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Doctor heads command post in war against illness

Glimpses into the heart of Dr. John G. Bartlett's medical practice come through a stack of pink telephone slips piled on his desk.

By the end of every day, the number of business calls is at least 50. They come from doctors in Ann Arbor, Mich.; Birmingham, Ala; Boston; Sao Paulo, Brazil, and Sydney, Australia, all stumped by the course of an infectious illness. They also come from his publishers, chiefs of medical staffs in distant hospitals, activists and his patients with AIDS.

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Dr. Bartlett is, in many ways, the physician of last resort for them all.

As chief of the infectious disease division at the Johns Hopkins Medical Institutions, he heads a command post in the war against illnesses from measles to hepatitis. Though in recent years much of the Hopkins arsenal has been aimed at the human immunodeficiency virus, which causes AIDS, the disease is only one among many enemies.

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And, throughout the world, when doctors and patients can think of nowhere else to turn with an unrecognizable symptom, an incurable sickness, they call or write this office.

Every day, the doctor sifts through his message slips, painstakingly picking out the 10 or 20 from patients.

Eventually, he will return each call. But first the patients.

For years, the 57-year-old doctor has worked to answer their questions, but the onset of the AIDS epidemic in 1981 has given his efforts greater urgency.

"Dr. Bartlett has pushed to understand the practical applications of what we know about AIDS and to tell us how to put it to use," says Kristine Gebbie, the nation's AIDS policy coordinator. "He can explain honestly where we are in AIDS research: What we don't know yet and also -- in a quite positive way -- what we can do for people with AIDS now."

In 1980, one year before reports of AIDS cases began speckling the country, Dr. Bartlett became chief of the Hopkins infectious disease division, a unit with two other faculty members, a secretary and a budget of $263,000.

Since then, fueled in part by the mushrooming needs of AIDS patients, the division has grown to 99 staff members -- with a budget of $6 million. In 1993, Hopkins AIDS services were ranked second in the nation -- behind those at San Francisco General Hospital -- by medical professionals polled through U.S. News & World Report.

AIDS-related programs at Hopkins include clinical trials, a hospital unit and an outpatient clinic. Patients have access to the services of case workers, lawyers and financial specialists. Last year, 2,600 people received ongoing care at Hopkins for HIV or AIDS. Hundreds more came for consultations.

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Constantly, Dr. Bartlett's goal is to gather information from every possible source -- people with AIDS, physicians, medical journals, research labs -- and to process it into the best course of treatment avail able. In turn, he passes that knowledge via conferences, committees, articles, books and conversations to other physicians and to patients.

It is a sweeping quest. But the doctor's reach, like his workday, is long.

"In a field as rapidly changing as HIV there is an immense need to translate the information and get it to as many people as possible, including clinicians and practitioners," says Dr. Paul Volberding, director of the AIDS program at San Francisco General Hospital. "In this, [Dr. Bartlett] has had a major impact in the world of HIV and AIDS."

In 1991, Dr. Bartlett and Ann Finkbeiner, a Baltimore science writer, wrote a book for people with the AIDS virus. Titled "A Guide to Living with HIV Infection," it is 368 pages and covers everything from whom to tell about a positive HIV test to the symptoms of AIDS.

Dr. Bartlett also has written more than 500 journal articles, been the co-author or the author of five other books and does a monthly column on AIDS for the Alternative, a local gay paper.

But the virus is unrelenting. In Maryland, 4,967 men and women have died from AIDS; nationwide, the toll is more than 200,000.

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In research laboratories, there is no sight of a cure for HIV or a vaccine to halt its spread. And myriad questions surround the anti-viral drugs -- AZT, DDI, DDC -- that are used to treat it.

Still, Dr. Bartlett is an optimist, in that he never remains discouraged.

"When I first got to know him, I thought, 'Maybe this guy is just a little naive,' " says Garey Lambert, director of AIDS Action Baltimore.

