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Ori Better Transcripts
Introduction by Dr. Eknoyan
GE: Born in 1928 in Haifa, in what was then Palestine, Ori Better witnessed its transfer
to what is now Israel. It is there that he graduated from medical school, from the
Hadassah Hebrew University medical school, in Jerusalem, in 1957. Inherently bright,
and a pioneering spirit, he went on to be on to be one of the founding fathers of
nephrology in Israel, particularly in his northern part of the country that was native to
him. In the process, he contributed to the emerging world nephrology community of the
1960’s, and helped focused its attention on the nascent nephrology discipline in Israel.
His interest in homeostatic role of the kidney, and ability to pose questions and resolve
important clinical issues, were evident from the outset when, he elected to dedicate
himself to collaborative studies on salt and water preservation in the Negev desert
where he studied the role of the kidney in homeostasis, at the site that is close to what
was then the biblical Sodom and Gomorrah.
Since then, he has continued to do good work, under adverse conditions, andcontributed to the understanding of the homeostatic process of the kidney. Uponcompletion of his service, he went to Cedar Sinai Hospital, in Los Angeles, for his firstformal exposure to a Nephrology training program in the United States. There, heworked with Chuck Kleeman, himself a student of John Peters, and one of the foundersof American nephrology and world leaders in the study of metabolism. Over the years,Ori expanded on his exposure to American nephrology training programs, byintermittently spending time at Georgetown, University of Utah, University of Colorado,Yale, and State University of New York in Stonybrook. He did this while establishing thefirst nephrology program in Northern Israel at the Rambam Hospital in Haifa, where hewas chief of nephrology from 1959 to 1993. In the process, he founded the renaltransplant program that performed the first cadaveric transplant in Israel in 1965. At thebroader level, and again under the leadership of Professor Ehrlich he helped in theestablishment of the Faculty of Medicine at the Technion Israel Institute of Technologyin Haifa in 1971, becoming dean of its medical faculty in 1983. In 1985, he wasappointed Annie Chutick Professor of Medicine, a title he still holds. In 1993, he retiredfrom his administrative responsibilities to devote himself to research as head of theRebecca Chutick Crush Syndrome Center. His work there has made him a sought afterworld consultant on post-traumatic soft-tissue injury.
Prior to his ultimate focus on this problem, and during the course of his flowery career,Ori has made important and seminal contributions to liver-kidney relationships, acid-base balance, particularly type 4 renal tubular acidosis, function of the post-transplantkidney, divalent ion metabolism, and obstructive nephropathy. Most of his work hascentered on human clinical research, using readily available techniques, and alwaysfocused on questions raised at the bedside. In fact, it is at the bedside that the uniqueattributes of Ori are most evident, as a first-rate physician, and teacher. He isworshipped by his patients, and adored by his students, and trainees. This is based asmuch on his vast medical knowledge that he shares freely, as his uniquely warmpersonality, that endears him to anyone who comes in contact with him. It is this that
has made him also a sought after friend and colleague of the international nephrologycommunity. It is a special pleasure for me to conduct this interview of Ori Better, for theVideo Legacy Program of the International Society of Nephrology.
Beginnings in Medicine and Nephrology
OB: Well I have been always interested in natural sciences. In medicine you have a
unique opportunity to be immersed in natural sciences, and, at the same time, help
people. So it’s the most beautiful career one can think of, so it came naturally to me.
I was interested always in the outdoors, in the sea, and in the desert. I am an avidsailor, and I have sailed many times from Haifa to the islands, which we just visitedtogether. Now when you are at sea, and these days were at the ends of World War II,there were people still stranded at sea, and the problem of desiccation, and salt andwater balance were important. There were several scientists in Harvard, if I remembertheir names, Dero, and another one, most of them were pediatric people – they werevery busy in designing the solution that people should take with them on rafts, in casethere was trouble, and of course desiccation in the desert. So I became very, veryinterested in that, volume regulation, and how to protect yourself against desiccation.
Then when I was in the Negev, in the desert, I was full of admiration to the solution thatnature chose to protect against hyperthermia, and against water deprivation, the cameland the goat. The goat and the camel can go for days without any water supply,whereas the dog will die in four hours because of the heat and the water problem. Sothis interested me very much, and in the first years at the start of my work as a youngphysician, there was no nephrology discipline, but I was still interested in volumeregulation, acid-base regulation, renal metabolism, and it was relatively easy to study inthose years. You could take blood, you could take urine, later do a biopsy, and youcould do enough studies in an emerging tough place like Israel, to put it in place, to takethe results and print them in the best American journals of that time, like Annals ofInternal Medicine, and even the New England, and even the JCI. It was difficult to do itin cardiology, in pulmonology, in hepatology, because you needed too much. Youcouldn’t do it with your own two hands, and you almost didn’t need to ask any consentfrom the patients because anyway you took urine and you took blood. So this put meimmediately in the direction of salt and water and volume.
GE: This was before the days that nephrology came into being. This was when renalphysiology was coming into being as a discipline, and metabolic studies were the way tolook at things.
OB: Right you are, but then suddenly, I found myself, like sitting in a rocket coming outof Kennedy missile range. Suddenly every one of us who was there were catapultedup, because the artificial kidney came into being, transplantation, and everyone whowas inside was really moved, whether he wanted to or not, whether he was bright ornot, when he was there he was moved with the current. So we went along with this,and this was very, very, very, very helpful. Suddenly you found, like in sailing, a goodwind, a good current that carried you along. With this, however, came problems. Thepublic was not yet ready for these inventions, and our center in Haifa, the Rambam
hospital, was swamped with requests for dialysis, for transplantation, not only fromentire Israel, but from the West Bank, and from the island of Cyprus, and this becamevery, very difficult to manage. So here is the beautiful part, the lucky part, and also thehard reality that you’ve got an invention, that came down to earth, to humanity too earlyfor the legislature, for the ethicists, for the lawyers, to understand, and for the financiers,for those who are to allocate the means. And then I suddenly found myself inconfrontation with my superiors who didn’t understand that people were dying in vain,because there was not enough dialysis facilities.
Early Influences and Mentors
OB: I had a very tough father. He believed in tough discipline, and when I was three or
four years old, I remember that. I went up, and we had a flat roof of a two-story
building, and I began to walk around the edge of the roof. He was the very strict father,
suddenly completely changed, talking very, very, very softly, so I prolonged the walk as
much as… “Ori come down. Go here. Go here.” And I knew it would not last long, and
then I came down, and he became himself, disciplinary. I think I got a spanking, but it’s
only loving parents who do the spanking, and I believe in the strict discipline that I got
from him. I believe in discipline.
GE: Who inspired you more to go into medicine, your mother or your father?
OB: I cannot decide. I got the more scientific side from my father and the morehumane side from my mother, so it’s a good blend. I got the best of both worlds.
…OB: Both of them were physicians; my father was also an investigator. He died veryearly of myocardial infarction, at the age of 50, but he had enough influence on me tocarry on, and go and have respect for scholarly tradition. So I really owe a lot to myfather and mother, and then in Israel, it is Dr. Ehrlich, with whom we did the firsttransplant. He was a great political ally. And…
OB: Yes. He was a great surgeon. He was a general surgeon. He was a urologist, andhe was also a good vascular surgeon, which made him ideal to do transplants, but Imust confess that with the facilities that we had, it was almost… today we wouldn’t getany Helsinki approval to do a thing like that, like the transplant under the conditions thatwe then did, and these are the local people in Israel, and then the orthopedic surgeons,with whom I cooperated a lot.
