The problem. Rheumatoid arthritis, which affects some 1.5 million people in the United States, is an autoimmune disease in which the body's immune system mistakenly attacks the joints. It can be disabling and painful and there is no known cure. The severity of the disease can vary enormously from patient to patient and there are tantalizing theories as to why. Agustin Escalante has dedicated his career to following that evidence trail, with its clues in genetics, ethnicity and the patient's state of mind.
Beginnings—a very young patient finds a mentor. Agustin Escalante, MD, grew up in Mexico City the son of an architect and a housewife but also the nephew of a medical student (who became a doctor). He had many of the usual childhood diseases, including measles and chicken pox, and until he was about eight, his uncle was always involved in his treatment. "My Mom relied on him for medical advice," he recalls. "He had a convenient subject to examine. I really looked up to him. I formed a plan in my head that I would do that when I grew up."
Medical school and a sense of direction. As a medical student at the Universidad Nacional Autónoma de Mexico, in México City—the same school his uncle had attended—Escalante did a rotation in rheumatology and, he says, "I was impressed by the level of skill and knowledge of the attending rheumatologist. The disease seemed interesting and challenging, and I fell in love with the field. Even before my residency I knew I wanted to be a rheumatologist."
The Amos years. After completing his internship and residency in internal medicine at Baylor Affiliated Hospitals, in Houston, Tex., Escalante began his career in academic medicine at the University of Southern California School of Medicine as a clinical instructor and then assistant professor. In 1992, he was appointed an assistant professor of medicine at the University of Texas Health Science Center in San Antonio and was named a scholar in the Robert Wood Johnson Foundation’s Harold Amos Medical Faculty Development Program two years later. The program provides four-year awards for postdoctoral research to physicians and dentists from historically underrepresented groups who are committed to developing careers in academic medicine and dentistry. (See the Program Results Report for more information about the program.) Escalante would get tenure in 2000.
Early in his fellowship, Escalante worked with his mentor, Cynthia D. Mulrow, MD, MSc, then a professor at his school, in laying the groundwork for his research in rheumatoid arthritis on a cohort of more than 1,200 patients in San Antonio and the surrounding area. "She helped me with the research design," Escalante says. "She gave me a lot of advice on how to assemble the cohort and follow it."
He describes his relationship—during this initial period of research—with Mulrow, a fellow Hispanic who is now senior deputy editor of the Annals of Internal Medicine, as "very valuable, very close. I'd meet with her every week."
He also remembered—and acted on—the emphasis placed by the Amos program director at the time, James R. Gavin, III, MD, on participation in the peer-review process, which Gavin called "the number one predictor of a faculty member's success."
Genetics, lifestyles and "the Hispanic Health Paradox." When he was in the Amos program. Escalante started working to isolate genetic factors that seemed to go along with the most severe symptoms of rheumatoid arthritis. Since then, he has used funding from the National Institutes of Health to extend the search to far more gene variants, and has isolated several.
He has also extended his work into the mental attitudes of patients and how it affects their symptoms. "Why do some patients have a really severe downhill course while some can soldier along for decades, with only mild symptoms?" he asks.
"My idea was that there was an interaction between environmental and genetic factors and also the psychological status of the patients."
He measured the physical signs of damage from rheumatoid arthritis through blood tests, x-rays, and physical examination; and assessed psychosocial factors through scales of depression symptoms. He estimates that the two factors—actual damage and patient attitude—were roughly equal in determining the effect of the disease on the patient: "It's about half and half," he says.
Escalante also noted that Hispanic patients in his cohort had lower mortality rates than those of similarly afflicted non-Hispanic whites of the same age and sex. On the surface, he says, this is surprising given the lower socioeconomic status of Hispanics.
He says that "one hypothesis is that Hispanics tend to have a slightly different social structure from (non-Hispanic) white people...larger families, with more family support. Closer-knit neighborhoods."
This phenomenon, known as the Hispanic Health Paradox, has been observed in connections with other diseases such as HIV/AIDS, diabetes, and kidney disease.
In the rear-view mirror. Escalante has no trouble summing up what the Amos program meant to his career:
"Without the Amos program, I don't know how long I'd have lasted in academic medicine.”
"It gave me protected time so I didn't have to be in the clinic generating my salary seeing patients. It gave me time to think, write proposals, write papers. As a minority investigator, it's not always obvious what you need to do. In day-to-day medicine they don't tell you about getting grants. That kind of advice is hard to come by."
RWJF perspective. The purpose of the Harold Amos Medical Faculty Development Program, launched by RWJF in 1983, is to increase the number of faculty from minority and other historically disadvantaged backgrounds who achieve senior rank in academic medicine and dentistry.
The program supports one of RWJF’s major objectives: to increase diversification of the medical and dental professions and, as a consequence, improve the health care received by the nation’s underserved populations.
Of Amos program scholars, RWJF Senior Program Officer David M. Krol, MD, MPH, says:
“Ultimately, we would like to see these individuals from historically disadvantaged backgrounds becoming full professors at prestigious institutions, putting out important, valuable work, looking at a variety of different issues—including how to decrease the disparities between rich and poor, majority and minority—while climbing the academic ladder.”
Agustin Escalante is one of more than 180 Amos program alumni in academic medicine today. His career and research exemplify the academic achievement and professional contributions that the program was designed to stimulate.
“The measure of the success of the program is the success of the individuals who participate in it and how they impact the culture of health in the United States,” says Krol.
Hispanic rheumatoid arthritis patients have lower mortality rates than white patients of same age and sex.