For personal use. Only reproduce with permission from The Lancet publishing Group. 904 THE LANCET • Vol 363 • March 13, 2004 • www.thelancet.com S etting out to interview Niall Dickson, I am acutely aware that he has spent his life involved in health and social care policy, as well as decades working as an editor and journalist. When he asks the questions, he is informed, pithy, and direct. My questions to him sound longwinded and ambiguous by comparison—he starts every reply by rephrasing them. But, in his carefully crafted answers, Dickson doesn’t seem too eager to push his own views forward. What Dickson does intend, as the new head of the King’s Fund, is to push for the fund’s policies to become actions within the UK health and social care systems. He wants the fund to be known as “the health think-tank that does”, a policy institution that doesn’t just stop at the report stage. If Dickson’s rhetoric has a fault, it springs from his need to be exacting. When I suggest that the fund’s latest report Managing Chronic Disease (January, 2004) proposes managed care for the UK National Health Service (NHS), he agrees “we looked at some of the models used by managed-care organisations in the US for their applicability here”, but clarifies that the report rather proposes the need for stronger incentives to encourage UK hospital and family doctor services to manage chronic conditions more effectively in the community, reducing the need for hospital treatment. The strongest incentives may be financial, he acknowledges, but nevertheless, strong incentives are needed “as a matter of urgency”. Dickson also intends the King’s Fund to be at the heart of the thinking around the UK government’s drive to improve public health. “Coronary heart disease and cancer—both largely avoidable—kill 200 000 people a year; smoking kills 120 000 people a year; and obesity has trebled in the past 9 years. Yet public health is not given the urgent attention it deserves. The weight of investment—not only of material resources, but of political capital, energy, and collective enthusiasm— remains with health-care services. We need a change in emphasis towards keeping people well.” When asked about governmental NHS policy, he is quick to point out what he applauds—more patient choice, locally determined services including foundation trusts, among much else. Though he dreams of an NHS with less bureaucracy, Dickson welcomes the government national framework to set, maintain, and monitor NHS standards, together with the latest of some hundred or so NHS- related agencies—the Commission for Patient and Public Involvement in Health and the Commission for Healthcare Audit and Inspection. Dickson was a Labour party member in the 1970s, and I wonder whether he is now a New Labour man. He isn’t shy of criticising government. No fan of centralised control, he notes that “the government itself accepts that it has been too fixated on centrally imposed targets”. Dickson reiterates the King’s Fund’s previous call for a debate about the government’s role in the NHS, and specifically on the possibility of creating an overall NHS agency. This “would take responsibility for delivering realistic improvement targets while allowing the government to focus on developing wider health policy instead of meddling in healthcare services on a day-to-day basis”. On the question of market forces in the NHS, Dickson is “cautious but certainly not hostile”, believing that thus far market forces have been useful to tackle waiting lists for elective services. The need now, he argues, is for a similar focus on chronic-disease management. That is why the fund is helping pilot incentive- based models, starting with a handful of primary-care trusts in London, based on the experience of successful health-maintenance organisations. Does Dickson anticipate further moves towards the US system, including increased user fees? “I see no need in the immediate future to move away from a tax-based system of funding. This remains the fairest and most efficient method of healthcare funding and the government is right to commit to it. Any insurance- based system would inevitably compromise equity and is likely to add to overall costs. But that does not preclude competition between providers and a move away from a system dominated by state provision. We can learn from other countries and look at how they use financial incentives to improve quality and increase patient choice.” The interview Books Lifeline Jabs & Jibes The interview Niall Dickson was born and educated in Scotland. He started work in health and social care aged 24 years, initially for the National Corporation for the Care of Old People and then for the charity Age Concern England. In January, 2004, he returned to the sector as chief executive of the King’s Fund—an independent charitable foundation working for better health and social care. More than a decade spent working in publishing started at Age Concern, where Dickson became head of publishing before moving on to edit Therapy Weekly and then Nursing Times. When he joined the BBC in 1988, he was a health correspondent on radio news. By his departure, as social affairs editor, he was responsible for more than 80 producers and correspondents. His own work ranged from health documentaries, investigations of institutional failure and scandals like the Harold Shipman murders, to a countrywide survey of public opinion during the Iraq war. In 1997, he won the Charles Fletcher Medical Broadcaster of the Year Award from the British Medical Association. Kelly Morris e-mail: [email protected]Niall Dickson “We need a change in emphasis towards keeping people well”
Transcript
For personal use. Only reproduce with permission from The Lancet publishing Group.