…OB: Kleeman is a very interesting and stimulating teacher. Maybe two-thirds of Israelnephrologists were trained by him. You can say that single-handedly he built the edificeof Israeli nephrology. He was a very tough, a very demanding person, great sportsman
to this day, almost ascetic in the physical demands that he has on himself. Still ridesthe bike to this day. I acquired this habit from him, and I rode the bike in my hometown,except that Los Angeles is flat and Haifa is really like San Francisco and going backfrom work is climbing the hill, which was good. I believe with Chuck that physicalexercise is good, is healthy for your physical health and for your mental health also. Ibelieve in the attributes of good exertion.
So with Chuck, we did several studies on the profound changes in the bones, in uremia,and these were the first studies, I think, in this field – came out more or less in parallelwith those of Neil Bricker, and his trade-off hypothesis. Early on, I was in dialogue withShaul Massry whom I met in the Negev in Israel. When I left Chuck Kleeman to go toIsrael, Shaul came and continued this work. Shaul also had a profound influence onme, and when I returned after seven years to LA, I worked with both of them, oncontinuing the work on divalent ions. After one year in Cedar Sinai where I learnedhow to operate the artificial kidney, I went back home to Israel, put the first artificialkidney, set it up, so we could do, with Dean Ehrlich, the first transplant. Now, talkingabout politics, which I shouldn’t, Internal Medicine was dead against the development ofnephrology as a subject, dialysis and transplantation, so I had to break ranks. I was agood, loyal internist; suddenly I found I couldn’t go on with Internal Medicine. I neededa new political ally, so I switched my weight and went to work with Dr. Ehrlich. Later on,I worked many years with orthopedic surgeons, because so much trauma was cominginto our hospital. Our hospital is a military hospital more or less, civilian-militaryhospital, that has patients from the catchment area of the entire southern Lebanon frontwhich has been active all the time.
Influence of Louis Pasteur
OB: Maybe the greatest name in medicine for me, is not a physician, is a chemist, is
Louis Pasteur. And it’s not only his genius as a chemist and as the father of
immunology, but it is the involvement of Louis Pasteur in everything in public life in
France. He was teaching in high school. He went to help the beer industry, the chicken
industry, the silk industry. He went to treat infectious diseases, prevent infectious
disease, and with his own hands, prevented or even cured rabies. So nowadays,
people find a niche, a molecule, a gene, and all they do during their lifetime is burrow
and burrow and burrow and burrow into the gene. This is okay; this is the way things
should go, but in parallel we should not forget the environment, we should not forget the
patient, after all it is a person who comes in the ambulance to the research room not a
gene, and how are we going to prepare our medical students for this. So Pasteur was
involved in all these in every aspect. There is no problem that was too little for him in
Furthermore, when France was beaten by Germany in the 70’s of last century, Francewas bankrupt, and Louis Pasteur got excellent, great, lucrative offers from othercountries, particularly Italy, lucrative offers, and he declined. He told the Italianuniversities, he says, and this is ingrained into my flesh, like your cattle in Texas haveinto their skin, the number, he said, “Science has no boundaries and no countries, butthe scientist has a homeland, and the scientist has to be serving his homeland, and in
touch with the homeland.” Now my homeland is unique. It’s much more than ahomeland; it’s a great heritage, and in the 3000 years of Jewish history, there occurredthe catastrophe of the holocaust, which only new Armenians know what it means, andthen, the creation of the state of Israel. So these two great events and the long history,and the friends that you have that you fought with them together with, never lets you beaway from Israel for more than one year, on these sabbaticals. I could never stay out ofIsrael for more than that although I must say that being here in the U.S.A. would havebeen much more supportive to my research. It’s easier to do research in the U.S.A.
than to do it in Israel, and yet it is these challenges that maybe incite you to discoveries.
It is the challenge of the desert, the challenge of the sea, being a pioneer and doing thefirst transplant in the country and studying them. Maybe if I’d been in the U.S.A. Iwouldn’t have done such studies on the transplants. I don’t know. So I believe thatanaerobic conditions are sometimes a spur and a stimulus to research. Maybe we arelike our bones. When there is weightlessness, we begin to lose the mass, like theastronauts have experienced. We need the stress on the bones all the time to make thebones strong. The great question is how strong should the stimulus be before breakingyour bones. This is always the question.
The Importance of a Pioneering Spirit
OB: Seldin could have been very successful in Yale, if he stayed in an established
place, but Seldin felt he wanted to open his own thing, he wanted to be a pioneer, he
wanted to start from scratch, from fresh, so he came here, and I saw the picture in the
last November‘s Science, of how the campus here looked. There were a few army
shacks, and this was the beginning of this great school. From this great school you
came, twenty of the most prominent, creative, and what is simply American
nephrologists came, and I believe also at least two Nobel laureates. I wonder if Seldin
could have achieved the same thing in Yale. He would have been great, but not that
spectacular, which goes to show that harsh conditions can sometimes be a stimulus,
and we can go immediately to the greatest two names in acute renal failure, these are
Bywaters and Kolff.
Bywaters, he is my great mentor, he’s still alive today. I am in dialogue with him, I gottremendous inspiration from him. He described the crush syndrome during the terribledays of the Blitz in London. Churchill said about the British, “their finest hour.” It wastheir finest hour. He described the crush, he founded part of physiology, he began tothink of therapy and was ready with therapy towards the end of the war, but all duringthe war, he was bombed in London. First with the blitz, then the V1, and then the V2,until ’45, and sometimes when you read it in his papers, while doing autopsies on crushpatients, crush casualties, he had to hide under the autopsy table, because the V1 andthe V2 were coming. Incidentally, the scud missile is the descendent of the V2, but thisis another story, which I think we’ll skip today. So this is Bywaters, who did classicstudies under the very anaerobic, dire conditions of the war, without any funds, withoutany support, with his bare hands, brains and few friends.
The other one is similar. Kolff did everything, developed, invented the artificial kidney in‘ 43, ’44. He didn’t know he had a great discovery in his hands, because he was
isolated from the rest of the world. Interestingly, the first patient that he saved, hehated. She was an old lady, seventy-something, who was the head of the Nazi Dutchparty. She had acute renal failure due to the hepatorenal syndrome with jaundice,another subject which interests me, jaundice and the kidney, and he saved her, saying,“I cannot choose the treatment. I hate the patient, I don’t hate the patient, I have tosave him. He is human, and this is my prime duty.”
Having said that, I must say that with all the turmoil in my home country, for which I amsorry, at least in Northern Israel the patient-doctor relationship, between us and theArabs are unaffected. It may sound as a joke, that the Arab patients are better patientsthan the Jewish patients. They never ask for a second opinion, and there are goodrelationships. And if, God forbid, an Arab patient will die, after five weeks, I’ll be invitedto the home of the family to show that there are no hard feelings. If a Jewish patientdies, I think that family will not enter the hospital again. One of my pupils is now a verysuccessful nephrologist here, is Sumitham, he is an Arab, and he is one of my bestfriends, and he has stood by me in good times, and in difficult times. So patient-doctorrelationships, doctor-pupil relationship, is unaffected by the circumstances, and this maybe a heritage of long tradition, where Jews were always eminent physicians in thecourts of the Arab caliphs, say, Maimonides, in Egypt, and so on and so on.
