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SPRING 2008 





Did psychiatric illness help 
or hinder the creativity 
of some of history's most 
celebrated composers? 

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Ida Henrietta Hyde was a woman 
of firsts: first woman researcher at 
Harvard Medical School, in its 
Department of Physiology; first 
female graduate of Germany's 
University of Heidelberg; and first 
woman to be elected to the Ameri- 
can Physiological Society. Although 
she was accepted to the Johns 
Hopkins School of Medicine, Hyde 
chose to research animals' physio- 
logical systems instead. To aid in this 
effort, in the 1 930s she invented the 
microelectrode, a device credited with 
revolutionizing neurophysiology. 

" ^ 




Letters 3 

Pulse 6 

Musical notations, from the Longwood 
Symphony Orchestra's performances, to 
the Music & Medicine section of the 
Bulletin's new website, to the choruses of 
the School's 101st Second Year Show 

President's Report 11 

hy William W. Chin 

Sparks of Inspiration 12 

Donald Berwick seeks to remedy health 
care's problems through redesign, not 
reprimand, hy Ann Marie Menting 

Bookshelf 14 

Bookmark 15 

A review by Elissa Ely of 8 Weeks 
to Optimum Health 

Benchmarks 16 

Research on ensuring transplantation 
success, spurring new bone to form, and 
determining when brain death occurs 

Class Notes 54 

InMemoriam 57 


InMemoriam 58 

Oglesby Paul 

InMemoriam 59 

Benedict F. Massell 

Obituaries 60 

Endnotes 64 

Remember the old joke about how 
God thinks he's a surgeon as he strides 
around Heaven in a long white coat? 
hy Anthony S. Patton 




Chords of Disquiet 20 

Did psychiatric illness help 
or hinder the creativity 
of some of history's most 
celebrated composers? 



This Side of Paradise 28 

Rampant violence in his barrio leads a boy to risk his life to immigrate 
to the United States — and inspires him to become a healer. 


Small Craft Advisory 36 

Medicine needs to steer a course that balances inspiration and science 
to achieve a health care system that works for all. 


The Obstacle Source 42 

The most critical roadblock to delivering care in the developing world 
is not money, but an implementation bottleneck. 


Inside Out 48 

Early investigations of x-ray by two Harvard-educated physicians 
revealed the technology's benefits — and dangers. 


Cover photo of George Gershwin: Edward Steichen/Condc Nast Archive/Corhis 

HarvarH Merlip^l 



William Ira Bennett '68 

In This Issue 


advantages only when an ecological niche remains unchanged. Who 
can know whether the dinosaurs looked out on the world they were 
losing with placid or terrified eyes? What we do know is that most members of 
the species latromcgalos amcricanus, also known as American physicians, are aware 
that something resembhng disaster is impending, and many of them are alarmed, 
but also seemingly immobilized, by the prospect. 

U.S. medicine has developed matchless capacity but suffers from severely 
unpaired delivery. Endowed with the most expensive health care system in the 
world, the United States achieves a relatively low yield in the health of its popu- 
lation as compared with those of other developed countries. We all know this is 
the case. Why are we not ashamed? Why are we not changing it? 

In the first half of the past century, "organized medicine" — also known as the 
American Medical Association — was successful in helping to block a national 
health care plan, calling it socialized medicine. In 1939, Morris Fishbetn, for 
25 years editor of the AMAs journal, called the plan, "... a beginning invasion 
by the state into the personal life of the individual ... a definite step toward 
either communism or totalitarianism." 

However misleading, this theme has ever since been a mainstay of opposition 
to a national health care program. It resurfaced in Ronald Reagan's 1961 venture 
into pohtics on behalf of the AMA, when he warned that if Medicare legislation 
were to pass, "one of these days you and I are going to spend our sunset years 
teUing our children and our children's children what it once was like in America 
when men were free." Three decades later, the insurance industry successfully 
played the same notes in its "Harry and Louise" advertisements, indefinitely 
setting back health care reform. 

Now it is 2008, and patients have learned how severely private insurance can 
restrict their freedom to choose a physician; physicians have learned how thor- 
oughly their therapeutic choices can be limited; and both have experienced con- 
siderable intrusion into the privacy of their relationship. The AMA continues to 
favor private insurance, but now with government subsidies. Other physician 
groups argue that nothing short of a universal, national plan makes economic 
or medical sense. And many in the trenches are disengaged. In this issue of the 
Bulletin, Daniel Federman '53 calls on physicians to recognize that medicine 
cannot continue on its old course and to get serious about plotting a new one. 


Cm[ IAa 

Paula Brewer Byron 


Ann Marie Menting 


Jessica Cerretani 


Kathleen Preston 




JudyAnn Bigby '78 

Rafael Campo '92 

Elissa Ely '88 

Daniel D. Federman '53 

Timothy G. Ferris '92 

Alice Flaherty '94 

Atul Gawande '94 

Robert M. Goldwyn '56 

Perri Klass '86 

Victoria McEvoy '75 

James J. O'Connell '82 

Nancy E. Oriol '79 

Anthony S. Patton '58 

Mitchell T. Rabkin '55 

Jason Sanders '08 

Eleanor Shore '55 


Laura McFadden 



Wilham W. Chin '72, president 

Steven E. Weinberger '73, president-elect 1 

JudyAnn Bigby '78, president-elect 2 

Ken OSit '81, vice president 

Rodney J. Taylor '95, secretary 

Douglas G. KeUing '72, treasurer 


Rosa M. Crum '85 

Laurie Ghmcher '76 

Edward D. Harris, Jr. '62 

Jim Yong Kim '86 

Triste N. Lieteau '98 

Christopher J. O'Donnell '87 

Michael Rosenblatt '73 

Rachel G, Rosovsky '00 

John D. Stoeckle '47 


George E. Thibault '69 


Mary Moran Perry 


Joseph K. Hurd, Jr. '64 
John D. Stoeckle '47 

The Harvard Medical Alumni Bulletm is 

published three times a year at 

25 Shattuck Street, Boston, MA 02115. 

o Harvard Medical Alumni Association 

Phone: 617-384-8900 • Fax: 617-384-8901 



Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 


T 17' nn nn yp "D C^ 


Plaudits for your excellent Spring/ 
Summer 2007 issue on medical edu- 
cation. I especially enjoyed the 
"Endnotes" piece on the curriculum 
rebellion of 1966, which was trig- 
gered by students' concerns that 
they were rapidly going brain-dead 
under the impact of the old preclini- 
cal years. Many members of the Class 
of 1956 felt similarly — how could 
the World of Ideas have disappeared 
so suddenly into a maelstrom of 
unrelated facts being crammed into 
one's brain like the Chinese method 
of preparing Peking duck by force- 
feeding young poultry with a pump and plastic tube? 

Three of us second-year students began meeting every Friday to 
drink wine and exchange ideas on how to avoid having our brains 
become shrunken walnuts. Each of us decided not to share with the 
others his own preventive measure for this fascinating neurological 
problem. So imagine our surprise when, in the spring, each of us 
announced that he was taking a year off from medical school to con- 
sume more nutritional brain foods. Lon Curtis '56 won a fellowship to 
Europe and the Middle East to delve into history. BUI Ruddick took a 
Woodrow WUson Fellowship to study philosophy at Oxford and 
remained there for his doctorate, never returning to HMS. I won a 
Frederick Sheldon Traveling Fellowship to the South Pacific and Africa 
and have kept international health as a hobby ever since. 

Our experience exemplifies how some classes earlier than the 1960s 
and 1970s dealt with the problem of the stifling, overly factual, idea- 
impoverished, mind-desiccating first two years of the old curriculum. 


Decoder Ring 

I enjoyed reading "Endnotes" in the 
Bulletin's special report on medical edu- 
cation. At the end of the piece, the author 
noted that the course syllabus the facul- 
ty provided was called a "camel" because 
it reflected "an organism designed by a 
committee." The definition of the 
"camel" I was given when I attended 
HMS, though, was "a horse designed by 

a committee." In my humble opinion, 
that is a more insightful — and pleasingly 
amusing — description of the beast. 

The piece's recounting of the cur- 
riculum rebellion of 1966 reminded me 
of what we might call the "grading boy- 
cott of 1973," which members of the 
Class of 1977 perpetrated. As I remem- 
ber it, we had been told during the 
application process and before our 
matriculation in 1973 that all grading 

would be on a pass/fail basis. After we 
matriculated, though, we learned that 
the grading system would consist of 
more levels than simply pass or fail. 
Having come of age during the rebel- 
lious and anti- establishment era of the 
late 1960s and early 1970s, we found 
this turn of events unacceptable. 

Discussion with the administration 
about this issue proved less than fruit- 
ful. If I recall correctly, Dean Robert 
Ebert, in a meeting with the entire class 
in one of the amphitheaters, reminded 
us that out there in the real world was a 
plethora of potential students who 
would gladly fill our slots, a notion that 
did not sit favorably with us. So we 
decided to stage a boycott. 

During the physiology final exam, 
which was the first test that would be 
graded using the disputed new system, 
we would substitute numbers in place 
of names on our papers, with the decod- 
ing key being held by a neutral faculty 
member or administrator. The idea was 
that any student receiving a failing 
grade on the exam would be honor 
bound to reveal his or her identity to the 
course's faculty. Those who received a 
passing grade were under no such oblig- 
ation, and the faculty would have to 
assume we had all passed. The resulting 
compromise was a grading system that 
had more levels than simply pass or 
fail but fewer levels than the School 
had planned. 

Our boycott did have one unintended 
and regrettable consequence: Clifford 
Barger '43A, the head of the physiology 
course, mistakenly beheved the boycott 
resulted from discontent with him and 
the physiology course. We reassured him 
that the purpose of this action was solely 
to remedy the situation with the School's 
grading system. 

This recounting is based on my memo- 
ry of events that occurred decades ago, so 
I encourage those of you with better 
memories or more knowledge to make 
any corrections or additions. 





Scrabble Game 

The "Endnotes" article in the Spring/ 
Summer 2007 issue of the Bulletin about the 
lecture ser^ice brought back memories. 

In September 1950, a number of us 
were sitting in Dave Poskanzer's room 
in Vanderbilt Hall — I believe Frank 
Austen '54 was there — discussing the 
absurdity of every student frantically 
scribbling notes. We decided to ask for 
three volunteers in each course to take 
notes and then combine them into 
coherent sentences. Fortunately we 
found someone in the dean's office to 

type them up and make mimeographed 
copies for the entire class. 

The plan worked surprisingly well — 
except Frank consistently did better on 
exams than I did! 



Simply the Best 

when Judah Folkman '57 died suddenly 
on January 14, the Harvard Medical School 
community suffered a devastating loss. 
Although he was best known for his 


I found the article that Anthony Patton '58 wrote on Augustus Holyoke 
of Salem, Massachusetts, in the Spring/Summer 2007 issue of great 
mterest, as my ancestors came from Dam ers which was part of Salem. 

When I was small, 
my parents took me 
to Danvers to cele- 
brate an anniversary 
of Rebecca Nurse, 
who was declared 
a witch and hanged 
in Salem in 1692. 
Those in attendance 
at the anniversary 
celebration were all 
Nurse's direct 
descendants. My 
cousin, a local histo- 
rian in Danvers, 
ended up writing a 
book about Nurse 
and her persecution. 
One time my 
father, who was a doctor in Hanover, New Hampshire, went to a meet- 
ing on diabetes with Elliott Joslin, a member of the Class of 1895 and the 
founder of the Joslin Diabetes Center in Boston. My father took me along 
on the trip, but I had to sit out in the car. I later asked him what they 
had discussed, and he replied that they had talked about ancestors. 


scientific discoveries, Judah actually 
centered his work on patients. Kind- 
ness, humanity, and curiosity were at 
the core of his life. 

I first got to know Judah when he was 
a fourth-year HMS student working in a 
dusty corridor of what was then Peter 
Bent Brigham Hospital. He was doggedly 
trying to transplant kidneys into rats; 
later he and I often chuckled over that 
memory, as his lack of proper instrumen- 
tation made it an exercise in futihty 

After graduating magna cum laude 
and completing a surgical residency at 
Massachusetts General Hospital, Judah 
worked with Bill McDermott '42 at 
Boston City Hospital. Later, when he 
started his own practice at Children's 
Hospital, Judah instituted a pohcy of 
giving his home phone number to 
patients. He also carried a notebook of 
their numbers when he traveled. 

As a teacher Judah was magnetic, and 
his lectures were always crowded. When 
necessary he could be firm. He once 
warned medical students, "You have 
chosen a service profession. Get used 
to it. If you don't like long hours, coping 
with patients, and being on call, then do 
something else. You could be a banker." 

My golden years with Judah were at 
Children's Hospital when he was sur- 
geon-in-chief. Driven by his multiple 
responsibilities, he practically lived at 
the hospital. At all hours he was consid- 
erate to senior staff, residents, anes- 
thetists, nurses, and orderlies alike. 
Nothing could distract him from his 
goal of giving his best to patients. 

During the 1970s, I discussed one of 
Judah's papers at the American Surgical 
Association meeting in Florida. His 
report on angiogenesis had been typi- 
cally sparkling. Yet I focused my 
remarks on his other, equally impres- 
sive qualities. 

Judah's outstanding leadership in 
biological surgical research is known 
worldwide, I told the association mem- 
bers. But when a person develops a 
highly visible profile in one phase of his 
professional life, there is a tendency to 


PARADE OF ROSES: Lois Hunter, a 1956 graduate of the Children's Hospital School of Nursing, is third ro>v from bottom, sixth from left. 

minimize his other talents. Only those 
of us working with him daily realize his 
solid clinical judgment and skills and 
the extraordinary effect his inquisitive 
mind has on the daily rounds of all the 
clinical services of Children's Hospital. 
Whether his studies lead to the control 
of cancer or the understanding of arterio- 
venous malformations, his influence on 
the thinking and teaching of staff, resi- 
dents, and students is enormous. He is 
an excellent clinical surgeon doing out- 
standing research. 

Afterward, Judah thanked me for my 
remarks, and I was especially pleased 
to learn that his mother had been in 
the audience. 

It is most satisfying for me to share 
Judah's attributes with his many griev- 
ing friends, colleagues, patients, and 
fellow graduates. 


A Touch of Honey 

o My wife and I appreciated the photo of 
£ the Children's Hospital nurse and 

patient in the Autumn 2006 issue of the 
Bulletin. My experience was similar to 
that of Henry Work 37, who noted that 
he had been fortunate to marry a Chil- 
dren's Hospital nurse. I met Lois Anne 
Hunter, CMldreris '56, while at Harvard 
College, and we are celebrating our 
fiftieth wedding anniversary this year. 

While at HMS, I was always 
impressed with Children's Hospital 
nurses, and I knew my patients would 
receive superb care when one of those 
graduates was on the ward. Shortly 
after Lois's graduation, Drs. Robert 
Gross and Robert Smith, who had just 
begun to perform open-heart pediatric 
surgeries, asked Lois to take a lead role 
in establishing the country's first pedi- 
atric recovery room. She was successful 
in this endeavor and was delighted, 
upon returning several years later, to 
find that the staff was still using the 
procedures she had developed. 

Once, while I was working as a tech- 
nician on a research project with Dr. Dav 
Cook, I had to go to the recovery room 
to ask my wife whether I could borrow 
a laryngoscope since the batteries in the 

one Cook was using had died. She 
emphatically told me that I couldn't 
have it because they might need it for an 
emergency. My "But, honey" had no 
effect except to cause smothered laugh- 
ter among the other recovery room 
nurses. When I returned to confess my 
failed mission to Cook, the entire group 
burst out laughing, and I learned that 
she had refused them as well. 

The Children's Hospital Alumni Asso- 
ciation had its final meeting in Boston 
in 2006, the fiftieth anniversary of my 
wife's graduation, and many of her 
classmates attended. I recognize that 
I am "chronologically challenged," but I 
regret the evolution from the nurse as a 
supportive team member to a "nurse 
manager" role. 


The Bulletin welcomes letters to the editor. 
Please send letters by mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115); fax (6J7- 384-8901); or 
email ( Letters may 
be edited for length or clarity. 




All the Right Notes 



the only instruments some 
physicians skillfully wield. 
When they aren't studying, 
conducting research, or caring for 
patients, the forty-odd HMS students 
and alumni who help compose the 
Longwood Symphony Orchestra (LSO) 
still have their hands full — ^with violins, 
cellos, and flutes. 

The orchestra's roots within Harvard 
Medical School run deep. Established in 
1982, the orchestra was the brainchild of 
musically inclined HMS students and 

professors who wanted to play together. 
Today, the LSO has 120 musicians, three- 
quarters of whom are physicians and 
other health care professionals from 
area hospitals and medical schools. Two 
HMS students — Sandy Mong '08 and 
Sherman Jia '11, both violinists — were 
appointed co- concert masters for the 
orchestra's 2007-2008 season. 

The connection between music and 
medicine is an instinctual one for many 
physicians, says the LSO's president, 
Lisa Wong, an HMS clinical instructor 
in pediatrics. "Medicine is based in sci- 
ence, but with practice, 
you make it an art," she 
explains. "Music is very 
similar. Once you per- 
fect the technique, you 
add the artistry." And 
like medicine, practic- 
ing music requires dedi- 
cation. "Residents often 
trade their call sched- 
ules so they can perform 
with us," says Wong, 
who admits that pagers 
do sound during prac- 
tice, but quips that 
"they go off in tune." 

That dedication isn't 
limited to the stage. In 
1991, the LSO cemented 
its commitment to com- 
munity service by intro- 
ducing its Healing Art of 
Music Program, an ini- 
tiative to raise funds and 
awareness for various 
medical nonprofit orga- 
nizations. "Rather than 
simply donating money 
to these groups, we ask 
them to purchase blocks 
of tickets and then work 

together to create a unique fundraising 
event," says Wong. This blend of creativi- 
ty and collaboration has paid off: Since its 
inception, the program has helped raise 
more than $800,000 for nearly 30 organi- 
zations, including the Dimock Communi- 
ty Health Center, Partners In Health, and 
the Shriners Burn Hospital Boston. The 
soundtrack for these events is equally 
varied. LSO conductor Jonathan McPhee, 
who also serves as music director for the 
Boston Ballet, enjoys introducing Boston 
audiences to pieces they may not have 
heard recently — or ever — such as the 
twentieth- century Czech composer Leos 
Janaceks Glagolitk Mass. 

