NL:I must congratulate you for the Bywaters Award that you are going to received tonight at the Banquet, for your outstanding career devoted to basic research in the field of nephrology and dialysis. It is a great honor for me to interview you on this occasion. I am a long-standing admirer of your career. Your were born on July 17, 1929 and you were born in Bombay, India. I see from your curriculum vitae that you stayed in Bombay up to the year of 1945. Why did you leave India and go to Israel.
HE: My family had to make a big decision and that was to go to Canada or to go to Israel. The conditions and the atmosphere were such that it was after the War and we felt that we belonged to Israel and not to start again in Canada. So I suggested it to the family and you know something - they accepted it! We all went to Israel which was still in the making and I went to Lebanon to study at the American University of Beirut which was then at the height of its fame because there was no medical school in Jerusalem at that time. In fact there was no medical school in the whole of Israel or Palestine.
NL: So you started your studies then in Beirut and when did you decide to become a doctor? And why? Or is that too difficult a question?
HE: I remember an incident. I was in 7th grade when the Principal in the Scottish High School, Mr. MacKay came in and said, "I want to ask you all what are you going to be? Who is going to be a lawyer?" I did not feel that I wanted to be a lawyer. He said, "Who is going to be a doctor?" And I managed to put my hand up very shyly. Since then I believed this.
NL: Really [yes]. So how many hands went up in that class?
HE: I think only two. I cannot really remember.
NL: So your training at the American Universities in Beirut (already one of the most famous University in that area) was one of a traditional curriculum, with lots of theory and some clinical practice. How was that conceived?
HE: I think the American University of Beirut was an excellent university at the time. It had professors from the US who came on sabbatical years to spend time. The best of the best were there actually. And I was exposed to many good teachers. I am thankful to them. For example, one of the colorful teachers was Dr. Ryman of period disease fame - Rymanís peritonitis which later was called familial Mediterranean fever by my Israeli boss, Professor Hiller.
NL: So you started already, during your student years, to be interested in what later was a subject of great interest.
HE: Yes, kidney diseases. I was always attracted to kidney diseases and I remember that after a few years in Tel Hashomer, I asked to go to England with the help of the British Council - I was a British Council Scholar - to go to England to study kidney diseases with Professor Graham Bull.
NL: But before that you first had to train in medicine in England.
HE: Yes. There was an interesting incident. When I went to England I was very much impressed by pediatrics. And I said to the boss of the hospital, "I want to do pediatrics." He said, "But, you know why waste your time on pediatrics. You should do medicine." And my answer was, "Medicine I already know!" And he almost fell off his chair.
NL: So he did not consider pediatrics to be medicine.
HE: Well, it was for lady doctors, for young people. It was small medicine.
NL: Regarding the training for nephrologists - if I may jump now to the present time in Israel - because there is still a discussion being held in Europe - whether after graduation as a doctor or MD one could directly go into nephrology or should one have to pass several years in internal medicine. What are your feelings about this?
HE: My feeling is that nephrology is not technology of dialysis and I maintain that. I called our Unit "The Department of Nephrology" meaning that it has to be an all encompassing nephrology and not just dialysis. This brought me a lot of conflicts and contradictions with internal medicine. I didnít want us to be called only "Dialysis", just as the cardiologist would not call it cardiac catheterization. And dialysis is only a means of treatment. That why I maintained and I still maintain that any nephrologist has got to be a good internist before he goes into the specialty of nephrology. He has got to do some medicine - internal medicine - to know what is scarletina, what is familial Mediterranean fever, what is hypertension. All these have to be known so that when he is called on consultation, it is not going to be just "Is this a dialysis or not a dialysis?" Any nurse can do a dialysis. But he has got to give the overall nephrological diagnosis and approach to treatment.
NL: So after your training in Beirut you returned to Israel, to Tel Aviv, to the Tel Hashomer Government Hospital. Why is it called the Government Hospital? Is it a public hospital?
HE: I had an internship in Duke University in 1953 and I went to Geneva and from there to Paris where I bought a ticket from Cherbourg to New York. And a few days later I went to the ticket man and asked him to change it to Haifa. Of course it was by boat, because you didnít travel at the time by plane. I remember the face of the man. He said, "From west to east, whatís happening?" I said, "Never mind, Iíll go east." And I went to Tel Hashomer. It was then a Government hospital. When Ben Gurion, who was the first Prime Minister, founded of the State of Israel, he needed a general hospital. Not just a labor union hospital which existed at the time. So he went to Sheba, who was the chief physician of the Israeli Army and asked him to build a government hospital - something that will accept anybody -army personnel, civilians, tourists, Arabs, anybody who needed hospitalization. And thatís why it was called a government hospital. It even had a number - number 5. A few years later he changed the name to Tel Hashomer.
NL: What does Tel Hashomer mean?