Interest in Exertional and Traumatic Myopathy
OB: In my years in the desert, in my years with the military, I was exposed to exertional
myopathies, sarabdomyolysis after a long march, dehydration after a long march,
hyperthermia, heat stroke, and I witnessed several fatalities in young people who were
highly motivated and were otherwise in good shape, and this interested me and really
made me preoccupied with the muscles. So this antedated my interest in crush by ten,
fifteen years, the exertional myopathy. And then I found a beautiful paper by two young
army officers, one of them called Joonk Norel, the other one called Bob Schrier. I knew
the two other names, I think Dick Tannen was there also, but these are the two names,
which, they described several fatalities in trainees here in the desert in Texas, because
all your trainees they converge from all over the U.S.A., and northern U.S.A. is cold,
here it’s warm, in Texas, and they were not acclimatized, and there were several
fatalities. They did beautiful studies, explained how it happened. At post-mortem
studies I see the muscles and the kidneys to this day. These two personalities, Joonk
Norel, and Bob Schrier, who as I said were in the army at this time, had a great indelible
impression on me, and I became associated with them to this day. These days I am
writing with Joonk Norel about this subject, and until recently I wrote with Bob Schrier on
similar topics, so this is where it started, caloric balance, water balance, and muscular
metabolism, muscular injury, and exertional myopathy which I believe kills in this
country every year at least six to seven great sportsmen or marines or people from the
special forces like delta and the paratroopers. And it hurts because these are
OB: Now we saw how easy it was to prevent the problems with exertional
rhabdomyolysis, and to prevent the acute renal failure. We decided this must also be
so in traumatic rhabdomyolysis, when people are buried alive under the rubble. Now
one of the geographical curiosities of my hospitals is that it is very near the frontline insouthern Lebanon. In southern Lebanon there are fundamentalists that blow upbuildings. They did it several times where many Israelis were killed, many Frenchmen,many Americans, and many Arabs too, and casualties were brought to us, and this isvery near to us. The town of Tyre is only maybe 40 miles from my town, and it’s veryeasy to reach by helicopter, so we could see the casualties very, very early, and wecould take blood early, and we could start treatment when they are still under therubble, and when you do it the right way, you can completely prevent acute renal failure.
In the London situation, every single person who was more than three hours under therubble would die of or will develop acute renal failure. He needn’t necessarily die today,in the post-Kolff era, but everyone would have developed it here. We could save themeven if they were 24 hours under the rubble, so we could prevent acute renal failure,myoglobinuria acute renal failure, on the lines that Bywaters suggested. Really wedidn’t add to the thoughts and pathophysiology that were delineated by Bywaters. Wegave plenty of fluid, and we alkalinize them, and we prevented acute renal failure.
Then we also have our own ideas on how to treat the compartment’s syndrome, whichis devastating in acute emergencies. We believe that the current treatment, in thetextbooks, is too radical, and too dangerous. We have different ideas on how do it. Idon’t know if what we think about, and suggest, and recommend about compartment’ssyndrome is accepted. What we suggested as a preventative measure of acute renalfailure I think is well accepted.
So, here is the patient side of the story, which we were able to handle successfullybecause we were prepared for it by the exertional rhabdomyolysis, and second,because we were so near to the catastrophe, so the time factor could be minimized.
We then went on to do experimental studies on dogs, and experimental studies on rats.
We did the compartment’s syndrome in the dog, and showed that it can be relievedwithout a fasciotomy, by different means, and in the crushed limb of the rat, we foundthat there is tremendous reduction of inducible nitric oxide, with vasodilatation. Here,we did go into the molecular level. We did show that the messenger RNA is induced,and then the enzyme is induced, and we did even some patch clamp studies to showthat stretching of the membrane will cause falling of calcium into the cytosol by stretchactivated calcium channels. So yes, you should do the molecular thing, but always partand parcel, in parallel with the physiologic studies.
Studies of the Kidney and Organs Physiology
OB: Being so interested with water deprivation, and sometimes salt deprivation due to
excessive sweating, I suddenly ran into patients like everyone does, with huge salt
retention. You get an emaciated patient with advanced cirrhosis of the liver, he may
weigh 50 kg, and has a belly full of fluid of 40 kg, so why this sudden, you can say,
failure of homeostasis? And when you look into it, it’s not so much a failure; in fact, the
kidney does its best. The kidney is very wise; the kidney perceives volume scarcity,
and it behaves appropriately, and when I say this, I feel myself a grandchild of Peters,
from Yale, who was the mentor of my teacher, of Seldin, or Kleeman, of Frank Epstein,
of San Field, and others that I didn’t include now, but I should have perhaps. They all
started with Peters and with his concept of affected blood volume, that has not beenimproved, to this very day. So I began to study the kidney in liver disease, and thekidney behaves in an interesting, grotesque way, and we tried to recreate the situationin animals, and with Shaul Massry we did it in the dog. We created a model that hasgreat ascites. We studied it, and then with Shaul Shasha, another friend of me, else hewas a disciple of mine, a pupil of mine, and then a co-worker, and then an equal-rightsfriend to this day. He went very far in his line. He’s one of the most important people inmedicine in northern Israel, and he is professor of Mao institution. We continued thatmodel with the cirrhotic dog, and we found that the cirrhotic dog has a hyperactive heartsituation, which is exactly mimicking what one sees in humans. I believe this is the firstillustration of hyperactive heart disease due to liver disease that you see so often in thehuman, in the canine model.
Now I’ve been talking about interplay between organs. There is a balance betweenorgans, the liver, the heart, and the kidneys, and it is this beautiful balance between theorgans, and study of the whole patient that I think suffers today. All the effort, all theglory, and all the grants go into molecular medicine. This is important, it should go, butnot to the detriment of organ physiology. After all, what we are seeing at the bedside isthe whole person, and organs playing in balance with each other, and if I were a deantoday, and I was a dean once, I would see to it there is almost a legislative balancebetween genetic, molecular, and organ and classic physiology. You can reach theabsolute, the saying that all human moods can be reduced to the seratonin level, andthe activity of the receptors in the brain, and you can cure it with prozac-like things, andyou needn’t worry about the person at all. Manage the seratonin in the clefts. So this isdangerous, and if we go in this direction, we’ll teach our students to be deterministic.
It’s in our genes, it’s the gene therapy, everything is genes, and nothing but genes. Wewill forget the patient. Let us remind ourselves that the two most important drugs, ormaneuvers in psychiatry were found by astute clinicians, and to this very day, we don’tunderstand how they work. One is electroconvulsive therapy. It’s the most powerfuldrug or procedure that exists in psychiatry, and no one understands how it works. It’slifesaving, and it’s the same with lithium. It’s astute clinicians – they found it, and thereis no molecular explanation. Maybe we will find the molecular explanation in the future,but if anyone goes into medical school and will be in charge of patients, he should bewell versed in organ physiology, in classic physiology, in parallel with the molecular.
Interest in Hyperbaric Medicine
OB: We got many young people with trauma, extremities trauma, losing one leg, and
once you lose a leg in a young man, you have to fight hard to save the other leg, and
you start going to all sorts of non-conventional treatments. One of these treatments is
hyperbaric oxygen. Why hyperbaric oxygen? Because it is so new to us. The navy
installation of hyperbaric medicine is just 400 yards from where we are situated. Doing
these, I discovered that hyperbaric medicine, hyperbaric oxygen is an excellent, under-
utilized, under-valued mode of treatment. It was, of course, designed primarily to treat
diving casualties and arterial air embolism and carbon monoxide poisoning where it’s
indicated definitely. It is life saving, but we found it ‘s also good for vascular injuries.
