ISN VIDEO LEGACY PROJECT

Dr. Ori Better
Interviewed by Dr. Eknoyan

 


 

GE: Born in 1928 in Haifa, in what was then Palestine, Ori Better witnessed its transformation. It is there that he went to medical school, graduating from Hadassah Hebrew medical school, 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 native, northern part of the country. He contributed to the emerging world nephrology community, and helped focused its attention on the nascent nephrology discipline in Israel. His interest in homeostasis, role of the kidney, and his ability to pose and resolve important clinical questions, were evident from the outset when, as part of his compulsory military service following graduation, he began his collaborative investigations in salt and water preservation in the Negev desert where he was stationed, not far from the biblical Sodom and Gomorrah.

Since then, he has continued to do good work, under adverse conditions, and contributed considerably to our understanding of the homeostatic role of the kidney. Upon completion of his military service, he went to Cedar Sinai, UCLA, for his first formal exposure to a Nephrology training program in the United States. There, he worked with Chuck Kleeman, himself a student of John Peters, and one of the founders of American nephrology and world leaders in the study of metabolism. Over the years, he has expanded on his exposure to American nephrology training programs, by intermittently spending time at Georgetown University, University of Utah, University of Colorado, Yale, and State University of New York in Stonybrook. He did this while establishing the first nephrology program in Northern Israel, where he was chief of nephrology from 1959 to 1993. In the process, he founded the renal transplant program that performed the first cadaveric renal transplant in Israel in 1965. At the broader level, and under the leadership of Professor Ehrlich he helped in the establishment of the Faculty of Medicine at the Technion Israel Institute of Technology in Haifa in 1971, becoming dean of its medical faculty in 1983. In 1985, he became the Annie Chutick Professor of Medicine, a title he still holds. In 1993, he retired from his administrative responsibilities to devote himself to research as head of the Dr. Rebecca Chutick Crush Syndrome Center in Haifa. His work there has made him a sought after world consultant on post-traumatic soft-tissue injury.

Prior to his ultimate focus on this topic, and during the course of his flowery career, Ori has made important seminal contributions to liver-kidney relationships, acid-base balance, specially Type 4 RTA, function of the post-transplant kidney, divalent ion metabolism, and obstructive nephropathy. Most of his work has centered on human clinical research, using readily available techniques, and always focused on questions raised at the bedside. In fact, it is at the bedside that the unique attributes of Ori are most evident, as a first-rate physician, and teacher. He is worshipped by his patients, and adored by his trainees, and students. This is based as much on his vast knowledge, which he shares freely, as his uniquely warm personality, which endears him to anyone who comes in contact with him. It is this that has made him a sought after friend and colleague of the international nephrology community. It is a special pleasure for me to conduct this interview of Ori Better, for the Video Legacy Program of the International Society of Nephrology.

I would like to begin the interview at the start of your career, by asking you, "Why nephrology? And why medicine?"

OB: Well I have always been 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 is 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 avid sailor, and I have sailed many times from Haifa to the islands, which we just visited together. Now when you are at sea, and in those days, we were at the ends of World War II, there were people still stranded at sea, and the problem of desiccation, and salt and water balance were important. There were several scientists in Harvard, if I remember their names, Dero, and another one, most of them were pediatric people Ė they were very busy in designing the solution that people should take with them on rafts, in case they were stranded, and of course desiccation in the desert. So I became very, very interested in that, volume regulation, and how to protect yourself against desiccation. Then when I was living in the desert, I was full of admiration for the solution that nature chose to protect against hyperthermia, and against water deprivation in the camel and 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. So this interested me very much, and in the first years at the start of my work as a young physician, there was no nephrology discipline, but I was still interested in volume regulation, acid-base regulation, renal metabolism, and it was relatively easy to study in those years. You could take blood, you could take urine, later do a biopsy, and you could do enough studies in an emerging tough place like Israel, to put it in place, to take the results and put them in the best American journals of that time, like Annals of Internal Medicine, and even the New England, and even the JCI. It was difficult to do it in cardiology, in pulmonology, in hepatology, because you needed too much. You couldnít do it with your own two hands. And you almost didnít need to ask any consent from the patients because anyway you took urine and you took blood. So this immediately put me in the direction of salt and water and urine.

