Perspectives on my 50th medical school reunion.

In 1682, William Penn, an English Quaker, founded the city of Philadelphia as the capital of his Pennsylvania Colony. 83 years later, in 1765, Drs. John Morgan and William Shippen convinced the Trustees of the College, Academy, and Charity School of Philadelphia to found the first medical school in the then-colonies on the eastern seaboard of North America—modeled on the University of Edinburgh, where they had trained. When the Medical School was founded in 1765, the College and the Medical School became a university, although the term “university” was not added to the institution’s official title until 1779.

At the first commencement, June 21, 1768, ten medical students received their M.B. degrees. (The College granted the first M.D. degrees to four of these men in 1771.)

Two hundred years later, in 1968, my class graduated from that same medical school at the University of Pennsylvania, and last weekend, 250 years later, we celebrated our fiftieth reunion. Perspective comes from such an event.

Individual lives, and deaths, occur. The patients, the teachers, and some of the classmates from whom and with whom we learned so much are gone. Soon we—with all the fragile neuronal connections that we treasure as our professional knowledge and skills—will also return to the dust. But the institution continues. What most concerns our class now is what that institution will look like after another half-century.

Philadelphia and its 1.5 million inhabitants could be vaporized in a thermonuclear holocaust, could be flooded by warm rising seas, or could fall victim to some other unpleasant end. But for the foreseeable future, our civilization, the city, and the university will most likely muddle on.

What can’t muddle on is our way of doing health care. From my experience in the US Navy and from visits to institutions all across the country representing Janssen Pharmaceuticals, I know that good medical care does not require the opulence, the cavernous spaces and grand edifices, that we see in major hospitals today.

What do we need to really do our work as doctors? Accessible simple, sturdy well-lighted buildings with good heating and cooling – easily cleaned surfaces – basic hematology, chemistry, and microbiology labs – a couple of reliable X-ray machines – a delivery room and an operating room – a few rooms for overnight stays –a basic food-service operation— a functional record system – a well-stocked pharmacy – high-speed internet, that’s all. Oh yes, and a place to send the patients when that simple facility can’t handle their problems. No questions asked.

What I’m describing could exist. Should exist. If we had a system where every person in the country had low-cost insurance to cover basic immunization and preventive care, maternity care, trauma, and out-patient primary care, then such places would exist. They would provide the network of referrals that research universities and their academic medical arms must have to do their work.

Every single one of us has benefited from what Penn, Harvard, UCSF, Stanford, and the other 137 accredited MD-granting institutions and 31 accredited DO-granting institutions in the United States do. We should help to fund them through taxes, grants, gifts, and health-care insurance that helps to pay for their services.

But we would also all benefit from extending basic care to our whole population. Make no mistake, breakthroughs in science will come; brilliant younger people are hard at work in their labs. My hope, as I left Philadelphia, was for progress in how we deliver care.

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I Love It When a Plan Comes Together

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Imagine a half-dozen or so college students in hip boots, brandishing wide nets and paper punches, invading your quiet, secure home. Fortunately, fish don’t think much at all, so the fish in the woodland pond that my ecology class visited back in 1963 probably don’t recall our visit to their ancestors, but I still do.

We set out to calculate the number of fish in the pond. The method required catching and counting a sample of fish, hence the nets. Then we marked them with a small, neatly punched hole in the thin membrane of their tails and carefully released the known number of marked fish (= M1) with detailed instructions to go and mix-and-mingle with their companions for a week. (Indicator dilution, for you purists.)

One week later, back in the hip boots, we netted a new sample and counted those with (=M2) and without (=M0) tail punch marks. With this much information, we could calculate the number of fish in the pond:
If x = number of fish in pond
Then M1/X = M2/M0 and the rest is algebra.
This was my favorite experiment in all my academic experience. Imagine getting OUTSIDE in HIP BOOTS and doing something scientific. Like a stonefly emerging from the depths of the library, I turned into an environmentalist.