The program recently expanded its 
direction in honor of the orchestra's 25th 
anniversary by offering a series of free 
daytime symposia on pubhc health issues 
such as AIDS, global health, and women's 
rights, with each symposium capped by 
an evening benefit concert by the LSO. 
The orchestra capped its latest season 
with participation in a London sympo- 
sium on cancer care, including lectures — 
both of the LSO's trumpeters are oncolo- 
gists — and a concert. 

The 2008-2009 season, which will 
focus on the role of music and the mind 
in healing, will feature a concert cele- 
brating the 60th anniversary of Albert 
Schweitzer's visit to the United States. 
In planning the program, Wong, a vio- 
linist, has considered the powerful 
effect of Schweitzer's reverence for life 
on the music and minds of her fellow 
symphonists. "The way we play changes 
when we know we're performing for 
something beyond ourselves," she says. 
"We don't obsess over hitting every 
note perfectly; we're thinking about 
what we're playing /ok" 

For more information, visit www. ■ 

SYMPHONY HAUL: The Boston medical community has yielded a 
trove of musical talents, including violinist Lisa Wong, president of the 
Longwood Symphony Orchestra, and violist Nicholas Tawa, Jr., '81. 


Live and Learn 



at your office complaining of 
painful, stiff joints that are 
visibly swollen. She's over- 
weight and fatigued but doesn't exhibit 
a rash or fever. After taking her history 
and performing a physical examination, 
you've narrowed the diagnostic possi- 
bilities to osteoarthritis, rheumatoid 
arthritis, gout, or fibromyalgia. Which 
is she most likely to have? 

Medical mysteries Kke this form the 
basis of CME Online, the distance learn- 
ing program of Harvard Medical School's 
Department of Continuing Education. 
And now, thanks to the initiative and 
efforts of the Harvard Medical Alumni 
Council, such opportunities for lifelong 
learning are not only easily accessible for 
HMS graduates, but more affordable as 
well. In agreement with the Council, 
the department is offering alumni sig- 
nificant discounts on its online courses, 
its live courses, and its primary care 
medicine programs. 

For 40 years, the department has 
offered quality continuing medical 
education programs that have earned 
international renown. More than 60,000 
clinicians participate in the depart- 
ment's live courses, conferences, or 
online programs each year. In 2003, the 
department launched CME Online, 
which allows health professionals to 
learn from peers around the globe with- 
out ever leaving their desks. In the five 
years since it was established, CME 
Online has enrolled 7,000 people from at 
least 110 countries. 

With the goal of providing health 
professionals with tools to help them 
optimize patient care, the department's 
programs present the most up-to-date 
medical information and strategies for 
physicians and other health profession- 
als. The courses pertain to all medical 
disciplines and cover a range of topics 
relevant to the science, practice, and 
teaching of medicine. 

Special Offers to HMS Alumni 


enjoy special discounts on Department of Continuing Education programs, including: 

Online Courses. The department offers several dozen online courses through CME 
Online, with many others under development. HMS alumni are eligible for a 50-percent 
discount on these courses. 

Live Courses. HMS alumni receive a 1 5-percent tuition discount on live courses. To be 
eligible, they must register at least 60 days before the start of the course. 

Primar/ Core Medicine Programs. The department has waived registration fees 
for HMS alumni enrolling in any of its seven Current 
Clinical Issues in Primary Care Medicine programs 
throughout the United States and in Mexico. Alumni 
are also welcome to make themselves at home in the 
HMS speakers' lounge, where they can meet with 
keynote speakers and other colleagues over break- 
fast and lunch and throughout the sessions. ■ 

To learn more about 
these offers, visit http:// 


CME Online offers a variety of 
approaches to learning. The computer- 
based program includes interactive 
quizzes, laboratory results, pho- 
tographs, and other related images that 
bring clinical cases to life and make 
learning enjoyable. Clinicians can 
choose from a range of topics, such as 
"Management of Atrial Fibrillation," 
"Endocrine Emergencies," and "Clini- 
cal Challenges in Toxicology." 

Each module contains a compelling 
case study that presents a patient's 
symptoms — in one case, a 58-year-old 
woman v^th a history of breast cancer 
experiences back pain; in another, a 23- 

year-old man exhibits stomach distress, 
depression, and fatigue — and questions 
users on the appropriate tests, diag- 
noses, and treatments. In addition to 
offering an interactive question- and- 
answer format, the program allows 
readers to compare their answers with 
those of their peers and to email the 
module's author for more information. 
And the "save as you go" function makes 
it easy for busy clinicians to pursue 
credits at their own pace. 

For more information about the 
Department of Continuing Education, 
visit its website at ■ 



Easing the Debt Burden 


about to get easier for many HMS students. Dean 
Jeffrey Flier recently announced a new financial 
aid initiative aimed at reducing debt for medical 
students and their families. The School has approved a signifi- 
cant decrease in the financial contribution expected from fam- 
ilies earning $120,000 or less annually — a reduction estimated 
to save each family approximately $50,000 throughout the tra- 
ditional four-year program. This policy revision wUl affect 
about one-third of HMS students. 

Formed in part by the School's Strategic Advisory Group 
on Education, the initiative comes as levels of student debt 
reach new heights. With rates of indebtedness rising more 
quickly than starting salaries in many areas of the profession, 
medical students often feel pressured to choose more lucra- 
tive specialties. Minimizing this pressure, says 
Flier, will help students make career •••*** 

decisions based on their interests and abilities rather than on 
financial concerns. 

Scheduled to begin with the 2008-2009 school year, the ini- 
tiati\'e will result in the awarding of an additional $3 rrdlhon in 
HMS scholarship funds, a nearly 40 percent increase over cur- 
rent funding levels. It wlU also exclude parents' retirement sav- 
ings from the ehgibihty equation, aUov^dng a larger number of 
families to qualify for financial support. And the Strategic Advi- 
sory Group on Education has joined with the Program in Med- 
ical Education and the Committee on Financial Aid in studying 
the feasibihty of replacing some of the School's current subsi- 
dized federal and institutional loans with scholarships. 

"The issue of student debt is of great concern to me, which is 

why I feel particular satisfaction with this first step toward 

making HMS more affordable," Fher says. "It is important that 

the School not be out of reach to a broad segment of 

*••••, undergraduate students and their famQies." ■ 

Connecting the Docs 


•* has launched a website aimed at better connecting HMS *• 

> graduates with one another and with the School. 

In addition to a continually expanding selection of Bulletin archives, the 

website offers three sections that curate the magazine's features: 

"Fascinoma," which borrows from medical slang to collect articles on 

such topics as music and medicine, history's medical mysteries, and 

white coat humor; "On Doctoring," which presents articles in areas of 

interest to working physicians; and "On Discovery," which captures the 

research findings of Harvard doctors. 

Other sections include "Alumni Resources," which highlights benefits 

the School offers its graduates (such as continuing medical education 

discounts and financial aid programs), and "Connect the Docs," which 

provides links to alumni websites and blogs; news and features about 

alumni; and plot synopses of past Second Year Shows. 

The Bulletin website can be found at Please send us links to alumni 

websites and blogs, information about published books that should 

, be added to our online bookstore, lyrics or links that will enrich 

*• the Second Year Show archive, and any •' 

•, suggestions you may riave. ■ ,• 



Lesson Plans 


L%Tnfl through anatomy class or 
^^^fl exploring an imaginary island, 
the Class of 2010 proved that 
HMS students have brains and talent in 
their production of the 101st annual Sec- 
ond Year Show. Directed by Andrew Chao 
and Camille Powe, All 1 Really Need to Know I 
Learned in Medical School cleverly skewered 
the class's experience as guinea pigs of the 
new integrated curriculum — with song, 
dance, and witty dialogue. 

The show unfolded as a collection of 
earnest first years — an overeager pedi- 
atrics student, an awkward social medi- 
cine groupie, a geeky Health Sciences and 
Technology student, an insensitive 
cultural competence advocate, and a ^ 
dental student with bad breath — 
arrive on campus and introduce 
themselves with "Our First Day," 
sung to the tune of the Sesame Street 
theme song (It's our first day / Off to 
learn the Harvard way / On our way, to 
where we fight disease). Soon, however, 
the students become plagued by self- 
doubt as they learn one of them has been 
admitted to HMS by mistake. 

The opening act focused on the students' 
journey through their first year, complete 
with the usual mercUess send-ups of favorite 
preclinical instructors. "Heart Attack," a 
spoof of Justin Timberlake's "SexyBack," 
let muscle-bound surgery professor Dana 
Stearns show off his biceps while per- 
forming CPR. Perky biology instructor Jen 
Stanford summarized the "Key Points" of 
the show at various intervals. And anti- 
tobacco crusader Allan Brandt (here, a 
chain smoker) transported the first years 
to a make-beheve island where social 
medicine superstars Paul Farmer '90 
and Jim Kim '86 were camped out with 
Hollywood superstar Angelina Johe, 
there to adopt her 17th child. 

The show's theme loosely fol- 
lowed Robert Fulghum's book All 
I Real!}' Need to Know I Learned in 
Kindergarten by higUighting life 




K X 

GETTING THEIR KICKS: Alexis Moore and Dan Drzymalski 
get into the swing of things during the Dance Off of Doom 
(above), while Steve Porter (as Paul Farmer) strikes a pose. 

lessons apphcable to both kindergarten and medical 

school, such as apologizing when you hurt someone. The 

show was infused with bits of comedic inspiration, 

including a suspiciously sniffling Big Bird — recently 

returned from Southeast Asia — and a series of amusing 

"training fffms" about the patient-doctor relationship. 

The most memorable feature of the show, though, was 
the Class of 2010 itself. As the Health Sciences and Tech- 
nology student, for example, Marc Walker used impecca- 
ble comic timing to deliver such lines as, "I can't wait to 
meet a patient. And then maybe when I finish my PhD, I'd 
like to meet another one." And Ashley Orynrich, as the 
dental student with halitosis, gave a sultry rendition of 
"It's Not that Easy Lovin' Teeth," set to the tune of Kermit 
the Frog's "Bern' Green." 

And who was the mistake? No one, of course, 
because HMS faculty would never make a mistake. 
They were simply trying to teach the students an 
"integrated life lesson." ■ 



Sickness, Wired 


other contagious diseases 
are now just a few key- 
strokes away. Their pres- 
ence, thankfully, is virtual, 
part of a comprehensive 
new digital library collec- 
tion mode possible by the 
Francis A. Countway 
Library of Medicine and 
other Harvard-affiliated 

The online collection, 
Contagion: Historical Views 
of Diseases and Epidemics, documents the scientific, historical, and social 
forces behind the development of contagion theory and modern epidemiol- 
ogy and details several "disease episodes," including epidemics of 
syphilis, cholera, plague, yellow fever, influenza, and smallpox. Visitors 
to the project's website have access to thousands of relevant materials, 
including digitized copies of books, serials, pamphlets, incunabula, manu- 
scripts, and illustrations. The Countway's many contributions include 
unique resources: a letter from Thomas Jefferson to Benjamin Waterhouse 
discussing inoculation against smallpox; the first printed medical book to 
contain illustrations; and graphic works by such notable caricaturists as 
George Cruikshank and William Hogarth. 

Contagion, which was created by the Harvard University Library 
Open Collections Program, can be accessed at http://ocp.hul. harvard, 
edu/contagion. ■ 

A Man of Vision 


Alumni Fund, should succeed the acting chair, Daniel Federman '53. 
After all, Hughes played Federman in his class's Second Year Show, "The 
Right Stiff." Federman now likes to introduce the new chair by telling a 
story about a secondary role Hughes played with the show. 

"As a student," Federman says, "Mark visited Carl Walter '32, the 
founding choir of the Alumni Fund, to solicit Carl's annual gift to the Sec- 
ond Year Show. Mark come away with a doubled gift and Carl's predic- 
tion that HMS would get a lot out of Mark in the long run. That long run 
begins now." 

Hughes maintains on ophthalmology practice in which he specializes 
in retinal disease. An early adopter of angiogenesis inhibition for macular 
degeneration, he has been widely published in the areas of ophthalmology 
and professional standards in medicine. ■ 

Gained in Translation 


received a five-year Clinical 
and Translational Science 
Award from the National 
Institutes of Health to launch a center 
that will transform patient-oriented 
research and create an unprecedented 
level of collaboration across the Har- 
vard schools and affiliated hospitals 
and institutes. With this award, the 
University will join a consortium of 
clinical and translational science cen- 
ters based at academic health institu- 
tions around the country. 

The Harvard center will be directed 
by Lee Nadler 73, the Virginia and D. K. 
Ludwig Professor of Medicine at the 
Dana-Farber Cancer Institute and HMS, 
and co-directed by Steven Freedman 73, 
HMS associate professor of medicine at 
Beth Israel Deaconess Medical Center. 
HMS will receive $23.5 miiUion armuaUy 
during the five-year period. The School, 
University, and affiliated hospitals have 
also joined together to contribute an 
additional $15 million to the effort. 

"This is an extraordinary moment for 
our University, our School, and all of the 
hospitals and institutes that make up 
the Harvard Medical community," says 
Jeffrey Fher, dean of HMS. "The grant 
apphcation required an unprecedented 
level of collaboration across our commu- 
nity, as well as a commitment to a broad 
and compelling \'ision of clinical and 
translational research at Harvard." 

Among the initiative's key strategies 
will be to improve communication across 
the University and to help clinical investi- 
gators locate tools, equipment, collabora- 
tors, and expertise throughout the Har- 
vard system. "Thanks to the efforts of Jeff 
Fher and Lee Nadler," says Steven Hyman 
'80, provost of Harvard University, "we'U 
be able to put together a bench-to-bedside 
translational and chnical research effort 
that will make the Harvard medical sys- 
tem bigger and more effective than the 
sum of its storied parts." ■ 





The Strongest Link 


Garland, a member of the Class of 1919 and the 
magazine's founding editor, begged the School's 
graduates to send news of themselves. "Our col- 
umn of Alumni Notes, brave enough a few months ago," he 
wrote, "has shrunk now to such proportions that we won- 
der if the graduates of the Harvard Medical School are 
entirely inactive in the arena of life, never even changing 
their addresses, or if modesty or fear of their local commit- 
tees on ethics and discipline prevents them even from 
announcing through our columns that little Mary Jane has 
come to gladden the hearts of both parents. The editor is 
tempted — almost — to insert his own name with the news 
that he has not bought a new fountain pen because the old 
one is still working." 

"Connect the Docs," or a newly available alumni resource — 
and offer other relevant information, including details about 
upcoming reunions and news about individual alumni. 

We also envision an e-community with even greater poten- 
tial, one that wiU help us foster such initiatives as the cultiva- 
tion of mentoring relationships between students and alumni, 
a clearinghouse of alumni willing to host students interview- 
ing for residencies outside of Boston, an exploration of service 
opportunities, and a forum for discussions on important issues 
in health care and medical education. 

My successor as president, Steven Weinberger '73, shares 
my interest in buHding this alumni interaction space. We hope 
that our work in developing online connections will prove as 
successful as several other recent Alumni Council initiatives. 
When Steven Schroeder '64 served as president, for example. 

We also envision an e-community that will help us 
foster such initiatives as the cultivation of mentoring 
relationships between students and alumni. 

Eighty years later, we find ourselves making the same plea 
for alumni to stay in touch with the School — and with each 
other. But we now have communication tools far more elab- 
orate than Garland's trusty fountain pen, and we are hoping 
to exploit them to bring members of the Harvard Medical 
School community a little closer to one another, no matter 
their geographic address. 

During my tenure as president, I have worked with Council 
members to estabhsh a virtual community of HMS alumni. A 
year ago the Harvard Medical Alumni Association redesigned 
and retnvigorated its website, and now the Bulletin has an online 
presence as weU. We have been working with Post.Harvard, 
the University-wide alumni website, to create additional 
avenues for communication. These websites are a good begin- 
ning; not merely a database, each has been designed with the 
goal of bringing alumni together. The Bulletin's "Connect the 
Docs" section in particular is aimed at forging links among 
alumni, faculty, and students. 

But these websites represent only a sliver of what we hope 
to provide. We plan to launch an e-newsletter, for example, 
that will bring content updates to interested alumni — such 
as the online availability of the latest Bulletin, irmovations in 

he brought his passion and energies to bear on the issue of stu- 
dent debt, and the Council helped spark renewed attention to 
reheving the financial burden on HMS students. And last year, 
A. W Karchmer '64 led the Council in working with Sanjiv 
Chopra, the faculty dean in the HMS Department of Continu- 
ing Education, to develop some terrific continuing education 
benefits for HMS alumni. 

Although these legacies serve to define the contributions of 
past presidents and Council members, the issues they tackled 
were ones that drew on the concerns — and wishes — of many 
alumni. We beheve our efforts to pull graduates together using 
today's communication tools also respond to those needs and 
hopes by helping alumni remain grounded in their profession 
and linked to their classmates while they circle the globe on 
their missions of healing. ■ 

William W. Chin 11 is vice president for discovery research and clinical 
investigation at Eli Lilly and Company. 

The Bulletin's website can he accessed at 
harvardedu; to learn more about the Har\'ard Medical Alumni Association, 
visit Mrmv.hms.harvard.cdu/alumni. 





Deliver the Goods 


resonates with Donald Berwick 72. "Joanne's story 
was a turning point for me," he says. "It showed me 
our approach to health care reform was bankrupt." 
Joanne, an administrator in a radiology department at 
Harvard Community Health Plan, had sent Berwick data 
showing that in a three-month period, her department had 
slashed patient waiting times from an average of 45 minutes 
to 2 minutes. Berwick simply had to know the details behind 
her success. So he had gone to her office. 

"Joanne, you've knocked the socks off this problem!" he 
exclaimed. "What did you do?" 

