History of the Wilford Hall USAF Allergy/Immunology Training Program
The program was approved by the Certifying Committee in 1962. Robert E. Smith, a pediatric/allergist, trained at Scripps Clinic in California, was the first Chief. He was assigned to the Department of Pediatrics in 1957 and functioned within that department as he initiated efforts to establish a training program. This was particularly difficult for the program would have to be a section within the Department of Internal Medicine. After approval of the program, space had to be allocated and staffing had to be obtained to operate a clinic. The clinic was located on the first floor of Wilford Hall Medical Center until 1970 when it was moved to one of the wards from the old, WWII Lackland AFB Hospital. The clinic was moved back into the newly constructed out-patient addition to the main hospital in 1980.
Initiation of the Fellowship Program; 1964
In July, 1964, the first fellow was Andrew M. Hegre, an internist, came into the program. Smith and Tannenbaum were the only staff.
In July, 1965, additions were made to the staff including Stephen R. Shapiro, an internist trained in allergy at Walter Reed, and J. Terence Sams, an internist, trained in allergy for one year at Ohio State and then drafted into the military. Max I. Michels, a pediatrician from the field, joined Andrew Hegre as fellows.
In July1966, James Tannenbaum returned to Ohio State as a staff physician and Andrew Hegre took an assignment and, after his military commitment , began his practice in New Orleans. The staff slot vacated by Tannenbaum was unfilled. Another fellow, Ramon Casanova-Roig, a pediatrician, joined second-year fellow, Max Michels.
In July, 1967, Robert Smith moved into an administrative position and Terence Sams exited the military and started a practice in Arlington, Texas. Max Michels was elevated to Chief of the allergy program despite just finishing his fellowship. This created some discord between him and Stephen Shapiro. Michels was superior in military rank but inferior to Shapiro in experience. No new staff and no new fellows were added to the program.
In 1968-69, Michels and Shapiro were the only staff and no fellows were in the program. Ramon Casanove-Roig had taken an assignment to the field and later began a practice in Puerto Rico.
In July, 1969, no new staff was added, but a fellow was accepted: Aubrey M. Worrell, a pediatrician. The clinic was moved from the main hospital to an old ward of the Lackland hospital (World War II style building). This building was large enough to house a few staff and fellows but proved inadequate as the program grew during the late 1970s.
In 1970, the staff remained unchanged, however, another fellow, H. Norman Richardson joined Aubrey Worrell as a second fellow. No research was ongoing and no meaningful publications were done.
In July, 1971, a new staff, John R. Bozalis, an internist trained in allergy at University of Michigan, was added. A new fellow, Robert L. Jacobs, joined Richardson as the 1st year fellow. Worrell took an assignment and later started practice in Arkansas. Bozalis was instrumental in the drive to improve the program by pointing out that there was no research being done and there were no laboratory capabilities available. He also brought in a somewhat different perspective and personality. He was more involved in teaching, not only of the fellows but the internal medicine residents. He also led a push on the Department of Medicine to allow hospital admitting privileges for the allergy staff and fellows.
1972 brought a new staff, Stacy Greenert, an internist trained in allergy at Cincinnati, and a 1st year fellow, Donald Q. Mitchell, an internist (Who would later become a President of the American College of Allergy, Asthma and Immunology). Richardson departed and, after retirement from the USAF, started practice in California. Greenert had a photographic memory and could quote the page number of a text where one could find a piece of information. Because of his unique personality, he was the source of many unusual stories that are talked about today by those individuals who knew him. He started practice in Cincinnati upon separating from the USAF.
In July, 1973, Stephen Shapiro took an assignment to Germany. Bozalis separated and began practice in Oklahoma. Jacobs was retained on the staff and was joined by Joseph F. Kelly, an internist, trained in allergy at Northwestern in Chicago. Joseph Kelly had trained under Roy Patterson (who had served as the National Consultant in Allergy/Immunology for the USAF) Kelly, like Bozalis, also brought a somewhat different perspective to the program. Edwin O. McCluskey, an internist, became a 1st year fellow with his second year to be served in Rheumatology in Denver. Don Q. Mitchell moved into his second year of fellowship.
In July, 1974, Max Michels retired and Stacy Greenert separated. Jacobs was elevated to Chairman and Director of the Training program. However, because allergy boards were given every other year, Jacobs had not taken boards and the program was discontinued. R. Neal Boswell, an internist, was assigned to the staff, however, he had no formal allergy training (There was a shortage of trained allergist in the military). Don Q. Mitchell was retained on the staff and Edwin McCluskey took an assignment since his Denver fellowship in Rheumatology had fallen apart. Bobby Q. Lanier (who would later become a President of the American College of Allergy, Asthma, and Immunology) transferred from the program at Galveston and spent the last 6 months (Jan – Jul 1974) of his fellowship at Wilford Hall. Notable in 1974, Jacobs and Mitchell began research projects associated with the army allergists at Ft. Sam Houston leading to two classic papers published in the Journal of Allergy and Clinical Immunology related to Immunotherapy to Fire Ants and to Mountain Cedar pollen. The Wilford Hall IRB, at that time, was controlled by an individual that felt that any research to be approved needed to be of “Noble Prize” importance, making it very difficult to do any research at Wilford Hall.