Stay with me for just a few more minutes. As an almost-ten-year-old growing up in northeast Ohio, I remember the November 1952 picture of the Cuyahoga River on fire that ended up in Time Magazine a month later – a truly arresting image showing flames leaping up from the water, completely engulfing a ship. Over the years, as a physician, I’ve followed the stories of various health problems that seem to have had roots in the environment; Dan Fagin’s Toms River is one of the best. A few years ago, I first read Steven Johnson’s marvelous book, The Ghost Map, the story of John Snow and the London cholera epidemic of 1854.

Then, just this morning, I had a real “Ah-ha!” moment. I read Margaret Talbot’s New Yorker article (The New Yorker, April 2, 2018), “Scott Pruitt’s Dirty Politics,” and my son David, an environmental economist, sent me a piece from the American Public Health Association on environmental health.
“Many communities lack access to nutritious, affordable food; are denied safe           places to walk and exercise; or live near polluting factories. The health risks for these families are greater. We support research and action to help ensure healthy environments for all.”–APHA Executive Director Georges Benjamin

All of these issues are related. It all comes together!

We are not separate from the environment. In populated areas, we ARE the environment, or at least, the environment is largely man-made.

Some individuals with political power do not seem to understand the connection between environmental health —clean air, clean water, open spaces— and human health. Those individuals will not be swayed by facts. In fact, they actively reject science as a basis for public policy.

For now, we can support the public organizations that do battle on behalf of the environment, particularly those that wage their battles in the courts. And soon, we can, we should, we must…VOTE.

PS: The photo this month is an outhouse in the Chinese section of Arrowtown, New Zealand. The Chinese, who came to New Zealand as gold miners, were keenly aware of the importance of sanitation.

How Often Do You Pull Out the Map?

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The photo above, taken on our recent visit to New Zealand, illustrates an irrevocable commitment. We did not explore this particular activity, bungee jumping, at any level deeper that photography!

This week, The Packet has arrived with two items, both well-seasoned, about leadership and learning.

Here’s some news from 1898. At the time, William McKinley was the President of the United States, the last president to have served in the Civil War.

On May 1, 1898, Commodore George Dewey led a United States Navy fleet to victory in the Battle of Manila Bay, in the Spanish-American War. In the words of Robert Merry, author of a recent, well-received biography of McKinley, Dewey’s victory “brought forth a kind of serendipitous imperialism.”

As a result of a very short conflict, the United States had gained control of Puerto Rico in the Caribbean, and Guam and the Philippines in the Pacific, and annexed Hawaii as well.

To continue Merry’s story, “The president, it was said, began his education on the Philippines by tearing a small map from a schoolbook, and when a government official arrived with more detailed charts he received them avidly while acknowledging his limited knowledge. ‘It is evident,’ he said, ‘that I must learn a great deal of geography in this war.’”

My point? McKinley had enlisted in the Union Army as a private; he attained the rank of brevet major. Before he was elected president, he had served in Congress, and as the governor of Ohio. Faced with the sudden, unexpected turn of events that transpired in the Pacific, what did he do? He immediately set out to educate himself.

That’s what leaders do; they look for information.

Fast forward to the New York Times Magazine of October 12, 2010. In a piece by Peter Baker titled “Education of a President, Baker says, “To better understand history, and his role in it, Obama invited a group of presidential scholars to dinner in May in the living quarters of the White House. Obama was curious about, among other things, the Tea Party movement. Were there precedents for this sort of backlash against the establishment? What sparked them and how did they shape American politics? The historians recalled the Know-Nothings in the 1850s, the Populists in the 1890s and Father Charles Coughlin in the 1930s. “He listened,” the historian H. W. Brands told me. “What he concluded, I don’t know.”

The two items span 112 years. There’s not much recently.

Come back soon for more photos of New Zealand.