Joanne looked at him; "It was easy. All I did was lie." 

Color Coded 

At the time, Berwick was the group's vice -president for quah- 
ty-of-care measurement. Joanne had sent her data in response 
to an assessment survey he had circulated. From Berwick's 
shocked expression she knew a fuller explanation was needed. 

"Let me tell you what happens around here," she said. 
"When I send you data that shows all the problems, you send 
that to my boss's boss's boss, and he circles it with red ink. 
Then he sends it to my boss's boss, and he circles it in yeUow 
marker and sends it to my boss, who circles it in orange ink and 
writes, Joarme, do something about this.' It then comes back to 
my desk — as if I didn't know we had a problem and wasn't 
akeady doing everything I could to resolve it. So I made up the 
data. I knew both you and I would be happier if I did." 

Her story opened Berwick's eyes. "I saw that so long as we 
kept beating up the workforce," he says, "so long as we just kept 
asking good people to try harder to fix chronic issues, we'd 
never, ever get going. This upended my whole way of thinking." 

Berwick, a clinical professor of pediatrics and health care 
pohcy at Harvard Medical School, has dedicated himself to 
changing the way people approach health care improvement. 
He beheves he has struck upon a better way to work for the 
Joannes out there — and for aU the patients she and so many 
other health care professionals seek to serve while operating 
within a hobbling system. In his approach, problems associated 
with the practice and deUvery of health care — problems like 
medical errors, waste, and a systemic inability to look inward 
and learn — are dissected as problems of process, not of people. 
And, taking a page from industry's push to improve productiv- 
ity, workplace morale, and product quahty, he encourages the 
health care industry to foUow a new paradigm. 

With searing clarity, Berwick points out the flaws of the 
health care system and analyzes how they can be overcome 

through redesign. He and the growing legion of hospitals and 
health professionals that work with him have shown that 
specifying processes and streamlining systems can avoid need- 
less deaths, alleviate pain and suffering among patients, elim- 
inate waiting and waste, and help banish the helplessness 
that patients and their families too often experience. 

Most health professionals are painfully aware of the need for 
improvement. If they aren't, numbers might help convince them. 
A patient safety study conducted between 2004 and 2006 by 
HealthGrades, a health care ratings organization, presented data 
on the costs of medical errors gleaned from an analysis of 41 nul- 
hon records of Medicare patients. Its findings showed that 
patient safety errors resulted in nearly a quarter of a miUion 
preventable deaths during the period studied. It further found 
that more than 60 percent of the common medical errors report- 
ed involved bedsores, failure to save patients once complications 
arose, and postoperative respiratory failure. With fewer such 
errors, the study analysts estimated thousands of hves and up 
to $2 bilhon in outright costs could have been saved. 

Industrial Strength 

The idea for applying the principles of what is known as con- 
tinuous quahty improvement to the service-based industry of 
health care came to Berwick in the mid-1980s, soon after Joanne 
had confessed the secret behind her success. Berwick had reg- 
istered for a weekend lecture series in Washington, DC, featur- 
ing W Edwards Deming, a mathematical physicist who had 
successfully appUed statistical methods to industrial quahty 
control questions. Largely unsung in the United States, Deming 
was a hero among Japan's industriahsts who had used his theo- 
ries to propel that nation's postmodern economic boom. 

"For the first day and a half, " says Berwick, "I sat there lis- 
tening to Deming explain his statistics-based, engineering- 
based theory for how proper management should work to 
achieve continual improvement. By noon of the second day I had 
left and flown back to Boston. I thought it was all nonsense." 

But the night of his return proved to be a restless one for 
Berwick. Agitated, sweating, and unable to sleep, he wan- 
dered into his living room and sat down to think. 

"Suddenly it hit me," he says. "I realized my discomfort wasn't 
the result of my being exposed to a theory that was wrong. I 
was uncomfortable because what I had heard made sense to 
me — and it violated almost every theory that I had been fol- 
lowing. I returned to DC and completed the seminar." 

Berwick walked away from this epiphany with an idea for 
fixing health care that was unKke almost anything that had yet 
been tried. In 1987, his innovation led to a role as co-principal 



investigator on an experiment known as the National 
Demonstration Project on Quality Improvement in Health 
Care. Teaming with A. Blanton Godfrey, who was then a qual- 
ity management theoretician with Bell Laboratories, Berwick 
set out to test whether methods used to improve industrial 
quahty were apphcable to health care. Berwick and Godfrey 
matched 21 professionals from health care organizations with 
a similar number of industrial quality assurance professionals 
from academia and industry. 

After 18 months of work, the groups reported their results 
on projects ranging from better billing procedures to improved 
ways of transporting infants between hospitals. The results 
were so stunning that the study sponsors granted the investiga- 
tors funding for three more years. The researchers used the time 
to estabUsh a network of hospitals that shares information on 
implementation efforts, to inaugurate forums on quality 
improvement in health care, and to develop courses on how to 
adapt industrial quahty improvement methods to health care. 

To spread the word further, in 1989 Berwick wrote a com- 
mentary for the New England Journal of Medicine. The title, 
"Continuous Improvement as an Ideal in Health Care," only 
hints at its true purpose: It is at heart a manifesto declaring the 
need for the profession to look anew at itself and its approach 
to improvement. Berwick oudines why an approach that 
blames problems of quahty on workers' poor intentions only 
serves to make people game the system — distort the data, fault 
others for perceived shortcomings, and fearfully avoid anyone 
associated with quahty measurement and improvement. 

On the other hand, Berwick points out, if problems with 
quahty are seen for what they truly are — fundamental flaws of 
a complex system — they can be understood and re\dsed on the 
basis of data about the processes themselves, not the people 
implementing them. The potential for improvement in quahty 
is nearly boundless, Berwick says, if we remove fear from the 
equation, learn from accurate information, and enhst the tal- 
ents and spirit of dedicated professionals. 

All Ahead Full 

The principles set forth in his article are ones Berwick 
applies in practice. In his work at the Institute for Health- 
care Improvement, a not-for-profit organization in Cambridge, 
Massachusetts, that he helped establish in 1991, Berwick has 
focused on fixing health care systems in the United States 
and abroad. One of the institute's more visible efforts 
launched in 2004 when it began a campaign to improve 
hospital safety. The 100,000 Lives Campaign was designed 
to help hospitals reduce unnecessary deaths by encouraging 

them to implement over a two-year period a handful of sci- 
entifically proven improvements in care delivery, such as 
rapid response teams for critical care interventions, the pre- 
vention of surgical site and central-line infections, and the 
reduction of medication errors. 

The campaign exceeded its goal: Hospitals participating 
in the campaign and in other initiatives prevented an esti- 
mated 122,300 unnecessary deaths within an 18-month cam- 
paign period. In December 2006, the Institute for Healthcare 
Improvement launched a second such effort, this time with a 
goal of preventing five million incidents of medical harm in 
the United States. 

With initiatives to transform medical and surgical care, 
perinatal care, clinical office practice, surgical outcomes, and a 
host of other improvements, the work of Berwick and his 
team is steaming ahead. Berwick knows, though, that the 
task is great and that protracted implementation means more 
lives lost, more frustrated health professionals, and a contin- 
ued escalation of costs in an increasingly inequitable health 
care system. Incremental change, he feels, is not the answer. 
Instead he believes the U.S. health care system needs funda- 
mental change. And if that means building it anew, well, 
Berwick may just be the one to spark that transformation. ■ 

Ann Marie Mcnting is associate editor of the Har\'ard Medical 
Alumni Bulletin. 












Manual ol 


sr&r ■ 

" ■ "' ■ 


Cardiovascular Disease in the Elderly Manual of Neonatal Care 

edited by Wilbert S. Aronow '57, 
Jerome L. Fleg, and Michael W. Rich 
(Fourth edition, Informa Healthcare, 2008) 

People older than age 65 currently 
account for more than 80 percent of all 
cardiovascular disease-related deaths. 
The updated version of this classic 
textbook provides a comprehensive yet 
readable overview of the epidemiology, 
pathophysiology, evaluation, and treat- 
ment of cardiovascular disorders in this 
population. The book offers an in-depth 
discussion of the elderly patient in the 
clinical setting and considers the impact 
of coexisting conditions, polypharmacy, 
frailty, and patient preferences on cardio- 
vascular disease management. 

Children of Divorce 

A Practical Guide for Parents, Therapists, 
Attorneys, and]udges, by William Bernet '67 
and Don R. Ash (Second edition, 
Krieger Publishing, 2007) 

Because every divorce has social, psycho- 
logical, and legal implications, this guide 
speaks to all the major players — parents, 
therapists, attorneys, and judges. The 
expertise of both psychiatric and legal 
professionals is presented, and the book 
offers readers advice to achieve three 
basic goals: to help children maintain 
good relationships with both parents; to 
help children continue to maintain their 
regular routines; and to help children 
learn how to accept inevitable losses and 
disappointments and then move on. 

by John R Cloherty, Eric C. Eichenwald 
'84, and Arm R. Stark '71 (Sixth edition, 

This revised volume offers a practical 
approach to the diagnosis and medical 
management of problems in newborns. 
The book contains new information on 
fetal assessment, new guidelines on the 
management of neonatal jaundice, and 
updated data on the survival of prema- 
ture infants and perinatal asphyxia. 
Intubation and sedation guidelines and 
an easy-to-access guide to neonatal resus- 
citation are also included. 

The Metabolic Syndrome and Obesity 

by George A. Bray '57 (Humana Press, 2007) 

Bray's survey of the current scientific 
understanding of obesity and the meta- 
bohc syndrome also includes an overview 
of the most significant changes in the 
field during the past 30 years. This com- 
prehensive reference addresses the prob- 
lems and offers solutions. Treatment 
options such as diet, exercise, behavioral 
therapy, surgery, and pharmaceuticals 
are also discussed. 

Where Did All the Fat Go? 

The WOW. Prescription to Reach Your 
Ideal Weight — and Stay There, by Robert 
Huizenga '78 (Tallfellow Press, 2008) 

Based on new obesity research, this 
book provides readers with the same 

successful diet and exercise program 
the author offers as the doctor for the 
NBC television show The Biggest Loser. 
He also addresses the psychological 
aspects of obesity and weight loss, 
including depression, temporary set- 
backs, emotional problems, and pitfalls 
and barriers. 

Manual of Pediatric Therapeutics 

by David S. Greenes '91 (Seventh edition, 
Walters Khwcr, 2008) 

Based on the experience of clinicians at 
ChUdreris Hospital Boston, this practical, 
point- of- care reference contains current 
information on topics such as acute care, 
behavioral disorders, and management of 
children with developmental disabilities 
and other specialized health care needs. 
An A-to-Z drug formulary is included. 

Lifting the Weight 

UnderstandingDepression in Men, Its Causes 
and Solutions, by Martin Kantor '58 
(Praeger Publishers, 2007) 

Long thought of as a "feminine" disorder, 
depression actually affects millions of 
men each year. In this jargon-free text, 
Kantor focuses on the human dimension 
of depression as it appears in men, 
emphasizing the "microscopic doings of 
the depressed maris inner and outer life." 
He takes a hohstic approach, melding 
various schools of thought with his clini- 
cal experience. The author also includes a 
chapter on how to cope with men who 
are depressed. 




8 Weeks to Optimum Health 

A Proven Program for Taking Full Advantage of Your Bodys 
Natural HcalingPowcr, by Andrew Weil '68 
(revised paperback edition, Ballantinc Books, 2007) 


except that she does not take my advice. For reasons 
I fully understand (yet cannot fuUy accept), she will 
not look to my years of cuUed professional knowl- 
edge and life experiences to guide her physical and mental 
health. There is no glow of the follower in her loving eye. She 
would rather suffer and learn on her own. She is stiU young. 

Lucky Andrew Weil '68. He has followers eager to learn 
from his knowledge and experiences. Perhaps this has 
caused a certain confidence. "If," he writes in his revised and 
expanded 8 Weeks to Optimum 
Health, "you are motivated to 
read this book and begin the 
program, you need no other 
outside help." A lovely idea it is. 

Readers of the Bulletin and 
0, The Oprah Magazine already 
know Weil as an expert in 
integrative medicine, a prolific 
writer, and a personality with 
a strong and jolly twinkle in 
his media-sensitive eye. The 
book is intended as a guide for 
the general audience. Each 
week, Weil assigns home- 
work: one new project (purify 
the water, lean toward organ- 
ic produce); one new piece of 
dietary advice (add salmon, 
soybeans, green tea); one new 
supplement; sequential walking and breathing techniques; and 
one spiritual recommendation (buy flowers, visit a park). There 
are also optional exercises — extra credit for the soul — and 
recipes. Two hundred and sixty-four pages boil down to this 
counsel: be good to yourself and others. The rest is merely detail. 

When the first edition of the book emerged a decade ago, 
this advice, especially the details, seemed revelatory. It is in part 
the result of Weil's efforts that most of his guidance now seems 
merely sensible. Alternative and integrative treatments are pro 
forma; Harvard itself has a whole division dedicated to their 
research and practice. And the influence of mind upon body is 
also indisputable, as Weil's work has helped show. 

His special interest is the healing system, which, he 
explains, is not structural but functional. It is more inclusive 
than the Western medical model, expanding to include soma. 

psyche, and spirit, and operating from the level of DNA "up to 
the level of cut fingers, and into the mental realm, where it 
helps us adjust to emotional shocks." This is the kind of phi- 
losophy you either believe or you don't. 

To Illustrate its potential. Well begins his book at his ovvm 
begiiming: an overweight, over-burdened person. His diet was 
"free form and thoughtless." His mind was "restless [and] sus- 
ceptible to boredom." He suffered from hives, migraines, and 
sunburns. The treatment he needed was not medicine but a 
lifestyle adjustment. He made that adjustment and now offers 
the same treatment to others. "Patients come to me with sto- 
ries of woe," he explains, "and instead of giving them magical 
cures, I tell them they must change their diets, habits of exer- 
cise, ways of handling stress, even their breathing." 

The testimonials in each chapter are not as interesting as 
Well's writings about alternative treatments. His chapter on 
tonics includes wonderful descriptions of herbs with poems 

for names (ashwagandha and 
cordyceps) and an unexpect- 
ed endorsement of aspirin. 
He informs us that more than 
400 compounds contribute 
to ginger's smell, taste, and 
biological activity, and that 
coenzyme Qjg should be taken 
with a fatty meal to increase 
bioavailability. This informa- 
tion is useful, at least to 
the believer. 

But the program has some 
problems. Some of the advice 
is dated (ginseng has seen 
better days). Also, it is easiest 
for those followers with both 
feet on firm financial ground. 
In the shelters where I work, 
patients cannot afford many 
of Weil's suggestions, including wild Alaska salmon, 
saunas, and hypnotherapists. And whUe I am quibbling, there 
is something about a recipe for "Dr. Andrew Weil's Favorite 
Low-Fat Salad Dressing" that sends a rebel straight to the 
high-fat salad dressing section of the supermarket. Too much 
first person can brmg out unspiritual and belittling tenden- 
cies in a reader. This is a shame, as the book was written for 
my own good. 

As I finish this, my daughter is refusing my suggestions for 
organizing her fourth- grade homework folder — again. It could 
use help. Her refusal does not discourage me, since I am never 
tired of giving advice. Interestingly, though, I'm sometimes 
tired of getting it. ■ 

Elissa Ely '88 is a psychiatrist at the Massachusetts Mental Health Center 





Adjusted to Fit 


transplanted tissue usually 
depends upon chemical induce- 
ments. These pharmaceutical 
aids can be taxing, though. For one thing, 
the transplant recipient must take the 
immunosuppressive drugs for the rest of 
his or her life. Yet even with perfect 
adherence, the drugs can fail in their 
task, leading the patient's immune sys- 
tem, unconvinced of the merits of the 
new tissue, to reject the transplant. 

Research from a team at Massachu- 
setts General Hospital, however, may 
have struck upon a way to ensure toler- 
ance of kidney transplants without the 
long-term assistance of immunosuppres- 
sive drugs. The team's irmovation relies 
on a quick succession of therapies that 
trick the immune system into accepting 
the new tissue as friendly rather than 

foreign. And perhaps most promising of 
all, the method is the first to work for 
patients and donors who were immuno- 
logically mismatched, a situation that 
can comphcate transplantation efforts. 

The senior researcher for the MGH 
team was David Sachs '68, the Paul S. 
Russell/Warner-Lambert Professor of 
Surgery and director of MGH's Trans- 
plantation Biology Research Center; the 
team also included Nina Tolkoff- Rubin 
'68, a professor of medicine and director 
of hemodialysis at the hospital. Their 
report appeared in the January 24 issue 
of the New England Journal of Medicine. 

Preparation Is Everything 

The team designed the study with pre- 
and postconditioning routines that they 
hoped would create a temporary state 

in which bone marrow stem cells from 
the donor would mix easily with those of 
the patient. The stem cells in a person's 
bone marrow spawn an array of other 
cell types that populate the body's 
immune network. 

In the chimeric state the researchers 
sought to induce, the bone marrow stem 
cells of the patient would form an 
alhance with introduced bone marrow 
cells from the donor. The mixed cells 
could then work to broker an amiable 
coexistence between the new tissue and 
the body's immune sentinels. If all went 
well, the patient's immune system would 
be tricked into accepting the donor kid- 
ney forever. 

To ease this transition, the team pre- 
conditioned each patient with a regi- 
men that used chemotherapy to partially 
destroy patients' bone marrow; an anti- 
body to disable immunologically active 
T cells, which form in the thymus; and 
irradiation of the thymus to further sup- 
press T cells. After transplantation and 
an infusion of donor bone marrow, 
patients were isolated for two weeks 
in a sterile room to allow cells in the 
bone marrow and the immune system 
to regenerate. 

The team enrolled five patients with 
end-stage renal disease who were 
scheduled to receive a kidney from an 
immunologically mismatched parent or 
sibling. The first two patients respond- 
ed well to the preconditioning, trans- 
plantation, postsurgical isolation, and a 
nine- to fourteen-month weaning from 
immunosuppressive drugs. 

