Harvard Medicine Spring 2023

SLEEP

Worries about their world can exact a toll on the mental health of young people

a sense of place

ILLUMINATION: The skylight spanning most of the roof of Gordon Hall is an architectural feat of utility and beauty. Throughout the years, it has allowed natural light to filter into the top floors of building’s interior: It has illuminated some of the collections of the Warren Anatomical Museum, and it has warmed the atmosphere and provided a window on the weather for staff working in several of the School’s core administrative offices. Soon, it will provide a portal to the sky for a reconfigured space designed to fill the flexwork needs of an even broader range of administrative and support departments.

CLASS NOTES: Alumni share suggestions for skills they have found valuable and that today’s MD students might find useful to augment their coursework as they prepare for the evolving demands of the practice of medicine.

SPECIAL REPORT MENTAL HEALTH

10 A World in Peril by Charles Schmidt

The existential threat posed by climate change leads to anxiety in many young people.

18 Loss of Separation by Stephanie Dutchen Microplastics are everywhere, including in our bodies. What might this mean for our health?

20 Broken Links by Elizabeth Gehrman

Loneliness among young people is on the rise, sparking concerns over their mental and physical health.

26 Stand in Line by Jake Miller

The need for mental health care among pediatric patients is growing, but the resources to provide that care are not keeping pace.

30 The Unblinking Eye by Ann Marie Menting

A filmmaking team uses visual narratives to tell stories that allow for understanding and humanity.

34 Inside View

The beauty of the brain is captured in photos.

FEATURE

45 Energy Grid

An excerpt from We the Scientists by Amy Dockser Marcus.

DEPARTMENTS

4 Commentary A letter from the dean

5 Discovery Research at Harvard Medical School

9 Noteworthy News from Harvard Medical School

40 Five Questions by Catherine Caruso

Natasha Archer on how academic medicine helps advance science and improve patient care

41 Roots by Catherine Caruso

Judith Edersheim on wedding law with medicine to better inform legal decisions

42 Student Life by Elizabeth Gehrman

PhD candidates on their neuroscience research

49 Rounds Alumni on the skills clinicians should learn today to better prepare for tomorrow

JOHN SOARES (COVER AND FACING PAGE)

STEVE LIPOFSKY

The crisis in mental health among young people requires our attention

EARLIER THIS YEAR, the Morbidity and Mortality Weekly Report, published by the U.S. Centers for Disease Control and Prevention, pertained to mental health surveillance data gathered between 2013 and 2019 on U.S. children. The wide-ranging analysis presented sobering statistics, indicating, for example, that 20 percent of those aged 12 to 17 had experienced a major depressive episode during the study period, and that in 2019 alone nearly 37 percent of high school students reported feeling persistently sad or hopeless and nearly 19 percent had considered suicide.

A few months after that report, the CDC released its Youth Risk Behavior Survey which presented data gathered between 2011 and 2021. The findings were equally alarming, especially pertaining to young girls and LGBQ+ students. In 2021, three in five girls indicated they felt persistently sad and hopeless, while one in four reported serious suicidal ideation, both measures reflecting an increase of nearly 60 percent from 2011. Suicide attempts also increased in 2021, with one in ten girls reporting an attempt, a 30 percent increase from a decade ago. Among LBGQ+ students, nearly 25 percent said they had attempted suicide in 2021 and nearly 75 percent reported persistent sadness or hopelessness.

HMS is deeply committed to addressing this mental health crisis. An initiative we’ve undertaken to improve mental health care for young people provides educational assistance to middle and high school counselors and community health workers; offers additional training to frontline health care providers; and weaves mental health firmly into the HMS MD curriculum so that our future physicians are more thoroughly prepared to identify and attend to mental health issues in their patients. These efforts are being supported by a generous $5.5 million grant from the Manton Foundation.

Vikram Patel, The Pershing Square Professor of Global Health in the Blavatnik Institute at HMS, is leading efforts to develop tools and provide educational assistance to school counselors and community workers. Patel and a collaborative of national and international experts in mental health treatment will partner with professional groups representing school counselors to design a digital skills-based curriculum for use by in-school counselors, faith-based organizations, and other youth-focused groups nationwide. The goal is to provide young people with access to the skills they need to cope with emotional stress and to manage their difficulties purposefully.

Our curricular effort is being led by Todd Griswold, an HMS assistant professor of psychiatry at Cambridge Health Alliance. With a team of clinician-educators, Griswold is crafting a curriculum that draws upon the lessons learned in the collaborative care model for depression, which provides access to mental health support in primary care settings. This new curriculum will integrate into the preclerkship courses for our medical students so that its lessons can be reinforced during clinical rotations.

The state of mental health in this country and throughout the world requires us to do more to help young people who are experiencing the pain of trauma and mental illness. HMS is leading efforts to address this issue.

Editor

Ann Marie Menting

Design Director

Paul DiMattia

Senior Copyeditor & Editorial Coordinator

Susan Karcz

Designer

Maya Rucinski-Szwec

Contributors

Catherine Caruso, Stephanie Dutchen, Elizabeth Gehrman, Amy Dockser Marcus, Jake Miller, Charles Schmidt

Editorial Board

JudyAnn Bigby, MD ’77; Emery Brown, MD ’87 PhD ’88; Rafael Campo, MD ’92; Elissa Ely, MD ’87; Timothy G. Ferris, MD ’92; Alice Flaherty, MD ’94; Atul Gawande, MD ’94; Donald Ingber, PhD; Sachin H. Jain, MD ’08; Perri Klass, MD ’86; Jeffrey Macklis, MD ’84; Victoria McEvoy, MD ’75; Barbara McNeil, MD ’66 PhD ’72; Lee Nadler, MD ’73; James J. O’Connell, MD ’82; Nancy E. Oriol, MD ’79; Anthony S. Patton, MD ’58; Mitchell T. Rabkin, MD ’55; Eleanor Shore, MD ’55

Dean of Harvard Medical School

George Q. Daley, MD ’91

Executive Dean for Administration

Lisa Muto

Chief Communications Officer

Laura DeCoste

Director of Editorial Services

Maria Fleming Buckley

Harvard Medical Alumni Association

Kenneth Bridges, MD ’76, president Louise Aronson, MD ’92, president-elect Chasity Jennings-Nuñez, MD ’95, vice president Douglas Chin, MD ’94 MMSc ’94; David Cohen, MD ’86 PhD ’87; John F. Cramer III, MD ’74; Sitaram Emani, MD ’97; Jessica Ann Hohman, MD ’13; Elbert Huang, MD ’96; Kristy Rialon, MD ’08; Michelle Rivera, MD ’92; Margaret Liu, MD ’81; Numa Pompilio Perez Jr., MD ’15; Coleen Sabatini, MD ’04; Nancy Petersmeyer, MD ’80; Douglas Zipes, MD ’64

Chair of Alumni Relations

A. W. Karchmer, MD ’64

Harvard Medicine magazine is published two times a year, with online editions appearing monthly.

PUBLISHERS: Harvard Medical Alumni Association and Harvard Medical School

© The President and Fellows of Harvard College

EMAIL: harvardmedicine@hms.harvard.edu

WEB: magazine.hms.harvard.edu/ ISSN 2152-9957 | Printed in the U.S.A.

George Q. Daley Dean of Harvard Medical School

This conceptual image presents a neuron with interconnected synapses, depicting how the structure might appear if seen through a scanning electron microscope.

Protein Source

RECENT RESEARCH in mice and in cultured mouse and human nerve cells indicates that inflammatory proteins found in the innate immune system may be at the root of a range of neurodegenerative conditions, including the fatal motor neuron disease amyotrophic lateral sclerosis. When HMS scientists at Boston Children’s Hospital inactivated an inflammation-linked neural molecule in the mice and the mouse and human nerve cells, they found that the progression of ALS in the mouse model was delayed and cellular damage in the human nerve cells was prevented. The research points to possible new pathways for treating ALS and for slowing neuronal dysfunction.

Neel DV et al., Neuron, March 2023

MENTAL HEALTH

Suicide risk higher after surgery for cancer

A STUDY BY A TEAM of HMS researchers at Massachusetts General Hospital has found that adults in the United States who undergo major operations for cancer have a significantly higher incidence of suicide than that of people in the general population. The risk was shown to be highest among patients who were male, white, and divorced or single. The researchers also found that approximately 50 percent of these deaths occurred within the first three years after the surgical treatments.

Previous studies have found that an estimated 6 to 38 percent of patients who undergo cancer operations develop major depressive symptoms after surgical treatment. This study, according to the authors, is one of the first to consider the risk of suicide in this patient population. This result is troubling, they say, because there are currently no organized programs in place to implement regular screening for distress in these patients.

Although patients who receive surgical treatment for their cancer often have excellent long-term survival rates, these surgeries can be stressful, and patients can face long and complicated postoperative recoveries. These factors, together with the possibility of postoperative symptoms of depression, may contribute to an increased risk of suicide in this patient population, according to the study team.

The findings, say team members, point to the need for regular screenings for distress and assessment for suicide risk among all patients who undergo surgery for cancer.

Potter AL et al., JAMA Oncology, January 2023

PSYCHIATRY Face blindness more prevalent than thought

THE FACE-RECOGNITION DEFICIT known as prosopagnosia has long been thought to be prevalent in no more than 2.5 percent of the world’s population. A recent study by HMS and VA Boston Healthcare System psychiatrists, however, indicates that this estimate

Immunology

Immunotherapy success may hinge on presence of a type of neutrophil

and maintenance of social bonds, complicate the effects of age-related cognitive decline, and, for individuals on the autism spectrum, contribute to a decreased face processing ability.

Expanding the diagnostic criteria, and letting patients know they have some form of the disorder, could help them plan ways to reduce the effects the condition has on their daily lives. Identifying the condition could help physicians too, by guiding care plans, including recommending treatment that, in severe cases, could introduce patients to cognitive training that could enhance their perceptual abilities or improve face associations.

GERONTOLOGY

Cancer immunotherapies, which recruit a patient’s immune system to destroy tumors, have been transformative. But their success has been uneven. Research by HMS systems biologists and colleagues at the University of Geneva and Ludwig Cancer Research may explain why. The scientists found that neutrophils have different molecular identities: some promote cancer growth, others combat it. The more cancer-combating neutrophils there are, the better the response to immunotherapy. These findings from work in mice, coupled with outcomes analyses of patients with cancer, could inform new treatments that would target neutrophils and boost immune responses.

Gungabeesoon J et al., Cell, March 2023

is low. In fact, the researchers found that as many as one in 33 people, or 3 percent, may meet the criteria for face blindness, which translates to more than 10 million people in the United States.

The researchers found that face blindness lies on a spectrum that can range in severity and presentation. This range, the authors note, indicates that diagnostic criteria should be expanded, and they offer diagnostic suggestions for identifying mild and major forms of face blindness based on guidelines for neurocognitive disorders described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

A better understanding of how to diagnose the condition is important because face blindness can be a socially debilitating. Having the condition can limit employment opportunities, cause social distress and embarrassment, hamper the development

Age-related fat may impair muscle function

RESEARCHERS AT HMS AND HEBREW SENIORLIFE have found that age-related accumulation of abdominal fat is associated with lower muscle density.

Low muscle density means that the muscle has more fat than muscle tissue in it, which can lead to less effective muscle function that in turn may lead to a greater risk of falls. According to the findings of their study, individuals with the greatest six-year accumulation of visceral adipose tissue, which is fat that wraps organs deep in the abdominal cavity, had significantly lower muscle density than they did at the beginning of the study, particularly in muscle around the spine, resulting in lesseffective muscle function.

The research is the first large, longitudinal study of the association between changes in visceral adipose tissue and muscle density. The authors note that the study’s findings may provide greater insight into the role that obesity has on the risk for low muscle mass or muscle density. In addition, the findings show that visceral adipose tissue may be a potential indicator for poor musculoskeletal outcomes with aging.

Liu C-T et al., Journal of Clinical Endocrinology & Metabolism, December 2022

DeGutis J et al., Cortex, February 2023

Unwelcome Return

GENETICISTS in the Blavatnik Institute at HMS and Brigham and Women’s Hospital have found that although the human immune system can create a diverse antibody repertoire, the antibodies do not act randomly on invading viruses but retain a molecular lock on the areas of a virus the antibodies were first taught to recognize. Because viruses make tiny amino acid changes as they mutate, the resulting variants can elude antibodies produced during earlier infections or vaccinations, allowing the viruses to invade and trigger reinfections.

This 3D rendering illustrates the process of infection by a virus such as SARS-CoV-2.

Parkinson’s disease, a neurodegenerative disease, is often associated with the presence of Lewy bodies, which are abnormal clumpings of the protein alphasynuclein. In this illustration of a neuron, the Lewy bodies are shown as small red spheres.

Skin Deep

A SKIN TEST THAT MEASURES the deposition and distribution of a protein linked with neurodegeneration in multiple system atrophy and Parkinson’s disease is capable of accurately identifying patients with MSA versus patients with Parkinson’s. Symptoms of the disorders look alike, making accurate differential diagnoses difficult. The findings by HMS researchers at Beth Israel Deaconess Medical Center could improve diagnostic tests for these diseases and help in clinical care, research, and life planning for patients with MSA, a disease that affects up to 50,000 U.S. adults.

Gibbons C et al., Neurology, April 2023

noteworthy

Office for Community Centered Medical Education opens

Last fall, HMS launched the Office for Community Centered Medical Education. Its aim: to better support students who want to work with community-based organizations and community health centers in the Roxbury, Mission Hill, and Jamaica Plain neighborhoods near Boston’s Longwood area. The office and its staff will serve students at HMS and the Harvard School of Dental Medicine.

According to Nancy Oriol, MD ’79, faculty associate dean for community engagement in medical education, students who seek out the office want community engagement to play a central role in their education.

“The students understand that it’s when you engage with the community that you get to actually understand the context of the lives of the people for whom you will provide medical care,” she said. “It’s seeing community engagement as a relevant part of academic medicine and expanding the ability of doctors to care for all their patients.”

The office serves as a central source of information and resources for students who are interested in community-engagement efforts and as an academic home for faculty who wish to work with those students. In addition, said David Duong, MD ’15 (fig 1), director of the newly launched office, it builds on the efforts of the HMS Center for Primary Care, which for more than a decade has worked and partnered with local community health centers to strengthen primary health care delivery services.

The office has already made curricular strides by bolstering existing HMS courses and electives on community health, creating a new community-engagement track, adopting a community-engagement clerkship, and developing a track for doing a scholarly project.

“Whether a student is going to be a primary care doctor, a cardiothoracic surgeon, or the director of the NIH, they will have to relate with people who are different from them,” said Duong. “Our office provides students with meaningful opportunities to do that.”

HMS withdraws from U.S. News &World Report rankings

In mid-January, Dean George Q. Daley, MD ’91, announced that HMS would no longer submit data to U.S. News & World Report “to support their ‘best medical schools’ survey and rankings” (fig. 2). In his letter to the campus community, Daley wrote that he has been considering this change since becoming dean six years ago, but reached his final decision following “careful consideration and consultation with colleagues and stakeholders across Harvard Medical School and beyond.”