904 THE LANCET • Vol 363 • March 13, 2004 • www.thelancet.com
Setting out to interviewNiall Dickson, I amacutely aware that he
has spent his life involved inhealth and social care policy,as well as decades working asan editor and journalist. Whenhe asks the questions, he isinformed, pithy, and direct.My questions to him soundlongwinded and ambiguous bycomparison—he starts everyreply by rephrasing them. But,in his carefully craftedanswers, Dickson doesn’tseem too eager to push hisown views forward.
What Dickson does intend,as the new head of the King’sFund, is to push for the fund’spolicies to become actionswithin the UK health andsocial care systems. He wantsthe fund to be known as “thehealth think-tank that does”, apolicy institution that doesn’tjust stop at the report stage.
If Dickson’s rhetoric has afault, it springs from his needto be exacting. When I suggestthat the fund’s latest reportManaging Chronic Disease(January, 2004) proposesmanaged care for the UKNational Health Service(NHS), he agrees “we lookedat some of the models used bymanaged-care organisations inthe US for their applicabilityhere”, but clarifies that thereport rather proposes theneed for stronger incentives toencourage UK hospital andfamily doctor services tomanage chronic conditionsmore effectively in thecommunity, reducing the needfor hospital treatment. Thestrongest incentives may befinancial, he acknowledges,but nevertheless, strongincentives are needed “as amatter of urgency”.
Dickson also intends theKing’s Fund to be at the heartof the thinking around the UK
government’s drive to improvepublic health. “Coronary heartdisease and cancer—bothlargely avoidable—kill200 000 people a year;smoking kills 120 000 peoplea year; and obesity has trebledin the past 9 years. Yet publichealth is not given the urgentattention it deserves. Theweight of investment—notonly of material resources, butof political capital, energy, andcollective enthusiasm—remains with health-care
services. We need a change inemphasis towards keepingpeople well.”
When asked aboutgovernmental NHS policy, heis quick to point out what heapplauds—more patientchoice, locally determinedservices including foundationtrusts, among much else.Though he dreams of an NHSwith less bureaucracy,Dickson welcomes thegovernment nationalframework to set, maintain,and monitor NHS standards,together with the latest ofsome hundred or so NHS-related agencies—theCommission for Patient andPublic Involvement in Healthand the Commission forHealthcare Audit andInspection.
Dickson was a Labour partymember in the 1970s, and Iwonder whether he is now aNew Labour man. He isn’tshy of criticising government.No fan of centralised control,he notes that “the governmentitself accepts that it has beentoo fixated on centrallyimposed targets”. Dickson
reiterates the King’s Fund’sprevious call for a debateabout the government’s role inthe NHS, and specifically onthe possibility of creating anoverall NHS agency. This“would take responsibility fordelivering realisticimprovement targets whileallowing the government tofocus on developing widerhealth policy instead ofmeddling in healthcareservices on a day-to-daybasis”.
On the question of marketforces in the NHS, Dickson is“cautious but certainly nothostile”, believing that thus farmarket forces have been usefulto tackle waiting lists forelective services. The neednow, he argues, is for a similarfocus on chronic-diseasemanagement. That is why thefund is helping pilot incentive-based models, starting with ahandful of primary-care trustsin London, based on theexperience of successfulhealth-maintenanceorganisations.
Does Dickson anticipatefurther moves towards the USsystem, including increaseduser fees? “I see no need inthe immediate future to moveaway from a tax-based systemof funding. This remains thefairest and most efficientmethod of healthcare fundingand the government is right tocommit to it. Any insurance-based system would inevitablycompromise equity and islikely to add to overall costs.But that does not precludecompetition betweenproviders and a move awayfrom a system dominated bystate provision. We can learn from other countries and look at how they usefinancial incentives to improvequality and increase patientchoice.”