A third participant, however, rejected 
the transplanted organ and had to under- 
go a second transplant. This rejection 
might have clouded the team's effort had 
they not discovered the patient's B cells 
had raUied to fight the new organ's pres- 
ence. In most cases, B cells, which devel- 
op in the bone marrow, depend on T cells 
to activate. In this patient, reactive B cells 
may have already existed. 



Weapon for Mass Construction 

By revising the plan to include a 
B' cell-depleting antibody in the precon- 
ditioning protocol, the team used the 
regimen successhally for the final two par- 
ticipants. Of the four patients for whom 
the study regimens worked, all have had 
stable renal function for two to five years. 

"This marvelous work exemplifies the 
progress occurring in the field," says 
Joseph Murray '43B. "It is simply mind- 
bogghng the way advances have manifest- 
ed themselves in the decades since the 
first soHd-organ transplantations." In 1954, 
Murray was surgeon for the team that per- 
formed the first successful human organ 
transplant. Four decades later, Murray, 
together with E. Donnall Thomas '46, 
received the Nobel Prize in Physiology or 
Medicine for pioneering work in the field 
of organ transplantation. 

Matched Set 

Across the country, another HMS alum- 
nus has broken new ground in the field. 
Samuel Strober '65 was senior researcher 
on a Stanford team that also reported 
findings on immune tolerance of organ 
transplants in the January 24 issue of the 
New England journal of Medicine. 

Unlike the MGH effort, the Stanford 
team focused on transplantations involv- 
ing matched donors and patients. The 
study rehed on a post-transplantation reg- 
imen of lymphoid irradiation and antithy- 
mocyte globulin, an antibody that fights 
tissue rejection by blocking the actions of 
T cells, to adjust each patient's immune 
system to accept the new tissue. After ten 
days of the regimen, patients were infused 
with blood stem cells from a compatible 
donor and a state of persistent chimerism 
was achieved. Of the six patients in the 
study, one has been off all immunosup- 
pressive drugs for more than two years. 

According to MGH's Sachs, the stud- 
ies' findings could offer patients hves free 
of the problems — and cost — of immuno- 
suppressive drugs. ■ 



diminished by age or disease could 
be just around the corner, according 
to results from a study by scientists at 
Massachusetts General Hospital and 
the Harvard Stem Cell Institute. A 
team of researchers wrote in the Feb- 
ruary issue of the Journal of Clinical 
Investigation that a drug used as a 
targeted chemotherapy in patients 
with multiple myeloma helped regen- 
erate bone tissue in mice by activat- 
ing stem cells critical to the formation 
of new bone tissue. 

The findings could represent a novel 
therapeutic strategy for bone diseases: 
targeting stem cells using drugs. If 
so, this news may one day help put 
the spring back in the step of post- 
menopausal women who suffer from 
osteoporosis or individuals who have 
lost bone mass because of cancer. 

The team of investigators led by 
Siddhartha Mukherjee '00, on HMS 
instructor in medicine at Massachu- 
setts General Hospital's Center for 
Regenerative Medicine and Technolo- 
gy, set up their study to examine the 

effects that the drug bortezamib 
might have on cells known as mes- 
enchymal stem cells (MSCs). Found 
in bone marrow, MSCs are multipo- 
tent; that is, they can develop into 
any of several types of cells. If trig- 
gered during their more impression- 
able period, they can become bone, 
fat, muscle, or cartilage cells that can 
then grow or repair tissue lost to dis- 
ease or trauma. 

The team selected bortezamib 
because clinical evidence from multi- 
ple myeloma patients taking the drug 
showed elevated serum levels of 
alkaline phosphatase and osteocal- 
cin, substances linked with bone for- 
mation. Hoping to isolate how the 
drug's actions might contribute to 
increased bone formation, the 
researchers tested possible targets for 
the drug. Surprisingly, they found it 
caused MSCs to form bone tissue. 

The in vivo mouse model the scien- 
tists used was one developed for 
menopausal osteoporosis. When 
they treated these mice with low 
doses of bortezamib, doses equiva- 
lent to between one-fifth and one- 
third what would normally be consid- 
ered effective against tumors, they 
found an increase in bone formation, 
in the mineralization of spongy tissue 
matrices that form the ends of long 
bones such as the femur, and in the 
production of osteoblasts, the cells 
that make up bones. Similar results 
were achieved when the researchers 
tested the drug in vitro on cultured 
MSCs derived from human bone 
marrow and from mouse models. 

The authors point out the drug's 
potential for people experiencing 
bone loss. In addition, they note the 
study offers proof of principle that a 
drug can harness the inherent power 
of the body's stem cells to repair 
and regenerate tissue — a strategy 
that might become increasingly key 
to regenerative medicine. ■ 




Not Even Death Is Certain 


one might expect. How to 
determine brain death, that is. 
Although the American Acad- 
emy of Neurology (AAN) has weighed in 
on the subject, a report in the January 22 
issue of Neurology found many of the 
nation's top-ranked neurology and neu- 
rosurgery centers differ considerably in 
how they apply the AAN's guidelines. 
And the researchers found some institu- 
tions had no guidelines at all. 

The members of the research team 
designed their study after they became 
curious about what they viewed as major 
discrepancies among such pohcies in cer- 
tain hospitals. So they set out to gather 
and compare protocols on brain death 
determination from 50 hospitals hsted 
high in U.S. News and World Report's 2006 
ranking of neurology and neurosurgery 
centers. The team was led by David Greer, 
an assistant professor of neurology at 
Massachusetts General Hospital, and 
included researchers at the Mayo Clinic 
in Rochester, Minnesota, and the Henry 
Ford Hospital in Detroit, Michigan. 

Their interest, and indeed that of med- 
icine in general, in the issue of brain 
death has its roots in questions raised in 
the late 1950s by two French physicians. 
Their published descriptions of 23 
patients in unending comas spawned the 
concept and gave rise to a definition: the 
irreversible loss of all brain function 
while systemic organs remain artificially 
supported. Equating brain death with 
standard concepts of death came in a 
1981 Presidential Commission on ethical 
problems in medicine. It stated that 
brain death was the legal equivalent of 
such long- accepted measures of death as 
cessation of heart and lung function. 

Currently, most states have enacted 
what is known as the Uniform Determi- 
nation of Death Act, which specifies that 
determinations of brain death be made 
according to accepted medical standards, 
be they national, regional, or local. In an 
effort to create a norm for such guidelines. 

in 1995 the AAN published practice 
parameters based on an evidence-based 
review of the Uterature and best practices. 

Dead Reckoning 

The researchers used five categories of 
the AAN practice parameters as points 
of comparison: guideline performance, 
preclinical testing, clinical examination, 
apnea testing, and ancillary tests. 
Among the 41 responding institutions, 
three had no policy at all. For the 
remaining 38 hospitals, the researchers 
found a surprisingly low percentage (42 
percent) required either a neurologist or 

a neurosurgeon be present during the 
determination. Of these, only 35 percent 
required an attending neurologist or 
neurosurgeon be present. 

Nearly three-quarters of responding 
hospitals required multiple examina- 
tions — 3 percent sought more than 
two — wtule allowable time between 
examinations varied from 1 to 24 hours, 
with 6 hours being the most common. 
More than 95 percent of the responders 
required preclinical tests but differed 
widely in what tests they recommended: 
estabhshing an underlying cause (63 per- 
cent); ensuring the absence of sedatives 
and paralytics (55 percent); verifying the 



absence of acid-base disorders (45 per- 
cent); or ensuring the absence of endocrine 
disorders (42 percent). 

Although apnea testing was missing 
from one group's guidelines for clinical 
examinations, guidelines that did include 
it stipulated a variety of techniques for 
such testing. Lowest acceptable tempera- 
ture, for instance, was specified in only 
26 percent of the guidelines; 66 percent 
required an arterial blood gas prior to test- 
ing; and 76 percent stated preoxygenation 
was mandatory, although the method for 
doing this was unclear in 69 percent. As for 
information related to ancillary testing, 66 
percent of the guidelines specified when it 
was necessary. And although specific tests 
were often mentioned, such as EEGs (84 
percent), the details of how the tests were 
to be administered were less common — 
only 33 percent mentioned EEG specifics. 

Grave Differences 

Although Greer and his team were 
encouraged by the rate of response from 
hospitals they contacted, they were dis- 
turbed by the variation they discovered. 
"We were surprised to find such signifi- 
cant differences among these hospitals in 
terms of their guidelines for brain death 
determination," says lead author Greer. 
"We anticipated more consistency with 
the AAN's practice parameters." 

In pointing to the ethical as weU as the 
medical-legal imphcations of such vari- 
abihty, the team underscored how wide- 
ranging guidelines can have unfortunate 
consequences, such as the administration 
of inappropriate treatment to patients 
who have been labeled brain dead. Noting 
that the AAN's practice parameters are 
more than a decade old, the researchers 
suggest a revision may be in order and 
that the results of their study could be 
used to inform such an effort. They also 
propose the development of web-based 
checklists or other new tools that could 
aid physicians who must make brain 
death determinations. ■ 

1 111^ 

1 1 111^ 

Research Digest 


A research consortium that includes Mass- 
achusetts General Hospital has found that 
the deletion or duplication of a section of 
chromosome 1 6 may be a strong risk fac- 
tor for autism. The researchers scanned 
DNA from more than 1 ,400 affected chil- 
dren and a similar number of unaffected 
parents and found an identical region of chromosome 1 6 was missing in five 
individuals with an autism disorder. Data from a separate group of 1 ,000 
patients from Children's Hospital Boston showed that among participants with 
a diagnosis of autism or a related developmental delay, five had the same 
deletion and four others had a duplication of the section. The work appeared 
in the February 14 issue of the New England Journal of Medicine. 


When oncologists talk of stems and seeds, chances are it's not a botanical 
discussion. Tumor stem cells, an immortal mutated cell type, are thought to be 
the seeds from which many, if not all, cancers develop. Impervious to all can- 
cer-busting therapies, such cells are also rare, making their study difficult. 
Their elusiveness may now be threatened. A U.S.-China research team, with 
senior investigator Judy Leiberman '81, an HMS professor of pediatrics at 
Children's Hospital Boston, has produced large numbers of human breast 
cancer cells in mice — and has discovered a genetic switch that decreases 
their ability to propagate tumors. The switch, a type of molecule known as a 
microRNA, turned off certain genes that helped the cells spread tumors. The 
study appeared in the December 1 4 issue of Cell. 


A class of drugs that is one of the more widely prescribed in developed 
countries may also be the source of its users' aches and pains. A team of 
researchers at Beth Israel Deaconess Medical Center has found that choles- 
terol-lowering statins act to increase levels of atrogin-1 , a protein involved in 
muscle atrophy. This breakdown of the muscle tissue could, says senior 
researcher Vikas Sukhatme '79, the Victor J. Aresty Professor of Medicine at 
HMS, explain the range of symptoms, from mild muscle weakness to pain, 
reported by people using statins. The study appeared in December's Journal 
of Clinical Investigation. 


Researchers have unmasked some unknown genetic players in the regulation 
of the blood's levels of cholesterol and triglycerides. In the February issue of 
Nature Genetics, an international team, which included scientists from the 
Broad Institute of Harvard and MIT, reported associating levels of these fats 
with 1 8 genetic variants, six of which had never before been linked with this 
activity. Lead author Sekar Kathiresan, an HMS instructor in medicine at 
Massachusetts General Hospital and a genetics researcher at the Broad, 
notes the findings may offer a way to predict a person's risk for heart disease 
as well as open the door to the development of new treatments. 


Did psychiatric illness help 
or hinder the creativity 
of some of history's most 
celebrated composers? 

hy Richard Kogan 

MAGIC WAND: Leonard 
Bernstein's exuberance was 
legendary, and audiences 
worldwide responded as 
much to his performances as 
to his orchestral and choral 
compositions. "Life without 
music is unthinkable, music 
without life is academic," 
he once ^rote. "That is 
why my contact with music 
is a total embrace." 






an unlikely muse: his psychiatrist. The Russian composer had 
suffered from a debilitating depression since the disastrous pre- 
miere of his Symphony No. J three years earlier, and the illness had 
robbed him of his ability to compose music. After his psychiatrist 
cured his creative block through hypnosis, Rachmaninoff 
produced his second piano concerto, which became arguably 
his most celebrated work. The arc of the composition reflects his 

emotional trajectory: the piece opens with mournful, 
elegiac chords and ends in triumph; Rachmaninoff 
marked the tempo of the piece's final section risoluto. 

The relationship between Rachmaninoff's illness 
and his music intrigues me, for I'm a psychiatrist by day 
and a concert pianist by night. Ten years ago, the Amer- 
ican Psychiatric Association asked me to give a presen- 
tation on the connection between creativity and mental 

illness. Until that time, my careers had progressed on 
parallel tracks. But that experience helped me appreci- 
ate the synergy between the two domains. My psychi- 
atric training enabled me to identify patterns of illness 
in the hfe stories of the great composers, and this under- 
standing gave me insight into the creative process. 

Posthumous diagnoses can be tricky, of course; it's dif- 
ficult enough to diagnose correctly the hving, breathing 




WOLFGANG AMADEUS MOZART composed symphonies so 
effortlessly that he seemed to be taking dictation from 
God. Lesser mortals would have suffered writer's cramp 
even copying that many notes. 

Mozart is indisputably the greatest child prodigy in the 
history of classical music. His talents first became e\'ident 
when he was three, and by the time he turned five he had 
already written short compositions for the clavier. Soon he 
had graduated to symphonies. He spent most of his child- 
hood on tour, dazzhng kings and queens at imperial courts 
throughout Europe with his precocious accomphshments. 

While there have been other musical titans, Mozart's 
genius set its own exquisite bar. Ludwig van Beethoven 
would fill wastebaskets with rough drafts before produc- 
ing a final masterpiece. Mozart, by contrast, was capable 
of mentally composing lengthy, complex string quartets 
while playing billiards. 

Mozart's unique talent has inspired much speculation 
over the centuries, and scholars have posited various 
neuropsychiatric conditions to explain his behavior. The 
unending stream of profanities that laced his speech and 
correspondence has led some researchers, for example, to 
suggest that he had Tourette's; coprolalia, an obsessive 
use of obscene language, is an occasional feature of the 
syndrome. But there is scant evidence that Mozart 



patients I see regularly in my office. But my exploration 
into composers' lives has taught me more about the very 
nature of music — and affirmed for me its healing powers. 

For all its healing properties, artistic production, 
unfortunately, often reflects a darker side. The notion 
that mental illness disproportionately affects practition- 
ers of art, literature, and music dates to ancient times. 
All great artists and philosophers, Aristotle believed, 
had to suffer from melancholy. Epidemiologic surveys 
have suggested, in fact, that the incidence of mental ill' 
ness is somewhat elevated among artists. 

It's important, though, not to romanticize the notion 
of mental illness as essential to creativity. Johann 
Sebastian Bach, Joseph Haydn, and Felix Mendelssohn 
are among the members of the classical music pantheon 
who seem to have escaped the burden of mental Ulness. 
And such maladies as depression are usually too para- 
lyzing to be considered an asset to creativity. 

Even so, an interplay often exists between illness 
and creativity. In Maurice Ravel's most famous work. 
Bolero, for example, the seemingly endless repetition of 

a single musical phrase dominates. In creating this 
work. Ravel was clearly perseverating, an early symp- 
tom of the dementia that would eventually overtake 
him. He may even have sensed the imprint of his illness 
on his work; he once trivialized Bolero as a "piece for 
orchestra without music." 

The link between mental illness and creativity 
requires a special sensitivity in treating mood disorders 
in artists. Psychotropic medications can lead to the 
blunting of emotional intensity. Some of the artists I treat 
have confided they would rather retain their creativity 
and suffer than sacrifice their expressive abilities. They 
raise a legitimate concern. Would Robert Schumann have 
been as productive a composer if he had taken mood 
stabihzers for his bipolar disorder? 

Music and medicine are both healing arts, and music 
has often provided salvation to great composers. It was 
Pyotr Tchaikovsky, tormented by suicidal impulses for 
much of his Me, who perhaps best summarized music's 
therapeutic properties. "Without music," he once 
declared, "I would go insane." ■ 

experienced the involuntary neuromuscular tics that 
would support such a diagnosis. 

Others have glimpsed hints of Asperger's syndrome 
in his intense focus on music and his struggles with inter- 
personal relationships. Mozart was often socially inept, 
but anyone making a diagnosis based on his interpersonal 
deficits must acknowledge that his operas contain 
extraordinary insights into human nature. 

Some scholars have speculated that Mozart suffered from 
a mood disorder, possibly cyclothymic or bipolar disorder. 
They have found evidence of mania in his amazing bursts of 
productivity; he composed his magnificent final three 
symphonies in six weeks. But he wrote more than 600 
compositions in his short Lifetime, and applying this stan- 
dard would suggest he had been in a manic phase from 
the age of five until his early death thirty years later. 

His mood shifts had Httle correlation with his creative 
output. He composed melanchohc pieces in spirited moods 
and joyful music while despondent. During the last year of 
his hfe, when he was suffering enormously from depres- 
sion, he produced The Magic Flute, which contains some of 
the most enchanting and rapturous music he ever vvrote. 

Regardless of whether Mozart would have satisfied 
any contemporary criteria for a psychiatric diagnosis, he 
clearly experiericed psychological conOict. His father had 

exerted tremendous control over him during his child- 
hood and seemed reluctant to relinquish that control 
when Mozart grew to adulthood. The two waged epic 
battles. His father urged him to write popular, more remu- 
nerative music, for example, while Mozart desperately 
wanted to establish his own artistic voice. Mozart was 
torn between the desire to please the father who had nur- 
tured his talent and the desire to assert his independence. 

The former prodigy, accustomed to receiving fawning 
attention from royalty, did have trouble growing up. As a 
youngster, he digested obscure textbooks on counter- 
point, wrote sophisticated operas, and had to forgo much 
of the unstructured play that most children are permit- 
ted. As an adult, he was often childish, impetuous, and 
tactless. He frittered away his family's money and missed 
deadlines on his commissions, behaviors that only wors- 
ened after his father's death. But Mozart did make the 
transition from wunderkind to mature master, and the 
compositions he wrote as an adult have far more subtlety, 
depth, and passion than anything he wrote as a child. 