It’s good not only for anaerobic infection, but also for staphylococcal infection. Later on,
I found it is excellent also for crush injury. Before leaving hyperbaric medicine, I have afeeling that the medical profession is frightened by oxygen free radicals and frightenedby oxygen and they are frightened by hyperbaric medicine. I believe we are aerobicanimals; we need the oxygen, at least during shock, in the short term, in the first days.
In the first hours of shock, oxygen therapy and oxygen treatment, hyperbaric ornormobaric treatment is very, very, very helpful, not only for hemodynamic situations,but also for overwhelming sepsis.
Performing the First Kidney Transplant in Israel
OB: Well first of all, the uniqueness of Israeli cadavers, since the time of the Egyptians,
the dead man is more important than the live man, and this is not just a way of saying it.
The dead man, the body is important. It’s holy, it’s not touched, in the Jewish, in the
Muslim, in the Jewish culture, so it’s very difficult to get consent to take cadaver’s
kidneys. So I must confess that what we did in the beginning was covert. Maybe it’s
dangerous to be so open about what we did, but we did it without permission, and we
were afraid there’d be problems, and what was more, we did it across ethnic borders,
and I was very tense that things would be publicized, before we crossed all the borders,
say Jewish kidney to Arab, Arab kidney to Jew, and so on, because the area is volatile
enough, we don’t want to inflame it even more, but with being very, very tactful, and
doing the thing in a decent way, and with great conviction that what were doing is right,
saving lives, we managed to do it. We started in ’65. By ’70 we had like twenty, thirty
patients, with excellent, good cadaver graft function. These years, we had only imuran,
isothioprene, and cortisone. It wasn’t nephrotoxic so life was easy. They’re still very
good drugs to this day, if someone cannot take cyclosporine.
OB: This is ’65. The cadaver kidney was stolen; we didn’t get any permission to do that.
GE: How long was the patient dead when the kidney was obtained?
OB: Oh, they were always dead for at least an hour. No heart beating cadavers at thattime, and we used to measure the time of death by the clock on their hands, during theaccident that killed them. We clocked it by the time, and remember Israel is a warmcountry. You can do things like that only in winter, when it’s cold. So it was donewithout permission. I say we broke the rules by taking the cadaveric kidney. Maybe –it’s very difficult to say so – but sometimes, you have to break the rules.
GE: Maybe this was one other instance of patient advocacy for the recipient. Could youtell us something about the recipient of that kidney.
OB: Well dialysis wasn’t… He was a young man of 23. He was a driving instructor, andI say we took the kidney without permission. He had great trust with us, he couldn’ttolerate dialysis as it then was, there wasn’t enough slots available on dialysis, so wedid it. At that time, we didn’t have any radioactive tracer studies of the kidney, and ittook three, four, five weeks for the kidney to open, because the ATN was very, very low,so it was a tense time, and then it suddenly opened, and it was a really great sense of
achievement and euphoria for everyone, and trailblazing for Israel. In fact, thattransplant ushered in organ transplantation in Israel. He lived for three years, went toBeer-Sheva, and in Bethesda he had difficulties with getting the imuran with hisinsurance, I don’t know what was completely wrong there, and he was once brought tous after three years by helicopter from Beer-Sheva, with fulminate rejection due to notenough imuran, and he then died, but we said to ourselves and to the family, “Here arethree years.” Three years are a lot, and one child was three, he had a father from threeto six, this is so important, and I met this child, this now grown-up man, and he told me,“You are right. From three to six, to have a father is a heck of a lot.”
So this was the first transplant, and then let me tell you, I want to give you the feelingthat we were riding a tiger. People deluged us, everyone wanted a transplant, and thenwe had another transplant, another successful transplant, and suddenly, after twoyears, he developed Kaposi’s sarcoma. All that you see in AIDS nowadays, we saw inthe sixties, because of induced immunosuppression. It’s an immune deficiency disease,immunosuppression. He developed Kaposi’s sarcoma, and we didn’t know what to do.
And we didn’t want him to reject the kidney so we continued the immunosuppressionand he rejected the kidney and then he died. The next case that developed Kaposi’ssarcoma, we decided to be clever, and we just stopped, and this was the first patient inthe literature, we stopped only the imuran, and he rejected the Karposi, and retained thekidney, and now I think it’s a common practice to lower the imuran dose. And here Iam, suddenly finding myself riding a tiger, inducing cancer in some patients, and thenbeing able to cure the case. I’m omnipotent, it’s frightening how much potency youhave. By the way, I wrote to all great people, of oncology, of virology, I wrote to theViceman Institute, I wrote to George Klein in Stockholm, he is the greatest man onKaposi’s, he sits on the committee of the Nobel Prize, Nobel laureates, and I said, “Ihave this situation. What can I do? What should I do?” He said, “Ori, I can’t. I don’tknow, I can’t help.”
Reflections on Kidney Transplantation
OB: Most of our transplants were cadavers, and I judged the moral fiber of a transplant,
at least in the seventies, in the early eighties, I used to judge the moral standard of the
unit that performs the transplants by the proportion, how many cadavers to live, with
80% cadavers, 80 dead to 20 live transplants, and I believe that is how it should be. If
you have too many live transplants that means you are promiscuous in a certain way,
and this should not be encouraged.
GE: Your success with the transplant program as you started it, created it’s ownproblems that you had to face with new patients, that needed transplants, and how didyou deal with them in setting up satellites, or how did you manage the problem that youhad to face in dealing with demand for organs.
OB: We had satellites in the West Bank, and again, beautiful Arab-Jewish cooperation,and the one of my disciples was a Cypriot, George Thiaditus, I sent him over to Nigeria,to John Nigeria in Minneapolis. He became a successful transplant surgeon in his ownright. He returned to Cyprus, and is doing now transplantation in Cyprus, as good as
we do, and maybe even better, so here is one really beautiful example of internationalcooperation. A country, it was a third world country, and now an emerging country; verysoon it will be part of Europe. So this is one way to solve the problem, by teaching thelocal people to do the job.
…OB: Well, now I am part of the establishment itself, because the Minister of Health putme in a supervisory position to oversee live transplants. There was lots of abuse of livetransplants in Israel, kidneys being bought and sold, and there was outcry in thenewspaper. So in order to regulate it, to supervise this, they made a committee of fouror five people, and I am sitting on it, and every live transplant that will be done in Israelwill need my signature. So here at a ripe age, I’m about to regulate the industry, so tosay. I’m also advisor to our home front command, which does all the search and rescueoperations and excavation of casualties under the rubble because what we talked aboutwas only the medical aspects, the engineering part of it and the logistics, the search andthe dogs, all this huge effort, we are just one part of it, so I am advising to them, and Iam part of their exercises. So this is it, I think.
GE: While you are part of the establishment, the rest of us who have remainedadvocates of the patient still have to face the shortage of organs for the number ofpatients who are awaiting transplantation. Do you have any thoughts on how to handlethat problem? Obviously the issue that you are looking at, buying and selling organs, isa solution. Ethical or not is another question. But the problem persists. Do you haveany thoughts on how to handle that problem?