HE: The Hill of the Guard. It is the little hill. It guarded the Tel Aviv area - the entrance to Tel Aviv and it was outside the city. This was the place that was chosen and it was in the beginning more of a military hospital, with a barracks that was built by the American Army to house the of the British who were withdrawing from attacks by Rommel. Rommel came up from Africa, invaded Egypt even, and the Allies needed a line of defence. The Germans had a pincer movement. They came from Greece and from Egypt. Thatís how this hospital was built. This was an army camp, hospital, everything.
NL: So the equipment and the comfort, which was at first a military hospital must not have been very adequate. A rough situation to work in.
HE: Yes. It was a very low standard in the beginning. Even when I joined in 1953 it was really very low standard and some others and myself tried to build up something that was worthwhile and I think that we did arrive at something which is nice. Today, the hospital is completely different. You would not recognize what was there.
NL: Before actually going to Tel Hashomer, you trained in nephrology in Belfast. Now it struck me when I read your curriculum vitae that you have been trained in what have been, in recent history, two rather violent cities - Beirut and Belfast. If you look back at these periods, you told me at those times they were peaceful cities.
HE: Beirut was a beautiful city. Very peaceful. You could go anywhere. You would neither be attacked nor robbed nor anything. And I studied in that city and today it is transformed into a violent city. When I went to Belfast, it too was a beautiful city but when I left it, it became violent also.
NL: Anything to do with you?!
HE: Nothing to do with me. But I studied in these two cities and unfortunately these two cities became violent.
NL: What made you choose Belfast?
HE: I did not choose Belfast. I chose Professor Bull. I got a British Council Scholarship but it is in Belfast. I asked "Where is that exactly? I know itís in the North." Then they told me it was in Northern Ireland. So I went there with my wife - we were a young couple without children. I heard a name coming up again and again - Ulster. I said "Ulster must be a very rich man." Of course, this is the name of Northern Ireland.
NL: For what was Professor Bull famous? It was for his work in acute renal failure but what else did you learn particularly in Belfast
HE: Professor Bull was a young promising Professor who described in 1950-51 acute tubular necrosis and he published this work in the Lancet and then he published in the British Medical Journal work on the concealed accidental hemorrhage as a cause of acute renal failure. So he was well known for acute renal failure and he treated acute renal failure by the "Bull Regime" which contained no protein because he wanted to tide over the patient, over his illness to keep him alive because dialysis had not yet started. It started when I was there and I did my first dialysis with Mary McKuen who has now retired in the Belfast City Hospital.
NL: You must have had peritoneal dialysis at that time or was that later?
HE: He did not use it. It was used in Boston but Bull did not use it. I donít know why.
NL: So he knew that in cases of acute tubular necrosis, as it was called (or mis-called actually) that when the patient survived that there was full recovery.
HE: Yes. He knew that there was full recovery if you could tide the patient over. And this was his problem. Thatís why he formed the "Bull Regime" and kept them in an isolated room and you had to wear a mask and gloves to treat the patient, so that they would not be infected.
NL: So did you know about the infection being one of the major causes of death?
HE: Oh yes. The oliguric phase, the polyuric phase and all that sort of thing was well realized by Bull but somehow he did not go into dialysis, even though dialysis existed in the Korean War. They took artificial kidneys in 1951 but he did not use it. It was 1958-59 that I spent these years with him but towards the end, he did influence the Belfast City Hospital to get the artificial kidney.
NL: How was he as a person?
HE: Lovely person. Very nice, pleasant. Very English of course. He was born in Burma.
NL: How would you define your relationship with him? We all have a picture of what being English is? How would you define him?
HE: With a dry sense of humor. Very cut, polite. I met him again in Tanzania. He was the advisor on medical schools to the British Government. He was invited by Julius Nerere to Dar es Salaam and I was there at the East African Conference on Kidney Diseases.
NL: It must have been one of the first organized meetings.
NL: Why were you invited there? You were already famous at that time.
HE: Dr. Sheba was the boss of our hospital. He came to me one day and said, "Do you have anything to present scientifically?" I said, "Why?" He said, "We donít want the Egyptians to come. We want to participate in the East Africa Conference on Kidney Diseases." I said, "I will present something on the concentration of the urea in acute renal failure." He said, "Go ahead, this is yours." Thatís how I went. I was sent actually as a government employee and succeeded in presenting a paper which was quite well taken and the Egyptians did not participate because of that.
NL: Because you went?
NL:Things have changed since then.
HE: Fortunately, it has changed, yes.
NL: When you then came back after your training in Belfast, I read in your curriculum vitae that you actually were associated with the Institute of Cardiology and that you were very well known for performing cardiac cathetherizations. So you almost took the wrong road and went in the direction of cardiology or is that a misinterpretation?