The mystery of artistic genius is a fascinating one for 
those of us who seek to understand the human mind. 
The scorching speed at which Mozart lived — and com- 
posed — will continue to fuel speculation on his behav- 
ior and the source of his creative intensity ■ 


SCHUMANN WOULD he besieg e d hy delu sional thoughrs 

He would have auditory hallucination s as well, cacop Vionmis 

sounds he could not dislodge from his hrain 




THE TALE IS OFTEN TOLD that Ludwig van Beethoven, 
upon becoming completely deaf, sawed the legs off 
his piano so he could feel its vibrations through the 
floorboards as he composed. We can easily imagine 
him sitting at that keyboard: unruly hair, wild eyes, 
fingers pounding the keys so forcefully that the 
strings broke. 

Beethoven has long evoked the image of a tortured, 
mad genius. He had an intense, tempestuous personal- 
ity, and he could slip from rage to raucous laughter to 
serenity within minutes. His hearing loss, which 
began while he was in his late twenties, became the 
central torment of his life. Deafness can be a hardship 
for anyone; for a musician, it's a catastrophe. 

When Beethoven lost his hearing, he contemplated 
suicide. But then he decided to seek salvation in the 
music he could no longer hear. With his career as a 
virtuoso pianist now ended, he dedicated himself 
anew to composing. 

Once Beethoven locked himself into the silent 
world of his imagination, his musical genius blos- 
somed. Unable to hear the music of his contempo- 
raries, he conjured a world of sound different from 
anything previously conceived. Much of his music 
reflected struggle and the attempt to achieve transcen- 
dence over that struggle. And his music, with its sudden 
shifts and enormous unpredictabihty, mirrored his 
emotional volatihty. Beethoven was capable of translat- 
ing melancholy and ecstasy into musical terms with 
unmatched virtuosity. 

One result of this inner unleashing was the Ninth 
Symphony, one of his most celebrated works. Poignantly, 
during the Vienna premiere of the work, Beethoven, 
in his first onstage performance in a dozen years, hov- 
ered alongside the conductor, offering tempos to an 
orchestra that for him was sUent. Following the sym- 
phony's conclusion, the contralto gently turned 
Beethoven around so he could witness the audience's 
thunderous applause. 

In 1812, the collapse of a romance with a woman 
known as the Immortal Beloved convinced Beethoven 
he would never experience marriage or a convention- 
al family hfe. The emotional fallout led to an extended 
period in which his productivity dropped precipi- 
tously. After his brother's death, he directed his energy 
toward the aggressive pursuit of sole custody of his 
nine-year-old nephew. He became overtly psychotic 
during this custody battle, accusing the boy's mother 
of poisoning her husband and insisting against all 
evidence that he was the actual biological father of 
the child. 

After bitter and protracted legal wrangling, 
Beethoven was eventually awarded guardianship of the 
child. The creative floodgates opened after his \'ictory, 
and the glorious final phase of his career commenced. 
The rages he had expressed as a younger man softened, 
and his music became more spiritual and ethereal than 
anything he had previously composed. 

Centuries later, the composer still provides one of 
the greatest examples of the sublimation of suffering 
into the creation of masterpieces. His moods, he 
once wrote, "... sound, and roar and storm about me 
until I have set them down in notes." Fittingly, 
Beethoven died amid the thunderclaps of a savage 
spring storm. ■ 






THE YEAR HE MARRIED Clara Wieck, Robert Schumann 
wrote nearly 150 love songs. His staggering productiv- 
ity was a sign of his infatuation with the brilliant 
young pianist, but it also signaled his entry into the 
manic phase of his bipolar disorder. 

No composer illustrates the link between mental 
illness and creativity better than Schumarm. Analyses 
of historical figures are speculative by nature, but his 
carefully kept diaries provide detailed information 
about his mental state for nearly every day of his 
adult life. 

In those diaries, Schumann wrote that he believed 
that the sole purpose for composing music was to 
express the composer's state of mind. While his con- 
temporaries were writing music following estabUshed 
forms like the sonata, Schumann was revealing ghmpses 
into his psychological world through pieces with such 
titles as Rapture and Feverish Dreams. And that world 
was filled with racing thoughts and flights of ideas. 

Schumann composed prolifically during his manic 
periods. In one two-week burst of inspiration, he com- 
pleted three string quartets, barely pausing for sleep. 
Such creative frenzies were inevitably followed by 
months of torpor, both literal and musical. During his 
depressive periods, Schumann was unable to concen- 
trate. He would be besieged by delusional thoughts, 
convinced he was worthless as a composer. He would 
have auditory hallucinations as well, cacophonous 
sounds he could not dislodge from his brain. 

Although Schumann felt hounded by these intrusive 
sounds, illness brought him undeniable creative advan- 
tages. The hypomanic state of his bipolar disorder 
brought him increased energy, a decreased need for 
sleep, and a sharpened imagination. His racing thoughts 
were frequently accompanied by a heightened mental 
flexibihty, resulting in innovative ideas and imaginative 
solutions to creative problems. 

As Schumann grew older and more psychologically 
disorganized, he turned to music as a source of heal- 
ing. Despite his mistrust of musical form, he began 
engaging in the writing of fugues and counterpoint, 
compositional techniques that rely on intricate sets of 
rules. He discovered that when his tfiinking was espe- 
cially chaotic, composing under the constraints of 
meticulous guidelines helped organize his thoughts 
and sometimes lifted his spirits. 

Yet even music ultimately failed to cahn his fevered 
thinking. At age 43, Schumarm jumped off a bridge into 
the Rhine River, but nearby fishermen thwarted his 
suicide attempt. He was taken to a mental asylum, 
where he spent the final two and a half years of his life. 

His deterioration in the hospital was dramatic. It has 
been suggested that neurosyphihs may have exacerbat- 
ed his psychiatric disorder, and he was subjected to a 
range of ineffective treatments, such as phlebotomy. 
A piano was available in the hospital, yet he never used 
it; one of the most poignant features of his terminal ill- 
ness was his loss of interest in music. 

One can only imagine how many more masterpieces 
he could have offered the world. Schumann once lament- 
ed that he had a hundred symphonies racing through his 
mind simultaneously. "Sometimes," he vwote, "I am so 
full of music, and so overflowing with melody, that I find 
it simply impossible to write down anything." ■ 



THE TREMENDOUS E NERGY Gershwin had p mired into 
delinq uent hehavior became redirecred . ''Smdyin^ 


piano," he said, ''made a good ho y out nf a had one" 



1 840-1 893 

WHEN CONDUCTING an orchestra, Pyotr Tchaikovsky 
would use his right hand to flourish his baton — and 
his left hand to keep his head fastened to his neck. He 
was convinced, he said, that when he mounted the 
podium his head would detach and fly off. This delu- 
sion reflects the psychological torment that plagued 
the Russian composer during his troubled life. 

Tchaikovsky was chronically depressed, and he filled 
his diaries with suicidal musings. "I have a boundless feel- 
ing of loneliness, despair," he once wrote. "I'm experienc- 
ing an insane sorrow Death is really the only blessing." 

The composer tried to numb his emotions with alcohol. 
"A man tormented by feelings such as mine simply cannot 
live without alcohol poison," he confessed to his diary 'Tm 
drunk every evening, and I cannot Hve otherwise." 

But the only truly effective therapy for his despon- 
dency, he found, was composing music. And it was dur- 
ing his most intense personal crises that he wrote some 
of his greatest music. This pattern of crisis and compo- 
sition was set early: His mother died of cholera when he 
was just fourteen, and he wrote his first musical compo- 
sition within several weeks of her death. 

Through his music Tchaikovsky sought to escape his 
anxiety and despondency by concocting fantasy worlds. 
His classical ballet masterpieces — Swan Lake, Sleeping 
Beauty, The Nutcracker — featured whimsical places of 
beauty and grace in which he could find solace. 

Yet his escapes were fleeting. Fear of being exposed as 
a homosexual dominated Tchaikovsky's life. This wasn't 
an irrational phobia; in czarist Russia, homosexual acts 
were punishable by loss of civil rights and banishment to 

Siberia. He spent his entire adulthood obsessed with 
hiding what he termed his moral ailment, going so far 
as to marry a woman to try to escape social scrutiny. 
The disastrous union ended after just six weeks. 

When Tchaikovsky died at the peak of his powers at 
the age of 53, the official verdict was that he had suc- 
cumbed to cholera after drinking tainted water. There 
is credible evidence, however, that he had become 
involved with a teenaged boy and had committed suicide 
to avoid the public humiliation of a sexual scandal. 

Tchaikovsky's final symphony, Pathttique, which pre- 
miered just days before he died, contains one of the 
most haunting evocations of death in all of music. As 
tragic as his torment was, it hkely enhanced his music. 
We can hear in his compositions intense suffering, 
melodic inspiration, and the transformation of great 
anguish into great art. ■ 





AS A BOY growing up on the Lower East Side of New 
York City, George Gershwin misbehaved. He set fires. 
He stole from pushcarts. He started fistfights. He played 
hooky. When he managed to attend class, he could 
barely sit still. Had he been a child today, he might 
have been sent to a psychiatrist, diagnosed with conduct 
disorder or attention deficit hyperactivity disorder, and 
sent home with a prescription for Ritalin. 

But Gershwin discovered his own medication at the 
age of ten, when he overheard a classmate's violin 
recital through an open window. From the moment 
the boy played the first notes of Antonin Dvorak's 
Humoresque, Gershwin was so entranced he decided 






"I'M THE ONLY PERSON I know," Leonard Bernstein once 
declared, "who is paid to have a fit in pubhc." And his per- 
formances as conductor validated his statement: He 
would flail his arms, wag his brow, and shake his great 
mop of hair. Audiences loved him. And he loved audiences. 
Bernstein's versatihty was breathtaking. He excelled 
as a composer, pianist, and music educator. He rel- 
ished the collaborative nature of musical theater, with 
the score for West Side Story his best-known contribu- 
tion to Broadway. He was most in his element, though, 
when conducting a hundred musicians before an 

to dedicate his life to music. The tremendous energy he 
had poured into delinquent behavior became redirect- 
ed. "Studying piano," he said, "made a good boy out 
of a bad one." 

Gershwin's hyperactivity became a hallmark of his 
musical persona; it is hard to imagine that those inces- 
sant, rapid-fire notes in Rhapsody in Blue could have 
been composed by anyone who wasn't hyperactive. And 
as a pianist, his style was fast and clipped. When asked 
why he played even slow songs that way, he responded, 
"We are living in an age of staccato, not legato." 

Sadly, in his mid-thirties, at the peak of his career, 
Gershwin lost a great deal of his vitality when he fell 
into a depression. Neurological symptoms, such as the 
perception of a phantom smell of burnt rubber, soon 
joined psychiatric ones. What he didn't know — and 
what his doctors wouldn't discover until the day before 
his death on an operating table — was that his brain 
hod been in the grip of a fatal tumor. 

Part of what I find compelling about Gershwin's 
decline is that his depressive symptoms coincided with 
his creation of Porgy and Bess, an opera that explores 
somber and painful themes. Gershwin, until then large- 
ly known for a repertoire of buoyant love songs, sud- 
denly produced songs of lament and even anguish. As 
his illness began to temper his staccato nature, he pro- 
duced a work of extraordinary depth and profundity. ■ 

audience of thousands of people. He was probably the 
most sought-after conductor in the world during 
his lifetime. 

Yet his gifts were shadowed by an internal struggle. 
Bernstein longed to write symphonic masterpieces, 
and he believed he had the talent to do so. But he had a 
hyperthymic temperament: energetic, exuberant, and 
indefatigably sociable. He was therefore far better suit- 
ed to performing than to the largely solitary task of 
composing. Whenever he sat down to write a classical 
piece, he felt overwhelmed by the loneliness of 
the process. While he did 
produce some wonderful 
symphonic works, he died 
believing he had fallen 
short of all that he wished 
to achieve. 

Some people have sug- 
gested that hyperthymic 
individuals — with their 
high energy and elevated 
baseline mood — are the 
fortunate few who are 
hard-wired for happiness. 
But some hyperthymics 
can experience a precipi- 
tous drop in mood when 
they feel stymied. In the 
last decade of his life, Bern- 
stein suffered episodes of 
severe depression, with 
each feeding an endless 
cycle of hobbled creativity 
and renewed despondency. 

During those later years, 
Bernstein found it demor- 
alizing to be celebrated 

more as a conductor than as a classical composer, for he 
believed only classical composers could achieve 
immortality. Ironically, nearly two decades after Bern- 
stein's death, professional performances of his popular 
compositions occur almost daily around the world. 
Each month, dozens of theaters worldwide stage West 
Side Story, which premiered more than five decades ago. 
And the audiences Bernstein found so necessary still 
love his work. ■ 

Richard Kogan '81, a Juilliard- trained concert pianist and a 
Harvard-trained psychiatrist, also co-directs the Human Sexuality 
Program at Weill Cornell Medical Center For more information 
about the performance-lectures he gives on the internal strug- 
gles of composers, visit 














: i-*^: 








ffSKAdBL -^Ij^^^^NWjH 




Rampant violence in his barrio leads a boy to risk his 
life to immigrate to the United States — and inspires 
him to become a healer, by Harold Fernandez 

this side of 

south, enter through the main marina gate, and proceed to 
the dock, where a boat would be waiting for us. The instruc- 
tions were simple enough. But that walk was the scariest of 
my life. • No stars illuminated the sky over the tropical island 
of Bimini as we stumbled along in the dark; our only light 
came from two small lamps at the marina entrance. There we 
were startled to see a tall man in a cowboy hat pointing to the 
dock. I felt a surge of panic. He wasrit part of the plan. Had 
something gone wrong? 



I could feel myself trembling as we continued to the 
end of the dock, where another man helped us onto a 
boat and guided us to its pitch-dark cabin. We couldn't 
make out the faces of the people already huddled there, 
and no one spoke. The only sounds we could hear were 
the murmurs of the two men on deck, the lapping of 
water, and our own labored breathing. Soon the boat's 
engine came to life, and we began to move. 

It was midnight on October 26, 1978, when my broth- 
er and I were smuggled, along with ten other illegal 
immigrants, onto a small pleasure boat to cross the 
treacherous waters of the Bermuda Triangle. Byron 
was eleven; I was thirteen. 

Tempting Fate 

Danger was not new to me; it had long been woven 
into the daily fabric of life in my hometown. I grew up 
in Barrio Antioquia, a poor neighborhood of Medellin, 
Colombia, with a long and rocky history. In the early 
1950s, the mayor had designated Barrio Antioquia the 
city's "zone of tolerance," to allow legalized prostitu- 
tion. Within days, hundreds of houses were converted 

into brothels, with red lights casting an odd glow over 
their entrances. 

Although the designation lasted only a few years, it 
tore at the social and moral fabric of the barrio and left 
it vulnerable to exploitation. Decades later, when the 
city became home to the Medellin Cartel, one of the 
world's most powerful drug-trafficking organizations. 
Barrio Antioquia served as a key suppHer of young tal- 
ent; the leaders; the sicarios, or hired assassins; and the 
mulas, or drug couriers. To retain their power and 
gain prestige, many cartel members formed gangs; Barrio 
Antioquia alone had eight. 

Under the leadership of the notorious Pablo Escobar, 
known as El Patron, or The Boss, the cartel grew to be 
almost as powerful as the official government of the 
country. Escobar was popular with the poor because 
he made considerable donations to charitable organi- 
zations, established welfare programs, and built hous- 
ing complexes, soccer stadiums, and churches. At the 
same time, the city remained hostage to his reign 
of brutality. 

Medellin and its people suffered deep wounds from 
the cartel's horrific acts of violence. During the worst 




people witnessed the fight, but no 
one ventured close to help the dying teen. An hour elapsed 
before an ambulance arrived to pick up his body. 

years, the city had a homicide rate more than five times 
those of the most violent cities in the United States. 

Despite this, the cartel held an allure for young peo- 
ple living in the despair of a poverty so deep that even 
toilet paper was considered a luxury. In contrast, the 
cocaine industry promised enormous wealth and 
power almost overnight. I remember spending hours 
with my friends gazing covetously at the flashy cars 
and motorcycles the drug traffickers parked outside 
neighborhood bars. The temptation proved too great 
for some of my friends; without exception, those who 
joined the drug trade ended up either imprisoned or 
gunned down. 


aying i 

n Traffi 


As a boy, I spent most of my free time playing soccer in 
the streets of Barrio Antioquia. Many of my friends 
played in bare feet because they couldn't afford shoes; 
on weekdays they eagerly waited for me to finish my 
homework, as I was the only one who owned a ball. 

Although this material poverty was difficult, it was 
the spiritual poverty — the loss of childhood inno- 
cence — imposed by the drug trade that was far harder to 
bear. It even invaded our childhood sports. One hot sum- 
mer day I was sitting by the side of my house, watching 
a soccer game, when an older player, Alvaro, started 
arguing with Marlon, a player from the opposing team. 
They began pushing each other, and Alvaro knocked 
Marlon to the ground. Marlon jumped up, rammed 
Alvaro with his head, and ran off. The game continued. 

A half hour later, I suddenly heard a gunshot. I could 
see Alvaro, just ten feet from where I sat, clutching his 
side, trying to stanch the blood now soaking his shirt. 
Then I noticed Marlon sauntering off, a gun dangling 
from his hand. He neither ran nor made any attempt to 
hide his weapon. 

Alvaro was bundled into a car and rushed to the 
emergency room. He was fortunate; the bullet had 
missed his major organs, and he was released from the 
hospital a week later. No one pressed charges because no 
one had the courage to testify against Marlon. He was 
not only a member of a powerful gang, but also a sxcar'w 
for the cartel. Just fifteen years old, he had already killed 
several people in the barrio. 