Although Daley noted that educational leaders have long criticized the methodology used by the media company to assess and rank medical schools, he said his concerns, and those expressed by others, were more philosophically based and rested “on the principled belief that rankings cannot meaningfully reflect the high aspirations for educational excellence, graduate preparedness, and compassionate and equitable patient care that we strive to foster in our medical education programs.”

Daley wrote that HMS will continue to make information about the School available on its admissions website and that comparable details for HMS and other U.S. medical schools remain available in their raw and unweighted form in the medical school admission requirements (MSAR) section of the Association of American Medical Colleges website.

HMS was the first medical school to announce this decision but has since been joined by twelve other schools, including Stanford University, Columbia University, the University of Pennsylvania, and the Icahn School of Medicine at Mount Sinai.

Building C to become the Bertarelli Building

Swiss biotech executive, entrepreneur, and philanthropist Ernesto Bertarelli ( fig.3) has pledged $75 million to advance basic scientific discovery, therapeutic science, and a culture of entrepreneurship at HMS. Bertarelli is a graduate of Harvard Business School, where he earned an MBA in 1993. This gift is the latest in more than a decade of support to HMS and the University from the Bertarelli family.

The gift will set in motion plans to transform the outdoor courtyard of Building C into a skylighted atrium that will serve as convening and collaboration space for occupants of the building as well as the broader HMS community.

In recognition of this generous commitment from the Bertarelli family, Building C will be named the Bertarelli Building upon completion of the construction.

“Ernesto Bertarelli is an ardent supporter of both fundamental and translational research at Harvard Medical School,” said Dean George Q. Daley, MD ’91. “He understands that to improve the health and well-being of patients, we must first support observations in the lab and then nurture and orient them toward interventions in the clinic. It is therefore fitting that the Bertarelli name will be inscribed in the marble of the building that personifies our commitment to both basic and therapeutic science.”

The building houses the departments of cell biology and of biological chemistry and molecular pharmacology; serves as a hub for the HMS Therapeutics Initiative, which aims to advance therapeutics research and translation of discoveries into medicines; and is home to the Blavatnik Harvard Life Lab Longwood, which provides collaborative workspaces for early-stage, highpotential biotech and life sciences start-ups founded by members of the Harvard academic community.

The atrium project, anticipated to begin in 2023 and be completed in 2025, includes enclosing the building’s existing outdoor courtyard, situated between the wet lab and dry lab arms of the Blavatnik Life Lab.

fig. 1

fig. 2

fig. 3

A World in Peril

BY CHARLES SCHMIDT

ELIZABETH PINSKY USED

as less a near-term threat than one whose effects loomed in the distant future. Then headlines about a 2018 climate report from the United Nations caught her eye. In the report, scientists claimed that if greenhouse gas emissions continue unabated, rising sea levels caused by warming temperatures would likely inundate some global coastlines and intensify droughts and poverty in other parts of the world by 2040. This was far sooner than previously projected. “I immediately thought of my two young kids,” says Pinsky, MD ’06, a child and adolescent psychiatrist at Massachusetts General Hospital. “I wondered what the world would look like to them. I started realizing these changes might affect their lives profoundly — and that would likely affect mine as well.”

J. ALLAN HOBSON, MD ’59, USED TO SAY that the only known biological function of sleep was to cure sleepiness. It was the only biological drive that humanity didn’t yet understand the purpose of. Hunger and thirst propel people to sustain their bodies; sex perpetuates the species. But sleep? Nothing. n Then his team found evidence of a far larger role for sleep.

TO THINK OF CLIMATE CHANGE

The existential threat posed by climate change leads to anxiety in many young people

Iceberg IX — Greenland 2010 Sebastian Copeland Photograph

©SEBASTIAN COPELAND

global survey published in Lancet Planetary Health in 2021 reported that among an international cohort of more than 10,000 people between the ages of 16 and 25, 60 percent described themselves as very worried about the climate and nearly half said the anxiety affects their daily functioning. Since young people expect to live longer with climaterelated crises than their parents will, “they feel grief in the face of what they’re losing,” Pinsky says.

As she feared, damage that threatens the planet’s future — and the anxiety that this threat can engender — is affecting the lives of young people. And it has changed her life: Pinsky now works at the forefront of mental health efforts to help young people manage the emotional burdens of climate change.

Anticipated peril

Compared to threats to our physical health from climate change — heat-related injuries, for instance, or the spread of tropical diseases — its mental health consequences are less researched. But emerging studies reveal a mounting toll, especially among young people. Young survivors of weatherrelated disasters report high rates of PTSD, depression, sleep deficits, and learning issues. Nearly three quarters of the child and adolescent population in Pakistan experienced learning difficulties after widespread floods devastated the country in 2010.

Young people also suffer emotionally from climate change’s anticipated effects.

The twenty-year-old Swedish activist Greta Thunberg, who chastised world leaders for inaction on carbon emissions during a speech at the United Nations in 2019, struggled for years with depression over climate change as young child. For many young people, worry over threats of future climate change results in panic attacks, insomnia, obsessive thinking, and other symptoms. And those feelings are often amplified by a pervasive sense that older people aren’t doing enough to fix the climate problem. “There’s a feeling of intergenerational injustice,” says Lise Van Susteren, a general and forensic psychiatrist based in Washington, DC, who specializes in the mental health effects of climate change. “Many young people feel invalidated, betrayed, and abandoned.”

Managing these issues poses hard challenges. Research on effective interventions

is virtually nonexistent, and parents and other people who want to help have little to go on. Professional organizations are only now beginning to provide needed resources. The Climate Psychiatry Alliance, whose members span academia and community care, has a searchable directory of “climate aware” mental health professionals on its website. These sorts of licensed therapists are described by the psychiatry alliance as “professionals who recognize that the climate threat is both a global threat to all life on Earth, and a deeply personal threat to the mental and physical well-being … of each individual, family, and community on the planet.” Another professional group, the Climate Psychology Alliance, provides a similar directory and lists support programs and resources for young people, parents, and teachers.

“I immediately thought of my two young kids. I wondered what the world would look like to them. I started realizing these changes might affect their lives profoundly — and that would likely affect mine as well.”

Elizabeth Pinsky

Pinsky emphasizes that any attempt to help young people navigate climate-related emotions must start by acknowledging the validity of their fears. News reports and researchers often refer to these feelings collectively as climate anxiety, or eco-anxiety, but Pinsky admits to having misgivings about the terms.

“Many people interpret anxiety as a pathological response that needs to be treated and solved,” she says. “But it’s also a constructive emotion that gives us time to react in the face of danger. And anxiety in the face of climate change is a healthy response to a real threat.”

Some people manage their climatetriggered emotions without spiraling into distress. But others become progressively hyperaroused and panicky, Pinsky says, or else fall into a sort of emotional paralysis.

These reactions can be especially debilitating for people who already struggle with underlying mental health disorders. Moreover, anxieties over climate change can interlace with broader feelings of instability over the pace of technological and cultural change, argues Ann-Christine Duhaime, the Nicholas T. Zervas Distinguished Professor of Neurosurgery at HMS, an associate director of the Mass General Center for Environment and Health, a pediatric neurosurgeon at Mass General, and author of Minding the Climate, recently published by Harvard University Press, which explores connections between environmental crises and neuroscience. “Technology is accelerating faster than culture can keep up, and humans in general are unmoored and struggling to adapt,” she says. “For some people, climate change is psychologically the last

straw. You realize you can no longer count on the stability of your planet, your atmosphere — your very world.”

Ways of coping

Counselors who work in this area travel in relatively uncharted territory, especially when it comes to managing anticipatory anxiety over future climate effects. Van Susteren describes that anxiety as a type of pre-traumatic stress disorder, with few existing precedents in the United States apart from fears of nuclear annihilation and the decades-ago experience of living through classroom drills on how to survive an atom bomb attack. Talk therapy for anxiety typically aims to help people identify and replace irrational thoughts, called cognitive distortions, with alternative thinking that isn’t so stressful. But since climate anxiety is based on rational fears, this particular approach risks alienating anyone who might feel their worries are being dismissed.

“You don’t want to give the impression that the client’s anxiety is exaggerated, or rooted in some experience from childhood,” says Andrew Bryant, a clinical social worker with a private practice in Seattle, Washington. “Otherwise, clients will think ‘this person doesn’t get me’ or ‘he’s in denial.’ They will leave and not come back.”

Bryant began specializing in climate anxiety in 2016, after nearby forest fires left much of Washington State blanketed in heavy smoke. Warming temperatures are fueling larger, more destructive fires in the Pacific Northwest, and, for Bryant, their effects on air quality were a wake-up call “that climate change was something that my clients and I are living with right now.”

Younger people were increasingly arriving at Bryant’s office frightened, depressed, and confused about how to manage climatetriggered emotions. Some were even wondering if they should bring children into such a world.

Bryant says his first step during counseling is simply to have people identify and express their feelings about these issues.

“We’re not saying that anxiety is good or bad,” he says. “We just want to bring those feelings out into the open. It’s more about

Younger people were frightened, depressed, and confused about how to manage climatetriggered emotions. Some were even wondering if they should bring children into such a world.

Ann-Christine Duhaime

validating that climate concerns are reasonable given what we’re reading in the news every day.”

Emerging evidence suggests that young people do best by cultivating a sense of agency and hope despite their climate concerns. The aim during therapy is for them “to engage with the world in a way that feels more meaningful and in alignment with who they are,” Bryant says. But getting to that point involves talking through feelings like despair, grief, or rage first. Without doing that, he says, many people get stuck in maladaptive coping strategies that can lead to burnout, frustration, or hopelessness. Bryant describes jumping into an urgent, problem-focused coping strategy as “going into action mode so you don’t have to feel any grief.”

Problem-focused coping has a societal benefit in that it leads to “pro-environmental behavior,” meaning that young people who engage in it typically spend a lot of time learning about climate change and focusing on what they can do personally to help solve the problem. But climate change is far beyond any one person’s control, and problem-focused coping can leave people frustrated by the limits of their own capacity and make them unable to rid themselves of resulting worry and negative emotions, according to Maria Ojala, an associate professor in psychology at Örebro University in Sweden.

Ojala studies how younger people think, feel, and communicate about global environmental problems and is an author of a 2019 paper in Environment and Behavior

on coping strategies young people are using to deal with their climate change concerns. In it, she and her colleagues describe emotion-focused coping, whereby young people ignore or deny climate change as a means of avoiding feeling anxious about it. In an email, Ojala notes that people who gravitate toward emotional distancing typically come from families that communicate about social problems in “pessimistic doom-and-gloom ways.” But since one type of emotion-focused coping involves de-emphasizing the climate threat, she says, it also precludes actions young people might take against it, and therefore has no environmental upside.

Ojala and other experts favor a third coping strategy that balances negative feelings about climate change with faith in the power of social forces working to overcome it. Called meaning-focused coping, this approach takes strength from individual actions and climate beliefs, while “trusting that other societal actors are also doing their part,” Ojala says in her paper. And since meaning-focused coping allows negative and positive climate emotions to coexist, young people who adopt it have an easier time maintaining hope for the future.

Pinsky would agree. The overall goal, she says, is for young people to achieve more resilience in the face of climate change, so they can function in spite of their environmental concerns. When people find meaning in what they do, she says, they have a greater sense of their own agency and self-efficacy. “You’re more empowered to take action, and

that can be a powerful way to deal with strong negative emotions,” Pinsky says.

But Duhaime cautions that anyone taking action against climate change should know they shouldn’t expect a quick payback. The brain’s reward system, which forms a core of human decision-making, evolved over eons of history to strengthen neural associations between actions and outcomes that promote short-term survival. And that system, she says, responds to the immediate consequences of what we do. One problem with climate change, Duhaime says, is that because it’s so vast and complex, people can’t assume that any single act will lead to a discernible effect on its trajectory. So, in place of near-term climate improvements, Duhaime says young people may benefit from seeking the rewards that come from being part of a group or a movement working to advance an agenda that furthers actions that protect the planet’s climate. “Social rewards are really powerful in the climate change battle, especially for young people,” Duhaime says. Recognizing the mismatch between how the brain processes reward and the novel challenges of the climate crisis may help people persist when it feels frustrating and ineffective compared to causes with more immediately visible effects. Even if you don’t see climate improvements or policy changes right away, she says, “that won’t diminish the importance of engaging in these efforts.”

Strength from unity

That theme resonates with Julia Malits, a fifth-year MD candidate at HMS and a graduate of the Harvard T.H. Chan School of Public Health. Malits says that like many of her peers, she grew up with a certain amount of climate anxiety, which she attributes to being overwhelmed by the scale of the problem and the immense effort required to address it. But Malits adds that she wasn’t overly burdened by her emotions. “I’m an optimist by nature and feel that society does have the capacity to make needed changes,” she says. “And what also helps me avoid climate anxiety on a daily basis is the community that I’ve been lucky enough to connect with here at Harvard. It helps

“For some people, climate change is psychologically the last straw. You realize you can no longer count on the stability of your planet, your atmosphere — your very world.”

Bryan Baxter (left) and Dimitrios Mylonas

to surround yourself with people who are similarly worried about these issues and are also engaging with you on solutions, in whatever capacity is meaningful to you.”

Malits says her interest in the health effects of climate change blossomed during conversations with professors and other HMS students. She became a student ambassador with the Harvard Chan Center for Climate, Health, and Global Environment (C-CHANGE), which has a mission to deliver solutions-based research that shapes climate actions — especially those that improve health for vulnerable populations.

In January, following a presentation delivered by Gaurab Basu, an HMS instructor and primary care physician with Cambridge Health Alliance, and jointly developed by Malits, Madeline Kline, a student in the Harvard/MIT MD-PhD program, and HMS students in an environment and medicine interest group, the HMS Educational Policy and Curriculum Committee voted to officially incorporate climate change and health into the MD curriculum as a priority societal theme. The curricular change builds on the pioneering work of students, faculty, and alumni, such as Eric Chivian, MD ’68, who founded and directed the HMS-based center that is now C-CHANGE, and Aaron Bernstein, an HMS assistant professor of pediatrics at Boston Children’s Hospital and the interim director of C-CHANGE.

Thanks to their efforts, climate themes will now be integrated into existing courses across all four years of the MD program and cover topics such as how climate change affects human health, how health care systems contribute to the problem, and how physicians can help in the move toward solutions.

“Climate anxiety is an important catalyst for the work I do,” Malits says. “I think you need avenues to channel it and talk about it with loved ones and peers, and have communities through which you can process those feelings and come up with remedies.” Collaborative activism dampens the anxiety, Malits says, and gives young people a sense of renewed hope for the future. “That’s why it’s important to roll up your sleeves and think about how you’d like to tackle the problem,” she says.

Caleb Dresser

“Seeking life in a new location is extraordinarily stressful and comes with long-term risks of anxiety and depression.”

But Malits says she worries most about how climate change is affecting marginalized communities, singling out those who live in urban heat islands, where inadequate green space intensifies extreme heat. While it’s true that extreme weather events are occurring with mounting frequency in wealthier nations, many countries in the developing world continue to bear the brunt of the climate problem.

