Livingston Trudeau Jr., a 1900 P&S graduate who had been president of his class, succumbed to TB.

Trudeau Institute
Francis B. Trudeau Jr.'50 at the Trudeau Institute
 Upon the death of Edward Livingston Trudeau Sr. in 1915, the sanitorium was renamed in his honor and another son, Dr. Francis B. Trudeau, took over as director.

 Ten years after the closing of the sanitorium in 1954, Edward Trudeau's grandson, Francis B. Trudeau Jr.'50, continuing in the family tradition, founded the Trudeau Institute, a highly respected independent research facility that specializes in the study of the detrimental effect of disease on the body's immune system. A P&S professor, Nobel laureate Dickinson W. Richards'23, offered valuable guidance in establishing the institute's original research goals.


copyright ©, Columbia-Presbyterian Medical Center

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