One Fall Day

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Last week at this time, I was at the American Heart Association 2017 Scientific Sessions meeting in Anaheim, CA. I’m not going to risk a libel suit for telling you what I think about Anaheim.

I’m sure that anyone who has read my previous posts knows that events of only a week ago have not aged sufficiently to write about anyway. But being at the AHA brings back memories. I attended the 1977 AHA meeting that was held in Dallas, and I have never entirely gotten past it.

If you remember, President John F. Kennedy was assassinated in Dallas in November, 1963. The 1977 meeting was my first visit to Dallas, and the United States had just traded Gerald Ford for Jimmy Carter in the Oval Office. The loss of JFK was still fresh.

On a sunny but chilly day in early November, I walked the several blocks from my downtown hotel to the Texas School Book Depository building. At the time, the building was in a sort of renovation limbo, and it looked haunted. It was impossible to keep from looking at the sixth floor and wondering which window Lee Harvey Oswald shot from.

I’ve never felt good about Dallas, or the American Heart meeting since.

President Kennedy gave his last public address at Amherst on October 26th, 1963. I was lucky enough to be in audience. I have joined a group of classmates (some of whom are shown here) working on a documentary that looks at the content and impact of that speech, and offers some commentary on its relevance today. As part of the effort, our group met at Amherst College on October 28th   for a Saturday event called “Poetry and Politics, A Celebration of the Life and Legacy of JFK.”

The day was not unlike the October day in 1963 when the President spoke: a crisp, sunny fall day in New England, enough leaves on the ground to rustle as you walk, and enough still on the trees to stand out in color against the blue sky and high, thin clouds. After three outstanding presentations by current students and a panel discussion, the 150 or so of us who were “celebrating” gathered on the grassy quadrangle in front of the Frost Library, the building JFK had come to dedicate.

The keynote speaker looked familiar as he stepped vigorously up to the podium. Congressman Joseph P. Kennedy III is unquestionably one of “the” Kennedys. He looks more like his grandfather, Attorney General Robert F. Kennedy, than his great-uncle the President, but the resemblance is strong.

After the speech, I took a little private walk around the campus. I looked at the second floor of James dorm where I lived, at the Chapel where I had listened to Robert Frost say his poems, and the playing field at the foot of Memorial Hill where I had watched JFK’s helicopter land.

The young Congressman gave a good speech. Not perfect, but perfectly adequate. He’s just 37; there’s time, and there’s hope.

Yankee Ingenuity

In previous posts on The Weekly Packet, I have offered the idea that fifty years is a good amount of time to gain perspective on issues.  As often happens, a recent trip has changed my thinking somewhat. Travel, of course, is a good thing.  That sounds straight out of Martha Stewart, so let’s turn to Mark Twain, who said, ““Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.”

So we (Katherine and I) took a short trip to get together with some of my Amherst fraternity brothers. The whole story of the Amherst fraternity experience (very benign in our era) will prompt another story.

Our travel took us to Old Saybrook, CT. where the 406 mile-long Connecticut River flows into Long Island Sound. Our host has a lovely old home on Ayers Point, and this is how we stumbled onto a bit of 246 year-old news to share with you. In Revolutionary War days, Ayers Point was the site for the fabrication of the Turtle, the first military submarine to attempt an attack on an enemy vessel. The standard information says only that Sgt. Ezra Lee, of the Continental Army was the operator of the one-man vessel, and that he unsuccessfully attempted to drill a hole in the hull of a British ship.

Actually, the story is considerably more interesting. David Bushnell, who had attended Yale, designed the Turtle and, enlisting a number of skilled craftsmen in the area, he solved a myriad of technical problems, not only constructing the boat, but also designing a timing mechanism to allow the boat to escape after attaching an explosive mine to the enemy vessel. But he needed someone with brawn to operate the boat. The operator had to move the boat forward and backward with a front propeller driven by a treadle and a hand crank and also supply the muscle required for a vertical propeller on the top of the boat that assisted with ascent.