The problem at our doorstep

Indeed, the countries suffering most from climate change now are also the least able to respond to its psychological effects. In Somalia — which is one of the poorest countries in sub-Saharan Africa — climate change is fueling the worst drought in decades and putting 8 million people, nearly half the population, at risk for famine. Catastrophic floods linked to climate change in Pakistan recently affected more than 33 million people living in the area. In addition, according to 2019 data from the World Bank, nearly 30 percent of Honduras’s population works for the agricultural sector, where rising temperatures and drought are contributing to a mass exodus, as documented that year by PBS NewsHour.

Researchers are finding that young people with the most extreme fears over climate change live predominantly in the developing world. The Philippines and India, for instance, are near the top of a list of recently surveyed countries where young people report climate-driven feelings that “humanity is doomed” and “the future is frightening.”

Mental health systems in the developing world need more resources to deal with this growing crisis, cautions Caleb Dresser, an emergency medicine physician at Beth Israel Deaconess Medical Center and a fellow at Harvard Chan School’s C-CHANGE. Disasters linked with climate change can create huge mental health needs, Dresser says, “and while many good programs and organizations step in to help, the need for services easily outpaces resources both during and after the disaster occurs.” Nearly a year after Hurricane Andrew struck South Florida in 1992, 18 percent of chil-

dren living in the area were still struggling with PTSD-like symptoms, and nearly 30 percent of those who lived through Hurricane Katrina in 2005 wound up with complicated grief, in which strong feelings of loss linger for a long time.

Dresser leads research focused on the health implications of climate change, especially in terms of its effects on emergency care and operations during extreme weather events. In 2017, he cared for people who had left Puerto Rico for Boston after Hurricane Maria decimated the island. Many were suffering emotional trauma as a result of both the storm and having been uprooted from their communities.

“We know from other displacement events in history that seeking life in a new location is extraordinarily stressful and comes with long-term risks of anxiety and depression related to a loss of place and a change in one’s sense of self,” Dresser says.

Emergency responders need to be ready for the forced migration of people affected by climate change, Dresser says, adding that many could benefit from access to care for mental health problems.

Even when people are not uprooted by disaster, a variety of climate-related mechanisms can affect their mental health or the safety of their mental health treatment. High heat and humidity worsen irritability and cognition, he points out, and they can also exacerbate side effects from some common psychiatric medications. Levels of lithium — a mood stabilizer used for treating bipolar disorder and major depression — can rise to potentially toxic concentrations in a person who is perspiring heavily; they can become dehydrated and may develop impaired kidney funtion, potentially causing tremor, slurred speech, confusion and other dangerous effects. In addition, serotonin-reuptake inhibitors, tricyclic antidepressants, and benzodiazepines may affect the body’s physiological response to heat with varied effects on blood pressure, sweating, and cognition. Patients with chronic mental health issues are at increased risk during hot weather and more likely to need emergency care. In extreme cases, heatstroke can occur, with potentially fatal results.

Pinsky points out that even as the effects of climate change on pediatric mental health are increasingly recognized, research in the field is in its early stages. She was an author on a 2022 Academic Psychiatry paper investigating the perspectives of more than a dozen scientists who work in this area. They identified several pending needs, including additional interventions to support and foster the resilience of young people experiencing climate anxiety, more funding, and the removal of logistical barriers that block access to care for affected individuals. Resistance from colleagues in the field was also raised as an issue. Pinsky and others stress that efforts aimed at responding to the mental health challenges of climate change must engage with broader work aimed at removing the root cause of the problem: our reliance on fossil fuels.

Pinsky now works with several organizations to raise awareness of climate change, including the Mass General Center for the Environment and Health and the new Youth Working Group of the Climate Psychiatry Alliance, which had its launch meeting in April 2023. And like others on the front lines of the climate change battle, she has her hands full as the pace of warming only accelerates.

According to the latest report from the United Nations Intergovernmental Panel on Climate Change, released on March 20, it is likely that without swift action, the world will exceed a global average temperature increase of 2.7 degrees Fahrenheit above preindustrial levels by 2030. Beyond that threshold, the panel warned, heat waves, crop failures, the spread of infectious diseases, floods, and species extinctions could outstrip humanity’s capacity to adapt. Warming will cease only if humans stop adding heat-trapping gases to the atmosphere.

“I believe the fundamental and best treatment for youth climate distress is just a rapid transition from fossil fuels,” Pinsky says. “I genuinely consider all that work to be in the area of mitigating climate anxiety.”

Charles Schmidt is a writer based in Maine.

Responding to the mental health challenges of climate change must engage with broader work aimed at removing the root cause of the problem: our reliance on fossil fuels.

Loss of Separation

BY STEPHANIE DUTCHEN

IBERS, FLAKES, SPHERES, FOAMS : every day we eat, drink, and inhale tiny bits of plastic. What happens once they enter our bodies is a question that worries a growing number of scientists and clinicians.

The study of whether and how microplastics — particles smaller than 5 millimeters that slough off plastic as it degrades — pose threats to human health is still in its infancy. As the World Health Organization underscored in a 2022 report, current technologies don’t yet enable researchers to quantify population-level microplastics exposures or gauge what proportion of those particles stay in our bodies. However, microplastics’ ubiquity in the environment, combined with preliminary findings from human cell and animal studies over the past decade, have led to urgent calls for more research and regulation.

“There are so many unknowns,” says Bernardo Lemos, an adjunct professor of environmental epigenetics at the Harvard T.H. Chan School of Public Health, “but we are seeing more data that suggest microplastics affect human biology.”

Understanding what these particles might do to our genes, cells, and organs is of increasing importance as changing weather patterns sweep microplastics into more of Earth’s lands, waters, and air.

Fortunately, according to Eşref Demir, an HMS visiting professor of dermatology at Massachusetts General Hospital, and Fatma Turna Demir, an HMS research fellow in neurosurgery at Mass General, the medical community is becoming more knowledgeable about plastic particle pollution and the diseases and syndromes that may be linked to it.

Where they are

We encounter microplastics everywhere: from trash, dust, fabrics, cosmetics, cleaning products, rain, seafood, produce, table salt, and more.

Little wonder that microplastics have been detected throughout the human body, including in the blood, saliva, liver, kidneys, and placenta. Investigators are probing how they get into other organs and tissues from the lungs and gastrointestinal tract. Microplastics smaller than 1 micrometer, known as nanoplastics, worry researchers the most because they can infiltrate cells.

Using a model of human intestinal lining, a team led by Philip Demokritou, director of the Environmental Health Nanoscience Laboratory at the Harvard Chan School, found that nanoplastics can enter cells in two different ways and even get into cell nuclei.

Lessons from the field of environmental toxicology raise flags about cancer and reproductive issues. Studies in cell cultures, marine wildlife, and animal models indicate that microplastics can cause oxidative damage, DNA damage, and changes in gene activity, known risks for cancer development. Microplastics have been found in human breast milk and meconium, an infant’s first stool. A few studies in mice have found reproductive effects such as reduced sperm count and quality, ovarian scarring, and metabolic disorders in offspring.

Microplastics’ physical properties are one source of potential hazards. Some marine organisms seem to be eating more microplastics and fewer nutrients, which can reverberate up the food chain. In humans, researchers point to illnesses caused by particulate air pollution, which contains microplastics, and by workplace exposure to plastic dust.

Other threats arise from chemicals in and on microplastic particles, including plastic components — such as BPA, phthalates, and heavy metals — that are known or suspected to cause disruption to nervous, reproductive, and other systems.

Although the variety of microplastics and the difficulty of estimating accumulation in human tissues make it challenging to pin down risks, findings in models show inflammation, cell death, lung and liver effects, changes in the gut microbiome, and altered lipid and hormone metabolism.

Mounting evidence suggests that microplastics magnify the potency of other toxicant exposures, such as cadmium, as Demir and Turna Demir have confirmed in fruit flies and Lemos has confirmed in mice and fruit flies. Others are chasing down hints that microplastics can carry antibiotic-resistant bacteria and other pathogens on their surfaces and into our bodies.

What to do?

While research develops, solutions beckon. Scientists are exploring plastic-eating microorganisms and plastic alternatives. Individuals can advocate for reduced plastic manufacturing and more recycling, and physicians can push for greater sustainability in hospitals and clinics.

“We want to get rid of terrible plastics in our transdisciplinary projects, our hospitals, and our patients’ lives,” wrote Demir and Turna Demir in a joint email. “Find strategies to segregate and recycle plastic medical waste. Review the use of plastic, especially single-use plastics, and synthetic textile products.”

As plastic waste skyrockets, threats to human health may escalate, according to a May 2021 Nature news article. The production and destruction of plastics produces particles and gases that contribute to climate change, and plastic left to break down in the environment releases greenhouse gases. Studies suggest that microplastics disrupt marine microorganisms’ globally crucial roles of sequestering carbon dioxide and producing oxygen. These deficits further jeopardize our health and that of our planet.

Stephanie Dutchen is the manager of feature content and multimedia in the Office of Communications and External Relations at HMS.

Microplastics are everywhere, including in our bodies. What might this mean for our health?

Michael Roy Kelly

Ethereal Figure IV, 2002 from The Solitary Figure series Graphite and china marker on paper 22 x 17 in

Links

BY ELIZABETH GEHRMAN

LONELINESS HAS BEEN INSPIRING ARTISTS and intellectuals for centuries. In Plato’s Symposium, Aristophanes says we will never be truly happy until we find our “other half”; a few centuries later the Roman poet Ovid expresses his sadness at being exiled in the letters and couplets of Tristia and Epistulae ex Ponto. Shakespeare touches on the topic with lines like “Society is no comfort to one not sociable” and “Now I see the mystery of your loneliness.” Virginia Woolf wrote about loneliness, Edward Hopper and Andrew Wyeth painted it, and the Beatles indelibly linked it to the names Eleanor Rigby and Father McKenzie in their poignant 1966 ode to “all the lonely people.”

Loneliness among young people is on the rise, sparking concerns over possible damage to their mental and physical health

t is only in recent years that science has begun to catch up in exploring the topic, and what it’s finding is harrowing. A robust body of longitudinal research strongly correlates loneliness to a host of negative health effects, including increasing the chance of recurrent stroke or heart attack by as much as 40 percent, according to the American Heart Association. A 2022 study in Neurology found that loneliness as much as triples the likelihood of developing dementia, and in 2021 Finnish researchers linked it to both total cancer incidence later in life and worse survival outcomes for patients with cancer. In 2010, Julianne Holt-Lunstad, a Brigham Young University psychology professor and the first U.S. researcher to publish a largescale analysis of studies showing that poor social support is a contributor to physical disease, found that loneliness exceeds alcohol consumption, physical inactivity, obesity, and air pollution in contributing to increased mortality and carries a risk similar to smoking fifteen cigarettes a day.

Why? “It’s not a mystery,” says Robert Waldinger, MD ’78, an HMS professor of psychiatry, part-time, at Massachusetts General Hospital. “Loneliness is a stressor. It increases chronic inflammation and hormones like cortisol and adrenaline and decreases immune function. And because it correlates with reduced social activity, that can mean you’re not being exposed to or accessing healthy behaviors as much.”

More than one study has even shown that social rejection, which can trigger loneliness, activates the same regions of the brain that physical pain does.

In person versus on screen

It’s hard to pinpoint how many people feel lonely on a regular basis, but one point of consensus is that loneliness varies signif-

icantly by age, and the stereotype of an older adult sitting at home alone waiting for Meals on Wheels to arrive while a laughing group of young people skip by outside is not entirely accurate. A prepandemic review of loneliness studies by cognitive and social neuroscientists at the University of Chicago indicates that twice as many people under age 18 as over age 65 report being lonely at least sometimes and that the pandemic exacerbated the conditions leading to loneliness. A 2021 survey of 950 people in the United States conducted by Harvard’s Graduate School of Education and the Making Caring Common Project found “serious loneliness” in 39 percent of the respondents. Of that seriously lonely group, 61 percent were people between the ages of 18 and 25.

While the emotional effects of the pandemic seem to be waning, some societal changes may be here to stay, such as remote work and virtual health visits. “Richard and I both have psychiatric practices in Cambridge,” says Jacqueline Olds, an HMS associate professor of psychiatry, part-time, and a consultant in psychiatry at McLean Hospital, speaking of her husband, Richard Schwartz, MD ’74, an HMS associate professor of psychiatry, part-time, and a senior consultant at McLean. “But people now find it so inconvenient to drive twenty minutes to get here. I totally respect and appreciate that, but in-person therapy can be much more effective. People have forgotten the joy of in-person social contact, and it’s hard to remind them of how important it is.”

A recent Gallup poll shows that loneliness is decreasing in all age groups from pandemic-level highs, but while Schwartz says that we may be gradually returning to “in-person ways of connecting,” he qualifies that by adding, “We’re just moving back to a level of connection that was inadequate before the pandemic, but still better than it is now.”

Vivek Murthy has made loneliness his platform as U.S. Surgeon General. During a 2020 interview with NPR after the release of his book, Together: The Healing Power of Human Connection in a Sometimes Lonely World, Murthy said he viewed the pandemic

as a chance to “rethink and recenter our lives around relationships.” It gave us an opportunity, he said, “to deeply appreciate the role and power that relationships have in our lives, not just to our spouses and our family members and our close friends, but also the relationships we share with colleagues at work, with classmates at school, and even with strangers in our community.” If we approach the moment with “intentionality,” he continued, “we may be able to come out of this much stronger in terms of our human connection.”

Jacqueline Olds and Richard Schwartz

The smartphone dilemma

Unfortunately, that may be an overly optimistic view in light of the effects of emerging and existing technologies. Because loneliness wasn’t studied a great deal before the beginning of this century, not much historical data exist, but research published in 2015 in the Personality and Social Psychology Bulletin found rates of loneliness among U.S. middle- and high-schoolers started to decline steadily in the late 1970s. Until, that is, 2007, when a dramatic uptick began. That was the year the iPhone was released, and, in her 2017 article in The Atlantic, Jean Twenge, a professor of psychology at San Diego State University, contends that that is no coincidence. Twenge presents graphs showing 2007 as the year teens started hanging out with their friends less, learning to drive less, dating less, getting less sleep, and feeling more lonely. “The arrival of the smartphone has radically changed every aspect of teenagers’ lives,” she writes, “from the nature of their social interactions to their mental health.”

Twenge calls young people born between 1995 and 2012 the iGen, distinguishing them from Millennials by noting they “do not remember a time before the internet.” It’s not an exaggeration, she writes, “to describe iGen as being on the brink of the worst mental-health crisis in decades,” in large part because smartphones and other digital devices are “ever-present in their lives.” Unfortunately, time seems to have borne out that prediction. A 2021 study in JAMA Open Network reports that rates of anxiety, depression, self-harm, and even suicide among children aged 5 to 11 climbed steadily from 2010 to 2019.

And it’s not just in the United States. A study on loneliness in school published in 2021 in the Journal of Adolescence showed a similar surge in the emotion beginning in 2012 in 36 out of 37 countries studied. “The synchronized global increase in teenage loneliness suggests a global cause,” Twenge and a fellow psychologist wrote in a 2021 opinion piece in the New York Times, “and the timing is right for smartphones and social media to be major contributors.” They tested this hypothesis against declines in

“We’re just moving back to a level of connection that was inadequate before the pandemic, but still better than it is now.”

family size, rising income inequality, and other factors, and found these other possible causes “less plausible.”