OB: Well you know that there are enough cadavers, except we can’t reach them. Somecountries like Belgium and Austria are the most advanced. They require that everyonethat dies in the hospital, or arrives dead on admission, and has not said something tothe contrary in his will, you can remove the kidneys. I think we should go in thisdirection, and have legislation like they have. I’m really sorry that Jews who are soclever couldn’t do it better, and find better legislation, and I envy the Catholics inAustria. They have got such advanced situation when they can take almost any kidneythey want almost.
GE: Do you advocate what you did with your first transplant as a solution?
OB: Everything has its timing. There is a time factor. Sixties or not, the nineties. In thearmy, they complained it’s difficult to conduct battles because the CNN factor. When Ido it, sooner or later, there will be CNN man in the morgue seeing me doing it, so thetime really has passed. So I believe in education and in making more publicawareness, but I feel sorry for every live kidney that is taken out. It leaves scar, itleaves morbidity, even though I don’t buy Brenner’s theory that reduction of nephronmass isn’t detrimental. I know of live donors who died. There are cases,underpublicized but there are, and there is morbidity, and these people are really thewage earners of big families. So on top of the family they are now handicapped withpain and so on and so forth. We should do less, than we do. We should encouragecadaver transplants.
GE: So you are in concept, not very supportive of live transplants.
OB: I frown upon it, and I’m glad we did the first cadaver transplant and not the first live.
Live is permissive, permissive attitude.
Work with Renal Tubular Acidosis
OB: We began to study the grafts, simple things like concentrating the urine, diluting the
urine, and acidifying the urine, and we found that the patient could not acidify the urine.
It was very, very easy. We took arterial blood from the mixed blood of the AV shunt, we
examined the urine, at first with the paper, then with the pH meter, and we saw that they
could not lower their urinary pH, so this is the classic type one. Later on, we found that
several of them have the hyperkalemic variety, and they have type four RTA. So after
kidney transplant you get all, the whole spectrum, type one, type two, bicarbonate-
losing, and the potassium, the hyperkalemic type. As every nephrologist, we were
extremely sensitive to hyperkalemia, and hyperkalemia, of course, is cardiotoxic, can be
fatal. Many trauma patients have dangerous hyperkalemia, and a crushed person will
have hyperkalemia within two hours of extrication from under the rubble, and they may
die an electric death from hyperkalemia, a death that was actually preventable. So we
were busy with these entities.
Later on, we went to geriatric institutions, and we found that a third of patients in theinstitute had type four RTA. So this may be a problem of the normal elderly.
Nowadays, it is simple to do an acidifying test. You just give furosemide, 80 mg, andexamine the urine after 2 hours. In my days, in the early days, in the 60’s, we had togive ammonium chloride, which is unpleasant, unless the patient has spontaneousacidosis. We also found that the cirrhotic patients, many of them had some type ofRTA, most of them type one RTA, that was reversed after giving mannitol, where thedistal delivery of sodium were elevated, showing the importance of adequate sodiumsupply to the distal site for acidification. This problem was further amplified in abeautiful, creative way by Daniel Batlle from Chicago somewhere. One day I came toDaniel Batlle, and I said, “Daniel, we all thank you for introducing the furosemide test sopeople don’t have to eat ammonium chloride.” He said, “Oh, it’s not me, it’s you whoinvented ammonium chloride.” I said, “I?” He said, “Yes. Don’t you remember that yougave your patients all sorts of diuretics to lower urinary pH?” And we gave them still themercurial diuretics, which was a heritage from my early days. Until the early 60’s,patients with pulmonary edema got mercurial diuretics, and there was nothing againstpulmonary edema. There was no furosemide, nothing, and there was nothing thatlowered your urinary pH better than mercurial diuretics, but this is all history. So this isthe acidification point. To summarize the renal tubular acidosis I can say with mymentors, Casier, and Raymond, and W.B. Schwartz, that this – the formations thatoccur after RTA are not so important, the body can handle it. What is important is thesecondary changes in potassium. You can get terrible hyperpotassemia, with flaccidparalysis, or you can get hyperkalemia with RTA. Also W.B. Schwartz, and JordanCohen, and Casier, the last two are good friends of mine, especially Jorde, they showedthe beautiful concept that the body will sacrifice acid-base balance in order to preservethe volume balance. Internal volume is the most important thing, and it’s the last thing
to be sacrificed. You will sacrifice the acid-base balance and you may enter intoalkalosis, in order to preserve your internal volume.
Advocacy for Research and Patients
OB: Everyone should fight for his research grant, should convince the public and the
committees that his research is good, and receive it on a competitive basis. We did it
with the U.S.A.-Israel binational fund, we did it with the German-Israel binational fund,
we did it with the Ministry of Health, we did it with the Ministry of Defense, so we got
budgeted in this respect. I also got funded by good people in New York, the family
Chutick, elderly ladies in New York who heard about my work, got interested in it, and
they are funding me to this very day. So the ups and downs of research, hiring and
firing personnel, this is all part and parcel of daily life. What I am really bitter about, is
that in the early days of dialysis, maybe the first ten, twenty years, I had to raise funds
to buy my dialysis equipment. I don’t know why this is so. Maybe I was so hard-
fighting, that my hospital, and I was part of the government, part of the Ministry of
Health, they thought, “He can do it. If we press him, he’ll do it,” and really, I had many
sleepless nights. What will I do? My dialysis machines are old, obsolete, I have to have
a new set, so I had 75% of all my dialysis machines, and even, I’m afraid, some
research money had to go into it. Twice I had to come to the U.S.A. to raise money
here, good money, that could have gone to good research, but looking back, maybe I
cannot blame my superiors, and the legislature, and the Minister of Health. Maybe the
whole thing was too new. When I look at artificial organs, I look at artificial fertilization; it
looks as if the technological advances come before the ethical advances. It takes them
time. Look at cloning. Suddenly there is an invention. It will take years for humanity to
sort out how good, how bad this is, so I don’t think it’s the duty of the clinician to buy for
the insurance company and for the government the hardware. They should supply it.
Now because they didn’t supply it, because the people didn’t understand it, I had to fight
very hard. And by hard, I mean hunger strikes, for one thing.
GE: Could you tell use more about that hunger strike that you went on?
OB: I wouldn’t like to elaborate on that too much. I went to the director of my hospitaland I said, “Unless you supply dialyzers and space, I stop eating,” and, “It’s yourproblem now,” and I went to the press and said so. I don’t like to elaborate on thatbecause I’m not a Gandhi type of martyr, and I’m angry that I was pressed into thatcorner. I did something, which was even worse. There were two hospitals in my town.
I wanted very much dialysis to be opened there, I even had the manpower to send overthere because I was raising young people for that. In one hospital there was a mandying from chronic renal failure. I brought the main news of the evening, I don’t knowwhat your counterpart here is, it is as if I brought our Walter Cronkite to that hospital andwe focused the camera on the dying man and all his family and then I asked theMinister of Health, “Do you have any reply to that?” and there was terrible turmoil in thecountry, terrible turmoil, and people had to resign, and I thought I would lose my license.
This was against the rules. I knew this was against the rules. So here is one pointwhere I really was abrasive, but ultimately…
GE: It’s really not abrasive. It’s the ultimate in patient advocacy. If the physician doesnot speak for the patient, who should speak for him? You did the ultimate in patientadvocacy, and you’ve done that all the time, as far as I know. I’ve seen the patient’sresponse to you.