HE: No. When I came back, Sheba, as he was called, the parental, benevolent dictator - the Director of the Hospital - said, "Youíre already big. What do you want to do?" And I said, "I want to do nephrology." and he said, "Whatís that?" And you know something, I did not know exactly was it is myself!
NL: It has been said that the name "Nephrology" originated from Hamburger.
HE: Yes. I copied the name "Nephrology" from Hamburger before meeting him. But I heard that he said "Nephrology" and I liked the word because it not only is dialysis, it is much more than that. And he said, "You know, in the Bible, it is written, "God is the Examiner of kidneys and of the heart. So you do both. You do the heart first, that is what we need now and you do the kidneys in the evenings in your spare time." I did the dialyses were done at night. Of course, it was not accepted because at the time, even our obstetrician, who was a very famous man, decided that we didnít need dialysis. They are no acute renal failures in obstetrics! I was shocked to hear that. They did not know how to diagnose it. So, I did the cardiology at a price to pay to do nephrology.
NL: You were the only one then in the so-called Department of Nephrology or were there other young doctors?
HE: No. I was the only one for a number of years. I think up to 1965-66.
NL: And where did you learn the technology of dialysis?
HE: The first dialysis was done with Mary McKuen, as I said before, at the Belfast City Hospital. Then when I came back, I knew how to do it and I asked them to buy the machine. The machine was bought and It was left in Customs. They waited to pay $100 or so to take it out of Customs. At that time a soldier girl was operated on because of her appendix. The appendix was ruptured. She developed peritonitis. After that she developed acute renal failure and I told them that this is acute renal failure and it needs dialysis but I was quite junior at the time. They listened to me but then they said that they didnít have an artificial kidney, what shall we do? In Jerusalem there is an artificial kidney. At the time this was the first helicopter evacuation. They took the soldier girl in this little Alouette helicopter with was given as a present by the French Government to the Israelis - I think the only helicopter and she was taken to the so-called Da.......... Square - a little Square in the city of Jerusalem. Because the Jerusalem people did not know that they should do a dialysis in the evening, they said we will do it tomorrow morning. And she died of hyperkalemia. Then her uncle came and with a $100 he told Dr. Sheba, "Hereís the hundred dollars so that others can profit." This was a dramatic moment and after that we got an artificial kidney.
NL: You realize now how many patients actually died unnecessarily during this stage.
HE: This is the problem of administrative power. You cannot overcome it so easily. I think sometimes administrators instead of serving you, they think that you should serve them. And here I would like to bring my resentment against this attitude. I think that medicine is the thing that counts and I would like to bring my belief that the administrator is there to help you and not to tell you what to do. Sometimes this border is not so sharp and they expect of you as a doctor to serve the economics or political-economics and then they dictate to you what to do and unfortunately many people have died because of lack of knowledge, because of misdiagnosis, because of misunderstanding and I hope that things will change into a better way.
NL: You started dialysis in Tel Hashomer after the $100 were paid and the artificial kidney was moved into the hospital. You had to train the nursing staff also in dialysis. Did you do that yourself?
HE: Yes. In the beginning I did almost everything myself. There was an interesting story that ................ had a grandchild. And his grandchild liked racing automobiles. And he had an accident in France. He was transported to London to be treated by dialysis and he was saved by Mr. Ralph S....man, a surgeon, who operated the artificial kidney at the time and then he was given a present to come to Israel for two weeks at the expense of the ............... family of Marks and Spencers. When he came to Israel he was asked to help Eliahou to do the dialysis. And you know something, in retrospect, he did not know how to do the dialysis himself. I think the nurses did it. I helped him rather than he helped me but it was an initiation. We did dialysis on an Arab girl who had hemolytic anemia and we saved the girl. Since then I became for the next three or four years before my colleagues, Ori Better and Rosenfeld, came, I was the only who did dialysis for acute renal failure and that started my career really.
NL: You must have worked 30 hours per 24. I mean if you did the routine things in cardiology and in internal medicine, I suppose, during the day and then at night these dialyses and the rest of the kidney diseases, you must have been working very very hard.
HE: But we enjoyed working at the time. We used to start at 7 in the morning and finish at 8 in the evening. We enjoyed it. My wife was a nurse at the same hospital and we even lived in the hospital compound and we enjoyed that. That was time worth spending. It was really a joy to do a lot of work at the time.
NL: When did you start your university career as a professor and teacher? How has the system in Israel changed over the years? You said that when you started there was no medical faculty.
HE: Yes. Late in the 50s the Jerusalem University opened up and some how the Jerusalem people looked down upon the people who were "on the hill", "near the sea". Quite a group got together and formed the Tel Aviv University. In the middle of the 60s I became a member of that University as a Senior Lecturer and worked my way up. The first scientific work which I did was with Professor Bull on atrial stretch receptors which today is actually atrial naturietic peptides.
NL: And was did you do with this?