While on the surface this may seem like a chicken-and-egg problem — perhaps lonely teens are simply turning to social media to ease their pain — a 2019 University of Arizona study of 346 smartphone users aged 18 to 20 concluded, as Science Daily put it, that “smartphone dependency predicts higher reports of depressive symptoms and loneliness, rather than the other way around.”

“The sense of engagement with others that can be provided by social media can make it easier to withdraw from social activities,” says Daphne Holt, MMSc ’04, an HMS associate professor of psychiatry, director of the Mass General Resilience and Prevention Program and the Emotion and Social Neuroscience Laboratory, and co-director of the Mass General Psychosis Clinical and Research Program. “And then comparisons with others, ‘likes’ and so forth, can trigger negative feelings about oneself, which can then exacerbate the tendency to withdraw.”

Or, as Jacqueline Sperling, an HMS instructor in psychology in the Department of Psychology at McLean Hospital and co-program director of the McLean Anxiety Mastery Program, says, “You may think based on the exclusively positive experiences shared that they have better lives, and feel like you’re on the outside looking in.”

An isolating brew

Of course, loneliness was around well before the smartphone. Among the causes postulated for loneliness in the second half of the twentieth century, social scientists name divorce, fewer children, the geographical breakup of the extended family, the increase in single-person households that started in the 1960s, and decreasing investment in social activities like going to church and volunteering. “We know all these things figure in because they’re isolating and they make people afraid of the world,” says Waldinger, who co-authored the book The Good Life: Lessons from the World’s Longest Scientific Study of Happiness and is the fourth director of the Harvard Study of Adult Development, which began in 1938 with a

cohort of 268 Harvard sophomores and has expanded to include their wives and children.

“It’s probably a bidirectional problem,” he continues. “When you’re lonely you don’t feel like connecting as much, which in turn leads to increased loneliness.”

Research also shows that experiencing poverty, bullying, bias and implicit bias, and being marginalized because of sexual orientation can increase feelings of loneliness. “Adversity and traumatic experiences during childhood and adolescence can lead young people to develop pessimistic assumptions about relationships,” Holt says.

“That can make it harder for them to trust people and form healthy bonds with others.”

Loneliness is a measure of the discrepancy between the number of meaningful connections one has and the desired number of connections, adds Sperling, and the teenage years are a time when peers become paramount in one’s life. “If young people feel like they don’t have enough friends, or enough good friends, they can feel deeply lonely,” she says. “When you’re feeling that way, it’s hard to have the energy to put yourself out there, so you might withdraw. It can become a negative cycle rather than an impetus to

Research shows that experiencing poverty, bullying, bias and implicit bias, and being marginalized because of sexual orientation can increase feelings of loneliness.

Daphne Holt

change.” Plenty of research supports that view, including a 2006 study published in the Journal of Research in Personality that found lonely people have lower self-esteem and tend to be shyer, more anxious, and more socially awkward.

From an evolutionary perspective that’s not surprising, say Schwartz and Olds, who have written two books on the topic, The Lonely American and Overcoming Loneliness in Everyday Life. “In order to survive for thousands of years we had to work in small groups,” Olds points out. As Murthy noted on NPR, being together in trusted relationships allowed early humans to pool food, keep watch for predators, and share babysitting responsibilities. Thus an antipathy for loneliness is built into our DNA.

“I think of loneliness as a signal that tells the individual they need to increase their level of social connectedness to survive,” says Holt. “That’s why loneliness is a negative experience. It’s similar to when you’re hungry, you need to eat, or when you’re tired, you need to sleep. Your body is telling you something is not right.”

A script for loneliness

Given the evolutionary demand for social cohesion, it’s also not surprising that loneliness is often stigmatized. “In the early nineties we noticed that a lot of people would come to see us talking about being depressed,” says Schwartz, “and it wasn’t until we got to know them better that we realized the real problem was loneliness. It was something that no one led with because they were embarrassed.”

A 2022 study published in the Journal of Social and Personal Relationships report-

ed that lonely men believe they are being judged more by their community, while lonely women experience more “self-stigma”; young people, the research concluded, had higher scores than older people on nearly all indicators of stigma.

“We hope that’s beginning to change now that loneliness has emerged as an issue, partly because of the pandemic,” says Schwartz. “People are starting to realize it’s a universal part of life that everybody feels at least some of the time. So the problem isn’t that people feel lonely, it’s that some people get stuck in a kind of chronic loneliness.”

Those people’s brains may be working against them, according to Holt. “Research has shown that people who have a bigger social circle have a bigger amygdala,” she says. “That’s a part of the brain involved in regulating emotions, emotional learning, and social functioning.” The hippocampus, striatum, and insula have also been implicated in loneliness studies, but so far only correlation has been shown.

Does that mean biology is destiny?

“We don’t know the answer to that,” Holt says. “But to speculate, I would say that we can change these things. The brain shows a lot of plasticity, and activity-dependent changes do happen.”

Of course, not everyone needs the same amount of interaction to avoid feelings of loneliness. “Some people don’t need many intimate relationships, and some are content with having a lot of acquaintances,” Holt says, “whereas others crave close relationships and feel lonely in a crowd. The important thing is to become aware of what your specific needs are.”

For individuals who do feel lonely, particularly young people who may be experiencing life transitions like marrying and having children on a different schedule than their friends, one solution that might sound trite but does seem to help is simply to get out and do something. Volunteer, attend a class, join a club, take up a sport. “Any time you can get people to join a small group and stick with it,” says Olds, “it can add years to their lives.”

“Just remember that making new friends takes time,” Sperling cautions. “It also depends on how vulnerable you’re willing to make yourself: Friendships are established when people start to become more open with each other.”

Some physicians have begun writing prescriptions for social activities tailored to the individual, a practice Murthy endorses. “A checkup of your social health is now part of most medical appointments,” says Schwartz, “and the authority or just the concreteness of a prescription can help some people who may not know how to begin to change a situation that’s not working for them.”

Doctors interested in making social prescriptions should familiarize themselves with the possibilities, say Olds and Schwartz. Skip the Small Talk, a group that encourages self-disclosure by giving participants cards with conversation-starting questions, and FriendshipWorks, a Boston-based entity that pairs volunteers with isolated older people, “set up relationships that can last over long periods of time and turn into true friendships,” Schwartz contends.

Various loneliness interventions have been tried in schools, with mixed results. One approach that research has shown to benefit children is social and emotional learning, which uses age-based activities to teach social awareness and relationship skills. Studies have shown that kids in such classrooms do better not only socially but also academically, and the lessons learned can be used throughout life.

“Nurturing relationships to keep loneliness at bay is an important part of health care,” says Sperling. “You don’t wait to brush your teeth until you have a cavity.”

Elizabeth Gehrman is a Boston-based writer.

“Comparisons with others, ‘likes’ and so forth, can trigger negative feelings about oneself, which can then exacerbate the tendency to withdraw.”

BY JAKE MILLER

Stand in Line

ON ANY NIGHT IN ANY EMERGENCY room in the United States, you might find a young person experiencing chest pains and another in psychological or emotional distress for, say, being the target of online bullying.

The young person with chest pains will get scans, blood work, and other exams deemed necessary. If they need to be admitted, an appropriate room will likely be found; if they’re discharged, they’ll leave with a follow-up appointment or a referral to a specialist and usually a plan for follow-up.

For their peer with psychological or emotional distress, it’s a different story. If their crisis is severe enough — for example, if they have indicated they are considering suicide — and they need to be hospitalized, it’s likely there will be no beds available on the appropriate wards. They will

either remain in the emergency department receiving inpatient care for possibly several days or be moved to the medical ward, where they will receive psychiatric treatment. When they’re discharged, they may need to wait months to get an appointment with an outpatient child psychiatrist.

“The mental health problems that kids come into the ER with are as life-threatening as any other illness or injury we might see, perhaps more so,” says Zheala Qayyum, MMSc ’19, an HMS assistant professor of psychiatry and medical director of emergency psychiatric services at Boston Children’s Hospital. Qayyum is right; 2020 data from the U.S. Centers for Disease Control and Prevention show that suicide is the second leading cause of death among young people between the ages of 10 and 24. The U.S. Surgeon General, the National Institutes of Health, and the American Medical Association have issued reports warning that adolescent mental health in the United States is in a state of emergency; in 2016, an article in the AMA Journal of Ethics called for policy changes that would promote more access to mental health care for adolescents through the funding of school-based programs and services.

“Schools and pediatricians are the two major referral sources for us in the emergency room,” says Qayyum. “They’re the places where people have the most contact with the kids. The teachers and doctors can pick up if something is going awry or a kid is in crisis. They’re the ones who pick up on it.”

According to the CDC, between 2009 and 2019, suicidal ideation, suicide attempts, and persistent sadness or hopelessness increased by 40 percent among U.S. high school students. Yet, the CDC estimates that in 2019 less than 20 percent of young people nationwide who sought care for mental health challenges received the care they needed.

“I’ve lived with this crisis for quite some time,” says Qayyum. “Before I began in the emergency department at Children’s, I was running an adolescent and young adult inpatient psychiatric unit. Pre-pandemic, we noticed that boarding times were longer — and we didn’t have enough beds.”

The need for mental health care among pediatric patients is growing, but the resources to provide that care are not keeping pace

MALERAPASO/ISTOCK/GETTY IMAGES PLUS

Qayyum adds, “People agree that hospitalizing kids is not the solution.The problem is that we don’t have enough supports in the community to prevent hospitalizations.”

Amid the crisis in adolescent mental well-being that, as Qayyum points out, has been decades in the making, physicians who care for young people are seeking solutions that can help them now. However, despite the acute need, a systemic solution will require long-term societal and policy shifts. Some are underway while many are still aspirational. Others wait to be discovered.

External forces

To explain this increase in mental health conditions and illnesses among young people, experts have cited a long list of social and cultural shifts, including the increasing pressure in all aspects of adolescent life. Discrimination based on race, gender, or sexual orientation and childhood trauma have long been identified as major risk factors for adolescent and adult mental and behavioral health problems. The Robert Wood Johnson Foundation recently added attending a high-performing school to their list of factors that put young people at risk for poor mental health.

A growing body of evidence indicates that some forms of social media may also be harmful for certain young people. An ongoing, crowd-sourced collaborative review of literature related to social media and mental health, overseen by Jonathan Haidt, the Thomas Cooley Professor of Ethical Leadership at the Stern School of Business at NYU, and Jean Twenge, a professor of psychology at San Diego State University, references studies indicating a causal effect between the arrival of social media platforms on college campuses and an increase in anxiety and depression among students on those campuses. Other experiments cited showed that even brief exposure to the idealized, filtered selfies often posted on social media sites was associated with body shame and lowered self-esteem.

Overwhelmed

The damage of such influences accumulates. Some physicians note that young people in

mental distress are sicker and younger than those they saw earlier in their careers. And these young people are less likely to find the resources they need to recover their mental health.

“Pediatricians are expected to provide considerably more mental health care than we were when I first started practicing thirty years ago, but support from child psychiatrists is much harder to find and there are not nearly enough child therapists to see all of the children in need,” says Carolyn Sax, MD ’87, an HMS assistant professor of pediatrics, part-time, at Boston Children’s and a pediatrician at Hyde Park Pediatrics, part of Boston Children’s Primary Care Alliance.

“There are more requests from patients and families for behavioral health services. There seems to be an increase in mood and anxiety issues among children and teens and a greater expectation that emotional issues should and can be addressed. We need to provide more mental health interactions with our young patients. Unfortunately, this need also coincides with an absolute famine of availability of mental health providers outside of primary care pediatrics.”

The pediatricians Sax works with take an integrated approach to providing mental health care to their patients by including behavioral health providers in their pediatric primary care medical home. This patient-centered, comprehensive, teambased medical home model provides their

young patients with access to mental health assessments and short-term interventions designed to help with psychological, social, emotional, and academic challenges.

Unfortunately, Sax notes, the practice does not have the capacity to offer fullservice psychotherapy, so the practitioners try to offer referrals for community-based outpatient care. It can, however, be difficult to find a provider who accepts MassHealth or even private insurance.

“If a child comes in with a severe mood disorder, I feel like I’m on my own,” Sax says. “The system is just broken.”

Woven throughout

As part of an effort to recognize the importance of mental health care and to integrate a recognition of mental health in wellness and illness, HMS is developing a core curriculum that will more thoroughly integrate mental health into MD education. The goal is to create a greater awareness and understanding among medical students of the mental health challenges faced by patients from the populations they might encounter during their careers, no matter which specialty they pursue. High up on the list of skills to be developed and honed are the basic ones useful in any clinical context: listening to and talking with patients.

“Our aim is to teach future physicians the basics of how to assess, when to refer, and how to follow up when they refer,” says Todd Griswold, an HMS assistant professor of psychiatry at Cambridge Health Alliance. Griswold, who has deep roots as a medical educator and a clinician in adult psychiatry and community-focused health care, is part of the team that is developing the curriculum. In addition to Qayyum at Boston Children’s, the team includes Brittany Jordan-Arthur, an HMS instructor in psychology and a staff psychologist with McLean Hospital’s school consultation service, and Sandra DeJong, an HMS associate professor of psychiatry, parttime, and a senior consultant to the child and adolescent psychiatry training program at Cambridge Health Alliance.

The HMS curricular initiative is one facet of a multiyear project funded by the Manton

Carolyn Sax

Foundation. The overall goal of the project is to develop education and training programs aimed at making mental health care more widely available to children and adolescents. The curriculum will also emphasize the importance of understanding the effects that social factors and trauma have on mental health.

The idea is to look at each patient as a whole person, to understand how their mind and body work together and how relationships to their doctor, family, and community affect wellness. Moreover, medical students need to remember that a patient is far more than a collection of organ systems, symptoms, and diagnoses.

“We don’t want to train people to practice humpty-dumpty medicine, where each specialty takes a piece and there’s no one owning putting things back together,” says Qayyum, who is also the training director for the Boston Children’s child psychiatry residency program.

Power tools

Efforts to supply practicing pediatricians and other clinicians with material or training to bolster their knowledge of adolescent mental health issues have been on the rise. In 2021, the American Academy of Pediatrics developed several mental health toolkits to aid clinicians when they work with young patients and their families. In February 2021, the organization released the second edition of Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit

for Clinicians and, in March of this year, it released a six-unit online course addressing trauma-informed care and resilience promotion. Each is designed to help practitioners refine skills and procedures for the integrated delivery of mental health care.

Individual hospitals, such as Boston Children’s and Massachusetts General Hospital, have also been developing tools to help pediatricians in the clinic and are building integrated care structures into many hospital-based specialties. For instance, a pediatric psychiatric collaborative care model developed at Mass General embeds mental health care within specialty medical practices such as the Pediatric Cystic Fibrosis Center and the Food Allergy Center, both at Mass General for Children. By integrating mental health care into other specialty centers, pediatricians hope to help patients and families deal with the mental health stresses often associated with chronic illness and other complex or long-term medical care.