The interview
Books
Lifeline
Jabs & Jibes
The interview
Niall Dickson was bornand educated in Scotland.He started work in healthand social care aged 24 years, initially for theNational Corporation forthe Care of Old People andthen for the charity AgeConcern England. InJanuary, 2004, hereturned to the sector aschief executive of theKing’s Fund—anindependent charitablefoundation working forbetter health and socialcare. More than a decadespent working inpublishing started at AgeConcern, where Dicksonbecame head of publishingbefore moving on to editTherapy Weekly and thenNursing Times. When hejoined the BBC in 1988,he was a healthcorrespondent on radionews. By his departure, associal affairs editor, hewas responsible for morethan 80 producers andcorrespondents. His ownwork ranged from healthdocumentaries,investigations ofinstitutional failure andscandals like the HaroldShipman murders, to acountrywide survey ofpublic opinion during theIraq war. In 1997, he wonthe Charles FletcherMedical Broadcaster of theYear Award from theBritish MedicalAssociation.
For personal use. Only reproduce with permission from The Lancet publishing Group.
THE LANCET • Vol 363 • March 13, 2004 • www.thelancet.com 905
DISSECTING ROOM
In the foreword to Kevin Cahill’sbook, Kofi Annan, UN SecretaryGeneral, says, “Traditions . . . are
what each society brings to the greatbanquet of human diversity”. Traditions,Values, and Humanitarian Action is asatisfying collection of rich and variedperspectives, some new, some difficultto digest, and all feeding the need tounderstand the complexities of theseissues in a rapidly changing world.Woven through the essays are themes:the just role of governments, tensionsbetween freedom and security in the waragainst terrorism, positive effects ofmigration, and, topically, the role of themedia and the importance of itsindependence and integrity.
Cahill, director of the Institute ofInternational Humanitarian Affairs atFordham University, New York, NY,USA, has dedicated his life tohumanitarian action, and is also aclinician, professor, and chief medicaladviser on counterterrorism to the NewYork Police Department—which seemsa heavy load for one person. Primarily,he is a doctor whose life changed afterworking for many months in the early1960s alongside an indigenous healer insouthern Sudan. Cahill spent part ofevery year for the next 33 travelling withSomali nomads across the Horn ofAfrica, learning how traditions andvalues allowed them to handle severedeprivations without complaint.
The book is divided into three parts:foundations, fault lines, and corrections.The importance of foundations insociety—in the context of inter-pretations of values and human-itarianism in Christianity, Judaism, andIslam—is discussed by the moderator ofthe World Conference for Religion andPeace, Prince El Hassan bin Talal ofJordan. He calls for a “civilisedframework for disagreement”, andsuggests that providing crossfaith andcrosscultural rules and guidelines forhow to disagree will be very usefulMuslim contributions to the world. Aculture with very strong rules and ethosis beautifully described in The World ofthe Dinka: a Portrait of a ThreatenedCulture, a chapter on the Dinka tribe ofsouthern Sudan that brings out everyanthropological instinct. Written byFrancis Mading Deng, an ex-Secretary
of State for Foreign Affairs for Sudanwho spent his boyhood herding cattle, itgraphically describes his people’sspiritual beliefs and values.
Understanding what motivates,scares, enhances, and diminishes peopleis key to many professions, including themilitary, journalism, and medicine. Thefoundation of military values andtraditions is discussed by Major GeneralTimothy Cross—a soldier with 30 years’experience, many of them in reliefoperations—and prefaced by a quotefrom Dr Johnson: “Every man thinksmeanly of himself for not having been asoldier.” Although this concept mightnot strike a chord with many of us, whatdoes resonate is the enormous worth ofcomradeship in times of stress anddanger. Cross’ description of the valuesof community, courage, discipline, andintegrity gives useful insight into amilitary, and humanitarian, mind.
The application of such values tojournalism is currently much discussed,in particular in the UK in the wake ofthe Hutton enquiry. What are the rightsand responsibilities of a journalist?Where do his or her primary loyaltieslie? To whom can he or she look for
guidance and protection? Should therelationship between the media andpoliticians be based on mutual trust,where both are trying their best andacting with integrity, or is a climate ofmutual distrust and cynicism justified?