HE: There was a group in the US, Gower and Henry. They decided that the atrium influences diuresis and we wanted to see if that is true. So Bull said make some stretch receptors. I said, "How can you measure stretch. You cannot." But then they invented a new technology the silicone rubber tubes which were very thin and he said put graphite in it. I put graphite in it and I did not get oscillations. So the only thing I could do was use mercury and as the mercury was stretched, the resistance went up and I got an oscillation. This amplitude of oscillation was correlated with diuresis.
NL: You have described that somewhere?
HE: Yes. With Bull.
NL: So at that time Bull had ............................... research unit
HE: Yes. He had two units. He was at the Queens University of Belfast and he was in the Institute of Clinical Science. He called it the Institute of Clinical Science and there he did his research and the unit was a hospital unit of the Department of Medicine. It was in the Royal Victoria Hospital in Belfast. There I studied kidney biopsy procedures and the first kidney biopsy I did with trepidation and they told me I was waiting for the answer hung in the room in a frame and they told me, "Look at it. Normal liver!"
HE: When I came to Israel they wanted to prove that familial Mediterranean fever had affected the kidney because they didnít know what was affecting the kidney. Later on we knew that it was amyloidosis and they depended upon me to do the biopsies. I must say it was not very easy to do the biopsies with a Vim-Silverman needle. If I compare todayís technology with the spring action, it was really very bad.
NL: So at the University then you became a teacher of teachers because you started a real school where foreign fellows and also Israeli fellows were trained. Do you have any idea how many fellows you actually educated and trained in research and clinical nephrology? Did you ever count them?
HE: No I didnít count them but there were a few who came from Israel and from abroad. The person whom I liked very much, for example, in the beginning, from Yugoslavia, Dr. ........., he came to me. He was older than me - I was a young doctor. I diagnosed acute renal failure by the osmometer. ..................................... osmotic urine and plasma together with high urine sodium and oliguria. And I said, "Letís publish our first 25 or 30 cases of acute tubular necrosis. He said, "No, donít do that. The methodology you have is more important." And thatís how I described the diagnosis of acute renal failure in the nephron which was published in 1965.
NL: So it started a whole range of publications. I didnít count them but there are numerous and they are still going on up until the present. Letís come back to your University career. Normally in University you have three jobs, yes? You have your teaching job, you are also a doctor and of course you have to be an administrator. How would you consider yourself as a manager of a renal division?
HE: I always wanted to do medicine and less administration. The administration was kept to a minimum by myself and thatís what caused certain frictions with the real administration. Because I wanted to develop things. I wanted to have freedom of research, freedom of development. I still believe that the freedom of research and development have to be given to the doctor. An example of this friction is when Dr. Sheba came to me and he said "Stop running! Donít run! The army goes by the slowest soldier." And I remember answering him, "If there is someone running, run after him and learn from him and donít make him go below his abilities." I was still a believer that we should run forward if we could because when you see the light suddenly, it comes and goes. It doesnít stay with you. You might have it this year, you might have 10 years later but it will go. So you should catch this bright brainstorm of the young man who is developing it and try to give him all the facilities to develop that bright brainstorm which he has. For example, I would like to stress that in "grantsmanship", when you apply for a grant, you have got to follow strict rules to get your grant. You must tell them what you are going to find. This is not real research. Research comes as a bright idea and you can never plan it - very rarely anywhere.
NL: Besides brains and intelligence, one also needs lots of money and sophisticated equipment to do research. How is the situation nowadays in Israel for public and private funding of research especially in nephrology?
HE: Itís difficult. Itís not easy like other places. The big funds come from the two countries - the USA and the German government. This is the Binational Fund. The Binational Fund is that if you have a collaborator in that country then he can, together with you, apply for a grant. If you have a local person and a German person or a local person and an American person and you apply to the Binational Foundation and then you are funded generously. Usually you can receive up to $80,000 which locally you cannot get. There are problems. For example, out 600 applications, only 50 will be funded from the Binational US/Israel Foundation.
NL: Are there other means of funding in the State of Israel?
HE: Yes. When you need funds of around $5000-$10000 you can find this more easily but big research projects need to comply with all the bureaucracy and the conditions of the Binational foundations and this means filling out forms, applying only once a year, not more. Itís not easy.
NL: Do you have an important teaching task. I mean in hours per week for the students. How is nephrology taught at the undergraduate student level at your institution or elsewhere in Israel? Is it part of a general medicine course or is it separate?