In July, 1975, Jacobs added Lanier and Peter M. Freedmen to the staff. Boswell was sent to Harvard to study bench-type immunology in order to return to boost the scientific side of the program. Mitchell separated from the USAF and started practice in Jackson, Mississippi. Freedman, an internist, had trained at Scripps Clinic and was academically inclined. No fellows were taken. Jacobs passed boards in October 1975 and immediately began to re-activate the training program. Since Lanier had spent ¾ of his training in an academic program, he was assigned to draft the outline of the program that we would begin at Wilford Hall in 1976. Freedman was assigned to confiscate any usable equipment from the massive warehouse storage areas at Kelly AFB and begin to build a functioning laboratory. Plans were being drafted to design and build onto Wilford Hall. Jacobs began to plan for an appropriate clinical facility with a significant laboratory space for the Allergy Department. The protocol to study and define the NARES patients was developed and written by Jacobs and Freedman. Collection of data for the Tetanus Toxoid paper was started. Despite these ongoing efforts, we had to manage the clinic patients with a reduced staff (Jacobs, Lanier, and Freedman) and no fellows.
In the spring of 1976, the Accreditation Committee accepted our Training Program plan in time to accept two fellows, Normand F. Trembley, a pediatrician, and Ralph S. Lowe, an internist. W. Cleve Posey, a pediatrician, trained in allergy at Fitzsimmons in Denver joined the staff. The training program plan generated primarily by Lanier was adopted as the model for other training programs, however, no credit was ever given to Bobby Q. Lanier. Lanier went into practice in Fort Worth in July 1976. Peter Freedman extended for a year until July 1978.
This was the year, 1976, in which the NARES and Tetanus Toxoid studies were initiated. The first patient that had severe anaphylaxis while on beta-blockers was seen in the hospital referred from Sheppard AFB in North Texas. The anaphylaxis patient was of high interest with Freedman pointing out that the pattern was consistent with what one would see with beta-blockade. This was not published until a 2nd case was seen in 1978.
In July 1977, Boswell returns from Harvard and becomes involved with the NARES protocol adding a nasal wash to increase the scientific value of the study; Freedman continues to run the laboratory; Jacobs and Posey continue on staff; Trembley and Lowe continue as 2nd year fellows; Robert E. Harvey and Donald Fournier came on board as 1st year fellows;
In July, 1978, Freedman separates and starts practice in Minnesota; Posey separates and starts practice in Mobile, Alabama; Trembley remains on staff; three new follows come on board, Gordon B. Strom, William G. Culver, and Robert F. Sacha. On a social note, with a planned barbeque of a goat by Boswell, Harvey injures hand trying to kill the goat with a karate chop, and later, shoots the motor of his truck while hunting coyotes, providing the subject of much amusement for the remainder of the year.
1979: Trembley separates and joins Lanier in practice in Fort Worth; Harvey and Fournier remain on staff for one year before going into field; Guillermo Villacorte, from Creighton Medical College, joins staff to boost the laboratory capabilities; Two new fellows: Jimmy Chevalier and Bruce L. Nelson join Strom, Culver, and Sacha; Angelo J. Freda transfers from Florida as a second year fellow; plans for new facilities in WHMC finalized; Jacobs and Boswell presented the NARES paper in New Orleans at AAAAI meeting. In the spring of 1980, potentiated anaphylaxis occurred in a patient following an immunotherapy injection in the old clinic building. Bill Culver, Don Fournier, and the cardiology staff spent hours before stabilizing the patient. I had seen the prior patient, three years earlier, referred from Sheppard AFB after the event, but did not recall the name nor did I have any records. Don Fournier spent a month searching the patient records who had been admitted to WHMC during this time period before finding the records.
In July, 1980, we moved into the new facility Fournier , Sacha, Freda, and Harvey go into the field; Culver and Strom remain on staff; Three new fellows come aboard: James Claflin, Geoffery W. Rake, and Dexter DeWitt; Moved into new facility in the new WHMC addition; Had to give up about 2/5th of our new space to the Dermatology section because they had made no plans for the new facility; Acquired a new position for a Laboratory Technician to manage the laboratory; Acquired a Personal Secretary (Annie Holmes); Presented and published the “Potentiated Anaphylaxis” paper and published the NARES paper in JACI in the spring of 1981.