Tom Brokaw, news anchor at NBCTelevision, describes his work as afounding member of the Committee toProtect Journalists, which acts toimprove the legal, political, and cultural
climate surrounding his profession.Brokaw quotes from Thomas Paine’sThe Rights of Man, “though man may bekept ignorant, he cannot be madeignorant”, and refers to the “Big Bang”of media expansion, warning, “There isalways the danger of inciting rather thaninforming, and it happens at warpspeed”. Brokaw states that it isimperative for primary media outlets toremain fiercely independent, especiallyfrom government, although—surpri-singly and disappointingly—he makesno specific comment about the mediamanipulation now rife in the USA,especially surrounding the conflict inIraq. Edward Mortimer, Director ofCommunications at the UN, discussesthe function of the media as “prism ormirror”, and acknowledges that Islam isnow seen almost entirely through theprism of terrorism.
So, values and humanitarianism in themilitary and journalism. What about inmedicine? In the chapter entitled,Human Rights and the Making of a GoodDoctor, Eoin O’Brien, Director of theCentre for International Health andCooperation and a professor of cardio-vascular medicine, makes the sad but
true observation, “Paradoxically, thepractice of medicine makes theexclusion of sentiment a pre-requisitefor the survival of self”. He suggests thatall in the medical profession wouldbenefit from applying the old adage“Physician, know thyself”. O’Brienmakes a strong case for more humanityand humanities in medical teaching andpractice. He recommends greater effortsto introduce human rights and medical
Traditions, Values, and HumanitarianActionKevin M Cahill, ed. New York: FordhamUniversity Press/The Center for InternationalHealth and Cooperation, 2003. Pp 466. $24.00.ISBN 0 8232 2288 8.
Books Humanitarianism in society
Ste
phen
Woo
d
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DISSECTING ROOM
I do not know who purchases booksof this type. These volumes areintended to update and summarise
information in a fairly small area ofinfectious disease, yet their intendedaudience (in this case intensive carespecialists) are either uninterested inthe detail they provide or would bebetter served by researching most ofthe areas covered using onlinedatabases. Several chapters provide a solid scientific introduction toquorum sensing and pseudomonalvirulence factors, but these topics arelikely to be of interest to academicphysicians who would seek more basic reviews in microbiological orphysiological journals. Perhaps aphysician in training who has beenassigned a report on a pseudomonalsubject would find this book anefficient way to summarise knowledgefor a report to his superiors.
Having said all that, the book hasuseful information on most aspects ofpseudomonal infections involving the
types of patients likely to be seen inintensive care settings. There is muchredundancy among the chapters thatdeal with antibiotic choice (the choicehardly matters) and the necessity of theuse of multiple antibiotics (not proven,but the subject of much speculation).The chapter on cystic fibrosis isespecially well written and useful, butmany of the others could easily havebeen condensed.
Much of the book deals with theadvantages of antibiotic use and notenough (but some) of the informationcovers the genuine harm that resultsfrom their use. This bias is consistentwith the thinking of intensivists I haveworked with for the past 25 years or so,and is understandable in light of theirself-perception as heroic doctors whosave lives at all costs.
So save your money. Read aninfectious disease textbook for most ofthe information in this book and referto recent review articles for the hotsubjects such as quorum sensing andbiofilm formation.
Haig DonabedianDivision of Infectious Diseases, MedicalCollege of Ohio, Toledo OH, USAe-mail: [email protected]
906 THE LANCET • Vol 363 • March 13, 2004 • www.thelancet.com
ethics (often present but not alwaystaught well) into all undergraduatemedical curricula. O’Brien highlightsthe work being done in these areas bythe International Federation of MedicalStudents, in conjunction with, forexample, International Physicians forthe Prevention of Nuclear War.
After foundations, fault lines—andCahill’s concept of these in society is afascinating one. Just as fault lines inearthquake-prone areas lie betweenmoving earth plates that can collide andcause great damage, individual orgovernmental acts that are in oppositionto the foundations of society can causedevastation and destruction. Forexample, the justification of the use oftorture on an individual suspected ofterrorism might seem logical, but canlead to acceptance of torture as alegitimate tool of government: China,Egypt, Burma, Israel, Russia, the USAin Guantanamo Bay, and Turkey arejust a few examples in the long list givenby Timothy Harding, a professor at theForensic Medicine Institute in Geneva,Switzerland.
Even insensitively providedhumanitarian aid can act as a fault linein a society. For example, after theRwanda genocide, humanitarian
assistance helped killers survive insecure refugee camps where they re-established their murderous regimes.