OB: But it’s interesting, Gary. I said the word ‘bitterness’ before. I want to delete theword ‘bitterness.’ I’m not bitter at all; I’m glad about all that I did, but you know I havesuccessors in this. There are three successors to my job in Israel, in nephrology, andtwo of them are world-class. They have got all the dialysis that they need, thedepartment has been renovated they don’t have to put a cent into it; more than that,they will even get money from the hospital. Part of the income from dialysis will bespent on their research, and each of them is getting at least one PhD to work with him.
So I don’t envy them at all, but they have it easier. Maybe they should envy me,because I had this pioneering time. So really let’s delete the word bitterness out ofthere.
OB: Well you’d be surprised. During my times in the Negev, in ’57, in the little kibbutz
called Debokar, there was a famous resident, called David Ben Gurian. Now I was his
family physician, so maybe he was my most important patient ever. He was in robust
health. So this was one of them.
Another young patient of mine, when I was a general practitioner in the kibbutz in theNegev, the kibbutz was called Revivim, I saw that the boy was squatting all the time,and I discovered, very soon, that he had tetralogy of fallot, and since Golda Maier had adaughter in that kibbutz, and she was very powerful at that time, and I met her severaltimes, I told her, “This boy must be flown from here to one of the clinics here.” I forgetwhether it was the Mayo, where they did perform this, when the Tausig and Blalockprocedure was still in vogue, and we flew him out, and he returned back, and everythingwas okay. I only know that the patient before him died on the table, the patient after himdied on the table, and he’s very good to this very day, and he’s a famous TVphotographer in Israel, and he did army service after the successful surgery, so nomedical student should graduate without being also a general practitioner in his heart.
He never knows when he will be called to help someone in the theater, or in an airplane,or a ship, or a young kid, and so on and so on. It is the duty of us as educators.
GE: How about some of your kidney patients, renal patients?
OB: Now the renal patient, the one with Kaposi’s he was an Iraqi Jew, and he was in theair force, and he returned to the air force to work in the air force, and one day there was,when there was a kidnapping of airplanes, with hostages, I forget if it was to Algeria orto somewhere, because he speaks such fluent Arabic, he was called by the army to gooverseas, and do the negotiations, and he phoned me and asked if he could do that, ifhe was healthy enough. I said, “Yes, you are healthy enough, and go ahead and do it,”and he went, and it was successful, and he came back, so these patients are fullyrestituted. Among my patients from the Arab bank, one was related to the mother of
Suha Arafat. She’s a very beautiful woman to this day, forgot her name. She was bornin Acre, she visited us, she’s a writer also, and a feminist, the mother of the wife of SuhaArafat, and we visited her in Nabus, and I would say this is the most prominent Arabthat we have met. I think nowadays, she is in Paris. She’s such a vehement feminist,that she may be even too much for Arafat, but a handsome woman to this day. I thinkI’ll remember her name if I think about it.
OB: Let me return. From time to time, we got undercover patients from Arab countries,and hostile countries. They used to send patients to us, and the country of origin waskept secret, and some of them were members of the Arab forces, or the security ofthese countries. They came incognito, they got the treatment, and they returned back,and no one talked about it anymore. So this area of the patient-doctor relationship isexempt from the problem, and this is important, very, very important. Yup.
OB: My greatest pride, like a father has pride in children, is in the pupils that became
teachers in their own right, and I would say that 60% of the important positions in Israeli
nephrology are my pupils, starting with Sudivan Moritz, professor and head of
nephrology in Beer-Sheva, great investigator, then Jason Rapaport in Tel Aviv at the
Sheba medical center, then Jacob Green, who is moving in my steps in Haifa. He is
chief of nephrology, renal services and dialysis, was also associate professor at Cedar
Sinai, in the footsteps of Kleeman, Chuck Kleeman in L.A. Then there is Shaul Shasha,
who is not only a great nephrologist, but also an administrator of a hospital, and this is
the best-run hospital in the country. Shaul does a magnificent job, really. It’s an
acknowledged fact: he is the best, and then Pedro Sheeman, who manages who is
Chief of Nephrology in Korea Hospital, and Israel is a small country. This is 60% of
Israeli nephrology. In fact, these leaders grew so fast, and went to help their own units,
that I developed like multiple pregnancy anemia of the pregnant woman. It was difficult
to replace all the iron, so to say, to the periphery, and then of course there is the one in
Cyprus also, whom I…
GE: Did you ever feel threatened by some of these young people that you trained, andwho were moving in, and…
OB: Never. I knew that in certain respects, they are better. I knew that biology is ontheir side, age is on their side, agility, creativity is on their side, and it was alwayscooperation, never envy, never jealousy. In fact, I was fully cognizant of the fact thatthey are one step ahead of me, and let’s do the thing together. There was neverquarreling over co-authorship of papers, never stealing of ideas. I think there was oneor two examples, when I was hesitant of sending a paper, and they said, “Stop it. Whyare you so sluggish? Let’s do it,” and we sent the paper, and to my surprise, it wasaccepted. So I can see in this respect, only harmony. I had disharmony with theMinister of Health, with the administrator of the hospital, but never, never, never with…and I helped them to find good positions. I gives a good massage to my ego to see my
pupils in eminent positions. It’s a good reflection on me. In fact, once or twice Iencountered the comment, “If you fight so hard to send him over here, maybe you don’twant him in your place. Why do you do that?” So, this is all straight.
OB: But I had great influence from my army buddies. This was an elite unit, the people
were selfless, they did something for a thing, that is greater than their own, they took
great sacrifices. So this milieu really influenced me, and I found great nourishment from
this milieu, more than I found in the civilian sector. And I must confess, I come to you
now here, from a meeting of the American army in Boston, and there were 400 people
there, all soldiers and officers and nurses and physicians. Their readiness to sacrifice
and to do altruistic things is overwhelming, and their attention to what I was saying was
greater than what you students, and young men here will have today, I’m sure.
GE: You referred to your buddies. I assume these are the paratroopers that you joined.
Why did you choose the paratroopers?
OB: Well I chose the paratroopers because I was interested in this type of personality,and in the 50’s, the late 50’s…
GE: What is this kind of personality? I don’t know anything about being a paratrooper.
OB: There was something technical in addition. In the late 50’s, the helicopter was notin great use, and those that were, were small, and couldn’t carry great weight, so if youwanted to project any military or medical effort, you could do it only by jumping. And Icalculated, that sooner or later, the need would arise, say in the Caucasus, in Turkey, orin Iran that was friendly, that they needed us for earthquakes. So one reason that Iwent to the paratroopers was to be able to deliver health care wherever it wasnecessary, and where you couldn’t reach it otherwise. It was a very close unit, allvolunteers, all very physically fit, and great friends. Most of them at that time came fromthe agricultural sector. Most of them were farmers, so this was a beautiful combinationof farmer-soldiers, and I like that, and we remained in good dialogue to this very day.
We all meet regularly, but one of the main thoughts was to be able to deploy us in agreat distance, where the helicopter was not yet sufficient, and we had a hospital thatwe could drop from the air, and assemble it on short notice.
Now, during our training, which was very, very vigorous, there were cases of heatstroke. There were cases of rhabdomyolysis. There were cases of sudden death. Andthis sudden death in young, healthy men really preoccupies me to this very day.
GE: Now you’ve held on to staying on the paratroopers’ service longer than mostpeople, would you say?
OB: Yes, I did stay until the mandatory age to get out.