GE: This was before the days that nephrology came into being. This was when renal physiology was coming into being as a discipline, and metabolic studies were the way to look at things.

OB: Right you are, but then suddenly, I found myself, like sitting in a rocket coming out of Kennedy missile range. Suddenly any of us who were there were catapulted up, because the artificial kidney came into being, transplantation, and everyone who was inside was very moved, whether he wanted to or not, whether he was bright or not, 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 good wind, a good current that carried you along. With this, however, came problems. The public 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 from entire Israel, but from the West Bank, and from the island of Cyprus, and this became very, very difficult to manage. So here is the beautiful part, the lucky part, and also the hard reality that youíve got an invention, that came down to earth, to humanity too early for 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 in a confrontation with my superiors who didnít understand that people were dying in vain, because there was not enough dialysis.

GE: This was a problem, both in research and in dialysis that everybody had to face. They must have been uniquely difficult at the time you were in a developing country having its many needs and pressures from outside, that magnified probably what you had to face, much more than what the rest of us in the United States, lets say, experienced.

OB: Yes. And then this is what brought me into nephrology, dialysis, transplantation, but, 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 in 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 itís 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 this is a preventable disease.

But talking about people who influenced me, letís go back to the last century. Maybe the greatest name in medicine for me, is not a physician, is a chemist, is Louis Pasteur. And itís 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 sink industry. He went to treat, 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 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 education, after all it is a person who comes and runs the research room not a gene, and how are we going to prepare all our medical students for this. So Pasteur was involved in all this in every aspect. There was no problem that was too little for him in public health. Furthermore, when France was beaten by Germany in the 70ís of last century, France was bankrupt, and Louis Pasteur got excellent, great, incredible offers from other countries, particularly Italy, lucrative offers, and he declined. He told the Italian universities, he says, and this is ingrained in my flesh, like your cattle in Texas have in their skin, the number, he said, "Science has no boundaries and no countries, but the scientist has a homeland, and the scientist has to be serving his homeland, and in touch with the homeland." Now my homeland is unique. Itís much more than a homeland; itís a great heritage, and in the 3000 years of Jewish history, there occurred the catastrophe of the holocaust, which only new Armenians know what it means, and then, 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 together with, never lets you be away from Israel for more than one year, on these sabbaticals. I could never stay away from Israel for more than that although I must say that being here in the U.S.A. would have been much more supportive to my research. Itís 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 the first transplant and studying them. Maybe if Iíd been in the U.S.A. I wouldnít have done such studies on the transplant. I donít know. I believe that anaerobic conditions are sometimes a spur and a stimulus to research. Maybe we are like our bones. When there is weightlessness, we begin to lose the mass, like the astronauts have experienced. We need the stress on the bones all the time to make the bones strong. The great question is how strong should the stimulus be before breaking your bones. This is always the question.

GE: I think it would be useful if we went through your research in some form of systematic approach, and get your comments on the issues that you have examined, and the people that you have worked with. I think the first exposure you had to a training program in the United States was with Chuck Kleeman at Cedar Sinai, where you started your work on divalent ion metabolism, which may be pertinent to your last comment on the bone. Maybe you could tell us some of your memories of those days and the lessons learned that you would like to share with others.

OB: Kleeman is a very interesting and stimulating teacher. Maybe two-thirds of the nephrologists in Israel were trained by him. You can say he single-handedly built the edifice of 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 rides the 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 back from work is climbing the hill, which was good. I believe with Chuck that physical exercise is good, is healthy for your physical health and for your mental health also. I believe 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 Ė came out more or less in parallel with those of Neil Bricker, and his hypothesis. Early on, I was in dialogue with Shaul Massry whom I met in the Negev in Israel. When I left Chuck Kleeman to go to Israel, Shaul came and continued his work. Shaul also had a profound influence on me, and when I returned after seven years to LA, I worked with both of them, on continuing the work on divalent ions. After one year in Cedar Sinai where I learned how to operate the artificial kidney, I went back home to Israel, put the first artificial kidney, set it up, so we could do, with Dean Ehrlich, the first transplant. Now, talking about politics, which I shouldnít, Internal Medicine was dead against the development of nephrology as a subject, dialysis and transplantation, so I had to break ranks. I was a good, loyal internist; suddenly I found I couldnít go on with Internal Medicine. I needed a new political ally, so I switched my weight and went to work with Dr. Ehrlich. Later on, I worked many years with all the big surgeons, because so many traumas were coming into our hospital.