Discrimination—on the grounds ofmigrant status, societal role, gender,etc—is another potential source offault lines. In Immigration in Europe:Promise or Peril?, Jan Eliasson, Directorof the Centre for International Healthand Cooperation, and Swedishambassador to the USA, arguesstrongly that the answer to thisquestion is “promise”. The populationof Europe is becoming older, andimmigrants offer valuable skills andrich diversity. Yet, a wave ofxenophobia is sweeping the continent.Eliasson effectively dispenses withprevalent myths surrounding immi-gration, and calls on the EuropeanUnion not to waver in its commitmentto the 1952 Refugee Convention. Hisnotion that cultures are “works inprogress” is a helpful one for us all.
Nancy Ely-Raphael, head of theOffice to Combat Trafficking in Personsat the US State Department, makes asound case for ending all forms ofgender discrimination and trafficking.Unfortunately, she omits one form—female genital mutilation. What shedoes include is a moving case study in
Books
which the voice of a victim of traffickingspeaks from the page, painfullyilluminating this issue. I felt that othercontributors’ chapters would have beenstrengthened with a similar use ofindividual human stories.
Several authors address terrorism, inparticular in the context of the attackson the USA on Sept 11, 2001. PaulWilkinson, Director of the Centre forthe Study of Terrorism and PoliticalViolence at the University of StAndrews, UK, argues that it is adangerous illusion to believe that thewar on terrorism will be successful, andrather that deeper causes need to beaddressed. Larry Hollingworth, aspecialist on relief and refugee issues,discusses the concept of state terrorism,often a taboo term, and the distinctionbetween terrorist and freedom fighter—he provides a chilling and personal casestudy in Palestine. John D Feerick, aprofessor of law, assesses the balancebetween national security and civilliberties, concluding that “Safety itself isan important pre-requisite for liberty”.Michael Veuthey, doctor of laws atGeneva University, cautions againstdisregarding the Geneva Conventions,the ethics of which encompass thesurvival of humanity and respect forindividuals, even in time of war. Herefers to the “Golden Rule”: “So,whatever you wish that men would do toyou, do so to them”, as the mostuniversal formulation of this ethicalapproach.
Moving onto corrections, whatactions could be undertaken to addressthese fault lines? Peter Tarnoff, formerUS Undersecretary of State for PoliticalAffairs, gives a critique of USgovernment responses, doctrinaireforeign policy, and sanctions, anddeclares, “It is essential for citizens tounderstand that values are as importantas military might”. Richard Falk,professor of international law and justiceat Princeton University, Princeton, NJ,USA, discusses what can be done torevive global civil society, and describeshow the fear of terrorism anddesperation for so-called security hasdiverted energy away from the newinternationalism that was growing in the1990s. Yet there have been recentsuccesses. The International CriminalCourt, intended to prosecute criminalstate leaders, was founded in 2002,despite opposition from the USA.
As Cahill says, “Even the mostpowerful nation on earth must rely onour noble traditions, values, and moralposition if we are to survive in a secure,humane world”.
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THE LANCET • Vol 363 • March 13, 2004 • www.thelancet.com 907
DISSECTING ROOM
Books
Today, many a Lancet reader’ssole experience of absinthe willbe limited to catching Kylie
Minogue’s fleeting cameo role as theGreen Fairy, materialising from thelabel of a bottle of the spirit, beforesending a ragged band of artists ontheir merry way to the Moulin Rougein Baz Luhrmann’s hit film musical of2001. However, in France, in the latterhalf of the nineteenth century, absinthedrinking was a massively widespreadphenomenon among all classes insociety: bourgeoisie, bohemians, andthe poor alike. It was absinthe’s verypopularity that led to its downfall,causing as it did one of the great moralpanics of that century, blamed by itsattackers as being responsible for thedegeneration of the French race,military defeats of World War I,sterility, madness, and lesbianism; by1915, the manufacture and sale of thisbitter-tasting green liqueur had been allbut banned worldwide.