HE: For many years I have prepared the exams for nephrology and I always looked at nephrology as something that I mentioned. I copied the words from Hamburger and they became a reality. It became a profession with examinations and I did not expect. Anyway I did the tests and we had to do two years of nephrology in a recognized nephrological unit and here there were problems. I maintained that every nephrological unit should have not only the dialysis unit, but also all of nephrology including a lab which served the purpose of development to develop the things needed by this unit. I think I succeeded and we do have labs everywhere. So that later on, as things developed, it became an established profession with exams, with teaching, with a syllabus and you had to do it but though there are many forces that try to minimize and say go into nephrology without going into internal medicine. The reason why they want to go into nephrology without internal medicine is that during internal medicine you might lose some of the people - they may enter another specialty. But this is not true because you are developing technicians and not a well-rounded physicians. Thatís why I think the syllabus of the University must have at least 2-3 years of internal medicine before the person goes into nephrology. I would like to see the nephrologist go into a consultation knowing what he is talking about and not just dialyzing or not dialyzing.
NL: So we have covered your teaching role, we covered a little bit of your management role. Now you are not only a researcher but also an excellent clinician. You must have had in your rich career quite some patients whose lives were saved by you. Can you remember some illustrious patients that you have saved or may be helped pass away, as they say in North America. At least one name comes to my mind but I will let you say it.
HE: Oh Moshe Dayan. In 1968 Moshe Dayan gave the order for the Army to go into Jordan and attack a certain area. To relax himself he went on an archaeological die. The hill caved in on him and he was buried alive under the rubble or the earth. Nearby there was a person, a farmer. He saw it and rushed and with his own hands opened a space so he could breath until help came. He was taken to our hospital.
He didn't have urine and that is why I was called immediately. At the time I toyed with the idea that if you catch acute renal in its incipient stage when the urine osmolality was still more than the blood's, like 350 as opposed to 300 you could save the patient by giving the osmotic diuretic, mannitol. I went to Moshe Dayan, I catheterized him, took some urine out, and wanted to send the urine to the lab. I looked around me to see if I could ask anyone for help to rush to the lab. And there was the Prime Minister, the Foreign Minister, the Minister of Internal Affairs, the whole Government was there. So I had to take the urine myself to do the osmolality. And there it was quite high, higher than the blood. I gave him some mannitol and some saline. He passed urine and I saved him from dialysis!
But the interesting story comes a couple of days later. He had a mediastinal hematoma because of fractures of vertebrae. I think it was thoracic 7-8 or 8-9 and you could see the whole area on the X-ray was blurred. It was a big, hematoma.
They called me at four o'clock in the morning. I said, "What happened?" They said, "We cannot find a carotid artery and the left hand has no pulse, no blood pressure. So we are going to call Debakey from Texas who is on standby to come and operate on his dissecting aneurysm!" And I was really sleepy. I said, "Can I examine the patient?". His patch was on the left side. The door was on the left side.
So I came in from the Ieft and to see me he turned around to see me with the good eye covering his carotid altogether. He told me, "Hello, Good morning." And I said, "Please could you look at the right side?" And like a good soldier he turned completely to the right side. And there was the carotid artery! I asked for the sphygmomanometer and they gave me two: one for the right hand and one for the left hand! I said, "No! Only one, please!" And on the right side there was blood pressure and on the left side there was blood pressure, 140 systolic! And it seemed that the sphygmomanometer with which they did the blood pressure on the left hand was blocked by plastic because it was new. For Moshe Dayan they would take a new one. It was blocked and that was how they found zero blood pressure!
He was very stoic, regimented, military-like. He did exactly what he was told. He woke up every day at 6 AM precisely to listen to the news from Cyprus, the BBC news. At the time our army was stuck in Jordan, some tanks had to be abandoned and he was giving the orders as if I was not doing anything. I was taking blood, I was measuring blood pressure. He was just letting this alone, letting us do what we needed, and he gave the orders. He was working.
The nurse who worked next to me was a lovely, nice-looking girl, who was born in Alexandria. The next day I came to her and said, "Maxa, did he pinch you?" She said, "No." I said "He is not well." And when she said "yes" then I knew he was recovered.
NL: In the clinical field of acute renal failure you were and still are a great believer in the prevention of acute renal failure. How many times could you actually do that by measuring the urine osmolality, defraction .................. of sodium, giving the .................. and the mannitol because that still is very valid today. I recall an episode with a soldier or a pilot who was shot down in 1970. I think this is a very instructive story also.
HE: In 1970 a pilot was shot down over Egpt, over the Suez Canal. He was on a mission and he was injured. He was captured by the Egyptians. He had amputation of the leg, the reason for which I do not know. An young Egyptian doctor decided that he would save his life by dialysis. So he did the dialysis with the arteriovenous shunt on one hand. The second dialysis on the other hand, and the third dialysis on one foot. And after that he told his army personnel, "That's it. He doesn't have any more accesses and he is going to die."
There was heavy pressure on the Egyptian Government by the Israeli Government through other countries to release the prisoner. They asked me "What should we do?" and I said, "Call Niels Alwall from Sweden. He is the adviser to the military of Egypt on kidney diseases." They told me to stay home, not to go out and we were going to a neutral country. And the next day they told me, "We are going to Nicosia, Cyprus and we are going to take everything with us". So I took an artificial kidney, I took the lab. I almost emptied everything in the Department and went into the plane.