A few months later, from behind the curtains of a win- 
dow, I witnessed Marlon's death. He had been staggering 
down the street, drunk and high on drugs, when he ran 
into a member of a rival gang. The argument that ensued 
quickly escalated into a scuffle. Marlon didn't have a gun 
this time; instead, he puUed out a machete. His opponent 
had no weapon, but he was older, taller, and neither 
drunk nor high. He picked up a rock and pounded 
Marlon's head until he knocked him to the ground. 
There he savagely punched and kicked him. Within 
minutes, Marlon lay motionless in a pool of blood. 

Several people witnessed the fight, but no one ven- 
tured close to help the dying teen. An hour elapsed 
before an ambulance arrived to pick up his body. 
Again, no one was charged, and the crime was never 
officially solved. 

Islands in the Stream 

For every Colombian who became involved in drug traf- 
ficking in those years, thousands more fled to fields and 
factories in the United States, seeking peace, security, 
freedom, and economic opportunity. My parents, who 
were already living in New Jersey as undocumented 
workers, were growing increasingly desperate to 
remove my brother and me from the barrio. They made 
arrangements, and we received elaborate instructions. 

Our adventure started with what was supposed to 
look hke a routine departure from the Medellin airport. 
We needed to keep a low profile; only a few people could 
accompany us to the airport, and we had to behave as 
though we were leaving for just a vacation, not a lifetime. 
Yet my entire extended family showed up, along with 
many friends. My grandmothers and aunts were sob- 
bing, and I was terrified about what the officials watch- 
ing us might be thinking. 

As Byron and I crossed the tarmac toward our plane, 
I glimpsed the terrace where I had stood to wave good- 
bye to my father four years earher and to my mother two 
years after that. Now I was on the other side, waving to 
a crowd of well-wishers. At best I would not see my 
beloved grandmothers for a long time; at worst I would 
never see them again. 

The group we were traveling with stopped in Panama 
briefly before boarding a plane to the Bahamas. During 


^/w aw^Mt-eoAe 

scenano was 

no lorn 


the layover, customs officials detained one member of our 
group; we never saw him again. 

According to the plan, we would stay in Bimini for less 
than a day. After arriving at our hotel, more than a dozen 
of us met to finalize our plans. Our boat trip would take 
place at night to reduce our odds of being caught by 
the U.S. Coast Guard. We were now only 50 miles from 
Florida, and the voyage would last five to six hours. I was 
excited; one day more, and I would see my parents. 

The leader of the group collected our fees — about $600 
apiece — and instructed us to wait while he met with our 
local contact. When the leader returned, though, he 
brought bad news. The sea was too rough. Even more 
worrisome was that our contact didn't know when we 
could leave. Hurricane season was in full force. Our 
departure would depend on the weather. 

For the next twelve nights, after our hghts — and that 
day's hopes — ^were extinguished, we would hear tapping 
on our door and unfamiliar voices offering us boat rides to 
Florida. We had been instructed to answer that we were 
merely on vacation and had no interest in crossing to the 
United States. As the days passed, and the members of our 
group grew more anxious, several accepted those offers. 
We never learned whether they made it safely to Florida. 

Those of us remaining had been warned that Bimini 
was swarming with undercover immigration officers 
looking for people who were trying to cross to the Unit- 
ed States. To avoid drawing attention to ourselves, we 
pretended to be tourists. But by the end of the first week, 
our tourist visas had expired. We holed up indoors; if 
caught, we could be deported. 

Finally the weather broke. That night we would risk 
death for a chance to live in the United States. 

The Young Man and the Sea 

As we huddled in the dark cabin of the boat, the reahty of 
our situation hit me hard. I dreaded crossing the Bermu- 
da Triangle, infamous for the mysterious disappearances 
of so many planes and ships. Byron and I couldn't swim 
and had no life vests. The worst-case scenario was no 
longer getting caught by the U.S. Coast Guard and being 
sent back to Colombia; it was dying at sea. 

The movement of the boat soon became unbearable. 
We felt the constant cycle of a steep chmb, a sudden 
descent, and a bang so loud it made us shriek in terror. At 
the end of each cycle it felt as though the boat would spht 
in half. We all began praying aloud. 

We also began throvvdng up. After a while, we didn't 
even try to maintain decorum. We vomited everywhere. 

Most of us sat with our heads down, praying, retching, and 
chnging to someone or something to avoid being thrown 
across the floor. On deck, the captain was fighting to main- 
tain control of the vessel, while the sole crew member used 
a bucket to try to bail out the water sloshing into the boat. 

Hours passed. Finally, on the other side of the cabin's 
small door, darkness began to give way to hght. With the 
dawn, the waves grew milder. The rocking motion of the 
boat eased and the thump of the boat against the waves 
softened. We aU began to feel safer. 

After hours of throwing up we were so dehydrated 
we could barely rise from a sitting position. Yet as we 
approached the Florida coast, the boat slowed, and I 
managed to stand up and peer through a cabin window. 
In the distance I could see other boats and a shoreline 
with buildings. I realized we were in U.S. waters. 

For an hour the captain searched for a safe place to 
dock. Meanwhile, those of us in the cabin cleaned our- 
selves up as best we could and chmbed up on deck. It was 
a beautiful, sunny day. The boat stopped at what 
appeared to be an abandoned dock. As we stepped off the 
boat, the captain handed us cards showing our location. 
It felt wonderful to stand on land again. 

My brother and I found a pubhc telephone several 
hundred yards away and called my parents' friends to let 
them know we had arrived. They put us up for the night, 
and the next day they drove us to the Miami airport, 
where we boarded a flight to Newark. 

The Dreaming Spires 

Our first summer in New Jersey proved pivotal. Byron 
and I had behaved during the school year, enduring the 
taunts of classmates, who often called us refugees, and 
struggling to learn Enghsh, a language we had barely even 
heard before. But now with the summer months we 
savored our freedom. From the streets of MedeUin we had 
brought not only advanced soccer skills but some bad 
habits as well. We smoked; we drank; we threw empty 
bottles at storefronts. 

My parents despaired that they had waited too long to 
briag us to the United States. Yet they also understood 
that this was a critical time in our development. So when- 
ever we visited my father at work, he would take time to 
show us his working conditions. He spent twelve to four- 
teen hours a day in a dank, dark building with no air con- 
ditioning and the deafening sound of embroidery 
machines. He cautioned us that if we didn't take advan- 
tage of the opportunities this country offered, we would 
end up working under similarly bleak conditions. 



getting caught by the U.S. Coast Guard; it was dying at sea. 

from far left: the author 
as a student in Medellin; 
as a baby ^th his par- 
ents in Cali, Colombia; 
and as a five-year-old 
standing with his brother 
Byron. Upon reuniting 
with their parents after 
a harrowing sea crossing 
to the United States in 
1978, Harold and Byron 
met a U.S.-born brother, 
Marlon, then sixteen 
months old, for the first 
time. A fourth son, Alex, 
was born in New Jersey 
three years later. 

These conversations with my father proved effective. In 
the eighth grade I buckled down and became a model stu- 
dent. My success through high school grew so much that 
I soon had my sights on Princeton, a university I had come 
to admire while competing in track meets on its campus. 

But as the time to apply to college drew near, I needed 
a green card and a Social Security number. I wasn't eligi- 
ble for legal residency, so I bought a green card on the 
black market. With that document, I could apply for a 
Social Security card. But when I went to a local office of 
the U.S. Immigration and Naturalization Service, the 
clerk, after taking my documents, excused herself to 
make a phone call. I panicked. I grabbed my papers, fled 
the building, and ended up purchasing a fake Social Secu- 
rity card instead. 

My family had long Hved in a shadow society, ever fear- 
ful of discovery, ever conscious of dodging immigration 
authorities. After I enrolled at Princeton, I felt like an 
imposter as I gazed at the imposing gothic architecture 

that F. Scott Fitzgerald had so eloquently described in his 
debut novel. This Side of Paradise: "... topping all," he wrote, 
"climbing with clear blue aspiration [were] the great 
dreaming spires of Holder and Cleveland towers." 

Like Fitzgerald's protagonist, I loved Princeton from 
the beginning. But as I walked through campus I doubt- 
ed my right to be there. For starters, I was an illegal alien; 
I had used a phony green card and Social Security number 
in my apphcation. I also harbored serious doubts about 
my scholastic achievements, and I suspected my SAT 
scores were the lowest of anyone in my class. My accent 
mortified me. Whenever I spoke, I thought the other stu- 
dents must be wondering how anyone with such a heavy 
accent could possibly have been accepted. 

One evening, at the beginning of my second semester 
at Princeton, I received a letter from the dean of my col- 
lege. She wrote that my first-semester grades had placed 
me at the top of my class. She congratulated me and 
encouraged me to keep up the good work. With that 



^9^ tAe (pk}/enee that ensued, 

hundreds of people across the city — including police 
officers, judges, and politicians — were murdered. 

letter, I began to relax. Perhaps I had earned the right to 
be part of this historic institution after all. 

The Legal Limit- 
Just weeks later, that sense of belonging vanished when I 
found a second letter waiting in my student box, this 
time from the dean for foreign students. As I opened it, I 
assumed it would be an invitation to a social event. But 
instead I discovered an official missive asking me to bring 
in my original legal residency documents so they could be 
photocopied and included in my file. 

Suddenly I felt sick. Years before, during my ocean 
crossing, the fear of discovery had compounded my feel- 
ing of seasickness. Now the fear of discovery rose again, 
along with my nausea. I realized how vulnerable I was; 
the wonderful dream that had begun at an abandoned 
boat dock on the Florida coast was about to end. 

After agonizing for several days, I realized I had two 
choices. I could present the dean for foreign students 
with my forged documents. But I decided this wouldn't 
work; I didn't have the stomach to continue my charade. 
My second option was to meet with her and admit I didn't 
have any legal documents. First, though, I decided to 
share my problem with someone I trusted. 

So one afternoon, after class, I asked my Spanish ffter- 
ature professor, Arcadio Diaz-Quinones, for a few min- 
utes of his time. He replied that I could have as much time 
as I wanted. He closed the door and sat down with me at 
a table. I tried to speak, but instead, under his sympa- 
thetic gaze, I burst into tears. He put his hand on my 
shoulder as I wept with my head on the table. After sev- 
eral minutes, I Mted my head and managed to talk. I 
detailed for Diaz all I had done to enter this country and 
conceal my residency status. I told him about my fear of 
being expelled or even deported. 

Diaz listened patiently to my story. When I finished, 
he advised me not to tell anyone else. Over the next few 
weeks, he met with several administrators. At first, he 
discussed the problem with them in theoretical terms, 
without mentioning my name. He then set up a meeting 
with university officials. They decided that I should 
meet with the dean of my college, the same woman who 
had sent me the encouraging letter at the start of my 
second semester. 

Nancy Weiss was just as friendly in person as she had 
seemed in her letter. She told me that Princeton was proud 
to have me in its student body. But the university had two 
problems with my case. First, I had broken its honor code. 
Second, I had been receiving U.S. government grants. 
Since I wasn't a legal resident, this was against the rules. 

But then Weiss went on to tell me that both problems 
had solutions. For the first one, I needed to write a 
detailed essay explaining my understanding of the honor 
code, how I had broken it, and why I was seeking a par- 
don from the university. To resolve the second problem, 
the university would change my status from that of a 
local student to that of a foreign student. With this 
change, Princeton could provide all my grants and schol- 
arships with university funds. 

I left the office feeling great rehef ; I could square with 
Princeton. But this was far from the end of my troubles. 
Now that my undocumented status — and that of some 
family members — had been revealed, we had to move 
quickly. While the university was willing to let me stay, 
immigration authorities could opt to send my family 
members and me back to Colombia. 

Princeton arranged for us to meet with one of New 
York's top immigration lawyers, who confirmed what we 
already knew: My family didn't qualify for any of the cat- 
egories under which people already in the country could 
be granted legal residency. We needed a miracle. 

As it turned out, our first meeting with an immigra- 
tion judge was a success. We weren't granted legal resi- 
dency, but we weren't deported, either. Instead, we were 
entered into a category known as suspension of deporta- 
tion proceedings, meaning that although we didn't qual- 
ify for any of the immigration proxisions, the judge was 
sympathetic. He realized that my family was humble, 
honest, and hard working. 

Our case seemed as if it would drag on forever, and 
over the next several months I spent many hours reading 
my organic chemistry textbook while standing in line at 
the regional immigration office in Newark. But in August 
1986 the judge announced that he was ready to decide our 
fate. We dressed in our best clothes and filed into the 
back of the courtroom, waiting for our case to be called. 
When the judge dehvered his verdict, my parents, who 
understood only Spanish, didn't immediately grasp his 
meaning: He had granted us legal residency. 



You Can't Go Home Again 

As a boy living with my grandmothers in Colombia, I 
often witnessed our doctor making house calls. The doc- 
tor would come to our house, examine my grandmothers, 
and provide healing advice over a cup of coffee. I also 
noticed that physicians, who could support their famihes 
without resorting to unlawful activities, were revered in 
the barrio. I wasrit the only one paying attention; from 
the time I was young, my grandmothers had decided I 
should be a physician. They even scrimped to buy me a 
toy doctor's kit. 

By the time I applied to medical school, I had confi- 
dence in my ability to achieve my professional dream. I 
was a legal resident and had done well at Princeton. 
When I received a letter of acceptance to the Harvard- 
Massachusetts Institute of Technology program in 
Health Sciences and Technology, I happily accepted. 

It was during my time at Harvard Medical School 
that I returned to Medellin for a research project. In the 
summer of 1992, with an education grant from Brigham 
and Women's Hospital, I undertook an evaluation of 
the city's emergency medical care system. My goal was 
to observe how critically injured patients were treated 
in the trauma center of the city's main public hospital, 
San Vicente de Paul. I analyzed ambulance response 
times, transportation modes to the hospital, and the 
care provided. 

One of my findings was that trauma victims 
tended not to be transported by ambulance. The 
injured, especially the victims of gunshot and 
knife wounds, were usually taken to the hospital 
by friends or family members in private cars. This 
finding didn't surprise me; I had only to recall 
what happened when Alvaro had been shot on 
that summer's day so long ago. 

During the six weeks of my study, I stayed at 
an aunt's house in Barrio Antioquia. This was the 
time when violence in Medellin — and my old 
barrio in particular — had reached its peak. Pablo 
Escobar had recently turned himself in to the 
Colombian government to avoid being extradited 
to the United States. In exchange, he was allowed 
to build his own luxurious jail. La Catedral, on 
a mountaintop overlooking Medellin. His con- 
finement was widely regarded as a joke — and 
an embarrassment to the government. He was 
rumored to be overseeing the cartel from his 
prison and to be coming and going as he pleased. 
But Escobar's hold on the city was no joke. 
One evening, I was sitting on the balcony of my 
aunt's house when the calm was shattered by the 
sound of gunshots. As I peered over the edge of 
the balcony, I witnessed the cold-blooded killing 
of a young man just a hundred yards away. The 
killer coolly walked away with the gun in his 
hand. The victim's family rushed him to San Vicente de 
Paul, where he was declared dead on arrival. Before my 
eyes he had become one of the more than 150 homicide 
victims in my old barrio that year. 

A week before my return to Boston, Escobar escaped 
from custody, and his organization started a ruthless 
campaign of terror against the government and the 
innocent people of Medellin. In the violence that ensued, 
hundreds of people across the city — including police 
officers, judges, and politicians — ^were murdered. 

On my return fhght, I thought about how dramatical- 
ly my life had changed since that night in the dark cabin 
of a sea-tossed boat. If I had stayed, I wondered, would I 
have become one of the doctors working in the emer- 
gency department at San Vicente de Paul, or would I have 
been recruited into a short life of drug trafficking and 
violence? Would I have fallen victim to an unsolved mur- 
der, just as seven members of my extended family had? 

Now, in my work as a surgeon, I often remember the 
senseless slaughter of aU those young men and women. 
The helplessness and fear I felt when witnessing violence 
have since given way to the confidence and knowledge 
that my education and experiences as a healer have 
instilled. My grandmothers were right; I have found 
much satisfaction in a life that helps relieve suffering. ■ 

Harold Fcrncmdcz '93 is a cardiothoracic surgeon at St. Francis 
Hospital in Roslyn, New York. 



ta Medicine needs to steer a course that 

batancis inspiration and science to achieve 

a health care system that works for al .. 

NINE YEARS AGO the television program IsHgktlinc 
spent a week at Harvard Medical School filming our 
approach to patient care. The reporter took ample time 
with our students and faculty, and the program devel- 
oped a wonderful picture of our high standards of care 
and our emphasis on the doctor-patient relationship. 

At the end of that week, the reporter and I were wafk- 
ing together when he suddenly asked, "What happens 
if you train your students the way you've shown me 

hy Daniel D. Federman 


|, -«,». ssy^JS^ 


s many as 50 million are uninsured, half that number mm 
class are just a serious illness away from bankruptcy 

and they then enter a world that worit let them practice 
as they were taught?" Without a moment's hesitation, I 
answered, "Then they ought to change the world." 

A medical student's life should be intellectually daz- 
zling, emotionally rewarding, and morally transcendent. 
It should be intellectually dazzling because the progress 
in biomedical science — from genomics to imaging to 
molecular diagnosis to therapy — gives the process of 
becoming a doctor incandescence. It should be emotion- 
ally gratifying because the opportunities for helping 
individual patients and populations of patients achieve 
better lives have never more closely aligned with enter- 
ing students' aspirations. And it should be morally tran- 
scendent because from the first day of medical school 
one should feel enhsted in the never-ending challenge of 
achieving better health for aU. 

Yet several imbalances persist in medical education 
today, while our health care system as a whole is sailing 
off course. Among these educational imbalances is the 
one between inspiration and science. At first glance this 
notion may seem both plulistine and counterintuitive. I 
don't mean medical schools have too much science; their 
faculty members in basic science represent a major frac- 
tion of the country's biomedical scientists. These teachers 
dehght in sharing their research passions with medical 
students. And since the introduction of evidence-based 
thinking in clinical departments, that domain of medical 
education has become rich in science. 

