Wake Forest University International Medicine. (Wake Forest Centennial).

THE INVOLVEMENT OF WAKE FOREST UNIVERSITY School of MEDICINE in international health is in keeping with that of the entire medical center: unique, provocative, and strong. Institutional roots in the Southern Baptist tradition created a global involvement, and this compilation presents a historical overview that addresses the areas of mission and services rendered, academics (including training of both scientists and clinicians from foreign countries), and patient care in the international health arena.

While the medical school was still a 2-year institution on the original campus at Wake Forest, North Carolina, 3 students went on to complete their doctor of medicine degrees at Jefferson Medical College, and then became career medical missionaries. The school moved to Winston-Salem, expanded to a 4-year degree program, and was renamed the Bowman Gray School of Medicine in 1941. World War II forced the adoption of an accelerated curriculum to provide more physicians for the military, and one individual from each of the first 3 graduating classes at the new school became a career medical missionary (2 in the Middle East and 1 in Africa). To date, 122 individuals involved full time in medical missions have received all or a portion of their training at the medical center. Their countries of service are listed in Table 1. Moreover, the North Carolina Baptist Hospital School of Nursing trained 4 registered nurses (RNs) who have served or are serving as career missionary nurses.

For more than a decade, the now-defunct International Journal of Missionary Medicine and videotaping services were housed in our institution. In addition, the Department of Pathology has provided interpretation of specimens, including Pap smears and other specialized tests, at no charge to mission hospitals around the world.

Students nominated by our missionaries have come to Wake Forest University as undergraduate medical students. An excellent example was Dr. Hideko Imamura of Fukuoka, Japan, who trained in Baptist mission schools and was sent to Wake Forest University for collegiate and medical education. He became an outstanding physician, bridging interests between Japan and Winston-Salem, NC. The tradition has been carried on since his death through the efforts of his wife, Kikuko.

Because of United States involvement in Africa and the Pacific, enormous numbers of troops became infected with malaria, dengue fever, gastrointestinal parasites, and serious cutaneous infections. When the 4-year medical school was established in Winston-Salem, Coy C. Carpenter, MD, then dean, initiated an outreach program that included tropical medicine. This unique department in the medical school, headed by Thomas T. Mackie, MD, was a continuation of his work for the United States military during World War II.

Dr. Carpenter also recruited Camillo Artom, MD, from Italy. A world-renowned biochemist, Dr. Artom became a stalwart in our medical school, developing international relationships through his colleague, Enrico Fermi, and other Jewish scientists displaced by Hitler's Nazism. Dr. Artom and his wife, Bianca, were Milanese and Venetian, and their heritage brought internationalism to Bowman Gray School of Medicine. The relationship between Wake Forest University and the Artoms culminated in the establishment of Venice (Artom) House, which is strategically positioned on the Grand Canal and welcomes undergraduate students as well as medical students for instruction throughout the year. On occasion, faculty members use the house for conferences, as was the case in 1981, with the first international conference on ultrasonography. Organized by Dr. William McKinney, this strategic meeting of individuals from 18 nations was crucial in the development of this new technology, since this founding group dispersed throughout t he world and became early leaders in the field.

Dr. Carpenter was also responsible for establishing a relationship between the university and Egypt. Manson Meads, MD, Dr. Carpenter's successor as dean, was posted to Southeast Asia, primarily Bangkok and Chiang Mai in Thailand, where the roots of cooperation run deep and are still intertwined. He and, later, Robert W. Prichard, MD, each served 1 year with the U.S. Operation Mission Program at the Faculty of Medicine Chulalongkorn and Siriraj Hospitals, helping to establish the Chiang Mai Medical School. Meads also assisted in the educational program of Dr. Charas Suwanwela, who received the Ananda Mahidol Scholarship from His Majesty, King Bhumibol, to study neurosurgery at the North Carolina Baptist Hospital under the tutelage of Eben Alexander, MD. Thereafter, Dr. Meads worked with the International Medical Boards to support many teachers from Thai medical schools who came to the Bowman Gray School of Medicine for graduate studies.