We went to Nicosia. The plane was noisy and shaky. They were all in uniform. I wasn't. I was a civilian. I stayed aside. I brought my long lens and camera to photograph the event. And then suddenly the UN officers told us, "The Egyptian plane is coming and bringing the prisoner. You better go and line up under the wing of your aircraft." We were given the order and we went and lined up with police protecting us.
The plane - a little plane - came and landed between two huge airplanes. They started marching, the UN people, towards the Egyptian plane and then suddenly they come back and say "But we need someone to come and take the prisoner!" And the commander looked around, looked at me and said "You! You go!". I said, "Why me? I am a doctor." He said, "You are the only one in civilian clothes. If they kidnap you it is not a problem. If they kidnap an Army personnel it is a problem."
So I had to go. I said, "You take the camera. You take the photographs. I'll go." I held the door and said "Anybody home?" But they did not care. They helped me take the prisoner. And the moment we took him we started working on him: We gave him an infusion. We took him to the dialysis unit immediately. I think it took less than an hour between the release of the prisoner to good dialysis at Tel Hashomer. We landed at the Lud airport. A helicopter waited. The ramp went down from both and the pilot was taken into the helicopter. Before the door closed they flew up. They were in the air.
We gave him an infusion right there and then. And he was put on dialysis from Saturday to Thursday nonstop. I operated on him higher up and used continuous dialysis. At the time it was not known and I wanted to reduce his hypercatabolism as much as I could. He was septic. He had a catheter. His urine was mucky with a lot of pus. We washed it and I remember we used neomycin solution. We did some debridement on his amputation. And he recovered and he became a doctor!
NL: Do you still have contact with him?
NL: That is fantastic. Did you ever meet the Egyptian colleague?
HE: No I never met him.
NL: besides these dramatic stories of patients, you must also know that in the academic nephrological world that you are frequently quoted and highly esteemed. You must also have met besides Professor Bull who was your mentor, other very famous, letís say founding fathers of nephrology. I know that at a given time, Gabriel Richet came to Israel and Jean Hamburger cam to Israel. Did you have a chance to meet them there and to appreciate or have other feelings about them?
HE: In 1968 Hamburger, Richet and Gra...... from Lyons came on a Government mission to Israel on a lecture tour but they were given the order to speak only in French. They were not allowed to speak in English because it was De Gaulleís time and he was very adamant about French fame and so on and so they came to Israel and they gave talks in Jerusalem, Tel Aviv and Haifa. I found it difficult to relate to Hamburger. he was too high up. Too lofty. Richet was warmer and ............. was a neutral person but Richet was a warm person. He understood us, he sympathized with us. But then there were established nephrologists of international fame and I was just sort of someone trying to find his way amongst all the developments that were happening.
NL: So you didnít have a long-standing relationship with Jean Hamburger? Was this the only occasion when you met him?
HE: No. I met him in his Unit in Paris. That was very dramatic also. He was in the centre of a kind of semi-circle. On the right and on the left you had his associates and assistants ("The Court") and there was a bed. And this little woman comes in a says, "Monsieur Le Professeur". She had a dialysis or transplant. He would say, "Suppose we examine Mademoiselle" and immediately the nurses would undress her and another doctor would come out from the side. "And suppose we give her this and that." Immediately the others were right in listening to him. It was very interesting.
NL: You were instrumental in the creation and also in the continuation of the ISN Disaster Relief Task Force. I am also involved in that, as you know but still other quite famous nephrologists are quite skeptical about this whole affairs, about this initiative of the ISN Commission on Acute Renal Failure. I know you are in favor of it but why should they remain skeptical? Do you have any ideas about that?
HE: I think that the other people are really looking at the nephrologist as a person who would sit in an easy chair and do the dialysis when necessary - to give the orders, to be in his castle, in his ivory tower. My background dictates to me that if you want to do anything, you have got to go into the field, give the diffusions right there and then, before you remove the patient from the rubble or from whatever disaster that happens. That is why I urged Kim Solez that we should not become only people who would come late to a disaster. We want to come early. We want to play a part in the prevention. We want to deal with the acute phase of the injury and not stand by and do only dialysis. This will bring us to something which is of quite political importance. Is acute renal failure going to be treated by intensivists without the nephrologists. This is a problem because if you stand back, there is no vacuum in life. Immediately it is taken by someone else and the intensivists, whoever, are going to take over. I think the nephrologist is going to be important. If he wants to keep his acute renal failure field, he has got to go to the field, to the site of injury to give the infusion, to make the diagnosis, to prevent acute renal failure
I have a feeling that you are not going to need dialysis in disasters. I have a feeling that our Task Force should aim more at prevention. Beside infusions and mannitol, which worked for so many years, we have a new treatment and that is the natriuretic agents, the atrial natriuretic peptides, what is called oriculin? Better still urodilatin? The Hanover Group is using urodilatin to prevent acute renal failure in liver transplants. Why shouldnít we use. It is true that we should not use the disaster area as an experimental ground but I think within a year or two this is not going to be experimental and I have a feeling that this is an answer to acute renal failure. So that I want to keep this within nephrology. Just like I want to keep hypertension in nephrology.