Enter David’s brother, Ezra Bushnell. Younger and considerably stronger, Ezra must also have been either somewhat less bright or much more courageous. Perhaps he combined both attributes. Nonetheless, Ezra provided the crew and the power for the Turtle’s initial trials that took place just off Ayer’s Point. By all reports, Ezra became quite proficient at maneuvering the vessel.

The intrepid submariners loaded the Turtle onto a boat, and headed for New York Harbor, where the British fleet with its flagship, HMS Eagle, were anchored. Before they could mount an attack, Ezra Bushnell became seriously ill. This brought Sgt. Lee into the picture, as a volunteer to step into Ezra Bushnell’s spot. The Connecticut History website details Lee’s courageous but unsuccessful efforts against the Eagle.

The “news” from almost 250 years ago?

Invention, ingenuity, creativity, and craftsmanship combined to make the impossible happen; a submerged vessel with a single man aboard attacked the flagship of the British fleet.

The success of the venture depended on the skills of one man, who was laid low by illness, and a second, who made a gallant effort on short notice.

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Today, we may have more powerful technology, but we would be hard-pressed to match the mind and spirit of the Connecticut Yankees.

 

Note: see also Manston R.R., Frese F.J.,  Turtle: David Bushnell’s Revolutionary Vessel. Westholme Publishing

Goldilocks.

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The Coast Range, British Columbia

 

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The Bulkley River, British Columbia

 

This has been a busy summer! I spent a week in Brooklyn with my son as he underwent and initially recuperated from a total hip replacement. During my stay, I had the opportunity to read Goldilocks and the Three Bears not just once, but several times. Probably about 11 times.

My grandson, Walker, (think Walker Percy, the writer or Walker Evans, the photographer) obviously thinks highly of the story and so do I.

Actually, my interest in Goldilocks began some years ago when I was managing immunosuppressive medications. The trick with immunosuppression is, of course, not too little and not too much! Abstracted a bit more, the story tells us that in many of our activities, the relationship between a given parameter (temperature of soup) and a desired outcome (good taste of soup) is not linear. These relationships often take a U-shape or a J-shape, depending on how one draws the graph.

Walker lost interest when I tried to explain how to graph his story (increasing soup temperature on the X-axis, increasing tastes good on the Y-axis = upside down U.) You shouldn’t. This is how a lot of things work in life. Now we’re going to talk about one of them.

The August 22 issue of JACC (the Journal of the American College of Cardiology) has now completed preliminary seasoning. It has rested quietly in a stack of printed material on the breakfast counter, slowly making its way to the surface.

In it are some interesting data, along with a thoughtful editorial. (data, Xi et al, J Am Col Cardiol 2017; 70:913-922 and editorial Gaetano and Costanzo, pgs 923-925.)  The data are a re-confirmation of the J-shaped relationship between alcohol consumption (gm/day) and the relative risk of total mortality.

If one sets the baseline relative risk of dying at 1.0 for “never consumed alcohol” abstainers (this excludes problem drinkers who are abstaining for health reasons), the relative risk of dying from any cause actually decreases to about 0.85 for those who take a drink or two a day. Then it heads right on up, so that when you get to a half-dozen or more pops a day, your risk is well above 1.0.

What does this mean? However the Goldilocks story began, it means that the concept of getting something “just right,” whether it’s the dose of cyclosporine or the temperature of the soup, is something that humans have been working on for a long, long time. Probably almost as long as they have been fermenting stuff…

Note: 20170827-DSC02182.JPGThe two landscape photos are panoramas of multiple shots with my Nikon D7100, put together in Adobe Lightroom. Enjoy!

Summer Reading. (Not required, but worthwhile)

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What did you think about over the past two major holidays, Memorial Day and the Fourth of July?

As I often do, I spent a lot of time wondering how we got to this strange point in our national history, and a smaller time hoping that the federal bureaucracy, in its nautical role as our national ballast, has sufficient inertia to hold the course in foul weather.