A focused, assistive tool being developed by clinicians at Boston Children’s is taking crisis intervention techniques originally developed for the emergency department and adapting them for use in pediatric and primary care settings. This training tool will be available to clinicians through OPENPediatrics, an open-access online community of health professionals.

Strong bonds

Vikram Patel, The Pershing Square Professor of Global Health in the Department

of Global Health and Social Medicine in the Blavatnik Institute at HMS, has been advocating for better mental health care globally for years — and has been innovating to achieve just that. Together with collaborators, Patel has found ways to deliver novel, highly effective mental health interventions that don’t rely on specialists or dedicated mental health clinics. Much of his early work was done in India with the community health organization Sangath.

Now Patel is working on projects that will apply those techniques in the United States, including one that will train middle school and high school counselors to deliver evidence-based talk therapy interventions to help young people get unstuck from negative thought cycles. Like the curricular design initiative underway at HMS, this effort is funded by the Manton Foundation.

According to Patel, data from the program indicate that individuals taking part in talk therapy interventions show progress; after only a dozen such sessions, he says, symptoms were alleviated in 60 percent of the participants, potentially preventing them from developing a more enduring mental illness. A similar study, published in 2018 in Behavioural and Cognitive Psychotherapy , assessed a small group of young people. This observational study indicated that after brief behavioral treatments, 65 percent of the participants needed no further intervention.

These techniques promise individual success and may also help reduce the demand for mental health care over time, as fewer people become seriously ill. An added advantage to this type of approach is that it builds and strengthens existing community relationships with school counselors and community health workers.

This bond-building is essential, says Qayyum. “We have to build a sense of connectedness, so young people don’t feel like they’re navigating this crisis on their own.”

“We don’t want people to practice humpty-dumpty medicine, where each specialty takes a piece and there’s no one owning putting things back together.”

Jake Miller is a writer in the HMS Office of Communications and External Relations.

The HMS curricular initiative will emphasize the importance of understanding the effects that social factors and trauma have on mental health.

The Unblinking Eye

BY ANN MARIE MENTING

A filmmaking team uses visual narratives to tell stories that allow for understanding and humanity

ACH DAY, SOCIAL INJUSTICES such as poverty, poor access to health care and education, food insecurity, and the violent or preventable deaths of parents and children confront people marginalized by society. Unrelenting exposure to such social traumas frequently inflicts deep psychological harm. For decades, Joe Brewster, MD ’78, and Michèle Stephenson have been crafting visual narratives that not only expose such harm but work to counter it. They do this by presenting candid narratives of socioeconomic oppression and injustice experienced by people and communities of color. Their clear-eyed, often lyrical storytelling portrays people who live with past and present injustices daily, yet draw upon their personal strength, culture, and community to persevere and challenge assumptions.

Brewster and Stephenson’s work has been praised extensively and earned national and international awards. For instance, their documentary American Promise, a coming-of-age story of two Black boys, one of them their eldest son, during their years at an elite, predominantly white school in New York City, earned them the U.S. Documentary Special Jury Award for Achievement in Filmmaking at the 2013 Sundance Film Festival. The outreach campaign they developed for that film won the 2014 BRITDOC Impact Award for the campaign’s significant achievements, including inspiring a nationwide movement among parents of color to consolidate their voices and work with their local schools to tackle issues of race, class, gender, parenting, and educational opportunity. In 2021, they produced The Changing Same, a magical realist, immersive work addressing racial trauma, which received the Tribeca Film Festival’s Grand Jury Award for Best Immersive Narrative. Earlier this year, the couple gained acclaim for Going to Mars: The Nikki Giovanni Project, a hybrid documentary celebrating Giovanni’s enduring influence as a poet, artist, and social commentator. It earned the Grand Jury Prize for U.S. documentary at Sundance.

Brewster, who trained as a social psychiatrist at HMS and Stanford University, and Stephenson, who graduated from Columbia Law School and McGill University, brought their expertise in medicine, law, and storytelling to a conversation with Harvard Medicine magazine. What follows is an edited version of that conversation.

Michèle Stephenson and Joe Brewster

HMM: Your film company is named Rada Studios. What does Rada stand for?

Stephenson: Rada goes back to Haitian voodoo roots. I was born in Haiti and when we were forming the company, we wanted to honor our African ancestors.

There are two main constellations of spirits in the vodou religion: petro, the more feisty, revolutionary spirit that comes out of the revolutionary struggle of Haiti; and rada, the wise and creative spirits that link directly to Africa in terms of their inspiration and how they envision life. Sometimes the spirits are in conflict, other times in conversation. Our logo is a take on the crossroads where you meet the spirits and seek their advice and guidance in this process of storytelling.

Brewster: When I met Michèle, she had moved to New York to attend law school. She was very much into her Haitian ancestry, so I learned a lot. I’ve always felt that the rada spirits are also nurturing and familybased. As a company, we are family first. And then it’s about how you create and collaborate in community to do your work.

HMM: What is it about storytelling that is so compelling?

Stephenson: Storytelling is what makes us human. It reflects our common humanity and helps us keep our humanity. Story has power. That’s why there’s so much conflict around whose stories are going to dominate. To allow some stories to dominate strips others of their humanity and lived experiences.

If we don’t have a common understanding of history, of our own history, society, or communities, there cannot be a common understanding of the legacy of that history and how it continues to affect us today. There can’t be a common coexistence. That really starts with a better mutual understanding of history that is not only truthful but that everybody believes in. It’s about reexamining history, building a new narrative, a true narrative, that allows for humanity and reimagines how we relate to each other systemically and individually.

Brewster: I think there’s a war of narratives going on right now. People don’t understand what that means for our health. Trying to determine whose history is most important is one thing, but the stories that help determine how good you feel about yourself are influenced by the gaze of the historian, and unfortunately, that gaze is often from the perspective of those with power.

As filmmakers, we know that gaze has an outsized effect on our health and wellbeing. There are parallels between writers and therapists that are important. The unconscious emotions of a therapist, called countertransference, can influence a patient. Likewise, writers have a similar power and must be aware of its influence. Once we see ourselves better, we are able to draw characters who bring a different level of understanding of our world to audiences.

HMM: Was there a pivotal moment when you realized you could use film to heal?

Brewster: During my residency, I wanted to learn about therapy from the vantage point of a patient. So I contracted with a psychoanalyst in Brookline, Massachusetts. I remember he lived in a castle. It was a beautiful home.

One day, I’d left his home office and was waiting in his driveway for my girlfriend. As I waited, I noticed a police car, then another, then another until I realized I was surrounded by six police cars. They wanted to know what I was doing in that neighborhood. I was so incensed I refused to speak to them. I felt my head was about to explode.

My therapist, who was white, came out and used his authority — his skin color — to vouch for me. I left in pain. The incident affected me for weeks, and yet my therapist was not able to discuss with me the power dynamics of what happened. He was one of the better-trained analysts in Boston, and yet he could not unpack the issues with me to help me heal.

Too often these difficult conversations are not had. My experience working with other psychiatrists is that we are blinded to the importance of the work that we do. I found

film provided a conscious acknowledgement of my dilemma and lived experience. And it could provide hope to others that a conscious expression of our lived experiences and needs can be shared as a step toward healing. Our films begin by doing the same work that I’m accusing my colleagues in psychiatry of not doing: looking at race and class and addressing the systemic struggles of the characters and communities of color we represent.

HMM: What are some of the ways you work to counter portrayals that might be harmful to people of color?

Brewster: Let me count the ways. We did a twenty-episode online series for the World Channel and PBS where we examined mental health issues and how communities of color were going back to their roots to reclaim methods for healing themselves and dealing with generational trauma. We looked at Indigenous communities in Montana and South Dakota and Asian communities in Southern California. That experience was a revelation for us. We had a sense of what trauma we would find but not the degree to which it remained significant. It went back generations and people were aware of it.

Stephenson: That series is titled Decolonizing Mental Health and features individuals who have been affected by mental health issues and/or are themselves trained in psychotherapy or psychology or mental health support and are working within their communities. We highlighted their stories as a way of engaging and validating different, non-Eurocentric, ways of approaching mental health, approaches based on community and culture.

HMM: Your 2013 documentary, American Promise, told a story that moved audiences. Could you talk a little about what happened following the release of the film?

Brewster: That film had an unimaginable effect on people nationwide. It follows our son and his friend through their education at an elite school in New York City and

There are parallels between writers and therapists that are important. The unconscious emotions of a therapist can influence a patient.

candidly shows the struggles that they — smart, confident, and loved children — went through just by being Black boys within a predominantly white school. We intentionally called it American Promise because we wanted to make the bold statement that our kids are an integral part of this country’s fabric.

People were inspired by the film. There were thousands of folks who basically changed their lives based on that film. They formed parent groups that focused on achieving greater equity and more agency for people of color at schools, both public and private. All I can say is that the film was as important as psychiatry for many: individual and group sessions were born and supported by the film.

But the radical statement that the film made was that we have been here a long time and are a part of the fabric of this country — we elevated the agency of families of color.

Stephenson: Well, it may show that the Black experience has been here since the beginning, but there has been a long and continued history of all types of migrations to this country as well as the violence of slavery and settler colonialism. Once we fall into the “I’ve been here this long, and you haven’t” position, we’re leaving out other narratives and complicated historical relationships to this country that transcend current borders.

I think there’s another outcome of the film that needs to be mentioned. The film flipped the script on Black male achievement and helped expose the effect of institutional racism on our children. The Dalton School, the New York City school that our sons attended and that we filmed, has by no means fixed its issues of power and its treatment of students of color. But there’s a definite difference between what’s happening there today and what was happening when our son was there.

The film is a thirteen-year narrative portraying strong characters who we root for as we watch them face obstacles. The story completely engages whatever community watches it. Yet the other reality is that it’s a story about two Black middle-class

families, all first-generation college-educated. This was a story many Black families, who were similarly situated, had not seen. It forced a certain conversation that would not have happened without the film. And that conversation happened across the board, across many schools. It illustrates the level of engagement that can happen from storytelling.

HMM: And you followed it with the book PromisesKept

Brewster: During the making of the film, Michèle and I visited Alvin Poussaint, who was the founding director of the Office of Recruitment and Multicultural Affairs at HMS. We talked with him about the reaction the documentary was already receiving before its release: Black parents from all over the country were calling us to find out when the film would be coming out. He suggested we write a book because what we described for our son in American Promise was also being experienced by Black professors at Harvard. Promises Kept was published in 2014.

HMM: Since we’ve touched on HMS, did you have mentors while you were a student here?

Brewster: I was encouraged by many people. The first day I walked into McLean Hospital as a resident, I told them I was interested in social psychiatry. I was warned that was not an area they explored, but Shervert Frazier, the hospital’s chief of service, said he wanted me to have a mentor who looked like me. He asked me to see Chester Pierce, a Black psychiatrist.

I met with Pierce weekly; I had to get up at 4:30 a.m. to work the meetings into my schedule, but I did it. Pierce inspired me to move forward with my interests in social psychiatry.

HMM: Before we end, I wondered whether you worry about the effects of images of violence perpetrated on people of color, captured on body cams or smartphones, and shared widely. Are these visuals — so different from the films you produce — adding to the conversation or doing more damage?

Stephenson: Visual storytelling can influence people to take action in certain ways. I would say that narratives, violent or otherwise, open a window into a lived experience. But it’s up to us, as people, to engage with that story and decide how to move with it.

Brewster: There is certainly the possibility that trauma will set back the viewer. But the bigger, more damaging trauma is the continuation of systemic injustice. We can’t look at just one point in time but need to address the systemic injustices in the country.

For example, we’ve been engaged to do a film about the death of a young Black man while in the custody of the police in Baltimore. We asked ourselves how we should tell that story and not fall into common narrative tropes of a “true crime” genre. We decided to focus on the systemic story and how media narratives are used to villainize the victim and his community despite eyewitness accounts of what happened. We have turned to our own complicity as a society in this killing.

But what does it mean to reexperience the trauma at the hands of the police? It might be that if you watch this narrative, you’re going to be harmed. Yet in reality we will never remove ourselves from this societal predicament unless there’s an understanding of how systemic oppression works.

We could compare it with therapy and the process of self-understanding. You can’t do it in a day, but gradually you understand that we have traumatic experiences and we can process them. I say that instead of looking at what it does today, look at how we can develop a three-dimensional understanding of trauma and process it so that over time we can eventually be whole.

Stephenson: I think Joe hits the nail when he says the greater harm and trauma is the continued systemic violence that is committed against communities of color. Anything that sheds light on that is needed.

Ann Marie Menting is the editor of Harvard Medicine magazine.

Narratives, violent or otherwise, open a window into a lived experience.

The brain and its functioning are endlessly fascinating to many. So, too, are images of the brain. In this photo essay, we present images captured by Harvard scientists as they conduct research they hope will help unravel neural mysteries. Their work involves deciphering the connections between regions of the brain, decoding the mechanisms that translate sensory signals from external stimuli, creating maps of the brain’s molecular activity, and investigating the genetics of nervous system tumors. The knowledge they gather further shapes what is known about how the brain oversees our physiological functioning, directs our behavior, becomes diseased, and responds to novel therapeutics.

Inside View

A cross-section of the mouse nasal epithelium is shown at right. Olfactory sensory neurons (yellow) detect volatile odorants and relay the information via their axons (magenta) directly to the brain, where the axons coalesce into structures known as glomeruli in the olfactory bulb, the rounded structures at the top. Cell nuclei (cyan) are stained with an agent known as DAPI. Nasal sensory neurons detect odors via a diverse set of receptors — the largest gene family in our genome. The Datta lab is developing high-throughput sequencing approaches to identify which odors activate which receptors: Each odor interacts with a subset of receptors and each receptor interacts with a subset of odors. The aim is to decipher the molecular logic that underpins our sense of smell.

Photo by: David Brann, PhD candidate

PI: Sandeep Robert Datta, MD ’04 PhD ’04, HMS professor of neurobiology

The apex of the snail-shaped cochlea, our hearing organ, is shown with its dense vascular network (green). The hair cells (magenta), which detect sound, are innervated by the primary auditory neurons, whose cell bodies and axons are also in magenta.

The neurons and sensory cells of the mammalian cochlea relay to the brain information on the diverse sounds that surround us daily, forming the basis of our sense of hearing. The auditory system is complicated, and researchers in the field continue to work to answer fundamental neurobiological questions. Past work in Goodrich’s lab has shed light on the development and molecular diversity of primary auditory neurons. Current work by Comeau builds on this earlier research by studying newly identified molecules that help neurons make the proper synaptic connections with the sensory cells in the cochlea.

Photo by: Katelyn Comeau, PhD candidate PI: Lisa Goodrich, HMS professor of neurobiology

PIs:

Lauren

Yogesh

Lab: Lauren Jean O’Donnell

The superficial white matter of the human brain is located beneath the cortex and plays an important role in cortico-cortical communication. This photo (left) was captured using ultrahigh-resolution diffusion magnetic resonance imaging and shows previously invisible u-shaped connections of the superficial white matter. The colors indicate the overall 3D orientation of fibers in the brain and their estimated white matter connections.