GE: Why? You not only wanted to stay, but from what you’re saying, you carried it withyou to impose on your service at work, that tough, difficult, pushy, demanding…
OB: But, but, but… Maybe I should have stayed longer, but why mandatory, I tell youwhy mandatory, because the authorities are afraid, that at that age, you’ve got a largerand larger family, and your chances of being hit in exercises or in combat are greater,so this is one reason why to ease you out.
GE: But how about you? Your love of it? Your fascination with the paratrooper and youreferred to the personality of the paratrooper, I still can’t figure it out.
OB: Well, it’s the dedication to the bodies, the dedication to the country, the love of theoutdoors, the ability to navigate by yourself. Nowadays you have the GPS. All the artof navigation is going to be lost. They could navigate by stars, they could navigate bymaps, and so on, and it’s this type of personality that comes in stark contrast to the “megeneration” phenomenon that happens in my country too, that happens a lot here. Youare the center, you do what is good for you, good for yourself and this bringsfragmentation to society. If I go back to my paratrooper buddies, we had all thecamaraderie of a partisan group, partisans, like partisans in the Second World War. It’sa dangerous concept. There is an element of anarchy, but the beauty of it is important.
The beauty of it is important.
Experience in Africa
OB: Well before going into the missionary, let’s talk about patient welfare. I saw that the
patients were so miserable, that in the early 70’s we put four dialysis machines on a
boat, and had the patients tour the Mediterranean, and this was a great boost to them,
great relief, and they forgot for one week, their problems. Now every one of us, of your
and my generation, was inspired by Albert Schweitzer, and wanted to go to Africa.
Then suddenly in July ‘60, the Belgians left Africa, and the Congo was without a single
physician, a single lawyer, and the country was completely in chaos. I was in military
service, with the paratroopers at that time; I was suddenly called to the chief of staff. I
was afraid when I was called to the chief of staff. We had one fear in the paratroopers,
that you would be transferred to the tank corps, which we didn’t like. Much to my relief,
he said it was not the tank corps, “Are you ready to go tomorrow to the Congo. There
are problems there. Israelis are sending a relief mission. “ I said, “Yes, I will go,” and
with this, “How many,” and we flew to the Congo, and from Kinshasa which was called
Leopoldville, we went to a bush hospital near what’s today Kisangali. It was civil war,
like today. In fact today, it’s very active in this area, the Kisangali, a week ago Kisangali
was occupied, and we were there in a bush hospital, 5 Israeli physicians and male
nurses, really detached from all communication with the free world, trying to build up
this hospital. It was very rewarding, very frightening; there was physical danger, and
also tropical diseases, like malaria, and filariasis, and all sorts of things, but I’m glad I
did it. We had to be pulled out with a relief mission; I think today Americans are landing
in the vicinity there to bring out American citizens. We had to be taken out in the end byAbyssinian UN troops. It was frightening but satisfying, and the local people told us inFrench, French was the language, “You are going?” they said in French, and Iremember the words, “Nous sommes orphelins.” We are becoming like orphans. Nowthat you are leaving, who will care for us? Incidentally, that geographical area is theheart of darkness. It is the geometric middle of Africa, and the book of Joseph Conrad,The Heart of Darkness, was written about this place, and depicts it quite well.
GE: Does this have anything to do with your interest in disaster relief, your involvementwith the International Society of Nephrology Commission on Acute Renal Failure?
OB: Yes. This was what brought me to an interest in disaster relief, and I repeat that Iwent into this highly mobile airborne unit to be part of relief, and I believe that any greateffort will always be airborne because it’s fast, and this was the case with Armenia. TheAmerican team with you, and the Israeli team, they were all airborne. I am veryinterested in disaster relief, and I am grateful to you for having been one of theorganizers of an important meeting in Macedonia last year on renal aspects of disasterrelief. I’ve been again in Yugoslavia, and I will go again, and I am beginning to havedialogue with this people, and it interests me very, very, very much. We were evenasked to give advice after disasters in enemy countries. People who are enemies to us,and they are fighting us, and yet, during disaster, through a third party, they ask usadvice on how to treat a casualty, and we give this advice. So medicine knows nofrontiers.
OB: Now I tried to be magnanimous when I was an editor. When people had views that
opposed my views, I tried to give them a fair chance of airing these views. I tried to
suppress my bias against it. I cannot complain in general about…
GE: Do you think all editors are as magnanimous as you are?
GE: Could you tell us an instance where somebody has not dealt with youmagnanimously? Specifics.
OB: I wouldn’t like to enter into it, but I know that a paper was a paper on handling thecrush syndrome, traumatic crush syndrome, was rejected, and quite abrasively, and itwas later republished in a journal that carries much more weight and impact factor;however, I think the editor who did it is a great editor, and he is a man of judgement, aman of creativity, and I don’t know why this was done, but it’s a lesson to young people,“Don’t give up.” By the way, I had to fight very hard with the other journal. I had to fightfor one year, and then there was a great disaster in this country, and immediately afterthat disaster things became easier and the paper was accepted. Then I went to theeditors, when everything was published. Everything was okay. I said, “Why did youfight me for so long? Why did I have to argue with you for one year?” They said, “We
wanted to see, Ori, how convinced you are of your views.” So this is one example. Iremain on excellent terms with this editor. I have great respect for him, and he didthings out of his way to go along with me. So, yes, I find the editors sometimes – howdo you say it?
OB: No, arbitrary, and I also feel…. You know, in Japan there was a culture a hundredyears ago, when a samurai gets up in the morning, and goes to work, he takes hissword, and just kills, he beheads the first one that he sees. This was a samuraitradition. He shows that he’s got guts, and that his sword is functional. I believe editorswill do that sometimes just to show that they can decide, and there is innocent bloodshed.
OB: Well, I used to ride on my bike like Charles Kleeman to work and start very early,
earlier than anyone else.
OB: Yes. It always upset people. They said it’s tough for them to come, they havetraffic jams. In this respect I was at odds with my staff, with the nurses, with the youngphysicians. They didn’t like the early rising.
OB: Well I always started at seven o’clock.
GE: For young people it was early, but did you do any swimming before you went towork?
OB: No. I did swimming after work in summer, and lunchtime in winter, becauseotherwise it was too cold. I do this to this day, the swimming and the windsurfing. Ithink it’s very edifying. The great thing about these two things is that within a very shorttime, within an hour of exposure to cold water, cold wind, you take out all the calories.
You don’t have to run, to jog for three, four hours to spend the calories, and you can eatwith impunity afterwards. It’s also very good for your sleep. It’s good for the night-dayrhythm. Also, I was gratified to see George Bush parachuting, although it was a specialkind of parachute. We had to parachute three, four times a year, just to keep in shapeand d some marches. So I have to be in great physical shape all the time. Also, I wasolder than my regiment. I was ten years older than my regiment, and I had to keep upwith them and a physician, a regimental physician in a paratroop regiment doesn’t have
an ambulance or facilities to carry things. You carry all your things with you. So I hadto be in very good shape whether I wanted to or not, just to keep up with my regimentjust so that I didn’t fall behind. So this was good, and this was a good antidote for therigors of hospital life, and the rat race of academic life.
GE: What is your favorite outdoor sport? Is it swimming?
OB: It’s swimming and sailing and windsurfing. It was once skiing until I broke a leg inan accident. I was a very avid skier. The fringe benefit of Schrier and Kolff was thatyou stride both sides of the Rockies. I could do this side and this side and the best partof skiing in the Northern Hemisphere is there. So skiing, and also I did ski on the littleslope that there is on the Hermon Mountain.