NL: Another battlefield?
HE: Another battlefield which I won. The Israeli Society of Nephrology is called "The Israeli Society of Nephrology and Hypertension. I have published on obesity in hypertension without salt restriction and I am presently publishing a paper, in the American Journal of Medicine, on insulin causing hypertrophy of the coronary media and causing hypertension in the spontaneously hypertensive rat or in the predisposed hypertensive patient with a genetic background. That means I am a great believer that, if I have to be a good nephrologist, I have got to be a good internist as well as a hypertension specialist. I think that hypertension belong to nephrology and not to another field.
NL: We have just had the very successful ISN meeting in Madrid. We are now here in Barcelona for another very successful meeting on Acute Renal Failure. When you look back (and you have lived the history of the international community of nephrology), are you satisfied with the evolution of our Society? Would you recommend some changes or give some directions to take? There is a tendency that the ISN is devoting efforts and money to the developing countries. Do you agree with this?
HE: I am a great believer in the International Society of Nephrology. I think it has done a lot. I did not want the Task Force to become a separate Society of Acute Renal Failure. I maintain that we should be within the ISN and I hope that we will remain. I am a great believer in the ISN, not only in the scientific field. The scientific field is a different world for those who are interested. I think it helped a lot in the formation of nephrology and to save the acute renal failure patients in developing countries. We are still needed there. It is hard for me to hear that cholera should cause acute renal failure, or a snake bite should cause acute renal failure in India. Today, I would accept acute renal failure if you do sophisticated cardiac surgery or bone marrow transplantation but I would not want to hear that a poor person bitten by a snake should develop acute renal failure and should have a mortality of 60-80%. Therefore, we are needed for the developing countries and I believe and always have that the better the services, the higher the mortality in acute renal failure.
NL: This you have to explain!
HE: You have good evacuation services, and good treatment to prevent acute renal failure in the milder cases. If you have good services, you are left only with the very very bad cases who are going to die anyway from the basic injury. So the better the services, the higher the mortality rate in ARF.
NL: Do you believe that the efforts that are going to take place in the near future in trying to establish a scoring system for severity of illness and that patients who are going to die anyway perhaps should not be started on treatment? Do you believe in this concept?
HE: I donít think that we should do the scoring system to decide on treatment. Things change. They will change for the better. What you score today is no good tomorrow. It is going to change. You should not use the scoring system as a parameter by which you judge if you are going to give treatment or not. You should use it to compare patients between one unit and another and the certain classifications. What is going to happen if a give too much treatment? Today dialysis is available. It is not rare. I can always call on the chronic unit and within a couple hours, I have solved the problem. So I give 4 dialyses more, 10 dialyses more, letís say 100 per year more and I am relieved of the task of playing God - who is going to live and who is not going to live?
I want to mention that in the early 70s, when we developed the chronic renal failure treatment, I was forced, for a while, to be a member of a group which would decide would is going to have dialysis and who is not because there were not enough available spaces. I remember my resentment and I remember a certain friction between the administration who told me, "You have got to be there." I said, "I donít want to be there because I will choose everybody for dialysis.
For example, there was a young woman, who was pregnant and they asked me if I wanted her to continue with the pregnancy. She had a kidney disease. I said "No. She will accelerate her nephritis. You have got to stop this pregnancy." So they performed an abortion. A couple of years later she came up for dialysis. I said, "You cannot take this woman because she has no children. You have a woman who has four children. She comes first." The Head of the Department came to me and said, "You have done harm to this woman twice. You stopped her from having a child and now you prevent her from taking dialysis." This I will not forget.
NL: I would like to spent a short time discussing what you are doing now? I know that you have retired from your official duties at Tel Hashomer. I know that you are still very very busy in research and probably also in patient care. Can you fill up your days now that you are officially retired?
HE: I would like now to make a strong point. I hope it will not hurt anybody. I do not believe in retirement. I do not believe in administrators who force you to retire. I resent that. I will combat it in every way I can. I continue to work as long as God gives me the health to work. I will continue to progress in my profession where ever I can find the background for it. I believe, as I said before, that those who are administrators are there to serve me and not me to serve them. They make the mistake of not knowing the borders and limitations.
I have developed now a system in which I do my research in another hospital, basic research in hypertension and in acute renal failure. We have just finished work on insulin in hypertension. We are continuing it. Thatís research - it does not make money. It costs money.