I’ve just finished reading two books that I want to recommend; both are appropriate for the packet. They are not new, but ripe for reading now.

The first is Fredrik Logevall’s Pulitzer Prize-winning Embers of War, a history of Viet Nam that focuses on the period from the end of WWII to 1959, at the beginning of the second Viet Nam war, the one the US fought.

The three main players of the story include war-weakened France, struggling to retain its colonial domination over Viet Nam, a home-grown independence movement desperate for military and economic support, and the suddenly superpower, the cold-war United States, operating on the basis of the “domino theory” and committed to halt the spread of “Communism.”

As Logevall tells the story, the players cannot shed the blinders that limit their vision and condemn them to act out their roles, no matter what the consequences. France poured blood and treasure into Viet Nam that could have helped stabilize her in Europe. Ho Chi Minh made a Faustian bargain with the Chinese, after his efforts to lead his country to independence were rebuffed by the US. Meanwhile, with the US caught up in the madness of McCarthyism and the “loss of China” political finger-pointing, the irrational political pressure to support first the French and then Ngo Dinh Diem and the South Vietnamese was overwhelming.

Logevall, a history professor, writes clearly and unobtrusively. As events unfolded, as a reader I could only shake my head, wondering, “Why?”

The second recommendation is Jean Edward Smith’s Eisenhower in War and Peace. Smith focuses much of the book on Eisenhower’s military career, an important approach in order to understand how Ike functioned as President. Eisenhower was extraordinarily fortunate throughout his career in gaining brilliant senior military men as mentors, probably because they recognized his extraordinary capabilities.

Smith emphasizes Ike’s skills at the card table, his perspective in structuring “carrot and stick” decisions for both his peers and his subordinates, and his ability to delegate responsibility.

The two books, taken together, help to clarify the complex path that led to the United States involvement in Viet Nam. The relationship between Eisenhower and DeGaulle, the political pressures within the Republican Party, the pressure to use tactical nuclear weapons, all played a role.

What’s my message here? We live with our successes, and with our mistakes. Americans should celebrate the 4th of July. The essential document of the day, the Declaration of Independence, stands as a remarkable example of our successes. And on Memorial Day, the Civil War and the Viet Nam War stand as stunning examples of the consequences of our mistakes. It takes about a half-century, a reasonable time for the dust to settle, to see how the mistakes were made.

The photos are all from Havana, Cuba. I think they speak to some of the issues. The lady in the rain was photographed on the grounds of the Hotel Nacionale in a sudden downpour. The red Buick was originally, I believe, a 1954 Roadmaster. The missile is an SA-2 Guideline surface-to-air missile of the type that shot down Rudolf Anderson’s Lockheed U-2 aircraft over Cuba on October 27, 1962,during the Cuban Missile Crisis. The wrecked engine of the U-2 is displayed below the missile.

“Outside of a dog, a book is man’s best friend. Inside of a dog it’s too dark to read.” ― Groucho Marx

About a year ago, two reviews of Annie Proulx’s novel, Barkskins, appeared in the New York Times. Neither was particularly favorable.

I bought an audiobook recording of the novel and have listened to it, all 26 hours of it, while driving up and down I-75 from Ann Arbor to the Upper Peninsula. I finished the last disc a few days ago driving west on M-28.

Two of Proulx’s previous works, The Shipping News and Brokeback Mountain, have won a Pultizer Prize and a National Book Award. Barkskins probably won’t scale those heights. Nonetheless, the book appealed to me at several levels.

First, Proulx is now over 80, and any octogenarian who has the dedication and energy to write and publish a 717 page novel spanning 300 years is OK in my estimation. Second, the tale is a prolonged, slowly intensifying, protest against the wholesale exploitation of natural resources for corporate profits. It’s a protest that might be more effective at a fraction of the length, but it certainly conveys the intensity of her feeling. At this stage of life, having intense feelings about issues seems to me extraordinarily admirable. And from time to time, she delivers positively lyrical descriptions.