Another example of international outreach was the recruitment of Dr. Carlos W. Rapela and his wife, Monjeca, who worked with Argentinean physiologist Bernardo A. Houssay in cardiopulmonary altitude physiology. Dr. Rapela, with Harold D. Green, MD (Fig 1), developed a worldwide reputation with his work in cerebral blood flow. In an epochal publication, they proved that the brain has the capacity to regulate blood flow on the basis of need, rather than constant, uniform perfusion. They further established that blood flow between organs and muscle is a give-and-take relationship that reduces the amount of cardiac work necessary to supply the body with varying quantities of blood, a phenomenon they termed autoregulation.

In 1965, the Department of Neurology, then chaired by James F. Toole, MD, initiated an exchange program with Keio University in Tokyo, Japan. This program led to the formation of a permanent, university-wide relationship with Tokai University through Dr. Shigeyoshi Matsumae (Fig 2) and Dr. Wakou Anazawa. It also led to opportunities for Japanese undergraduate students to come to Wake Forest University, and for faculty and students from Wake Forest University to go to Tokyo House in Japan to learn Oriental culture. Later, similar programs were arranged with institutions in Egypt, Australia, Finland, and Germany, and a steady stream of well-trained investigators from these countries have returned to their home countries and now hold prominent positions in the neurologic and research communities.

In 1993, the neurology department and Dr. Toole initiated a collaboration with the universities of Vienna and Innsbruck in Austria on the "Iceman Project", an investigation of a 5,000-year-old body found frozen in the Alps. This fully clothed Stone Age man is unique in that his internal organs were intact, and he was suffering diseases of aging, despite being only approximately 38 years old. This research led to the formation of Flow House for the study of Germanic and Austrian culture. The university also maintains Worrell House, located in London, England, for the convenience of students and faculty members involved in international studies.

In addition to personnel, the medical center has a long track record for providing surplus and, in some cases, new medical equipment to mission hospitals and other hospitals in underdeveloped countries. This has been uniquely true in the fields of ultrasonography, endoscopy, and arthroscopy. Individual faculty members would travel with the scopes or equipment and teach their use and care to personnel on site, leaving the equipment in the hands of missionary or national physicians. For instance, the first arthroscopy program in reopened China was started by the Wake Forest University Department of Orthopedics (Fig 3). Two-way radio communication was established from the medical center to Central and South America for purposes of consultation. This service was provided not only to mission hospitals and stations, but to government hospitals as well.

The medical center offers 2 fellowships, varying from 3 months to 2 years in length, for the training of foreign physicians in health care delivery. To be a category I fellow, a physician must pass the Educational Commission for Foreign Medical Graduates (ECFMG) examination, and must have received supervised postgraduate health care experience. Category II fellows are observers only. Both are provided stipends and full benefits with an agreement that they will return to their home countries upon completion of their training. The Broyhill Foundation has made this possible. Table 2 shows the countries of origin of the 34 trainees who have completed their fellowships so far.

In 1982, the medical school's Office of International Health Affairs was founded by Richard Janeway, MD, who was then dean and executive vice president. He appointed Timothy C. Pennell, MD, as director of the office. Since then, formal affiliations have been established with Tokai University (Japan), the University of Rome (Italy), Sun Yat-Sen University of Medical Sciences (China) (Fig 4), St. John's Medical College (India), and Tromso University (Norway), establishing affiliations for exchange of faculty, students, research protocols, and, in selected situations, residents. Less structured agreements in i or 2 areas of special interest are available in order to meet or expand educational opportunities. These are listed in Table 3.

Ongoing projects are those in which a definite goal is established and service rendered. In the mid-1990s, Michael D. Sprinkle, MSLS, established a library approved by the Liaison Committee on Medical Education (LCME) at Universidad Central del Caribe in Puerto Rico. Stephen H. Richardson, PhD, was involved in determining the microbiology of cholera, and vice president Robert Parker was instrumental in establishing hospice care in India. Dr. Pennell has been involved in helping mission hospitals transition from basic general surgery institutions into facilities that have been expanded or replaced with community health and development programs (Table 4). In Turkey, Medge D. Owen, MD, currently teaches obstetric anesthesiology. Avinash K. Shetty MD, a specialist in pediatric infectious diseases, maintains ongoing human immunodeficiency virus (HIV) research, and educational and preventive programs in Zimbabwe.

Through the Office of Student Services and the Office of International Health Affairs, an average of 17 students take international electives each year; these include missionary service, and involve populations in indigent, rural, urban, and developed countries (Fig 5).