My point, rather, is that medical education offers too 
httle inspiration. Medical students don't spend enough 
time with the senior faculty who are eager to nurture 
their talents. They don't witness the continuity of 
patient care that is the essence of internal medicine. 
They don't see surgical patients before the patients are 
draped — that magical moment in which one human 
gives another human permission to cut into his body. 
And they spend too much time with junior faculty and 
with residents who are often too tired, irritable, and 
troubled to inspire young people. 

Even Keel 

It's a long way from the bench to the examining table. 
Most of the scientists in our basic science departments 
hold doctorates but have no training and often httle 
interest in medicine. And in recent years, faculty 
members have been rewarded for basic science 

research through appointments, promotions, honors, 
and opportunities for supplemental income. Important 
advances in basic science are now crying out for clinical 
investigation and translational research, and we're des- 
perately short of people entering those disciplines. We 
must rebalance the value structure of our schools to 
invite bright young students into translational research. 

In addition, we need teacher-clinicians who remain 
close to the emerging science of their areas — even 
though they are not doing the research — and can convey 
the meaning of this progress to medical students and 
patients alike. These individuals are critical members of 
medical school faculties and should be developed and 
rewarded as such. Outstanding examples of the role of 
teacher-chnician have been grossly underrepresented in 
the past, and that balance should be restored. 

A close coroUary of this imbalance is an inadequate 
respect for clinical excellence. Most medical students 
will practice medicine, and their learning environment 
and experience should include a veneration of outstand- 
ing doctoring with all it entails. 

There is no such thing as too much attention to the 
indi\ddual when one is caring for the sick. All one's intel- 
lect and empathy must conjoin in the ser\'ice of diagnosis, 
management, and care. But in the overall distribution of a 
medical student's time, we pay too much attention to 
what is immediately wrong and give too httle thought to 
preventive measures addressing what is likely wrong or 
what is going to be. The closer you hover to death, the bet- 
ter a fourth-year medical student or intern can serve you. 
Yet most people are not at any given time fatally ill, and 
the almost onanistic absorption v/ith the chnicopatho- 
logical conference, our most revered teaching function, 
should be replaced with a broader interest in likelihoods, 
prevention, and ameUoration. This emphasis should be 
enriched with insights from social science, including a 
focus on the patient's family and the pubhc as a whole. 

By a wide margin, though, the most serious imbalance 
in the education of our students is the faculty's focus on 
the intense care of the sick while the setting in which 
that care occurs — the U.S. health care system — is in seri- 
ous disarray and getting worse. As many as 50 milhon 
are uninsured, half that number again are underinsured, 
and many members of the middle class are just a serious 
iUness away from bankruptcy. In addition, gross dispar- 
ities of care and health indices persist along racial, 
ethnic, and socioeconomic lines. We fail to apply the 




power of preventive measures well enough to make a 
difference, and our health outcomes are barely competi- 
tive with those in developing countries. 

Where is the disquiet that African American new- 
borns have more than twice the mortality of whites? 
Where is the outrage that more than half our citizens 
cannot access or afford routine primary care? Where is 
the shame that among 19 industriaUzed nations we are 
ranked dead last in health care measures? Where is 
the horror these findings should evoke? And where is the 
agreement, or at least the debate, that health care is a 
fundamental right, one no more ahenable than those 
protected in the U.S. Constitution? 

Sailing Close to the Wind 

To help answer such questions, perhaps we should 
start by analyzing the clinical exam. Imagine for a 
moment watching a doctor-patient encounter as 
though you were utterly naive of it. First, two 
strangers meet in a closed room, unobserved. One is 
fully dressed, the other at least partially undressed. 
Within a minute or two — especially these days — one 
of them starts asking questions not only about medical 
symptoms, but also about intensely private matters, 
such as sexual preference, the number of sexual part- 
ners, and the consumption of any illicit drugs. And the 
other person answers if not with aplomb then certain- 
ly with the view that the questions — which would 
have absolutely no standing in any other setting — are 
appropriate in that room. 

Next, the questioner moves on to a physical examina- 
tion that combines intrusiveness and physical access 
completely without parallel in social interaction. With- 
out consent, the process of the physical examination 
would indeed fit an expanded definition of rape. 

Third, the person in the flimsy hospital gov\Ti agrees to 
take medications the fully dressed individual suggests — 
up to and including general anesthesia. In other words, 
there is a total submission, admittedly with informed 
consent, to an undoing of consciousness and self. 

And finally, the questioner receives permission to 
operate on the other person — to remove an organ, to 
perform a transplant, to alter the body in any way he or 
she deems fit. This final act, which takes place every 
day in our operating rooms, would be a felony in any 
other setting. 


s it ethical to have patients wandering in the 
decide whether to pay for food or a new prescription? 

what justifies this extraordinary transaction? A sim- 
ple utterance, "Good morning! I'm Dr. Jones." And with 
those words comes the unspoken but unqualified 
promise that the person has the knowledge, skills, 
and — most important — the commitment to use them 
ethically on the other's behalf. 

But is it ethical to have appointments so short that you 
can't remove the shoes and socks of a diabetic patient? Is 
it ethical to have an elderly patient with poor vision on 
a dozen drugs when you have no access to a database of 
drug interactions? Is it ethical to have patients wander- 
ing in the doughnut hole of Medicare Part D and needing 
to decide whether to pay for food or a new prescription? 

Clear Sailing 

Such imbalances bring me to a metaphor from the 
world of sailing. There are three principal points of sail. 
When the wind is at your back, the boat is flat and 
progress is real but almost imperceptible. There's no 
tipping so there's no problem with balance. When 
there's a following sea, however, you can feel a little 
sick to your stomach. 

When you're sailing on a reach, or perpendicular to 
the wind, the boat is still almost flat and your lunch can 
remain stable. The sandwiches won't slide, the wine 
won't slosh. Again, balance is no problem. But sailing 
across the wind will not get you to a challenging target. 
When you want to go exactly where the wind is coming 
from, you can't. You have to slant shghtly off the direct 
course, which is called beating, or sailing to windward. 
Now the boat is heeling, and maintaining balance can 
be difficult. 

But when things go exactly right — the sails are 
trimmed perfectly, the crew's weight is distributed 
correctly, and the sheets are as tight as possible — the 
thrill is incomparable and you can let out a scream. It's 
not truly human; it's not even primate. But it's close to 
a primal scream, and it signals that the boat is sailing as 
well as it can against the wind, and progress toward 
the goal is predictable. 

I stated earher that the worst imbalance in current 
medical education is the failure of our medical schools to 
trumpet the defects of the U.S. health care system and to 
commit to correcting them. Our health care system has 
terrible shortcomings. I beheve we should erdist medical 
students as agents of change, committed to designing a 

system of care that is equitable, cost-effective, preven- 
tion oriented, and universal — and thus moral. The stu- 
dents should have coursework, summer experiences, 
projects, an activist focus, and consistent mentoring on 
this subject. I envision a program similar to an MD/PhD 
or other joint-degree design. I picture a cadre of dedicat- 
ed and innovative faculty who would bring to the pro- 
gram insight from diverse areas of medicine and from the 
social sciences. Following this rich activist experience 
should be additional medical training that prepares 
these students for leadership. 

I don't know what the specific recommendations 
would be. (Peter Medawar, the British immunology 
Nobelist, said, "Never ask me about the future of 
research. If I knew what it was, I'd be doing it now") But 
I'm not troubled that we'll be starting with amateurs. 
Noah's ark was built by amateurs; professionals built the 
Titanic. Similarly, I'm not concerned that we'll be starting 
with so few people arrayed against the titans of health 
care. As Margaret Mead said, "Never doubt that a small 
group of thoughtful, committed citizens can change the 
world. Indeed, it's the only thing that ever has." 

If we can convince medical students and faculty to 
apply the standards of medical education to the prob- 
lems of health care; if they search for solutions that are 
intellectually dazzling, emotionally gratifying, and 
morally transcendent; if they join with students and fac- 
ulties from related disciplines in pubhc health, social sci- 
ence, and economics; and if they recognize that a broad 
systems approach is needed, then we'll see roaring 
progress to windward. 

There's a big wind out there opposing change. It is 
generated by a hugely successful commercial and for- 
profit world entrenched against the radical revision of 
health care that I believe we need. But when our new 
craft is saihng just right — when the hehn, the sails, the 
sheets, the keel, and the crew are all in balance — and we 
start to make our ineluctable course to windward, 
through the noise we'll hear that deep, throaty, primal 
scream, and we'll know we're on the way to better health 
and health care for aU Americans. ■ 

Daniel D. Federman '53, the Carl W. Walter Distinguished Professor 
of Medicine at Harvard Medical School, has served as a mentor 
to generations of EMS students. This article was adapted from a 
tribute Federman gave to Jordan Cohen '60, president emeritus of 
the Association of American Medical Colleges. 




SOLITARY WEIGHT: A 15-year-old 
schoolgirl, burdened by AIDS, 
av/aifs antiretroviral treatment' 
at a clinic in South Africa. The 
care came too late; she died 
two weeks after this photograph 
v/as taken. 







f in 






I* \ 

^ ^^^^^^^^H 



r -^ 

1 '^^^^^^^^P^^^^Sj 



The most critiCciJ roadblock to' 

(:kli\ Cling care in tfu: lu \Li( 

\\(ir1d i^ 110! money, hut an 

!nip1emcntati( . bottleneck. 

hy Jim Yonc; Kim 

preventable deaths occur around the world. 
Most of these deaths take place in develop 
ing countries, usually among children, 
young mothers, and people with HIV. While 
more money is alwa)"s needed, funding isn't 
the biggest challenge we face in preventing 
these tragedies The biggest challenge is the 
delivery gap that prevents existing, often 
simple health interventions from reliably 
reaching those who need them. 

The situation in Africa is especially dire. 
In southern Africa, millions have already 
died from xAIDS. In South Africa, more than 
one -quarter of adults are infected with the 
virus. The HIV epidemic has also created a 
resurgence of tuberculosis, which kills more 
than a million people a year. Again, the toll 


espite the existence of proven treatments and much mc^rc 
money available now to pay for them, an implementation 
30ttleneck prevents care from reaching patients. 

is highest in Africa. A child dies of malaria every 30 
seconds, and most of those deaths occur in Africa as 
well. Every year, v^e bear vs/itness to millions of deaths, 
all from conditions that are routinely treated in the 
developed world. 

Meanwhile, health spending in Africa — both pub' 
lie and private — though much improved over the past 
decade, falls far below levels found almost anywhere 
else. The number of physicians working in Africa is 
just as skewed. We often hear that more Malawian 
physicians live in Manchester, England, than in 
Malawi, and that more Ethiopian doctors can be 
found in Chicago than in Ethiopia. 

What's especially tragic is that we know how to 
prevent or treat the most prevalent and deadly dis- 
eases. Take, for example, the risk of an HIV-positive 
mother transmitting the virus to her unborn child. 
Currently, the best way to prevent transmission is 
to provide the mother with prenatal services and, if 
appropriate, a combination of antiretroviral therapies 
to reduce viral load to undetectable levels. In an emer- 
gency, a single dose of nevirapine wUl also prevent 
transmission. Yet only an estimated 30 percent of 
pregnant women who need prevention-of-mother-to- 
chUd-transmission services actually receive them. And 
only half of pregnant women infected with HIV have 
access to nevirapine. 

Statistics on the use of insecticide-treated bed nets 
to prevent malaria infection are just as troubling. These 
nets can reduce infant mortaUty from malaria by 20 to 
30 percent. Every African child Hving in areas where 
disease-carrying mosquitoes are endemic should be 
sleeping under a bed net, but less than 10 percent do. 

In neither of these cases is the problem the lack of a 
proven solution. The fundamental problem is one of 
consistently and effectively delivering interventions 
that are known to save lives. 

Bridging the Gap 

African nations and other resource-poor countries are 
not alone in this delivery gap, of course. The U.S. 
health care system has its own share of delivery 
problems. As of several years ago, we were still only 
69 percent successful at meeting the standard for 
administering beta blockers within 24 hours to people 

admitted to hospitals for chest pain. The United 
States spends up to 17 percent of its gross domestic 
product on health care, and yet our health outcomes 
aren't as good as those in countries that spend far less. 

Admittedly, few African countries can rely solely on 
their own national budgets to fund the kind of health 
care systems they need. But the estimated cost of pro- 
viding decent primary care — and even more comph- 
cated care — in developing countries is much lower 
than one might expect. A recent analysis of a project in 
Rwanda suggests that it is possible to build a system 
that — when linked to primary care services — can 
treat such diseases as AIDS, tuberculosis, and malaria 
for $25 to $50 per person each year. Compare that to 
the United States, where we spend about $7,500 per 
person on health care annually. 

As funding for health in developing countries 
grows, it is conceivable that there will soon be 
enough resources to build functioning health care 
systems in even the poorest settings. To achieve such 
a lofty aim, though, we will need to dramatically 
improve our capacity to deliver health care interven- 
tions, both simple and complex, in resource-poor set- 
tings. Eor, despite the existence of proven treatments 
and much more money available now to pay for them, 
an implementation bottleneck prevents care from 
reaching patients. 

Meanwhile, the Bill & Melinda Gates Foundation 
and other funders are investing billions of dollars to 
develop new tools to treat the deadliest diseases. This 
investment is absolutely critical. Any physician who 
has confronted drug-resistant tuberculosis will tell 
you how desperate the need is for new treatments. 
But when these new tools hit the market, I fear the 
bottleneck will just become more clogged. 

One key to clearing the bottleneck is, I believe, to 
work toward developing what might be called the 
science of health care delivery — to systematically 
capture global health successes and failures, study 
them, and then widely disseminate the lessons 
learned to practitioners and policy makers. More- 
over, we must create robust programs that will train 
a new generation of implementers and link those 
implementers together in communities of practice 
to allow the process of generating — and spreading — 
new insights to continue. 


FEVERED PURSUIT: This year-old boy v/aits 'with his aunt for malaria treatment at a hospital in Tanzania. Unless treated 
within 24 hours of developing symptoms of the disease, children under the age of five risk death. 

The Discovery Channel 

At the press conference to announce the eradication of 
smallpox in 1979, physician and epidemiologist D. A. 
Henderson was asked, "Now that you've eradicated 
smallpox, what's the next major disease you want to take 
on?" His answer: "Bad management in pubhc health." 

Indeed, if you asked anyone who was involved in 
smallpox eradication what it was Kke to be part of a vac- 

cination campaign of that magnitude, they would tell 
you it wasn't a vaccination campaign. It was an epidemi- 
ological and management campaign — and those strate- 
gies were the key to the campaign's success. That kind of 
intense focus on management and implementation is 
lacking in today's efforts to stamp out other diseases, 
which just might help explain why we're falling short. 

Health care delivery is complex, but it's not a black 
box. We can and must develop better ways to capture 



c \'c made hiipc contrihurions to clinical research 

the science ot health care 

> ( \t^\A\j(^r\i 

HOME ALONE: Orphans hold candles of remembrance 
during a ceremony marking World AIDS Day in 
Johannesburg, South Africa. More than one-quarter 
of adults in South Africa are infected >vith HIV. 

this complexity and then teach what we learn about 
effective care delivery to our students here and — most 
important — in the developing world. We can lay claim 
to being the best in the world at teaching basic sci- 
ence. We've made huge contributions to clinical 
research and clinical science. But one piece is miss- 
ing — the science of health care delivery. To overcome 
the challenges we face today in global health, we need 
a new cadre of leaders — ones who are trained in the 
best and most effective ways to dehver interventions. 

Of course we need to keep investing in health care 
systems in poor countries. We need better infrastruc- 
ture; we need more money for medications, equip- 
ment, and supplies; we need new therapies. All of 
these things are critical, but this type of investment 
won't unstop the implementation bottleneck. 

In fact, if we don't unclog the bottleneck, we run 
the risk that much of what we invest will be wasted. 
Today, we have literally billions of dollars in new 
spending — all of it sorely needed — to treat disease in 
the developing world. But we don't have support — or 
even a plan — for the creation of leaders who will 
ensure the money is well spent. 

Stopping needless deaths in the developing 
world — from AIDS, from tuberculosis, from malaria — 
is within our reach. Let me tell you about a recent 
patient of ours in Rwanda. Jean presented at our clin- 
ic with both tuberculosis and HIV. He hterally looked 
hke a skeleton. Yet his CD4 count was over 500, so we 
didn't need to start him on antiretrovirals. With just 
food and medications for his tuberculosis, he began to 
recover. In a short time, he had his health back and, 
soon, had grown downright chubby. 

This case illustrates what is possible, not just for 
Jean, but for nulUons of others. The challenge and the 
opportunity are before us — to significantly increase 
our understanding of effective care dehvery, to teach 
what we learn to implementers worldwide, and to 
make good on the promise of dramatically improving 
the health of poor nations. ■ 

]im Yong Kim '86 is chairman of Harvard Medical Schooh 
Department of Global Health and Social Medicine, director of 
the FrangoiS'Xavier Bagnoud Center for Health and Human 
Rights at the Harvard School of Public Health, and chief of the 
Division of Global Health Eciuity at Brigham and Womens 
Hospital. This article was adapted from the HMS Alumni Day 
Symposium talk he gave in 2007. 



Change of Address 

Harvard Medical School is playing a new role to help 
ensure the sustainability of international health projects. 

Despite unprecedented new financial 
resources and medical advances, a 
significant global health delivery gap 
prevents care from consistently reach- 
ing the patients who need it most. To 
remedy the situation, Jim Yong Kim 
'86, chairman of Harvard Medical 
School's Department of Global Health 
and Social Medicine, teamed with 
Paul Farmer '90, a cofounder with Kim 
of Partners In Health, and Michael 
Porter, a Harvard Business School pro- 
fessor who leads in the field of strate- 
gy for complex organizations, to 
launch the Global Health Delivery Pro- 
ject (GHD). Their goal: to transform 
global health delivery from a series of 
small, well-intentioned but disconnect- 
ed efforts to a worldwide movement 
based on twenty-first-century technolo- 
gy, standards, and efficiency. 