The O’Donnell lab is working to create the first atlas of the human brain’s superficial white matter using submillimeter ultrahigh-resolution diffusion MRI. Located between the deep white matter and the cortex, the superficial white matter plays an important role in neurodevelopment and aging and has been implicated in a large number of diseases, yet is vastly underrepresented in current descriptions of the human brain connectome. The creation of comprehensive, anatomically curated maps of the superficial white matter would allow it to be studied in health and disease.

Photo by: Fan Zhang, former HMS instructor in radiology, Brigham and Women’s Hospital

Nikolaos Makris, HMS professor of psychiatry, Massachusetts General Hospital

Jean O’Donnell, HMS associate professor of radiology, Brigham and Women’s

Rathi, HMS associate professor of psychiatry, Brigham and Women’s

The fruit fly larval brain shown in this image (right) is

type of brain tumor.

types of brain cells shown include glial cells (blue), which support, nourish, and protect neurons, glial nuclei (red), and neuropils (green), which are dense networks of fine glial processes and neuronal processes (axons and dendrites).

Neurofibromatosis type 1 is a genetic disease characterized by tumors of the nervous system. The Walker lab has developed fruit fly models of the disorder and uses them to improve our understanding of the mechanism that drives neurofibromatosis type 1, with the goal of identifying potential therapeutic targets.

Photo (right) by: Torrey Mandigo, postdoctoral fellow

PI: James Walker, HMS assistant professor of neurology in the Center for Genomic Medicine, Massachusetts General Hospital

used by researchers to study glioma, a

The different

The images presented in this essay won special recognition in the annual The Beauty of the Brain photo contest from the Harvard Brain Science Initiative, a crossschools effort launched in 2014 by the Office of the Provost at Harvard University. The initiative is jointly directed by David Ginty, the Edward R. and Anne G. Lefler Professor of Neurobiology at HMS and chair of the Department of Neurobiology in the Blavatnik Institute at HMS, and Venkatesh Murthy, the Raymond Leo Erikson Life Sciences Professor of Molecular and Cellular Biology at Harvard University and director of the Harvard Center for Brain Science.

Multiplexed RNA imaging of part of the human brain was used to produce the above image, which shows RNA molecules (various colors) expressed from 4,000 different genes in individual cells. The imaging technique was used to identify transcriptionally distinct cell populations and to generate a molecularly defined and spatially resolved cell atlas of the human cortices.

The Zhuang lab develops novel imaging methods, molecular probes, and image analysis algorithms, and uses these tools to study a variety of biological problems. The research that produced this image involved the development of high-resolution, spatially resolved single-cell imaging methods that can be used to study how the spatial and molecular architecture of the mammalian brain alters during evolution and in diseases.

Photo (above) by: Rongxin Fang, postdoctoral fellow

PI: Xiaowei Zhuang, Harvard University professor of chemistry and chemical biology and professor of physics

A conversation with Natasha Archer, assistant professor of pediatrics, HMS; pediatric hematologist, Boston Children’s Hospital; affiliate, Department of Global Health and Social Medicine in the Blavatnik Institute at HMS

How did you develop your passion for delivering sickle cell disease care to children worldwide?

I had long been interested in providing care to individuals who were not getting care, and it became clear to me that caring for people with sickle cell disease was an unmet need domestically and globally.

I get to provide longitudinal care for patients and families: I meet patients when they’re babies and follow them from early childhood and adolescence into early adulthood. I always joke that I went into pediatrics because baby feet are much cuter than adult feet, but I really just love working with children and families and watching children grow while helping them to be their best selves.

As I learned more about sickle cell disease, I also fell in love with it from an academic vantage point. Clinically, there’s so much variability in patients’ symptoms and how the disease manifests within them. Scientifically, sickle cell disease is fascinating: I learn something new almost every day, and there’s still so much more to learn.

What is one of your proudest career moments so far?

I am so proud of my promotion to assistant professor of pediatrics. I’m happy that I can serve as an example to other Black women who are interested in hematology/oncology and academic medicine and show them that there’s a path and a place for them in the field.

Where do you draw inspiration when facing obstacles in your work and career?

My patients. What I go through is nothing compared with what they’re going through

and living with, and if there’s any way that I can make their everyday lives better, that’s what I’m going to do. People are depending on me to do the work.

What do you enjoy about working at the intersection of science, medicine, and public health?

I like providing intimate clinical care to patients, then taking the questions that arise in the clinic and applying the science that may help change the way care is delivered globally. For example, my research on the relationship between malaria and sickle cell disease stemmed directly from my patients. The beauty of academic medicine is that I get to move the science and care forward and touch the lives of people beyond my patients.

What do you do for fun?

I don’t know if this is a boring answer, but I love spending time with family and friends. On most days, my free time is occupied by my husband and my three little girls. I love my girls, but they do keep me busy. I played Division I basketball in college and used to work out a lot, but now I only have time to ride a stationary bike at night while checking my emails.

— Catherine Caruso

Where Law and Medicine Meet

“I HAVE A DREAM JOB. Every day is more exciting than the last,” Judith Edersheim exclaims with palpable enthusiasm for her work as director of the Massachusetts General Hospital Center for Law, Brain & Behavior. The center requires Edersheim to draw daily from her Harvard degrees in medicine and law as she strives to bring sound science into the courtroom.

Edersheim notes that when she began her career, her path “was not very usual, nor was it particularly planned.” While her law school experience was “fascinating and mind-blowing,” as Edersheim began working in corporate and real estate law, she realized that something was missing. “The work didn’t have enough stories. It didn’t have enough immediacy and intimacy. It didn’t solve personal problems,” she recalls.

So Edersheim pivoted to a field with plenty of problems to solve: medicine.

She began her psychiatry residency certain that law was “in the rearview mirror.” But then a colleague asked her to look at a legal case involving medicine. The result was eye-opening and led her to complete a fellowship in forensic psychiatry, ultimately placing her squarely on a path that led to her co-founding the center 15 years ago. The goal: bridge the divide between medicine and law and champion great science in the service of justice.

The center began by responding to incorrect neuroscience in legal settings but now actively promotes accurate neuroscience. It does this in four main areas: the aging brain, sentencing reform, juvenile and emerging adult justice, and trauma and the law.

In practice, this involves teaching lawyers, judges, and others in the legal system about the science of mental illness, substance use disorders, memory, trauma, and developing and aging brains. In addition, Edersheim and her colleagues offer judges scientific expertise by filing amicus, or friend-of-the-court, briefs on brain-related topics in landmark legal cases. They’ve written briefs explaining why the science of memory makes single-eyewitness identification inaccurate, how the brains of adolescents and emerging adults differ from the adult brain, how the isolation of solitary confinement has lasting neurologic effects, and how trauma affects the brain in people seeking asylum.

“If we’re looking for justice, the law is about mental states, and mental states start with the brain,” Edersheim says.

Now, the team is working to expand the center’s influence to reach legal systems throughout the world by working with the United Nations to develop an international law and neuroscience executive diploma. It is also creating a digital database of amicus and legislative briefs, case law, and video tutorials about neuroscience.

Yet even as her ambitions for the center grow, Edersheim remains focused on the little things.

“It’s knowing that we changed a life. That we managed to help an innocent person be released, prevented someone from losing a nest egg, or gave the justice system the science to believe in the redemption of a young person. Those victories keep me going.”

—Catherine Caruso

Judith Edersheim, MD ’96 | Co-founder and co-director, Center for Law, Brain & Behavior, Massachusetts General Hospital | Assistant professor of psychiatry, HMS | Attending psychiatrist, Mass General

Student Life

Winthrop Gillis

WHAT “CHANGED EVERYTHING” for neuroscience PhD candidate Winthrop Gillis was taking his first biology class as a high school sophomore. “I had been interested in science — robots and space and atoms — from the youngest age I can remember,” he says. “But when I learned that DNA controls how we look, how we behave, and how we develop by encoding proteins, I was hooked.”

He looked for a college with a protein-engineering department but was ahead of his time. “The field hadn’t developed enough to have an entire department dedicated to it,” he says, so he attended Boston University, majoring in behavioral biology. And again, one class — this time in psychology — was all it took to “steer my interest from proteins to the brain.”

He joined a lab that studied how zebra finches generate specific and consistent songs, or, more broadly, “how the brain stably generates stereotyped behaviors,” he says. Because there was also an engineering element to this work, he learned how to program a type of open-source software that runs microcontrollers used in experiments. This skill allowed him some creativity in designing experiments and helped him get a job in that same lab after graduation.

Harvard neurobiology professor Sandeep Robert Datta, MD ’04 PhD ’04, stopped by the lab Gillis was working in one day to talk with the lab about his research exploring animal behavior by breaking it down into discrete modules similar to the “syllables” in a zebra finch’s song. Gillis took the opportunity to make a connection, and Datta later encouraged him to apply to the Harvard PhD Program in Neuroscience. He also invited Gillis to join his lab.

“We’ve found that dopamine is released all the time in the brain, even during spontaneous behavior,” Gillis says. “We believe that the dopamine released during spontaneous behavior is important for making sure animals can live effectively in dynamic environments where they have to modify their behavior. I’m hoping our work will lead to a better understanding of how the brain generates behavior in more naturalistic settings.”

Once Gillis completes his graduate work, he plans to switch gears, leaving academia for industry and using what he’s learned, along with his expertise in engineering and managing large data sets, to solve problems related to climate change.

“It’ll be a 180,” he says, “but I think the skills I’ve learned will be valuable wherever I go.” There’s a part of him, he says, that would like to establish a start-up, perhaps one focused on genetically engineering algae to remove carbon at a faster rate. “Climate change feels like an unsolvable problem,” he says, “but with more time and more people thinking about it, maybe this insurmountable hill will look like something we can climb. I’m hoping working on it will scratch my itch to see what I can do to help to change the world.”

—Elizabeth Gehrman

Alyssa Larios

WHEN SHE WAS ABOUT EIGHT YEARS OLD, a special issue of National Geographic caught Alyssa Larios’s eye at the grocery store. Its cover promised a user’s guide to learning 100 things about the brain.

“My parents had zero influence on my choice of science,” she says, “except that they were keen to find opportunities to facilitate my interests.” Her mom bought the publication, and Larios spent hours poring over it. “I just really liked learning,” she recalls. “Once I got to middle school, what grabbed me most was cell biology. I thought it was elegant the way these tiny ecosystems fit together and that the molecular machinery that keeps it all clean and functioning and fed was happening at these microscales. I thought it was all so beautiful.”

At around age sixteen Larios sustained a minor chemical burn, and her mother’s friend, a nurse, made an unofficial house call to treat her. Through that nurse, Larios began volunteering in a burn clinic, where she became fascinated by how tissue repairs itself. “It was there I realized I wanted to do research,” she says. “Of course, at the time I didn’t know what failure feels like in a lab. But even failed experiments are informative.”

She started in the Harvard PhD Program in Neuroscience right after graduating from Northwestern University with a degree in the field. She had applied to several schools but when she came to Cambridge for her interview, she says, “I was struck by the sense of community in the neuroscience program. I got a great feeling from the other students. They seemed happy.”

The other reason she chose Harvard was that every conversation she had with a professor that weekend “left me feeling inspired by science and the possibilities for discoveries I could make here,” she says. “They were all just so excited to talk about their work and that was infectious.”

Now in her fourth year, Larios thinks the program has been a good fit for her, in large part because “the science being done here is so impactful.” She works in the lab of HMS neuroscientist Chenghua Gu, where she is studying how changes in blood flow to the brain affect neurons. “It seems intuitive that lowered blood flow might exacerbate disease,” she says, “but right now we only know there’s a correlation. If we could learn more, we might be able to start treating the root causes of neurodegenerative diseases rather than just the symptoms.”

Though Larios is “in the exploratory phase career-wise,” she thinks it would be “cool to work in science strategy, considering how to allocate resources, people, and time within a therapeutic program.” While she concedes that her work is just a small fraction of the research being done in her field, “science builds on itself,” she says. “Eventually progress is made on a grander scale.”

—Elizabeth Gehrman

Richard Hakim

GROWING UP IN A SUBURB OF LOS ANGELES, Richard Hakim could be found around town with a video camera in hand. In high school, he won awards for editing and production and, after graduating, he got a job at an indie film studio. But when the movie industry was hit hard by the 2008 recession, he had a chance to step back and question whether Hollywood was really the place for him. He started reading more, taking long walks with his dog, journaling, and just “absorbing information.”

He took a few classes at a community college, but nothing really grabbed his attention until he took an introductory course in biopsychology. “I was blown away by how the retina and cochlea worked. I realized I had to transfer to a university doing neuroscience research, so I dedicated myself to getting perfect grades and really understanding everything.”

He went to the University of California, Berkeley, where he found the opportunities and challenges he was hoping for. “The classes were hard, the research was serious, and the people were weird in a good way.”

At Berkeley, Hakim worked in a lab studying how and why brain activity oscillates and generates what are known as brain waves. His work led to a few publications and eventually brought him to the Harvard PhD Program in Neuroscience. He anticipates his graduate school career will soon be completed.

At Harvard, Hakim works in the lab of HMS neuroscientist Bernardo Sabatini, MD ’99 PhD ’99. where he builds brainmachine interfaces in rodents with the aim of studying how to optimally infer “intention” from neural recordings. He’s not sure what his future holds but knows he wants to “be free to explore my own curiosities.”

What he is sure of is that the work he’s doing has important implications for people with motor impairments, and for the world in general.

“Animals have been useful in building the groundwork,” he says, “but once we start getting large amounts of human data, the things we’ll be able to find will be incredible. I see a world where people are able to relate to each other more intimately, where we can empathize with each other’s peculiarities a lot better. I hope it will lead to a more harmonious society.”

—Elizabeth Gehrman

Energy Grid

Collaborations between scientists and nonscientists are shifting disease research toward what may become its new paradigm

An excerpt from We the Scientists

by Amy Dockser Marcus

ntil the late nineteenth century, there were no professional scientists. Science was pursued by anyone with curiosity, intense passion, or personal interest in a topic. … In the twentieth century, however, the notion that anyone could be a scientist gave way to the establishment of a profession. Science became a guild. To get in, you needed years of study, the acquisition of expertise, specialized training under the tutelage of seasoned veterans, and a university degree.

Over time, scientific projects got more complicated, and more expensive, to run. Governments stepped in, providing grants to fund research. As stewards of public monies, they required that recipients demonstrate some sort of sanctioned expertise. Professionals directed the studies, evaluated the utility of the projects, gathered the data, and analyzed and published the results.