Our hospital is a military hospital more or less, civilian-military hospital, that is the catch, as patients from the catchment area of the entire southern Lebanon front which has been active all the time. 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, primarily to treat diving casualties and arterial air embolism and carbon monoxide poisoning where it is indicated definitely. It is life saving, but we found it Ďs also good for vascular injuries. Itís good not only for anaerobic infection, but also staphylococcal infection. Later on, I found it is excellent also for crush injury. Before leaving hyperbaric medicine, I have a feeling that the medical profession is frightened by oxygen free radicals and frightened by oxygen and they are frightened by hyperbaric medicine. I believe we are aerobic animals; 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 or normobaric treatment is very, very, very helpful, not only for hemodynamic situations, but also for overwhelming sepsis.

So this was my interest with hyperbaric medicine, with which Iím involved to this very day, but 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 with a belly full of fluid of 40 kg, so why this sudden, you can say, failure of homeostasis? And when you look into it, itís 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 Sergei, or Kleeman, of Frank Epstein, of San Field, and others that I didnít include now, but should have perhaps. They all started with Peters and this concept of affected blood volume, it has not been improved, to this very day. So I began to study the kidney in liver disease, and the kidney behaves in an interesting, grotesque way, and we tried to recreate the situation in animals, and with Shaul Massry we did it in the dog. We created a model that has great ascites. We studied it, and then with Shaul Shasha, another friend of me, else he was a disciple of mine, a pupil of mine, and then a co-worker, and then an equal-rights friend to this day. He went very far in his line. Heís one of the most important people in medicine in northern Israel, and he is professor of Mao institution. We continued that model with the cirrhotic dog, and we found that the cirrhotic dog has a hyperactive heart situation, which is exactly mimicking what one sees in humans. I believe this is the first illustration you see of hyperactive heart disease due to liver disease that you see so often in the human in the canine model.

Now Iíve been talking about interplay between organs. There is a balance between organs, the liver, the heart, and the kidneys, and it is this beautiful balance between the organs, and study of the whole patient that I think suffers today. All the effort, all the glory, and all the grants go into molecular medicine. This is important, it should go, but not to the detriment of organ physiology. After all, what we are seeing at the bedside is the whole person, and organs playing in balance with each other, and if I were a dean today, and I was a dean once, I would say to it there is almost a legislative balance between genetic, molecular, and organ and classic physiology. You can reach the absolute, the saying that all human moods can be reduced to the seratonin levels, and the activity of the receptors in the brain, and you can cure it with prozac-like things, and you neednít worry about the person at all. Manage the seratonin in the clefts. So this is dangerous, and if we go in this direction, weíll teach our students to be deterministic. Itís in our genes, itís the gene therapy, everything is genes, and nothing but genes. We will forget the patient. Let us remind ourselves that the two most important drugs, or maneuvers in psychiatry were found by astute clinicians, and to this very day, we donít understand how they work. One is electroconvulsive therapy. Itís the most powerful drug or procedure that exists in psychiatry, and no one understands how it works. It is lifesaving, and it is the same with lithium. Itís astute clinicians Ė they found it, and there is 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 be well versed in organ physiology, in classic physiology, in parallel with the molecular.

GE: Your work has always began by looking at the clinical problems, and investigating them and trying to answer the problems encountered at the bedside. One of the areas that you have contributed to have been the transplanted kidney, and perhaps you could share with us some of your early experiences with the transplantation procedure and the problems encountered, as well as the studies you did.