A Phone Call from Bob Schrier
OB: Now you know that I am interested in the interrelationships between organs, and I
believe that jaundice, obstructive jaundice, is very bad to the heart, and will suppress
cardiac function. I think I contributed to Uri and Suki’s book, a chapter on jaundice and
the kidney or something like that, jaundice and the kidney. Now, one day, about nine
years ago, I was recovering from an accident in my home, and all the brass of the
university were with me, visiting me, well-wishing me, and then suddenly I get a
telephone call from Bob Schrier, in Thailand. He was in northern Thailand, and in
northern Thailand, they have a parasite that blocks the bile duct, and causes obstructive
jaundice, a liver fluke, and then these patients come to a physician only when it’s late,
when the bilirubin is forty or fifty. You don’t see in western medicine such
hyperbilirubinemia. So patients like that enter the clinic and they give echo on the heart,
and the heart, on the echo, was flabby, and they did half screen, normal heart
compared with flabby heart. The normal heart was like that, and the flabby heart, in a
patient with a bilirubin of thirty, was like that. And he phoned me, he said, “Ori, your
theory is correct. I’ve seen your model in obstructive dogs. I’ve seen it in patients, and
it dilated my coronaries that Bob phoned me such good information, that your theory
was shown in humans, and the brass of my university, they were, “Who was this? Who
was this phone call?” I said, “This was a phone call from Bob Schrier in Thailand, who
said that a theory of mine has been just verified in men,” and it made great impact so it
was very useful to me and to the university people. You see, Faculty of Medicine, in the
university is always like a funny son. They don’t know exactly how scientific we are or
not. We raise funds more than they do, they are jealous, and they don’t think we are
quite scientific, and here, suddenly, they get a message from the other part of the world,
that a theory has been verified by more or less an independent experiment. So here
you have international nephrology at its best.
Self-Experimentation and Immersion Studies
OB: Also, studies today are difficult to do. There is the Helsinki, and you know what I
would do today to bypass the Helsinki, and this is what I did all my life, I’d take eight, ten
people, and I’d tell them, “Let’s do it ourselves.” No need for informed consent. This is
how many of my experiments were done. We did it on ourselves first.
OB: Now in the concentration, dilution, and acidification experimentation, we had tohave controls, so the controls were ten, fifteen normal physicians, and paramedics, andwe did it on ourselves, and this bypassed the question of informed consent. We alsodid it in immersion studies, immersion studies to the neck.
OB: It feels good. It feels like you do it in thermoneutral water, which is thirty-fourdegrees.
GE: For somebody who loves swimming it may be good, but how about the rest of uswho don’t have that love affair with swimming?
OB: No. It’s a pleasant feeling. You see I try to compare immersion in fresh water toimmersion in the Dead Sea water. We had great expectations from that because DeadSea is very, very dense, but the results were opposite to what we expected, so we…
GE: What do you mean, the results were the opposite of what you expected?
OB: We thought that if you get tremendous diuresis…
GE: …by immersing someone into the Dead Sea.
OB: You get tremendous diuresis by immersing someone in fresh water, you will geteven more diuresis by putting him in the dead sea, which is very…
OB: …and then we thought that we would take cirrhotic and nephrotic patients to theDead Sea and…
OB: …and get tremendous diuresis, except we got the opposite.
GE: Why? They absorb salt from the water?
OB: No, no, no. They absorb nothing from the water. Their skin is impermeable.
Because the Dead Sea is so heavy, that it acts like tourniquet. The pressure is like 90mmHg on the lower body, and it acts like a venous tourniquet. To get immersiondiuresis, you need centripetally removal of fluid and central hypovolemia, and then youget diuresis. The Dead Sea will prevent the water, the volume from going centrally.
GE: So if someone has heart failure and he goes swimming in the Dead Sea water, hemay get reduced cardiac return.
GE: It’s good for people with pulmonary edema.
OB: I wouldn’t say that. Don’t immerse people with pulmonary edema. It will get worse.
So in all these respects, I had a database of what fifteen normal people are, how muchthey concentrate, dilute, acidify, what is their response to immersion, and then also wecreated uremia in normal people by infusing urea, and having high level of urea in theblood to see what effect it has on the kidney. We did it on ourselves.
OB: Infusing urevert, yes. This is not a pleasant feeling at all.
GE: You know, I drank urea. I didn’t have IV urea, so I drank urea when I did myplatelet studies. That’s why I was asking you those questions.
OB: Well drinking is different than having it IV.
Advice to Young Nephrologists
OB: Well I don’t know if I would go into nephrology today, because all the pioneering
spirit in many, many units is gone. Dialysis, which was so exciting, transplantation
which was so exciting, is routine, and the large companies have so much to say.
So I don’t know if it’s too institutionalized, there is not enough pioneering spirit in it. It’sbecoming like an industry, and our great first love, acid-base, mineral metabolism,volume control, it’s not appreciated anymore, as much as it was in our time, maybebecause there is no money in it, I don’t know. So I feel somewhat at a distance frompresent-day nephrology. I wouldn’t know if I would go into nephrology today.
…OB: I will only say that it lost a lot of its avant-garde status, and the breakthroughs arebehind us, and the breakthroughs are now in different fields. If the nephrologist will bethe man who will be in charge of all the acid-base problems, the hypertension problems,the volume problems, edema problems in the hospital, yes, then yes, but other thanthat, it’s less exciting in our time.
GE: Do you think nephrologists have given that up too easily? When critical carepeople came and started taking care of the acute problems? Do you think nephrologylost some of its flair, and attractiveness, and challenge by giving up?
OB: Nephrology lost a lot to the intensive care people, and it’s their loss, I think. Weshouldn’t have done it; we shouldn’t have allowed it; we shouldn’t have relinquished the
treatment of hypertension. This is all part and parcel of nephrology.
GE: How about the radiological procedures, and doing kidney biopsies, or renal arterystenosis?
OB: Well, they can do the renal artery stenosis, we will do the biopsies.
GE: But they are doing the biopsies also. As you know, forty percent of kidney biopsiesin the United States are being done by radiologists.
OB: Well, as long as we all sit together, and study the biopsies, we do plenty of…
GE: But that’s maybe the heart of the problem. Radiologists have no devotion to thekidneys, it’s just a procedure, and do you think they have an interest in studying thekidney?
OB: Well nephrology… I mean radiology, and imaging people, will always be in thesecond line. They are not directly responsible to people, they are only consultants. It’swe who see the patients. It’s we who make the decisions, so they are behind.
GE: But they are the ones who are being paid. The procedure is what generates themoney that is necessary to sustain the war.
GE: Maybe you don’t have that problem. We do have it in the States.
OB: Well, I am exempt from this problem in Israel, but maybe dialysis should be paidmore, and transplantation paid more, and the role of the nephrologist in transplantationshould be more.
…GE: But how about renal physiology? Would you go into it today?
OB: Oh yes, but always doing the whole animal in parallel with the molecular. You see,there is in physics the Gallilean, normal-day, daily physics, and the sub-atomic, which iscompletely different, has completely different rules. Gravity does not exist because theparticles are so small, but you cannot neglect gravity, you cannot stop teaching aboutgravity. So there should be balance between.
OB: Sometimes when I drive with my family, we see a man standing on the highway
urinating, and they say, “Oh! What a shame! Why does he do it?” I say, “Don’t say
that, you don’t know what a great miracle it is. Let him urinate.”
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