The electives are set up primarily for senior medical students, last 8 weeks or more, and are closely supervised. Funding sources include the Missionary Assistance Program, the Reader's Digest Fellowship, the Pennell International Scholarship, and various denominational sources. In addition to medical students, 4 physician-assistant students have completed international health rotations (Table 5).

The occasions and locations at which faculty members of Wake Forest University School of Medicine have served as lecturers and visiting professors in the global arena number well into the hundreds.

The international connections at Wake Forest University School of Medicine have provided both breadth and depth to our educational programs and have introduced students and faculty members both here and abroad to the seemingly limitless range of opportunities for service and growth as a member of the medical profession.

TABLE 1

Countries of Service of Medical Missionaries Who Trained at Wake Forest
University

Afghanistan
Bangladesh
Belgian Congo
Belize
Bolivia
Brazil
Cambodia
Chile
Colombia
Costa Rica
Egypt
Ethiopia
France
Gaza
Ghana
Haiti
Honduras
India
Indonesia
Iran
Japan
Jordan
Kenya
Lebanon
Liberia
Madagascar
Mexico
Nepal
Nicaragua
Niger
Nigeria
Pakistan
Panama
Paraguay
Philippines
Poland
Puerto Rico
Rhodesia
South Africa
Sudan
Taiwan
Tanzania
Thailand
Togo and Lesotho
Uganda
Upper Volta
Uruguay
Venezuela
Vietnam
Yemen

TABLE 2

Countries in Which Wake Forest University Has Collaborative Agreements

Bangladesh
Bolivia
Brazil
Chile
Colombia
Costa Rica
Denmark
Egypt
Ghana
Goa
Japan
Kenya
Mexico
Mongolia
Nicaragua
Nigeria
Paraguay
Poland
Sri Lanka
Thailand
Turkey
Uganda
Uzbekistan
Venezuela
Zimbabwe

TABLE 3

Sending Agencies for Missionaries

African Inland Mission
American Baptist World Evangelism
Baptist Medical Dental Fellowship
Catholic Relief Fund
Christian Medical and Dental Associations
Church of Christ
Church of God Ministries
Cooperative Baptist Fellowship
Doctors without Borders
Episcopal Diocese of Haiti
Episcopal diocese of North Carolina
Flying MDs
Global Ministries
International Mission Board
Methodists Global Mission Board
National Council of Churches
Nepal Council of Churches
Presbyterian Board of Missions
Project HOPE
Red Crescent
Red Cross
Samaritan's Purse
Seventh Day Adventists
Sudan Interior Ministries
World Council of Churches
World Heatlh Organization
World Medical Mission

TABLE 4

International Fellowships

Country                     Specialties

Colombia                    General surgery; Anesthesiology
Denmark                     General surgery; Anesthesiology;
                            Orthopedics
Honduras                    Infectious disease
India                       Pediatric infectious disease;
                            Hospital administration;
                            Geriatrics; Pulmonary medicine;
                            Internal medicine; Microbiology
Italy                       Hematology/oncology (3);
                            Transplant immunology
Japasn                      Oncology; General surgery; Trauma
Nigeria                     General surgery; Pediatrics
People's Republic of china  Orthopedics (3); Health education;
                            General surgery; Cardiology;
                            Radiation therapy
South Africa                Anesthesiology (3)
Tanzania                    General surgery
Thailand                    Neurosurgery
Venezuela                   General surgery

TABLE 5

Student International Health Electives

Country       Specialties

Australia          6
Austria            6
Bangladesh         1
Velize             1
Brazil             2
Bolivia            5
Canada             4
China              6
Colombia           4
Ecuador            2
England           15
Ethiopia           1
France             1
Germany            2
Ghana              4
Honduras           3
India              9
Indonesia          4
Ireland            1
Italy              3
Japan             10
Kenya             22
Mexico             8
Nepal              1
New Zealand        1
Niger              2
Nigeria           16
Norway             1
Paraguay           6
Philippines        2
Puerto Rico        1
South Africa       3
Tanzania           4
Thailand           5
Uganda             4
Venezuela         20
Vietnam            1
Zimbabwe           3

From the Stroke Research Center and the Division of Surgical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC.

Reprint requests to James F. Toole, MD, Stroke Research Center, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1068.