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. Itís holy, itís not touched, in the Jewish, in the Muslim, in the Jewish culture, so itís very difficult to get consent to take cadaverís kidneys. So I must confess that what we did in the beginning was covert. Maybe itís dangerous to be so open about what we did, but we did it without permission, and we were afraid thereíd 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 on, because the area is volatile enough, we donít want to inflame it even more, but with being very, very tactful, and doing things in a decent way, and with great conviction that what were doing is right, saving lives, we managed to do it. We started in í65. By í70 we had like twenty, thirty patients, with excellent, good cadaver graft function. These years, we had only imuran, as a thioprene, and cortisone. It wasnít nephrotoxic so life was easy. Theyíre still very good drugs to this day, if someone cannot take cyclosporine, and 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, first with the paper, then with the pH meter, and we found 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, so 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 crush patient will have hyperkalemia within two hours of extrication from under the rubble, and then they 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 the institute 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, 18 mg, and examine the urine after 2 hours. In my days, in the early days, we had to give ammonium chloride, which was unpleasant, unless the patient had spontaneous acidosis. We also found that the cirrhotic patients, many of them had some type of RTA, most of them type one RTA, that was reversed after giving mannitol, where the distal delivery of solvent were elevated, showing the importance of adequate solvent supply to the distal site for acidification. This problem was further amplified in a beautiful, creative way by Daniel Batlle from Chicago somewhere. One day I came to Daniel Batlle, and I said, "Daniel, we all thank you for introducing the furosemide test so people donít have to eat ammonium chloride." He said, "Itís not me, itís you who invented ammonium chloride." I said, "I?" He said, "Yes. Donít you remember that you gave your patients all sorts of diuretics to lower urinary pH?" And we gave them still the mercurial diuretics, which was a heritage from my early days. Until the early 60ís, patients with pulmonary edema got mercurial diuretics, and there was nothing against pulmonary edema. There was no furosemide, nothing, and there was nothing that lowered urea and urinary pH better than mercurial diuretics, but this is all history. So this is the acidification point. To summarize the renal tubular acidosis I can say with my mentors, Casier, and Raymond, and W.B. Schwartz, that this Ė the formations that occur after RTA are not so important, the body can handle it. What is important is the secondary changes in potassium. You can get terrible hyperpotassemia, with flaccid paralysis, or you can get hyperkalemia with RTA. Also W.B. Schwartz, Jordan Cohen, Casier, the last two are good friends of mine, especially Jorde, they showed the beautiful concept that the body will sacrifice acid-base balance in order to preserve the volume balance. Internal volume is the most important thing, and it is the last thing to be sacrificed. In sacrificing the acid-base balance, you may enter into alkalosis, in order to preserve your internal volume. So this group, which was derived from Peterís group, really influenced me, but letís go back to Seldin, who brought the flame of effective blood volume from Yale to here. 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 Ďs 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, heís still alive today, and I am in dialogue with him, I got tremendous inspiration from him. He described the crush syndrome during the terrible days of the Blitz in London. Churchill said about the British, "their finest hour." It was their finest hour. He described the crush, he founded part of physiology, he began to think of therapy and was ready with therapy towards the end of the war, but all during the war, he was bombed in London. First with the blitz, then the V1, and then the V2, until í45, and sometimes when you read it in his papers, while doing autopsies on crush patients, crush casualties, he had to hide under the autopsy table, because the V1 and the V2 were coming. Incidentally, the scud missile is the descendent of the V2, but this is another story, which I think weíll skip today. So this is Bywaters, who did classic studies under the very anaerobic, dire conditions of the war, without any funds, without any support, with his bare hands, brains and few friends. The other one is similar. Kolff did everything, developed, invented the artificial kidney in Ď 43, í44. He didnít 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, he hated. She was an old lady, seventy-something, who was the head of the nazi Dutch party. She had acute renal failure due to the hepatic renal syndrome, the jaundice, another subject which interests me, jaundice of the kidney, and he saved her. He said, "I cannot choose the treatment. I hate the patient, I donít hate the patient, I have to save him. He is human, and this is my prime duty." Having said that, I must say that for all the turmoil in my home country, for which I am sorry, at least in Northern Israel the patient-doctor relationship, between us and the Arabs are unaffected. It may sound as a joke, that the Arab patients are better patients than the Jewish patients. They never ask for a second opinion, and there are good relationships. And if, God forbid, an Arab patient should die, after five weeks, Iíll be invited to the home of the family to show that there are no hard feelings. If a Jewish patient dies, I think that family will not enter the hospital again. One of my pupils is now a very successful nephrologist here, is Sumitham, he is an Arab, and he is one of my best friends, and he has stood by me in good times, and in difficult times. So patient-doctor relationships, doctor-pupil relationships, are unaffected by the circumstances, and this may be a heritage of long tradition. The Jews have always been eminent physicians in the courts of the Arab caliphs, say, Maimonides, in Egypt, and so on and so on.