Finally, though, I was drawn to her failure to get the story ended. I’m sure we have all sat through to one or another piece of classical music in which the audience raises its’ collective arms, ready to applaud and get the damn thing over with, only to have the orchestra continue on, repeatedly swelling toward but not achieving a grand finale. In the last chapters of Barkskins, Proulx just can’t stop the music.

Most stories often have natural endings. The detective solves the crime. The traveler returns home. The horse wins the race. But Barkskins won’t end for Annie.

I find that appealing. She doesn’t want to hang it up, to say, “There, that’s all I have to say about that.” Good for her!

I don’t think many Weekly Packet visitors will head to the local bookstore to buy this very long novel. You just won’t have time to read it. So, here’s an offer you can’t refuse. Anyone who is facing a long drive, for instance, New York to Los Angeles by way of New Orleans, can let me know. I’ll send the audiobook to the first reader I hear from. You’ll enjoy it.

Time Travel is REAL!

This time last week, I was in Havana.

This is not a report from last week. It is a report from the late 1950s or early 1960s. If you don’t want to take my word for it, read Carlos Manuel Alvarez in the New York Times. 

Packet-style breaking news from Cuba: we Americans have been involved in armed conflicts twice there, in the Spanish-American War in 1898 and in the 1961 Bay of Pigs invasion. The count so far looks like one and one. After 1898, Cuba shook off Spanish rule to become a unique and vibrant society, and most Cubans seem to view that intervention positively. Plus, San Juan Hill gave Theodore Roosevelt an enormous boost.

By the mid-1930s, Fulgencio Batista, strongman, dictator, and certainly a friend of the mob, consolidated his hold on Cuba. He eventually brought rampant gambling and widespread corruption to Cuba. Although the US government supported Batista, revolution was in the air by the mid-1950s. A young lawyer, Fidel Castro, and his brother Raoul, along with Che Guevara, led the successful overthrow of the Batista government in 1959.

In April of 1961, a Nicaragua-based, CIA-sponsored, 1400-man anti-Castro “brigade” invaded Cuba at the Bay of Pigs. The invasion was a disaster. Over 1100 of the brigade were captured. “14 were put on trial for crimes allegedly committed before the revolution, while the others were returned to the U.S. in exchange for medicine and food valued at U.S. $25 million. Castro’s victory was a powerful symbol across Latin America, but it also increased internal opposition primarily among the middle-class Cubans who had been detained in the run-up to the invasion. Although most were freed within a few days, many fled to the U.S., establishing themselves in Florida.” https://en.wikipedia.org/wiki/Fidel_Castro

Having seen the terrain around the Bay of Pigs, including the dense Cienaga de Zapata, it’s not hard to understand why the invasion stalled. Most Cubans seem to view the Bay of Pigs for what it was, a fiasco.

After the events of 1961, time stopped. In fact, with the fall of the Soviet Union, from 1990 to about 2000, time went backward. This was Cuba’s “Special Period,” when support from the Soviets ended and the entire country fell into dire straits, short of everything.

Today, what we saw was how Castro’s unrestrained idealism, with the best of intentions, nearly destroyed a country. Cubans have universal education, universal healthcare, and no homelessness. But in this society, the infrastructure has crumbled; housing stock has steadily deteriorated, and the highly educated are vastly under-employed and underpaid.

The current government has reduced restrictions on free enterprise. Independent restaurants, “paladars,” flourish in Havana (see the photos). Some restoration and refurbishing is happening. But the work to be done is daunting!

High points of the trip: the Hemingway museum at Finca Vigia  and the National Museum of Fine Arts in Havana.

If you click on any of the photos in this post, you should get a slide-show view that will have nice size and detail. I have almost 900 photos sitting in Lightroom; more to come.