Discoveries have been made that gave scientists hope of finding a successful weapon against AIDS, says Dr. Bartlett. "One by one, they all crashed: experiments with heat therapy, bone marrow transplants, all the drugs. None of it paid off.

"We had a fast start off the blocks [of research] and then brutal confrontations with reality, and it has been hard."

But, he says, somehow the epidemic will be stopped. "It has to be done. It will be done."

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'Remarkable ability to focus'

Though the sun won't rise for two hours, Dr. Bartlett's office is brightly lighted and is beginning to smell of singed coffee. He dictates into a hand-held tape recorder: letters, memos, journal reviews, whole chapters of books.

He works feverishly, rumpling the crown of white hair that half-circles his head, pushing his glasses back on his nose.

The click of the recorder punctuates his sentences and paragraphs. Off. He turns a page. He gulps black coffee. On.

He hurries because the hours go so quickly between 4 a.m., when he arrives each day, and 8 a.m.

He never eats breakfast, never eats lunch -- has nothing but endless doses of ever-thickening coffee. Visitors who begin to wilt under the strain of keeping up are offered sustenance: a Rite Aid cough drop.

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"He has a remakable ability to focus," says Dr. Sherwood L. Gorbach, professor of medicine at Tufts University School of Medicine, who has known Dr. Bartlett for 24 years.

"When he gets started on a project he grabs a yellow pad of paper and a stubby pencil and he just goes at it furiously."

Once, the story goes, Dr. Bartlett had a back problem. His solution was to move a gurney into his office.

"He would have us come in and sit around him and he acted like everything was normal. It was a riot," says Dr. Janet Horn, a Baltimore physician who trained and worked under Dr. Bartlett.

But often, zeal becomes overcommitment. "You have to watch him. He wants to do too much," says Ms. Finkbeiner, the writer. "He wanted to put in another chapter and we had to take the book away from him. . . . We were four years overdue."

In 1988, Dr. Bartlett suffered a heart attack that kept him home for about a month. Then he was back.

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A former junk-food addict, he says, "I changed my diet, that's it."

And at 8 a.m., when the office begins to stir, the doctor turns to his other duties.

There are many.

A brutal schedule

The Bartlett workload is the stuff of a medical resident's nightmares.

A typical week is 90 hours long and includes staff meetings, interviews with prospective fellows and many conference calls.

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Fifteen hours are for teaching. Tuesday afternoons are spent at the Moore Clinic, the Hopkins AIDS outpatient program, where Dr. Bartlett cares for about 120 patients, many of whom represent the most complicated HIV cases at Hopkins.

At any given time, Dr. Bartlett has final responsibility for from seven to 17 clinical trials of drugs.

Locally, he sits on four AIDS-related committees including the Greater Baltimore HIV Health Services Planning Council, which allocates to Maryland AIDS organizations nearly $4 million annually in federal funding.

And there are six university and 15 national committees, including the executive committee of the AIDS Clinical Trial Group.

A consortium of 71 adult and pediatric AIDS research centers, the clinical trial group plays a key role in allowing access to cutting-edge HIV or AIDS treatments to patients throughout the United States.

To keep up with it all, Dr. Bartlett hastens from meeting to clinic, airport to office, often muttering: "Ah gawd, I'm late. Everyone is probably mad at me."

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As he scurries through the labyrinthian halls of the medical complex, he brushes by oil paintings, a portrait of a woman, a still life of green apples. They are his -- fruit of a passion second to medicine and donated to decorate the walls of the Moore AIDS Clinic.

The doctor gave up painting, however, when his two sons and daughter, now ages 15, 20 and 22, were born. "When the last kid leaves, maybe I'll start again," he says.

Whatever free time there is gets spent with his wife, Jean, who is a nurse. Fun is going to auctions and shopping at outlet stores. Saturday mornings are spent with a friend browsing at the Cross Street Market and lingering amiably in a coffee shop. "We don't talk about medicine stuff," Dr. Bartlett says.

In 1955, when young John Bartlett left his parents' home in Syracuse and set off to Dartmouth College, he had no intention of being a physician.