GE: Ori, I would like to come back to some of your own personal experiences in the context of some of the general notions that you have commented on. One of the things that you highlighted is the importance of the pioneering spirit, and the merit of encountering difficulties in being able to accomplish things in the long run. Perhaps you can relate some of your own, personal difficulties, that you encountered in obtaining local support, in obtaining funding and research for the work that you are doing, and in recruiting people to your program, and I would like to keep this to your own personal, your own life experiences, rather than observations about the world in general.

OB: Well, letís go to my research. 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, were 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 donít know why this is so. Maybe I was so hard fighting, that my hospital, and I was part of the government, part of Ministry of Health, thought, and "He can do it. If you press him, heíll 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 was bought, and even, Iím 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 though the technological advances come before the ethical advances. It takes them time to 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 donít think itís the duty of the clinician to buy for the insurance company and for the government the hardware. They should supply it. Now because they didnít supply it, because the people didnít 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 you went on?

OB: I wouldnít like to elaborate on that too much. I went to the director of my hospital and I said, "Unless you supply dialyzers and space, I stop eating," and, "Itís a problem now," and I went to the press and said so. I donít like to elaborate on that because Iím not a Gandhi type of martyr, and Iím angry that I was pressed into that corner. 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 over there because I was raising young people for that. In one hospital there was a man dying of chronic renal failure. I brought the main news of the evening, I donít know what your counterpart here is, it is as if I brought our Walter Cronkite to that hospital and we focused the camera on the dying man and all his family and then I asked the Minister of Health, "Do you have any reply to that?" and there was terrible turmoil in the country, 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 point where I really was abrasive, but ultimatelyÖ

GE: Itís really not abrasive. Itís the ultimate in patient advocacy. If the physician does not speak for the patient, who should speak for him? You did the ultimate in patient advocacy, and youíve done that all the time, as far as I know. Iíve seen the patientís response to you.

OB: But itís interesting, Gary. I said the word Ďbitternessí before. I want to delete the word Ďbitterness.í Iím not bitter at all; Iím glad about all that I did, but you know I have successors in this. There are three successors to my job in Israel, in nephrology, and two of them are world-class. They have got all the dialysis they need, the department has been renovated they donít 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 be spent on their research, and each of them is getting at least one PhD to work with him. So I donít envy them at all, but they have it easier. Maybe they should envy me, because I had this pioneering time. So really letís leave the word bitterness out of there.

GE: I want to go back to this pioneering thing, and again get a little bit more of the actual events and your own responses to the first kidney transplant that was done in Israel. If you could tell us more about the patient, how it was, the circumstances under which it occurred, and your own reactions in making it all happen. I know it must have been difficult, I know it must have taken a lot to do, and under adverse circumstances, but for the record, for the video legacy and the history of nephrology, thatís as important to record as your advocacy of the dialysis patients.

OB: This is í65. The cadaver kidney was stolen; we didnít get any permission to do that. Itís difficultÖ

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 that time, and we used to measure the time of death by the clock on their hands, during the accident that killed them. We clocked it by the time, and remember Israel is a warm country. You can do things like that only in winter, when it is cold. So it was done without permission. I say we broke the rules by taking the cadaveric kidney. Maybe, itís 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 you tell us something about the recipient of that kidney.