Scientists still needed help from wider society. For one thing, they wanted patients and families to lobby Congress for more government funding to support basic science

and advocate for bigger budgets for agencies that gave research grants, such as the National Institutes of Health. They needed patients to enroll in the clinical trials they organized, and to donate blood, tissue, and other samples to help advance their research, which revolved around questions they found the most interesting. …

***

When I first began reporting on the NPC [Niemann-Pick disease type C] project, I could see the parents and scientists were trying to construct a fundamentally new kind of collaboration. They were good people who all wanted to save the children’s lives. But despite their common goal, it quickly became apparent that they had

different attitudes and approaches toward the production of science. For over half a century, the focus in medical research had been on discovery launched by an individual investigator and experiments inside a lab. The parents tried to force the lab doors open. They didn’t intend to follow the usual rules. …

… This new group of citizen scientists started collecting data about themselves. They released patient-driven studies online — and found themselves cited as experts by the director of the NIH, who in a blog post about their work linked to their self-reported data alongside a paper published in a traditional scientific journal. The pandemic offers a historic opportunity to finally build an infrastructure that can both enable and grow citizen science. It is too soon to know if the sense of urgency and spirit of collaboration that marked the early days of Covid will continue once the acute phase of the pandemic starts to recede. I realize that there are scientists who likely still remain unconvinced that collaborating with citizen scientists is a good idea. They might continue to insist that only those with elite and specialized training can do the work they do, or raise concerns that people who are not professionals could end up pursuing questionable or even potentially dangerous treatments in a desperate attempt to save themselves or their loved ones. There are also certainly members of the public that don’t see themselves as experts, capable of shaping and directing and participating in meaningful scientific research. Still, I like to think that after they read this book, they will

be persuaded by the evidence and change their minds — just as the very best scientists often do. …

Chris Austin [MD ’86] was the neurology resident on call one evening in 1989 when a severely ill patient arrived by ambulance to his hospital in Boston. The patient had latestage amyotrophic lateral sclerosis, or ALS, a fatal neurological disorder also known as Lou Gehrig’s disease, that paralyzed people’s muscles. The man had signed a do-not-resuscitate order and wanted to die at home, but because of a mix-up, the paramedics revived him. Angry that his wishes had been disobeyed, the man requested that the ventilator keeping him alive be shut off. Doctors at the hospital complied with the patient’s plea. The twenty-nineyear-old Chris sat with the family at the bedside, watching as a life ebbed away. It

took three hours before the man took his final breath.

Through the long and agonizing vigil, Chris felt increasingly enraged not only at his own helplessness but at a system that seemed to be failing its most central task: healing the sick. Chris had undergone years of grueling and intense training at some of the top institutions in the country. He graduated summa cum laude in biology at Princeton University, earned his medical degree from Harvard Medical School, and was accepted for a top-tier neurology residency at Massachusetts General Hospital, one of the premier hospitals in the country. He was the product of the best that medicine had to offer, and yet in his retelling of the story, he couldn’t offer much. He always emphasized that his job that evening was to “turn off the monitors when the patient died.” His moral distress that he could not do more shook him to the core. …

The diseases Chris encountered most frequently in the neurology clinic were intractable and devastating. Huntington’s disease relentlessly destroyed nerve cells in the brain. Alzheimer’s disease stripped people of their memories and identity. Chris’s patients came into the office seeking hope and, more often than not, he had no effective therapy to offer. He usually wasn’t even able to point to a promising drug on the horizon. “I couldn’t stand simply telling patients with incurable neurological diseases that there was nothing we could do for them and having that be my life’s work,” Chris recounted.

As a doctor, Chris saw one patient at a time and tried to alleviate their symptoms. He valued the relationships he developed with his patients and their families. Working in a neurology clinic, taking care of people over the course of many years, gave him insight into the magnitude and burden of the diseases he treated. He saw the devastation that the loss of memory, abilities, and function wreaked, not only on the patient but also on loving family members, friends, and colleagues who struggled to help. The reverberations from the death of a single person affected an entire community. Chris tried hard to improve patients’ lives, but he decried the system that left him with so few options. He wanted to try to change the course of the disease not only for the person sitting in front of him but also for “the many, many patients out there, even those I won’t see,” he said.

He set out to understand the ecosystem of medicine. He joined the lab of Constance

“I couldn’t stand simply telling patients with incurable neurological diseases that there was nothing we could do for them and having that be my life’s work.”

Science and the scientists who loved and practiced it were isolated from the people they wanted to help and needed to engage in order to advance.

Cepko, a developmental biologist and geneticist at Harvard Medical School. He figured that by studying genetics, his findings might lead to advances in the field, potentially reaching more people than he could care for in a clinic. In the lab, he learned the foundations of basic genetics, devising experiments with model organisms such as mice and fruit flies that sometimes shared important common genes with humans. …

While Chris spent most of his time running experiments in the lab, he continued to see neurology patients, moonlighting at Massachusetts General as well as at a community hospital that had a walk-in clinic where patients with no insurance could come in off the street …

Science and the scientists who loved and practiced it were isolated from the people they wanted to help and needed to engage in order to advance. “Research is ultimately about the patient, about humanity,” Chris said. “But on a day-to-day basis, it is divorced from that …”

Everywhere he looked, he saw a divide. Researchers didn’t focus on the body as a whole, but rather specialized in its many different parts; cancer doctors treated the breast, prostate, or brain as if they were separate entities, even though the gene mutations that caused cancer in one organ might be the same in another, or located along common molecular pathways. Drugs that were already being prescribed for one disease might be useful in treating another, but there was no systematic program that tried to identify these compounds. …

By November 2002, he was ensconced at the NIH as senior adviser for translational research to Francis [Collins]. …

Chris came to the NIH at a time when the agency’s mission was the subject of public debate. The NIH’s funding came from the people, and therefore, some scientists argued, the money should be spent on basic research, studies that focused on fundamental scientific questions or tried to understand the processes that drove disease. Funding the research to turn ideas into drugs that could be used at a patient’s bedside should be left up to the pharmaceutical companies, this line of argument went.

Chris knew from his own experiences that patients, especially those with rare diseases, could not rely on drug companies to find solutions for them. One only had to look at the statistics: there were around seven thousand known diseases that affected humans, and only five hundred had treatments. Many people were left without recourse or options. …

***

Chris set out to build a lab containing sophisticated equipment that could do rapid screening of drug libraries, enabling a more accelerated approach to identifying potential compounds to treat disease … Chris built a robotics system at the NIH lab that could do the type of automated screening typically employed at drug companies. It cost around $30 million, was fully automated, and included three robots that worked round-the-clock, twenty-four hours a day, seven days a week. Chris estimated the robots screened hundreds of thousands of compounds every day. …

To help spread the word about the lab, Chris spent a lot of time on the road traveling … Chris figured that the people most likely to want to partner with NIH would be scientists working at universities or medical centers who didn’t have access to the kinds of sophisticated screening technologies the new NIH lab boasted.

But increasingly, much to his surprise, Chris also fielded requests for help from people who were not scientists. Many of them barely recalled the fundamentals

of their high school biology class but had turned themselves into experts on conditions most general practitioners never saw. At rare disease conferences, after Chris gave a talk, ordinary people with no scientific training at all frequently waited for the crowds to disperse so they could tell their stories to him. Some were parents of children with fatal diseases who had raised funds and were looking to support good ideas that might help their children and accelerate the development of a drug.

Chris wanted to build a scientific team consisting of patients and advocates and parents as well as scientists, clinicians, and researchers. Could professional scientists and citizen scientists work together as partners and combine their different types of expertise? Scientists could never know the answer for sure unless they ran the experiment. Now all Chris needed was an opportunity to test the idea. He finally got the chance in November 2007.

More than a dozen people showed up for the meeting in Chris’s lab to discuss the prospect of working together. …

… Chris took the visitors to see the robots. Standing together, the parents and scientists watched as a robot claw added patients’ cells to small plates, then moved them to another place in the work area where drugs and chemicals were added. During the tour, [a visitor] asked Chris Austin whether they had named the robots yet. The scientist said they had not. “I have a name for you,” [the visitor] said. “I think you should name it Hope.” … Looking back on the day years later, [Austin] said, “I felt like we might actually be able to conquer this thing working together.”

Amy Dockser Marcus, MBE ’17, is a staff reporter for The Wall Street Journal. In 2005, she was awarded the Pulitzer Prize for Beat Reporting for her series on cancer survivors and the challenges they faced living with the disease. This edited excerpt from her 2023 book We the Scientists: How a Daring Team of Parents and Doctors Forged a New Path for Medicine appears with permission of the author and the publisher, Riverside Books Penguin Random House.

Ordinary people with no scientific training at all frequently waited for the crowds to disperse so they could tell their stories to him.

What skills would you recommend clinicians start learning today to be better prepared for tomorrow?

Robert Colvin, MD ’68

Clinicians should develop an understanding of how bioinformatics, genetic engineering, artificial intelligence can assist them.

Vic Piotrowski, MD ’74

How to manage and balance time commitments to profession, family, and social activities, and how to plan personal finances, both short- and long-term.

Nneka Holder, MD ’97

Learn time management skills and how to be strategic about the project you pursue. Also focus on developing an approach to taking a history that is based on humility and an open mind. This approach will improve communications with patients and ultimately lead to better compliance with treatment plans and recommendations.

Jan Polissar, MD ’61

The use and understanding of artificial intelligence is important. It already can detect cancer on X-rays better than clinicians can. I suspect soon an automated preliminary interview with a patient will enable orders for lab tests and provide a comprehensive differential diagnosis list for the clinician. The tool could also provide customized education for the patient and their family and treatment recommendations for some conditions, especially for patients in areas short on medical care.

Christopher Baker, MD ’74

Instill the importance of becoming lifelong learners who are able to adapt to change. Develop the skills for delivering patientcentered care and learn about tools that help you care for yourself and your family and friends, to better maintain resilience and avoid burnout.

Marguerite Barnett, MD ’79

The skill of knowing how to listen to the patient.

Craig Comiter, MD ’92

I think it’s important that clinicians speak a second language fluently.

Scott Wasserman, MD ’97

We took a statistics course during our first or second year. It was not one of my favorites, but now, more than 25 years later, not only do I love statistics, I know that a strong foundation in statistics is critical in medicine. Being able to parse the medical literature and understand how to apply clinical trial results and analyses to your patients is essential.

Susan Haas, MD ’79

Clinicians need to know about public health principles and practices.

Steven Jonas, MD ’62

In addition to trying to do the best you can in your medical studies, also try as best you can to stay up with what is going on in the outside world.  Medicine, politics, and the economy are intermeshed, as the COVID pandemic has shown us all too well.

Robin Yuan, MD ’78

Emphasize the development of communications skills and learn how to maintain compassion with their patients.

Michael Hirsh, MD ’79

Our contact with patients is absurdly short so honing skills associated with observation and active listening is essential — and priceless.

Mary Flowers, MD ’78

Typing and computer skills to deal with electronic medical records and patience (not patients) to deal with insurance forms and phone calls for authorization for procedures and treatments.

James MacDonald, MD ’96

I would recommend students read widely and well beyond scientific writing. Have a thorough understanding of the history of U.S. medicine, with all its successes and flaws. Students should also learn to write well. There is no skill so singularly lacking from most physicians’ tool kits. Finally, I think students’ education should emphasize the development of a “growth mindset.’’ Our profession and our world as a whole are changing at ever-increasing speeds. Physicians will be re-inventing themselves throughout their careers.

Michael Quinoñes, MD ’86

Learn how to NOT be a snowflake. Life is hard.

Richard Peinert, MD ’73

Besides the usual doctor stuff, I would advise medical students to learn how to manage their money and wisely invest for retirement. I would also recommend cultivating empathy and a sense of humor.

Peter Zawadsky, MD ’68

I believe artificial intelligence will assume a greater role in establishing the diagnoses and management plans of sick patients. Artificial intelligence will be accurate only if the patient’s history is entered accurately. Therefore, medical students should concentrate on honing their history-taking skills.

Howard Kirshner, MD ’72

How to interview and show interest and empathy, how to deliver gender-based care, and how to effectively manage pain.

“Instill the importance of becoming lifelong learners who are able to adapt to change.”

Brian Lewis, MD ’69

Learn to see the individuality of each patient and cherish the aphorism that “the secret of the care of the patient is in caring for the patient.” Keep your ego in check and do the kind thing — and do it first.

Karen Singer, MD ’77

Clinicians need to be skilled at using electronic medical records.

Robin Smith, MD ’88

The business of medicine. You can be a private practice physician and earn a fair wage and retain your independence from large hospital systems if you know the business side of medicine in your state and community, specifically, how clinicians are paid and what market forces are at work to determine that payment (fee for service, population health quality and efficiency incentives, for example); an understanding of patient billing and how to help patients receive quality services at lower cost; and how medical insurance works (both for patients and for clinicians) and what it means to be a part of a network.

George Lewinnek, MD ’67

I would suggest that those starting out learn how we know what we know — what is proven, what is speculation based on sound theory, what is usual and customary but has no other basis, and what may be misleading marketing. That makes it less likely that a practitioner gets caught up in a fad that later proves to be a mistake. Also, prepare to change: learn how to learn the new, especially when it involves techniques that require practice under supervision.

Robert Hodge Jr., MD ’72

Practicing medicine has become increasingly more stressful and burnout and suicide are major hazards of those delivering health care. Learn and practice the skills that can help you to lead a balanced life. Compassion and empathy are critical.

Richard Schwartzstein, MD ’79

Analytical thinking based on core physiological/pathophysiological principles to avoid reliance on illness scripts and pattern recognition. Be curious, embrace uncertainty.

Stephen Smith, MD ’63

Our profession requires multiple sources of knowledge and skills for best results. Knowledge evolves over the span of a long career, sometimes requiring change in viewpoint. Keen observation in the presence of the patient may lead to astounding accuracy and efficiency. The successful clinician develops positive and sympathetic communication skills that encourage the patients to unburden themselves of their story and engage in a management plan regarding their problems.

Lily Conrad, MD ’80

Become adept at the physical exam and taking a thorough history. Touch and examine the patient. Basic skills are being lost; these are timeless, and essential, if technology fails or is simply not available.

Cheryl Kovacs Warner, MD ’79

Essential skills to develop at the start of a career include empathetic and patientfocused care, taught as part of the interview, examination, and diagnosis; and counseling and managing care. These need to be gender-sensitive and include an awareness of socioeconomic disparities driven by race, religion, and immigration status, among others. Other skills include understanding the importance of evidence-based care that is efficient, decreases error and complexity, and improves health.

In this 2019 photo, members of the 2023 class of MD students read their oath to the profession.

Martin-Jose

Learning how to partner and collaborate, developing an awareness of implicit and explicit bias and cultural competency, and learning the language of the predominant minority population served (most often, Spanish).

Sylvester Sviokla III, MD ’72

Develop the skills to conduct motivational interviewing aimed at changing healthrelated behaviors.

Wendie Grader-Beck, MD ’96

Learn to listen and build your capacity to share in vulnerability. These skills increase our ability to connect with our patients.

Jorge

All medical students should receive some basic education regarding death and dying. This is not the most attractive aspect of medicine, but it remains one of the most important.

Andrew Warshaw, MD ’63

In today’s world the practice of medicine must be complemented by an understanding of the business of medical practice, whether as an employee or an independent practitioner.

Jane

Every physician should have a solid understanding of statistics and a basic understanding of study design. Almost all medical advancements today need to be interpreted with an eye to understanding benefit and risk. Without understanding statistics and potentially flawed study design, a clinician cannot hope to discern how relevant the findings are for their patient or their practice.