Yet, only a few decades earlier,absinthe was reputed as being one of themain sources of inspiration for writersand artists such as Paul Verlaine, ArthurRimbaud, Edouard Manet, EdgarDegas, and Henri de Toulouse-Lautrec.It is this sudden plunge into notoriety,(roughly spanning the years bookendedby Charles Baudelaire and PabloPicasso), that Jad Adams sets out toexplore in Hideous Absinthe; a History ofthe Devil in a Bottle. He traces the originsof absinthe as an antimalarial used byFrench troops serving abroad in NorthAfrica, who then took the taste for the
wormwood-based drink home withthem. Back in France, absinthe caughton among the bourgeoisie, who wishedto symbolically share in the victory oftheir army. Its popularity in thefashionable cafes of the mid 1800s led toa trickle-down effect of its use throughall classes: the urban poor and the manyartists, poets, and other denizens of thedemi-monde in pre-fin-de-siecle Paris.
It was the artists and poets who wereto prove the main propagandists in thecreation of the absinthe myth, bothdepicting the absinthe drinkers thatsurrounded them, and partaking freelyof the green fairy themselves, lauding itas a magical, thought inspiring elixir.However, as Adams notes, the paeansto absinthe were mainly penned byminor writers—the major ones merelyusing it as one of the many weapons intheir creative arsenal, if at all. Themost noted artists used absinthedrinking not as a short-cut to higherunderstanding, but as subject matter(perhaps, one suspects, because anabsinthe drinker deep in solitary reverieduring “the green hour” would neithernotice nor particularly care that theywere being sketched or painted).
It was the use of absinthe drinkers assubject matter, and, more specifically,the rejection by the art establishment,of the painting The Absinthe Drinker byManet, that led to the birth of theImpressionist school of painting andthe lessening of the influence of theconservative Institut de France. Adamsargues that the fears and concernssurrounding the growing popularity of
absinthe consumption and its depictionwere inextricably linked with, andsymptomatic of, wider social trendsand concerns during a time of greatturbulence and uncertainty (the sectionon the fears surrounding increasingabsinthe consumption among youngemancipated women is oddly redolentof the current moral panic concerningthe “binge drinking” habits of young, financially-independent Britishwomen). These associations with thedrink are shown by the author to bemore important than any propertiesinherent in absinthe itself. After somediscussion of absinthe’s psychoactiveingredient (thujone, a constituent ofwormwood) Adams describes the drinkas a “mildly hallucinogenic greenliquid”, arguing that its perception-altering powers stemmed from morethan the mere combined effects of itsconstituent parts. It gained its powerfrom the codes and connotationsinterwoven around its use, and therituals involved in its consumption—such as the use of paraphernalia likethe slatted silver absinthe spoon, adevice that we learn originated fromrich absinthe drinkers seeking to setthemselves apart from their less well-off countrymen.
Elsewhere we learn of how absinthewas held in great suspicion by theEnglish, leading to its provocativechampioning by such home-growndecadents as Oscar Wilde. This is alsothe reason why it was never thoughtnecessary to ban it in the UK, since itsimmediate associations with theFrench aroused instant disapproval ina country that preferred gin anyway.Adams relates the events that led to itsprohibition practically everywhere elsein the world, its discussion in medicaljournals of the day (much of itpublished by, or commented on, byThe Lancet), the development of a USabsinthe subculture, and its rebrandingand resurrection in the pre-millennialwestern world. All in all, this is a well-researched, often poignant, and alwaysfascinating biography of a subjectwhose history, rather like the liqueuritself when added to seven partswater, has often been clouded andopaque.
Stephen WoodThe Lancet, London, UK
Hideous Absinthe: a History of theDevil in a BottleJad Adams. London: I B Tauris: 2004.Pp 320. £18.95. ISBN 1 86064 920 3.
Rights were not granted to include this image inelectronic media. Please refer to the printed journal.
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908 THE LANCET • Vol 363 • March 13, 2004 • www.thelancet.com
DISSECTING ROOM
My main reason for never, everbecoming a psychiatrist wasmy Uncle Charles: a man who
married into our family by kidnappingmy aunt on learning she was planning tomarry someone else. This happenedyears before I was born, but, for as longas I can remember, Charles—the onlypsychiatrist I knew—brought disruptionto all around him. His life was an experi-ment in learning what was possible.
Charles established that it was possibleto drive home from church in reversegear; possible, even, to drive from hometo the office in a straight line—providedhe traversed curbs, peach orchards, andthe occasional back yard. He deducedthat the best place to hide a berry pie wasthe clothes dryer; if someone found thepie before he could finish it, the chanceswere that they found it by throwing wetlaundry in and turning the dryer on.