OB: Well dialysis wasnítÖ He was a young man of 23. He was a driving instructor, and I say we took the kidney without permission. He had great trust with us, couldnít tolerate dialysis as it then was, there wasnít enough slots available on dialysis, so we did it. At that time, we didnít have any radioactive tracer studies of the kidney, and it took 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, that transplant ushered in organ transplantation in Israel. He lived for three years, went to Beer-Sheva, and in Bethesda he had difficulties with getting the imuran with his insurance, I donít know what was completely wrong there, and he was once brought to us after three years by helicopter from Beer-Sheva, with fulminate rejection due to not enough imuran, and he then died, but we then said to the family, "Here are three years." Three years are a lot, and one child was three, he had a father from three to six, this is so important, and I met this child, this now grown-up man, and he told me, "You are right. To have a father from three to six is a heck of a lot." So this was the first transplant, and then let me tell you, I want to give you the feeling that we were riding a tiger. People deluged us, everyone wanted a transplant, and then we had another transplant, another successful transplant, and suddenly, after two years, he developed Kaposiís sarcoma. All that you see in AIDS nowadays, we saw in the sixties, because of induced immunosuppression. Itís an immune deficiency disease, immunosuppression. He developed Kaposiís sarcoma, and we didnít know what to do. And we didnít want him to reject the kidney so we continued the immunosuppression and he rejected the kidney and then he died. The next case that developed Kaposiís sarcoma, we decided to be clever, and we just stopped, and this was the first patient in the literature, we stopped only the imuran, and he rejected the Kaposi, and retained the kidney, and now I think itís a common practice to lower the imuran dose with Kaposi. And here I am, suddenly finding myself riding a tiger, inducing cancer in some patients, and then being able to cure the case. Iím omnipotent, itís frightening how much potency you have. By the way, I wrote to all great people, of oncology, of virology, I wrote to the Viceman Institute, I wrote to George Klein in Stockholm, he is the greatest man on Kaposiís, he sits on the committee of the Nobel Prize, Nobel laureates, I said, "I have this situation. What can I do? What should I do?" He said, "Ori, I canít. I donít know, I canít help." So you are ahead of every thing and you have to decide by yourself. So this was the other thing that was frightening, being this omnipotent. Now, 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 this is how it should be. If you have too many live transplants that means you are being promiscuous in a certain way, and this should not be encouraged.

GE: Your success with the transplant program as you started it, created itís own problems that you had to face with new patients, that needed transplants, and how did you deal with them in setting up satellites, or how did you manage the problem that you had 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 send him over to Nigeria, to John Nigeria in Minneapolis. He became a successful transplant surgeon in his own right. 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 international cooperation. A country, it was a third world country, and now an emerging country; very soon it will be part of Europe. So this is one way to solve the problem, by teaching the local people to do the job.

GE: You must have had to deal or consult on important patients, and you must have dealt with some interesting patients. Maybe you can tell us something about the unique instances that you remember, whether it is an important patient, an interesting patient. What are some of your physician-patient encounters that you found so rewarding or that you learned a lesson from.

OB: Well youíd be surprised. During my times in the Negev, in í57, 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 the Negev, the Kibbutz was called Ravivim, 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 a daughter in that kibbutz, and she was very powerful at that time, and I met her several times, I told her, "This boy must be flown from here to one of the clinics here." I forget whether it was the Mayo, where they did perform this, when the Tausig and Blalock procedure was still in vogue, and we flew him out, and he returned back, and everything was okay. I only know that the patient before him died on the table, the patient after him died on the table, and heís very good to this very day, and heís a famous TV photographer in Israel, and he did army service after the successful surgery, so no medical 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, your renal patients?

OB: Now the renal patient, the one with Kaposiís he was an Iraqi Jew, and he was in the air 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 Nigeria or somewhere, because he speaks such fluent Arabic, he was called by the army to go overseas, and do the negotiations, and he phoned me and asked if he could do that, if he 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 fully restituted. Among my patients from the Arab bank, one was related toÖ the mother of Suha Arafat. Sheís a very beautiful woman to this day, forgot her name. She was born in Acre, she visited us, sheís a writer also, and a feminist, the mother of the wife of Suha Arafat, and we visited her in Nabus, and I would say this is the most prominent Arab that we have met. I think nowadays, she is in Paris. Sheís such a vehement feminist, that she may be even too much for Arafat, but a handsome woman to this day, but I think Iíll remember her name if I think about it.

GE: How about some of yourÖ

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 was kept secret, and some of them were members of the Arab forces, or the security of these 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 is exempt from the public, and this is important, very, very important. Yup.

GE: How about some of your personal experiences in teaching? Youíve been an inspiring teacher, a master lecturer Ė some student encounters or trainee encounters that stand out in your mind that you would like?

OB: My greatest pride, like a fatherís pride in children, has been 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 is 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, which developed for multiple pregnancy anemia. 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.