But somehow, the son of a Syracuse University vice chancellor and a music teacher majored in zoology and wound up at the State University of New York, Upstate Medical Center.

"At some point I changed my course. I don't know why," is the best explanation he can muster.

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His interest in infectious diseases came later, sparked while he worked in a fever unit in Vietnam during the war. What drew him to ID, he says, was that he could conquer his patients' illnesses.

"The 'quick fix' of medicine is found either in infectious disease or surgery. You can take a disease, treat it, cure it," he says. "I just loved working on these fevers: You faced diseases that you could cure in a day."

Subsequently, long before he became known as an expert in the treatment of HIV, Dr. Bartlett was known for his work in infectious diseases.

During the 1970s, he was the first to identify and prescribe the treatment for an anaerobe known as clostridium difficile, which causes diarrhea in people who take antibiotics, and can be life-threatening.

Dr. Bartlett also identified and developed treatments for anaerobic infections, which thrive in the absence of oxygen. Some anaerobic infections are potentially fatal such as gas gangrene; others occur in the mouth or in the gut.

"What stands out about John is his ability to identify an infectious disease problem, put it in perspective and identify the best [treatment]," says Dr. Thomas C. Quinn, who has a dual appointment in infectious diseases at Hopkins and at the National Institutes of Health.

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"He did it with anaerobic infections. He did it with difficile and now he's trying to do it with HIV."

When the first diagnoses of acquired immune deficiency syndrome were reported by hospitals, few doctors recognized how widespread a threat the fatal virus would become.

But the late Dr. Frank Polk, a Hopkins epidemiologist, whom Dr. Bartlett calls "visionary," was convinced -- and worked to persuade his colleague -- that this disease would be the biggest medical challenge of the century.

At that point, Dr. Bartlett's reputation had been built on anaerobes. Switching his focus and his specialty at age 43 "didn't make a particle of sense," he says.

Switched his focus

He did it anyway.

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More than a dozen rocky, wearing years have passed since then. Long years in which there have been few breakthroughs in scientific research -- and an unprecedented amount of criticism of the medical establishment from the patients themselves.

As the head of Hopkins AIDS services and its research, Dr. Bartlett was the target of heated attacks by local activists, who disagreed with the direction of AIDS research nationwide.

Mr. Lambert, who is editor of the Alternative and is now a friend of Dr. Bartlett's, was among those who publicly denounced the physician. "AIDS activists viewed Hopkins and what they were doing there as going in the wrong direction," Mr. Lambert says. "It was really unfair. I was wrong."

Dr. Bartlett won't talk directly about the attacks, saying only that AIDS and its activists have changed medicine. "Many people in the field who have been driven by goals or achievements not as humane as they should, have been made to see the face of AIDS," he says.

"The activists have made us aware that they need to be participants in the decisions we make."

There is still a staggering amount of work to be done. Public health experts who, with any other disease, would speak of the wonders of drugs, the power of immunization, now talk of "slowing" the spread of the AIDS epidemic through changes in sexual behavior or drug abuse.

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And in recent months, many doctors and scientists have questioned the thrust of much of AIDS research.

Hopeful signs

As he talks about the battle against AIDS, Dr. Bartlett takes off his glasses. He wearily rubs his whole head with both hands. He sighs. And then, very slowly, his face brightens a little.

People infected with HIV are living for years before developing AIDS; drugs are being developed that keep patients from succumbing to the infections that prey on weakened immune systems, he says.

Among older gay men, modification of risky behavior has slowed the spread of the virus. And a recent study proved that if HIV-positive women take AZT during pregnancy, the chances of their babies being infected with the virus drop by two-thirds.

Eventually, the disease will be defeated, not by a single drug or vaccine, but by "a variety of mechanisms," he says.

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Meanwhile, scientists must persist, Dr. Bartlett says and picks up his tape recorder again. But before clicking it on, he mumbles, "Just the fact that the odds are low doesn't mean that the odds are nil."


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