Effective and consistent care delivery 
is, in many ways, a managerial chal- 
lenge: In poor settings especially, its suc- 
cess depends on understanding the mul- 
tiple factors that affect complex health 
systems, as well as the ability to carry 
out basic public health functions, accom- 
modate multiple medical specialties, and 
mobilize staff, facilities, and information 
over sustained periods. Yet efforts to 
capture and learn from program experi- 
ences have been limited, leaving global 
health implementers isolated, with little 
opportunity to learn from colleagues' 
experiences or to share their own. 

GHD aims to create such opportuni- 
ties by — for the first time — systematically 

evaluating the outcomes of care deliv- 
ery projects worldwide and sharing 
them with other global health imple- 
menters. To jumpstart this initiative, 
GHD is developing a new generation 
of tools that not only use rigorous 
analysis, but also draw on numerous 
disciplines, web-based information- 
sharing communities, and partnerships 
with centers of excellence in health 
care delivery. 

In doing so, GHD has taken a les- 
son from Harvard Business School by 
creating analytic frameworks, include 
ing in-depth field case studies that doc- 
ument the best and most challenging 
examples of health care implementa- 
tion. Ten such case studies have been 
completed, with 25 more planned for 
the next two years. 

The project's online presence, 
GHDonjine, is just as critical. The web^ 
site's virtual communities of practice 
connect health care implementers 
across borders. By joining the commu- 
nities, implementers throughout the 
world can rapidly share their best 
practices and experiences, collaborate 
with peers both locally and internation- 
ally, and access an extensive library of 
practical information. And a targeted 
custom search engine allows members 
to quickly find relevant information 
without weeding through standard 
search results. The first four GHDonline 
communities to become active now 
center on tuberculosis infection control, 
patient adherence and retention, drug- 

resistant tuberculosis, and health infor- 
mation technology. 

But current health care implementers 
aren't the only focus of GHD. A new 
academic field of global health delivery 
studies will teach tomorrow's global 
health leaders to become experts in 
health care implementation. A curriculum 
is being developed to reach a range of 
students — including undergraduates, 
graduate students, physicians, and mid- 
career global health implementers — in 
the United States and around the 
world. Using GHD's in-depth global 
health case studies, this new curriculum 
is being piloted at Harvard before 
being made widely available. 

GHD plans to partner with a num- 
ber of centers of excellence to create 
hubs for collaborations that link acade- 
mic institutions, nongovernmental orga- 
nizations, and public sector health care 
delivery organizations. Such partner- 
ships will allow faculty to study care 
delivery at leading global health sites 
and to teach their findings to students. 
These training sites will also offer pro- 
gramming as diverse as field intern- 
ships for graduate students, sessions for 
large groups of community health work- 
ers, and executive education leader- 
ship courses for mid-career profession- 
als. GHD expects to establish three 
partnerships with centers of excellence 
during the next five years. 

To learn more about the Global 
Health Delivery Project, visit www. ■ 



hy John W. Gittinger, Jr. 



the surgeon and the dentist-physician — 
bones and the nearly magical light that 
penetrated flesh to reveal them. That magic 
was the x-ray. During the latter half of the 
1890s, both men would use this newfound 
hght in ways that would prove pivotal to 
future generations. 

The surgeon rode the wave of early 
enthusiasm for the technology to construct 
a Christmas card that boasted an x-ray of 
his professor's arm — and the Civil War 
bullet lodged in it for nearly three decades. 



Early investigations of <y\> 
x-ray by two Harvard- ^ 
educated physicians ^ 
revealed the technology's '7 
benefits — and dangers. ^ 

He also used the technology to lay a founda- 
tion of anatomical knowledge that would for- 
ever inform his profession. 

The dentist-physician, a man for whom 
research was a part of life, devoted decades 
to characterizing the new imaging tool and to 
tweaking its design to improve its perfor- 
mance. He also sought to make the technology 
safer: An x-ray-induced injury to his hand 

proceed with care. 

We don't know if the two men ever met. 
They did, however, debate one another in the 


-LvL-yl A ALy O stated, "X-light kills" He then presented 
evidence by detailing the fatal results that two-hour exposures on each 
of eleven days had produced on two robust male guinea pigs. 

pages of the Boston Medical and Surgical Journal. 
The exchange between these two — Ernest 
Amory Codman, Class of 1895, and Wilham 
Herbert Rolhns, Class of 1879 (and Har- 
vard School of Dental Medicine Class of 
1873) — ^was brief but feisty. It occurred 
in 1901, less than five years after a holi- 
day card and an injury had affected each 
maris life. 

Take a Letter 

It was in the winter of that year when letters 
exchanged between Rollins and Codman 
appeared in the weekly predecessor to the 
New England Journal of Medicine. The corre- 
spondence began with a note from Rollins, 
published on February 14, a day usually 
reserved for hearts and flowers. For Rollins, 
however, it was a day for directness and 
urgency: "X-hght Mis," he began. 

Rollins then presented evidence of the dan- 
gers of x-hght — a term he persisted in using 
when describing the x-ray — by detaihng the 
fatal results that two-hour exposures on each 
of eleven days had produced on two robust 
male guinea pigs. Rollins was convinced his 
experimental design showed x-rays were the 
deadly force. The experiment was hardly 
RoUins's first or last with these energetic 
waves. It would become one of near- 
ly 180 investigations, observa- 
tions, and comments he 
united in his book 
Notes on X-Light, 
pubhshed in 1904 
by The Univer- 
sity Press in 

Massachusetts. The findings he was reporting 
to readers of this medical journal had been 
introduced three years earher in an engineer- 
ing journal. Rollins elected to restate them for 
physicians; without proper precautions, he 
worried, x-rays posed significant dangers to 
both patients and doctors. 

At least one reader took an interest in 
Rollins's letter. With a rapidity not found in 
printed journals today, the February 21 issue 
of the journal carried a response from Cod- 
man. In "No Practical Danger from the X-Ray," 
Codman stated, with the occasional added 
emphasis, ''practically, in careful hands, there 
is no danger from the use of the x-ray to the 
patient and very httle to the operator." He went 
on to describe thousands of exposures he had 
made of patients at Massachusetts General 
Hospital, Childreris Hospital, and in his pri- 
vate practice, "without a single case of der- 
matitis," an outcome that stepped carefully 
around Rollins's worry that cumulative and 
unprotected use caused death, albeit death to 
a laboratory animal. To ensure Rollins under- 
stood the breadth of his experience in the 
field, Codman signed himself, "Surgeon to 
Out Patients, Massachusetts General Hospital; 
Skiagrapher [an early term for radiologist] to 
the Childreris Hospital." 

The journal's next issue contained Rollins's 
response. In it he provided a second example, 
this time involving a pregnant guinea pig. The 
fetal guinea pig had died, a lesson Rollins 
extrapolated to humans, cautioning that he 
was aware of one instance where the use of 
x-rays had caused a woman to abort. Empirical 
to his core, Rollins then gently upbraided his 
critic. With new agents, he said, it was impor- 
tant to determine their power so as to know 
how they could be controlled. "Nothing is 
gained by criticizing such experiments," 
Rollins wrote, "for criticism is sterile, while 


X-'Ray" that, ymctically, in careful hands, there is no danger from the use 
of the x-ray to the patient and very httle to the operator." _^^__._ . _ 

experiment is fertile. An experiment can only 
be discredited by another experiment." 

Catch Some Rays 

So who were these correspondents, and what 
was their interest in this new tool that could 
see to the bone? Rollins, age 48 at the time, is 
considered the Father of Health Physics. He 
was also the first to describe radiation-induced 
cataract. Codman, who had just turned 31, is 
celebrated as both the Father of Shoulder 
Surgery and as the founder of the End Result 
System, the outcomes movement that gave 
birth to today's Joint Commission on Accred- 
itation of Healthcare Organizations. 

Like many physicians in the late 1800s, 
Rollins and Codman were drawn by the 
promise and mystery of the wondrous hght 
that had been introduced to the world by a 
quiet German physics professor. In November 
1895, Wifhelm Rontgen had been experiment- 
ing with cathode ray tubes when he made one 
of those experimental mistakes that history 
christens serendipitous. During a test, Rontgen 
placed a cardboard screen that had been 
treated with a fluorescent substance, barium 
platinocyanide, in front of an electrified vacu- 
um tube known as a Hittorf-Crookes tube. 

hi the darkened laboratory, the tube pro- 
duced fluorescence on the cardboard screen. 
Satisfied with the test, Rontgen was about to 
turn off the tube when he glimpsed a Hght sev- 
eral feet from where he was working. To see 
what it was, he struck a match. Its glow fell 
upon a forgotten screen that had been coated 
vvdth a fluorescing solution and left to rest on 
his workbench. His surprise turned to amaze- 
ment when he realized the screen was being 
illuminated by a faint cloud of fhckering Hght 
waves that moved in unison with the electrical 
discharges of the tube's inner coil. 

Rontgen began feverishly testing the 
properties of the phenomenon. A month later 
chance again intervened, and one of the 
principal future uses of the ghostly glow was 
revealed. As Rontgen was placing an iron pipe 
between an electrified Crookes tube and 
a capture screen, he saw the bones of his fin- 
gers as they grasped the pipe. 

Rontgen quickly wrote up his findings for 
pubhcation. They were immediately accepted 
and Rontgen's paper, accompanied by an 
x-ray of his wife's ring-bearing hand, was 
circulated among a select group of German 
physicists. By the end of January 1896, "On 
a New Kind of Rays" had been translated 
into Enghsh and published in a London- 
based engineering journal. Soon it was the 
talk of scientists and physicians on both 
sides of the Atlantic, and by year's end, an 
incredible 1,044 papers on x-rays had been 
pubhshed in medical and scientific jour- 
nals. In 1901 the discovery earned Rontgen 
the first Nobel Prize in Physics. 

Ray of Hope 

Following Rontgen's announcement, hos- 
pitals throughout the world quickly opened 
x-ray rooms. By May 1896, Boston City Hos- 
pital had set up an x-ray department, over- 
seen by the physician and early radiologist 
Francis Williams, Class of 1877. Williams's 
fascination with x-rays was matched — 
perhaps surpassed — by that of his collabora- 
tor, Rollins, who also happened to be 
Williams's brother-in-law. For nearly 
two decades, the two men took 
x-rays of hospital patients, 
amassing more 



Dullet lodged near his elbow since his military service, 
x^^as delighted when an x-ray revealed the Ci\il War relic. 

150,000 images as well as an understanding of the tech- 
nology that Rollins would use in his efforts to refine it. 

In his writings, WiUiams credits his brother-in-law 
with being one of the first to recognize the treatment 
potential the technology offered medicine. But perhaps 
each inspired the other. In the preface to his Notes on 
X'Light, Rolhns attributes his dedication to the field to 
Wilhams: "In these notes are recorded some impressions 
derived from experiments made after the day's work, as a 
recreation, yet with the hope of learning to design and 
construct apparatus for my friend. Dr. F. H. WUhams, 
who has done most to show the importance of X- Lights 
in medical diagnosis." This "recreation" was both kind 
and costly. Although RoUins had a thriving dental practice 
in Boston, his passion for research and invention contin- 
uaUy challenged the household income. In the last volume 
of his personal journal, Rollins credits the mindfulness 
and thrift of his wffe, Miriam, with the fact that his 
research, which may have cost upwards of $30,000 over 
the years, strained, but never broke, the RoUins's bank. 

Rolhns continually chronicled his observations and 
experiments in his Notes. By early 1898, he had begun 
jotting down reports of what would become just one of 
the dangers of the technology: skin burns, a problem he 
had learned of on the job. In January of that year, RoUins 
suffered a severe burn on one of his hands after it was 
exposed to an activated vacuum tube. 

For the next six years, Rollins devoted himseff to 
determining the dangers of x-rays, devising precau- 
tions to protect against those dangers, and redesigning 
the vacuum tubes and apparatuses associated with the 
technology to improve the efficiency of the tubes and 
the resolution of the radiographic images. Some of his 
inventions — the Rollins box, a shielded housing that 
permitted rays to escape only through a single opening; 
the use of coUimating diaphragms to narrow the beam; 
and the development of high-voltage tubes — ultimate- 
ly served to limit the exposure of patients, physicians, 
and other workers who operated or produced x-ray 
equipment. In addition to hardware improvement, 
Rollins dispensed cautionary advice to those who 
applied the technology to medical purposes: wear 
radio-opaque glasses; enclose the tube in a leaded 
housing; and limit irradiation of patients to only those 
areas of interest, covering adjacent areas with radio- 
opaque material. 

Unfortunately, RoUins's cautions were ignored, per- 
haps because of the bhnd enthusiasm of those working 
with the new technology. Or perhaps the neglect 
occurred because Rollins toUed alone in his home labo- 
ratory, pubhshed his findings quietly and in somewhat 
obscure engineering journals, and rarely ventured to 
professional meetings. His reluctance to participate in 
such meetings was so great that he had to be persuaded 
to attend an American Roentgen Ray Society gathering 
at which he was awarded an honorary membership. The 
citation he received may have only added to Rolhns's 
frustration; it did not mention his x-ray safety work. 

Brought to Light 

As with Wilhams and Rollins, Codman was mesmer- 
ized by the x-ray and its ghostly images. In 1895 Codman 
had just begun his surgical practice and his position as 
an assistant in anatomy at Harvard Medical School 
when he began exploring Rontgeris rays. Like many 
who were probing the new technology, Codman sought 
out the needed equipment. The proper ingredients were 
found right in the laboratory of his mentor, Henry 
Pickering Bowditch, Class of 1868. 

Codmaris excitement is palpable in his writings of this 
period. In the autobiographical preface to The Shoulder, a 
landmark treatise published in 1934, Codman wrote: "It 
would be impossible to give the reader an idea of the thriU 
experienced by those of us who did the early X-ray work. 
1 remember that an early contribution of mine in the Boston 
Medical and Surgical Journal was to show that the X-ray was 
likely to help us in studying the epiphyseal lines! . . . We 
almost forgot that it was all because Rontgen had noticed 
something that many others might have obsers'ed." 

For two of his years in Bowditch's laboratory, Codman 
concentrated on taking images of the entire human 
skeleton, a body of work he gathered into a single bound 
edition that he donated in 1898 to the Rare Books Room 
at the School's Francis A. Countway Library of Medi- 
cine, where it stiff resides. 

Codman also may have indirectly used the x-ray as a 
courtship tool. In his first year of work with Bowditch, 
Codman took an x-ray of the professor's right arm. The 
image dehghted Bowditch, for it clearly showed a rifle 
buffet lodged near his elbow, a rehc he had been unaware 
of for 30 years but had likely acquired during his ser^'ice 



in the Civil War. Codman, too, was pleased by the image, 
so much so that he turned it into a Christmas card for the 
professor. The careful surgeon and researcher made a 
mistake on the card, however. "Merry Christmas" became 
"Marry Christmas," perhaps an inadvertent shp revealing 
Codmaris affections for the professor's niece, Katherine 
Putnam Bowditch. The two were married in 1899. 

Codman continued to research the apphcations of 
x-ray for several more years, giving special attention to 
its uses in the practice of surgery. Before long, though, 
the pull of surgery won Codman over and he set aside 
x-ray work. As his autobiographical preface shows, this 
return to surgery may also have allowed him to express 
his change of heart about the dangers of x-ray exposure: 
"for we all had burns and some of us gave them. Many of 
my old friends are dead from x-ray cancer. It was fortu- 
nate for me that my interest in surgery was greater than 
in Rontgen's discovery." 

Indeed, evidence of the dangers of unprotected 
exposure to x-rays was mounting. Radiologists offered 
the best — or worst — proof. Their ranks were being 
thinned by early deaths. And those who lived had the 
evidence written in their hands: scarred, distorted, and 
often lacking digits. Such disfigurement was so preva- 

lent that banquet planners for radiology meetings in 
the 1920s avoided serving roast beef; the gloves most 
radiologists wore to hide their hands made cutting 
such food dffficult. 

Service for Two 

Before he died of metastatic cutaneous melanoma in 1940, 
Codman had built a considerable legacy. His "End Result 
Idea" or "End Result System of Hospital Organization" 
would lead to the estabhshment of standards for the mea- 
surement of the outcomes of medical care. And in addi- 
tion to his contributions to the field of surgery, Codman 
had developed the Registry of Bone Sarcomas. Spurred by 
the development of a bone tumor in "one of my best 
patients," Codman had contacted physicians throughout 
Massachusetts, poUed them on their bone sarcoma cases, 
and compiled the treatments and outcomes they had 
achieved. After a book on bone sarcoma and five years of 
work — done without compensation — Codmaris data 
engendered the first cancer registry in the United States. 
Rollins, too, left a legacy, one that mandated discov- 
ery in generations to follow. In addition to his research 
and inventions in radiology — as well as in dentistry, 
photography, radio, and mechanical pianos and 
organs — Rollins sought to ensure there would 
always be an opportunity to tinker and dream. In 
his wlH, he bequeathed $58,000 to the Smithsonian 
Institution for the establishment of a fund "for 
exploration beyond the boundaries of knowl- 
edge." The fund was formalized in 1935, six years 
after his death. 

Rolhns's warnings of the dangers of x-rays lay 
quietly through decades that brought war and mass 
destruction until those of a new age, the atomic era, 
rediscovered — and began to heed — them. 

Absent a record of a meetimg or even of other 
letters personally exchanged between these physi- 
cian-researchers, it is impossible to know if they 
ever had the chance to discuss face-to-face the dif- 
ference of opinion they had inked for pubhc airing. 
It is tempting, however, to think they did. After 
all, both were members of Boston's professional 
class and had affiUations, either direct or indirect, 
with Boston's social register. Both were avid out- 
doorsmen, each arranging their professional 
schedules to include blocks of days out of the city 
on hunting and hiking getaways. And both 
enjoyed walking along the streets of the city's 
Back Bay neighborhood, where they li\'ed just a 
few blocks apart. 

Had they talked, they hkely would have discov- 
ered that aside from this single professional dust- 
up, they approached hfe with much the same \dsion. 
They would have found that each held as a core 
value the importance of a life devoted to humanity. ■ 

]ohn W. Gittingcr,]r. 71 is a professor of ophthalmology and 
neurology at Boston University School of Medicine. 


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