GE: Did you ever feel threatened by some of these young people that you trained, and who were moving in, andÖ

OB: Never. I knew that in certain respects, they are better. I knew that biology is on their side, age is on their side, agility, creativity is on their side, and it was always cooperation, never envy, never jealousy. In fact, I was fully cognizant of the fact that they are one step ahead of me, and letís do the thing together. There was never quarreling over co-authorship of papers, never stealing of ideas. I think there was one or two examples, when I was hesitant of sending a paper, and they said, "Stop it. Why are you so sluggish? Letís do it," and we sent the paper, and to my surprise, it was accepted. So I can see in this respect, only how I had disharmony with the Minister of Health, with the administrator of the hospital, but never, never, never withÖ and I helped them to find good positions. I gives a good massage to my ego to see my pupils in eminent positions. Itís a good reflection on me. In fact, once or twice I encountered the comment, "If you fight so hard to send him over here, maybe you donít want him in your place. Why do you do that?" So, this is all straight.

GE: There must have been people who have influenced you more than others, whether itís in your family, whether itís in the people you encountered, some people must have either stimulated you, challenged you, or tagged you along, independent of your inner drive, that has lead you to accomplish what you have. Could you tell us something about key figures like that?

OB: Well, on the local scene, itís my parents, of course. Both of them were physicians; my father was also an investigator. He died very early of myocardial infarction, at the age of 50, but he had enough influence on me to go and carry on, and have respect for scholarly tradition. So I really owe a lot to my father and mother, and then in Israel, it is Dr. Ehrlich, with whom we did the first transplant. He was a great political ally.

GE: Was Dr. Ehrlich a surgeon?

OB: Yes. He was a great surgeon. He was a general surgeon. He was a urologist, and he was also a good vascular surgeon, which made him ideal to do the first transplant, but I must confess that with the facilities that we had, it was almostÖ today we wouldnít get any city health approval to do a thing like that, like the transplant under the conditions that we then did, and this are the local people in Israel, and then the orthopedic surgeons, with whom I cooperated a lot. But I had great influence from my army buddies. This was an elite unit, the people were selfless, they did something for a thing, which is greater than their own, they took great sacrifices. So this milieu really influenced me, and I found great acknowledgement from this milieu, more than I found in the civilian sector. And I must confess, I come to you here, from a meeting with the medical army in Boston, and there were 400 people there, all physicians and nurses and soldiers. 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, in the Armed here will have today.

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 50ís, the late 50ísÖ

GE: What is this type of personality? I donít know anything about being a paratrooper.

OB: There was something technical in addition. In the late 50ís, the helicopter was not in great use, and those that were, were small, and couldnít carry great weight, so if you wanted to project any military or medical effort, you could do it only by jumping. And I calculated, that sooner or later, the need would arise, in the Caucasus, or in Turkey, or in Iran that was friendly, that they needed us for earthquakes. So one reason that I went to the paratroopers was to be able to deliver health care wherever it was necessary, and where you couldnít reach it otherwise. It was a very close unit, all volunteers, all very physically fit, and great friends. Most of them at that time came from the agricultural sector. So this was a beautiful combination of 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 today they could deploy us in a great distance, where the helicopter was not yet sufficient, and we had a hospital that we could drop from the air, and assemble it on short notice. Now, during our training, which was very, very vigorous, there were cases of heat stroke. There were cases of rhabdomyolysis. There were cases of sudden death. And this sudden death in young, healthy men really preoccupies me to this day.

GE: Would you tell us about some of your own, personal experiences in the relief work for rhabdomyolysis and trauma? I think you were involved in some of the work that was done out of Haifa. If you could just narrate your own personalÖ