Harvey Clermont, MD ’65

Develop the ability to have an honest dialogue with both the patient and the family. Stay current on all recent public health issues.

During their first week at HMS, the students in this 2019 photo assembled for a lecture designed to introduce them to the medical profession.

Sepulveda Sr., MD ’78

Casas-Ganem, MD ’98

Liebschutz, MD ’91

Gregory Juarez, MD ’92

I would recommend taking a general course in financial management to understand the language and priorities of an organization or medical group. I would also recommend a course in operations management and project management to help assist a department or medical group to bring administrative value to colleagues.

Marvin Bittner, MD ’76

Learn how to function effectively in organizations. Developing good relationships with patients is a traditional component of medical education; however, increasingly, physicians are working in organizations. This calls for another set of skills.

Daniel Kopans, MD ’73

A habit of lifelong learning and the ability to read publications carefully. Don’t just read the abstract. Were the data collected correctly, and are the conclusions supported by the data?

Matthew Keller, MD ’07

Telehealth and virtual medicine should be incorporated into medical education because they are here to stay.

Morris Fisher, MD ’68

Clinical skills. Arguably in one fashion or another we will have a fixed-cost medical system. In such a system, physicians who order fewer tests will be valued. Also, develop the ability to learn from patients and how to avoid fitting patients into preconceived categories.

Alena Balasanova, MD ’12

Start developing a capacity to self-reflect and adopt a growth mindset. These are skills that are valuable in medicine and often get overlooked in favor of more technical or procedural skills. Finding mutual meaning with patients is critical for any specialty and to do this you must first understand yourself.

Jessica Wu, MD ’93

If you can’t imagine finding joy in working for a large health care system where you are a “provider” judged by your “productivity,” I strongly recommend learning the skills to start an independent practice: leadership, accounting, and human resources. Yes, it’s a risk to turn away from a paycheck but your reward will be more time to care for patients, loved ones, and yourself.

Michael Kochis, MD ’20

Team management and leadership skills. As a surgical resident, I am struck by how much our day-to-day work depends on not only knowing the clinical medicine we are explicitly taught as students and on building relationships with patients, but also on collaborating with other doctors, nurses, and allied health professionals.

Gordon Cutler Jr., MD ’73

Develop the habit of reading daily on medical progress and develop a deep understanding of molecular biology, genetics, metabolism, immunology, epidemiology, statistics, computer science, and digital technology. Cultivate the skill to hold clear, brief, prioritybased, empathic communication that meets the patient where they are. Learn to accept uncertainty and to keep an open mind to reassess diagnosis.

Jonathan Friedberg, MD ’94

Bioinformatics, big data analysis, and artificial intelligence skills will be essential for basic and clinical research and are highly sought at academic medical centers.

Edmund Lee, MD ’96

Develop the ability to actively clear your thoughts. Modern medical practice is a barrage of information, tasks, and demands. The ability to clear your mind will allow you to focus on the one thing that is most crucial.

Felipe Jain, MD ’08

There is an enormous wave of depression surging due to social isolation, our sedentary society, and the automatic comparisons made on social media. Learn how to recognize depression.  Determine how you’re going to help patients along the course of their treatment and don’t give up if your initial recommendations don’t work. Most people will get better after a few treatment trials — if they persist.

Bruce Lyman, MD ’72

Develop the ability to be intentional about asking open-ended questions such as “Tell me about that pain.” Learn to listen deeply while making eye contact with your patient and observe body language. Learn to be comfortable without a computer screen in the room. Learn “again for the first time” the skills of a meaningful physical examination.

Lise Johnson, MD ’88

Communication. Clinicians need to know how to engage with patients and form a trusting relationship and how to take responsibility for the patient and proactively communicate with all team members.

“Finding mutual meaning with patients is critical for any specialty and to do this you must first understand yourself.”

Above all else, clinicians need and will continue to need good communication skills. Patients will always need to feel heard and understood, and to be educated and advised about their health.  Good communication between doctor and patient is not only crucial for the patient’s health and peace of mind, it’s also wonderfully fulfilling for the physician.

For students who seek to become surgeons, learn to read all types of imaging without a radiologist’s assistance.

Develop a commitment to self-learning by reading, attending conferences, and conducting internet searches. Develop an absolute commitment to evidence-based decisionmaking.

There will be enormous, well-meaning pressure to include added curriculum in public health, addiction, violence, and the economics of medical care. But short of extending the medical school curriculum, either into college years or after four years, faculties should continue to emphasize clinical competence, basic science, and mental health. Relevant statistics, communication skills, and demonstrable professional behavior and humanistic qualities need more time and faculty to teach them.

Thanks to all who shared thoughts on the skills that will better prepare tomorrow’s clinicians.

We hope you will share your thoughts on some of our upcoming questions. How has the oath you took during your first days in medical school influenced your practice of medicine? and Which scientific or medical development has excited you the most during your career?

Responses for these will appear in print, online, or both in the coming months.

Responses can be submitted online: alumni.hms.harvard.edu/rounds; via email: hmsalum@hms.harvard.edu; or by phone: 617-384-8520

Students in this 2017 photo are shown attending a clinical skills class.

Elizabeth Kaufman, MD ’85

Robert Duerr, MD ’88

Daniel Weingrad, MD ’73

John Benson Jr., MD ’46

1930s

1939

John B. Stanbury, MD July 6, 2015

1940s

1944

Edward P. Wallace, MD July 4, 2014

1947

Samuel A. Montello, MD December 31, 2022

Alexander G. Rogerson, MD August 24, 2022

William W. Waring, MD February 27, 2023

1950s

1950

Sheldon M. Levin, MD October 1, 2020

1951

Eugene Marshall Renkin, PhD November 11, 2022

Donald C. Reusch, MD

November 10, 2022

1952

W. Hardy Hendren III, MD March 1, 2022

Samuel L. Katz, MD October 31, 2022

1953

Frank E. Boyd, MD

January 14, 2020

David A. Eaton, MD September 15, 2020

Neal Nathanson, MD August 11, 2022

1954

Donald W. Clark, MD September 27, 2022

Monto Ho, MD December 16, 2013

John B. Lunseth, MD

December 22, 2022

Emanuel Rubin, MD February 13, 2021

Richard E. Senghas, MD

September 10, 2022

1955

W. Gerald Austen, MD

September 11, 2022

John T. Boyer, MD

February 15, 2023

Paul M. Prusky, MD November 21, 2022

Charles P. Summerall III, MD

August 31, 2022

Harold C. Urschel Jr., MD

November 12, 2012

Marian Woolston-Catlin, MD

September 20, 2022

1956

Samuel Bogoch, PhD September 3, 2022

Robert W. Chamberlin, MD

September 9, 2022

Wayne P. Cockrell, MD August 26, 2022

Alexander L. Kisch, MD

July 31, 2021

Charles E. Norton, MD November 14, 2020

Philip F. Parshley Jr., MD July 16, 2022

1957

Donald K. Brief, MD November 9, 2022

Donald S. Pierce, MD March 3, 2022

Harry L. Senger, MD September 30, 2022

Frank M. Weiser, MD September 11, 2022

Donald M. Yamaguchi, MD July 27, 2022

1958

Stanley P. Bohrer, MD

September 18, 2022

Benjamin V. Smith, MD

July 30, 2022

Richard L. Soffer, MD December 16, 2022

1959

Karl Engelman, MD August 19, 2022

Alan D. Persky, MD December 17, 2022

1960s

1960

Robert J. Dobrow, MD October 25, 2022

Abba J. Kastin, MD April 6, 2022

Richard J. Wurtman, MD December 13, 2022

1961

Llewellyn B. Bigelow, MD July 12, 2022

Robert K. Ockner, MD September 26, 2022

William J. Otto Jr., MD January 14, 2023

1962

Richard L. Conn, MD December 1, 2022

David L. Ravella Jr., MD August 1, 2022

1963

Jerome B. Bart, MD October 29, 2022

Wesley Peter Peterson, MD September 20, 2022

Edwin L. Prien Jr., MD September 7, 2022

Murray A. Towle, MD February 13, 2022

1964

Joseph L. Dorsey, MD November 22, 2022

Jay M. Jackman, MD January 17, 2022

Nancy Bowen Kaltreider, MD November 7, 2021

Rob R. MacGregor III, MD May 12, 2022

Robert A. Scott, MD

November 13, 2022

1965

Stanley H. Wishner, MD

June 15, 2022

1966

Norman Lippard Lasser, PhD

January 19, 2022

Norman S. Levine, MD

May 13, 2022

Maria Christine Linder, PhD

September 25, 2022

1967

John M. Dorman, MD

February 26, 2023

Richard Hudson Quarles, PhD

August 9, 2015

1969

Tamara T. Mitchell, MD

September 28, 2019

Bruce C. Nisula, MD

August 30, 2022

Michael F. Rein, MD

December 5, 2022

1970s

1971

John H. Kissel, MD December 6, 2022

1973

Stephen S. Arnon, MD August 17, 2022

Richard Morrison Fulks, MD

February 21, 2023

1974

Geoffrey M. Greenfield, MD July 30, 2022

1975

Lettie Marie Burgett, MD

August 13, 2022

1976

Beryl R. Benacerraf, MD October 1, 2022

1978

Thomas L. Force, MD November 30, 2020

1979

Debra Andrews, MD May 27, 2020

1980s

1982

Jonathan Rhodes, MD March 31, 2022

1983

Jerome C. Landry, MD July 8, 2022

1984

Evan B. Dreyer, MD PhD ’84 August 2, 2022

1985

Edward M. Andujar, MD April 1, 20213

1990s

1997

Steven Andrew Brown, PhD December 14, 2022

2010s

2010

Lauren Gilstrap Milley, MD October 21, 2022

This listing of deceased alumni includes those whose notices of death were received between September 1, 2022, and March 31, 2023.

A Strong Future for Our School and Our Students

THE ALUMNI COUNCIL OPENED ITS VIRTUAL WINTER MEETING in early February with the selection of Neal Baer, MD ’96 (Class of 1995), as the 2023 recipient of the Distinguished Service Award for HMS Alumni. Given in recognition of outstanding commitment to the School, including volunteerism, peer/community engagement, and enrichment of the student experience, the award will be presented on June 2, Alumni Day, at HMS.

Turning to financial commitment, David Nierenberg, MD ’76, chair of alumni giving, reported the receipt of $5.3 million in pledges from MD alumni through December 31 of the current fiscal year. This amount exceeds the gifts and pledges received at a comparable point in fiscal year 2021. Further, 2023 reunion giving, currently at $5.1 million, is on track to meet or exceed its $7 million goal.

Dean George Q. Daley, MD ’91, updated the Council on the search for the next dean for medical education being led by Jules Dienstag. Ed Hundert, MD ’84, who previously held this post, will now focus his talent on working with the HMS alumni office while maintaining his faculty role at the Center for Bioethics.

The dean also noted that the HMS curriculum continues to evolve with the completion of the first phase of the Sexual and Gender Minorities Health Equality Initiative, which will broaden student and faculty clinician training in that arena. In addition, HMS has approved a new curricular societal theme of climate change and health.

The dean said that recent gifts will allow for the renaming of Building C as well as a restructuring of a courtyard area to produce twenty-five thousand square feet of added space. Other major gifts include $50 million to establish the Paul Farmer Collaborative between HMS and the University of Global Health Equity in Rwanda, along with an anonymous $10 million gift of an endowed chair in Farmer’s name for the Department of Global Health and Social Medicine.

The meeting concluded with an update on the URiM mentorship project, including insights from Tola Ibikunle, a third-year medical student, and Kyeisha Laurence, a firstyear medical student, co-presidents of the HMS chapter of the Student National Medical Association (SNMA). Both found mentors and advisors at HMS to be highly accessible and dedicated to student professional development, and noted that the HMS Office of Recruitment and Multicultural Affairs created a welcoming and supportive environment at HMS, counterbalancing some of the lingering negative perceptions of Boston for people of color. Both continue their undergrad advocacy and activist efforts at HMS through programs like the HMS Chapter of SNMA and its Empower Conference, a symposium on underrepresented voices in medicine. Both programs help URiM students understand what is necessary to successfully apply to medical school.

Intellectual depth, broad global ken, and diverse composition continue as mainstays of the School’s strength.

Kenneth Bridges, MD ’76, is vice president of external affairs for Global Blood Therapeutics, Inc., in South San Francisco.

Distinguished Service Award for Harvard Medical School Alumni

Congratulations to the 2023 winner, Neal Baer, MD ’96 (Class of 1995), who is being recognized for his staunch advocacy and support of HMS’ LGBTQ+ community and anti-racism initiatives; his invaluable service as co-director of both the Master of Science in Media, Medicine, and Health program and the Media and Medicine certificate program; and his enthusiastic participation on various leadership boards and volunteer committees to help further the School’s mission and advance alumni engagement and philanthropy. Learn more at alumni.hms.harvard.edu/service-award.

Provide Career Advice to Students

Alumni are invited to sign up for the MD Alumni Advisor program, which lets students select a volunteer who can help them choose a specialty, find the right residency, and practice interviewing for internships. Interested alumni can contact Dea Angiolillo, MD ’79, at dea.angiolillo@gmail.com.

MD Class and Master’s Listservs

Do you want to connect with your classmates or fellow master’s alumni to share updates or initiate conversations?

Private class listservs allow MD alumni to connect with their classmates while the Office for Graduate Education offers a dedicated email discussion group for graduates of the School’s master’s programs. To learn more about contacting MD classmates, visit alumni.hms.harvard.edu/connect. To join the email discussion group for graduates of master’s programs, go to alumni.hms.harvard.edu/masters-listerv.

Join Your 2024 Reunion Committee

MD classes ending in “4” and “9” are celebrating their reunions June 6 to 8, 2024. Join your reunion committee to help plan a class-specific event and encourage your classmates to participate. For more information, contact the alumni engagement team at 617-384-8520 or hmsalum@hms.harvard.edu.

Electronic Journal Access

Never stop learning. Alumni can access thousands of peerreviewed journals and more than 2,000 seminars online. To browse the available collections, visit alumni.hms.harvard.edu/online-journals.

Benefits

Shared by both gift options:

• Fulfill your financial, tax, and estate planning goals

• Reduce or eliminate estate tax

• Improve health and well-being for all

Did You Know?

Without a will, the laws of your state will decide how your estate is divided.

TIP: Work with an attorney to create a will or living trust that accomplishes your personal and philanthropic goals.

Including HMS in your will or living trust is a simple way to make a gift—it costs nothing now but provides future support for the causes most important to you.

A retirement account can be the most highly-taxed asset that people pass to heirs.

TIP: Leave other types of assets to your heirs and gift retirement assets to a charitable organization such as HMS.

Designating HMS as a beneficiary of your individual retirement account, investment account, savings account, or donor-advised fund is as easy as filling out a form.

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Sentinel and signal

Most days the U.S. flag flies atop Gordon Hall, the main administration building on the HMS campus, standing watch above the laboratories, classrooms, and green space that make up the quadrangle. Occasionally, however, it yields its position to make way for the HMS flag. On those days, the School’s flag is lowered to half-staff, a gesture both of farewell and of thanks to honor the memory of a notable member of the HMS campus community.