In1981: Nelson and Chevalier go to the field; Three new fellows come aboard: Jeffery S. Hallett, Gregory K. Lux, and Edwin J. Whitney; DeWitt was dismissed from training; Staff remains the same; Published Tetanus paper in JAMA which was translated into German, Japanese, and Russian for JAMA publications in those countries; several other publications were accomplished in 1982;
In July,1982: Claflin and Rake go to the field; Whitney withdraws from the program and enters a cardiology fellowship; Two new fellows arrive, Gary L. Smith and Arthur N. Fokakis; Staff addition of Bruce Martin from Fitzsimmons AMC; Boswell transferred to an Immunology laboratory set up by Jacobs and Robert Lordon (Chairman of Medicine) to manage the influx of patients with what would be known as AIDS later; Acquired a position for a fellow to do a third year of Laboratory Immunology at a civilian facility;
In July1983: Hallett and Lux go to the field; Lux was turned down for the third year of immunology training on the basis that he had the military pay for college (Air Force Academy), medical school, pediatric residency, and fellowship (13 years) and he had never served in the field; Three new fellows came aboard: Raiqua Arastu, Luis Matos, and Edward E. Philpot; Strom separates and goes into practice in Paris, Texas; Culver takes an assignment to Wiesbaden, Germany with the plan to return and take over as Chairman when Jacobs retires in 1986; Michael Ruff joins the staff from Duke; Six year rule was to be enforced leading to disruption of plans; Jacobs forced to retire in June 1984; Search for a new chairman began and ended with Bruce Martin elevated to that positon in July, 1984.
Summary: The first 8 years was clearly only a clinical program. There was little known science, as compared to the present time, and there was a lack of proper laboratory facilities. The only equipment in the clinic was a spirometer and a slide-staining tray (for doing nasal and sputum smears). Robert Smith continued to publish but no sustained research efforts were undertaken by Michels and Shapiro.
In the second 10 years, dramatic changes occurred. Six individuals played significant roles in the development of the program as it now functions. Three staff, who did not overlap, contributed to a change in attitude concerning the allergy/immunology approach: John R. Bozalis 71-73 (Michigan trained) and Joe F. Kelly 73-75 (Northwestern trained) were both amazed at the number of patients and pathology seen at Wilford Hall and recognized the potential for meaningful research. Peter M. Freedman 75-78 (Scripps Clinic) was instrumental in developing the 1st laboratory and was an intellectual power on the teaching side.
To begin the transition to a different approach, Mitchell and Jacobs conspired with the army allergist at Brook Army Medical Center to do two studies. Bobby Q. Lanier drafted the format for modern combined allergy/immunology programs as we activated the Wilford Hall program. This format was adopted by the Certifying Board for Allergy/Immunology training programs and remains the standard for which all allergy-immunology training programs must meet to remain certified. Peter M. Freedman developed a laboratory, using equipment from the warehouses at Kelly AFB, to lay the foundation for a more sophisticated laboratory in the planned new facilities. Robert L. Jacobs developed the plans for the new facilities. R. Neal Boswell was granted a fellowship at Harvard to develop and manage the more sophisticated laboratory.
The initial research efforts took place with army allergists at Brooke Army Medical Center (due to difficulty with IRB approval at Wilford Hall) leading to two hallmark papers concerning immunotherapy to Mt. Cedar allergy and Fire ant allergy. Research protocols were begun on Tetanus Toxoid sensitivity and NARES syndrome. Two patients with anaphylaxis potentiated by propranolol were recognized. These three papers were highly recognized world-wide which cast the program at Wilford Hall as one of the top programs in the country. (Our program was in direct competition with the Fitzsimmons Army Allergy/Immunology program directed by Harold Nelson for the top programs)
Upon moving into the new facility in 1980, the program continued to flourish. The facility was very spacious allowing office space for all fellows, adequate laboratory area, and a conference room. Bert Strom remained on the staff and completed the first study utilizing the new laboratory area. This protocol required ‘milking’ of live fire ants to collect venom. This fire ant paper confirmed a previous paper with objective data and set the stage for several additional studies by future staff and fellows concerning fire ants. A paper concerning primary nasal polyps coupled with the NARES paper and a publication from Mason Clinic in Seattle were credited with cleaving nasal disease into allergic and non-allergic forms.
In 1982, because of a high level of referrals for an acquired immune deficiency in homosexuals, Jacobs and Robert Lordon (Chairman of Department of Medicine) assigned an allergy staff slot and R. Neal Boswell with developing an Immunology Laboratory to manage this population.
In 1983-84, the six-year rule was enforced that disrupted individual allergists careers but did not disrupt the trajectory of the training program.
Robert L. Jacobs retired in 1984 and Bruce G. Martin assumed the Chairmanship.