I began medical school with the hazyplan of pursuing family practice orpaediatrics, but discovered that I mostenjoyed anaesthesiology’s blend ofchemistry, physiology, and patient care. Idelayed my psychiatry clerkship untilsenior year, confident I had no interest inthe specialty. Psychiatry rotation was ashock: I loved it. If you paid a certainkind of attention, your patients justabout told you their diagnosis, which inmy book was an improvement over, forexample, trying to hear a heart murmurin a 3-year-old child who was screamingat the stethoscope on his or her chest.
Charles’ oddities continued. On visitsI’d find a crow in the kitchen sink,Charles’s pyjamas in the dishwasher, orthe phone receiver off the hook while onthe other end a phone rang in an emptyhouse (“I just want to know when theyget home”, Charles explained).
When Charles learned I was interestedin psychiatry, he insisted I accompanyhim to the hospital for his rounds, asurreal experience featuring a burlynurse with one eye who’d beenenucleated in a scuffle with a patient.
Interviewing an agitated young womanwho’d tried to kill herself, Charles turnedto me to recount the abuse her fatherhad inflicted on her during childhood.“Can you believe it?” he asked me, “thather own father would do that?” Heshook his head in astonishment. Theyoung woman’s eyes widened indisbelief. Even then, I knew enough torecognise Charles’ professional mien asinappropriate. But I also saw the patientrelax a little, and raise her eyes from thefloor for the first time. In a weird way, Ithought, it was an affirmation for her, toknow that someone else saw her father’sviolations as an outrage.
By the time I applied for postgraduatespecialty training, I’d narrowed mychoices to anaesthesiology and, in spiteof Charles’ influence, I also applied forpsychiatry. I felt I simply couldn’tdistinguish between these two futures.Each had appeals and drawbacks, butmy crystal ball was murky.
A time-zone miscalculation finallydecided my fate. On elective rotation inanother state during the deadline forsubmitting final choices for postgraduatetraining, I decided to drop psychiatry. Iphoned to notify the friend to whom I’dentrusted the task in my absence, butshe’d already posted my list, at the timewe’d previously agreed on, leavingpsychiatry as my first choice. I hung upthe phone with trembling hands,aggrieved at myself for the error, but alittle excited, too—a fate had chosen me,in spite of myself. Psychiatry wasapparently my destiny.
I should probably mention that Inearly drowned in a river when I was2 years old and that, in the momentbefore my death, at considerable peril tohis own life, Uncle Charles rescued me.In having done so, I think, he bearsultimate responsibility for my being apsychiatrist after all, in spite of his cont-ribution to its seeming implausibility.
Pat Cason
Amin J Barakat
Received his MD from the AmericanUniversity of Beirut (AUB), Lebanon. Didpaediatric training at AUB and JohnsHopkins University, Baltimore MD, USA,and paediatric nephrology at GeorgetownUniversity, Washington DC, USA. CurrentlyClinical Professor of Paediatrics/Nephrology atGeorgetown University. He has published over75 scientific papers and chapters and twobooks.
Which patient has had most effect onyour work, and why?In 1977, I reported four siblings with renaldisease, nerve deafness, andhypoparathyroidism; this condition is nowknown as the Barakat syndrome.
How do you relax?By leaving my work behind at the office.
What apart from your partner is thepassion of your life?My children and the children who areunder my care.
Do you believe there is an afterlife?I believe in an afterlife and that peopleshould live as if there is one.
What are you currently reading?In Plato’s Cave, by Alvin Kernan.
What is your worst habit?My wife should answer this question.
Do you believe in capital punishment?I have doubts about the benefits of capitalpunishment and am essentially against it.
Do you apply subjective moral judgmentsin your work?After a life spent in the practice ofpaediatrics, I believe in creating astructural environment for children andthat parents and paediatricians have aresponsibility to teach children morality,which is in a way subjective.
What do you think is the greatestpolitical danger to the medicalprofession?I think this is a country-related issue.Apathy of physicians, government control,and control by special interests and theinsurance industry may be the greatestdangers to our profession in the USA.
What part of your work gives you themost pleasure?It is very rewarding to contribute to theprevention and treatment of disease inchildren. I enjoy the relationships Iestablish with children and their families.
If you had not entered your currentprofession, what would you have liked todo?If I had to choose a profession again, Iwould still be a paediatrician.