Then, on the other side, I have developed a private dialysis centre. It is smaller than Tel Hashomer which numbers 140 patients. Now I have about 20 patients. I can remember their names and I will try to give them the best service I can. I believe in the prevention of chronic renal failure by proper hydration and the work that was done by Liz Bankir, for example, on hydration delaying the progression of chronic renal failure is of note and I follow that. And my specialty now is to delay rather than accelerate the need for dialysis as much as I can within my limitations. I hope that within the near future, we will have developed better drugs, antiinflammatory drugs or antinephritic drugs to delay the progression of chronic renal failure and decrease the need for dialysis.
NL: Before we conclude this interview, there is one problem that I would like to discuss with you. This is the problem of renal transplantation, particularly in Israel. If you look at the numbers, as you know they participate in the EDTA Registry, I think that transplantation is not so high in Israel as you would expect from a country with that standard of living. Is there any particular reason for that? Is there a religious reason for that? I know, for example, that some Israeli people come to Belgium to be transplanted.
HE: It is a small country - 5 million more or less. The number of transplants come to 120. That means just over 20-25 per million. It is rather small. The religious groups do not allow organs to be taken from the body. In the early 80s, I tried to fight that law that came into being I wanted to ask the family. It was enough if one said "no". Then we should not transplant and we do not take the organ. That law came into being because it was a political issue but I have fought it quite a lot in the early 80s. I went up to Jerusalem and had even a chair in Knesset where I used to go every morning and shout and follow the debates. This is history now. The rule is that you should ask the family. If you cannot find anybody for a reasonable amount of hours, like 6 or 8 hours then you can take the organs. I believe that you really should ask the family. I do not believe in snatching organs. And I think we need to educate the public more. Somehow we have a problem with the religious groups who do not want to give the organs.
NL: It happens quite often that a country like Israel that the religious sentiments are so strong, which of course everybody respects. But this must cause some conflicts for a doctors, who really wants to give priority to a given problem. Does this create a moral dilemma sometimes?
HE: Yes. Many times when the very religious person needs a kidney, and you tell him "I want to take from this person." He doesnít want to see, he doesnít want to hear. You can take it from anybody you want. It is just like going into a ham shop and asking for some chicken. The sales clerk says, "You mean ham sir?" The buyer says, "I did not ask you what it is. I asked for chicken." It is a problem and it will take time but there are people from Israel who go abroad to look for kidneys and livers and hearts.
NL: I think we must come to a conclusion and I think the obvious last question that I should ask you is: If you look back at your career, you are in an extremely good position to give advice to young people. What would be your recommendations to a brilliant young doctor who says "I want to do nephrology. What kind of attitude should I have? " Can you based on your experience say "Donít do that but do this" or any other comments?
HE: I would like to tell my young colleagues that if you want to be a nephrologist, donít aim at a low standard. Go and do internal medicine, go and specialize in a good lab and then become a nephrologist, so that you will not stand helpless when you are presented with a patient. You will know about everything. The antibiotics that you use, the NSAIDS, the physiology, the pathology, the heart transplantation, the cardiac output, you know what an ejection fraction is and you will not just stand there and have someone tell you what the ejection fraction is. So learn a little more before you become a nephrologist and when you do become nephrologist, try to be independent, try to help your fellow man and try to give the best service you can but do not be pressured by those people who hold the money - economics politics - it is a problem sometimes. Try to go in between the drops, so to speak and not to get wet and do the best you can for the patients because after all it is the patient who we care for. All our stimuli should come from the patientís needs - for research, for development. We donít need to do research on something theoretical. We still need the practical aspects. That is what I would tell my colleagues.
NL: Can I ask you a last question - Are you a grandfather?
HE: Yes. I became a grandfather last year. I have one grandson.
NL: Would you advise him to become a doctor?
HE: My daughter is studying medicine. She thinks that the medicine we are doing is not good enough and she wants to combine the Chinese medicine with the classical medicine - the alternative medicine with the classical medicine. I wish her success but I told her that if she wants to do medicine, you have to know the classical medicine first. In the back of my mind, I hope that she will stick to classical medicine.
NL: Haskel, thank you, for me least, a very very excellent hour that we passed today.
HE: Can I tell you just one little story about Mrs. Karyonides. Mrs. Karyonides was from the Isle of Rhodes and her husband, who owned a shipping company and a hotel and a bus company, brought her to me. He said, "I donít want her to go into dialysis. She has chronic renal failure." I then found out - what gave me a big push - that she was a salt loser. She was going into hypochloremia and going into uremia. The moment you gave her a liter of salt, everything was fine. She used to come every year by boat and we were invited to go to Rhodes. It took 10 years before she really needed dialysis. In the meantime, her husband died and Mrs. Karyonides now is on dialysis on the Isle of Rhodes but not in 1980 as her doctors wanted. She started after 1991-92. So that is one of the things that I do for the prevention of renal failure.
NL: Thank you very much.