OB: 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 geographic curiosities of my hospitals is that it is very near the frontline in southern Lebanon. In southern Lebanon there are fundamentalists that blow up buildings. They did it several times where many Israelis were killed, and French, maybe Americans, and many Arabs too, and casualties were brought to us, and this is very near to us. The town of Tyre is maybe only 40 miles from my town, and itís very easy to reach by helicopter, so we could see the casualties very, very early, and we could take blood early, and start treatment when they are still under the rubble, 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 the rubble would die or develop acute renal failure. He neednít necessarily die today, in the post-Kolff era, but everyone would have developed it here. We could save them even if they were 24 hours under the rubble, so we could prevent acute renal failure, myoglobinuria acute renal failure. All the lines that Bywaters suggested, really we didnít add to the thoughts and pathophysiology that were delineated by Bywaters. We gave 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 compartmentís syndrome, which is devastating in acute emergencies. We believe that the current treatment, in the textbooks, is too radical, too dangerous. We have different ideas on how do it. I donít know if what we think, and suggested, and recommend about compartmentís syndrome is accepted. I think what we suggested on the prevention of acute renal failure is well accepted. So, here is the patient side of the story, which we were able to handle successfully because we were prepared for it by the exertional rhabdomyolysis, and second, because we were so new to the disaster, 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 compartmentís syndrome in the dog, and showed that it can be relieved without a fasciotomy, by different means, and in the crushed limb of the rat, we found that there is tremendous reduction of inducible nitric oxide, with vasodilatation. Here, we did go into the molecular level. We showed that the messenger RNA is induced, and the enzyme is induced, and we did even some patch clamp studies to show that stretching of the membrane will cause falling of calcium into the cytosol by stretch activated calcium channels. So yes, you should do the molecular thing, but also part and parcel in parallel with the physiologic studies.

GE: There is a humanistic aspect of your personality, that began with the paratroopers, and being able to deliver care at a distance, with the dialysis patients, or the transplant patients, how to obtain kidneys for them, that has driven you into something that can be termed missionary work. Youíve done some of that, and I know youíve gone places that others have not. Youíve done things that others dream of doing. Youíve been to Africa and established facilities there. Again, I wish you would tell us about your own personal experiences with those events.

OB: Well before going into the missionary, letís talk about patient welfare. I saw that the patients were so miserable, that in the early 70ís 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 Ď60, 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; I was suddenly called to the chief of staff. I was afraid when I was called to the chief of staff. You had one fear in the paratroopers, that you would be transferred to the tank corps, which you didnít 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 in near what is today Kisangali. It was civil war, like today. In fact today, itís very active in this area, the Kisangali, a week ago Kisangali was occupied, and we were 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, but Iím glad I did it. We had to be pulled out with a relief mission; I think today Americans are landing in the vicinity to take out American citizens. We had to be taken out in the end by UN troops. It was frightening but satisfying, and the local people told us in French, French was the language, "You are going?" they said in French, and I remember the words, "Nous sommes orphelins." We are becoming like orphans, now that you are leaving, who will care for us? Incidentally, that geographical area is the heart 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 involvement with 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 I went into this highly mobile airborne unit to be part of relief, and I believe that any great effort will always be airborne because itís fast, and this was the case with Armenia. The American team with you, and the Israeli team were all airborne. I am very interested in disaster relief, and I am grateful to you for having been one of the organizers of an important meeting in Macedonia last year on renal aspects of disaster relief. Iíve been again in Yugoslavia, and I am beginning to have dialogue with this people, and it interests me very much. We were even asked to give advice after the disaster in enemy countries. People who are enemies to us, and they are fighting us, and yet, during disaster, through a third party, they ask us advice on how to treat a casualty, and we give this advice. So medicine knows no frontiers.

GE: Now, you must have had some encounters editorially, both in publishing your articles, and how you deemed them important as opposed to the views of some reviewers, and you must have been on the other side, of being the editor, trying to respond to an article. Could you share with us some of your own personal experiences that stand out in your mind, either side of the story?

OB: Now I tried to be magnanimous when I was an editor. When people wrote 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 aboutÖ

GE: Do you think all editors are as magnanimous as you are? Could you tell us an instance where somebody has not dealt with you magnanimously? Specifics.

OB: No. I wouldnít like to enter into it, but I know that a paper was a paper on handling the crush syndrome, traumatic crush syndrome, was rejected, and quite abrasively, and it was 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, a man of creativity, and I donít know why this was done, but itís a lesson to young people, "Donít give up." By the way, I had to fight very hard with the other journal. I had to fight for one year, and then there was a great disaster in this country, and immediately after this disaster things became easier and it was accepted. Then I went to the editors, when everything was published. Everything was okay. I said, "Why did you fight 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. I remain on excellent terms with this editor. I have great respect for him, and he did things out of his way to go along with me. So, yes, I find the editors sometimes Ė how do you say it? Ė Exacerbating, no, arbitrary, and I also feelÖ. You know, in Japan there was a culture a hundred years ago, when a samurai gets up in the morning, and goes to work, he takes his sword, and just kills, he beheads the first one that he sees. This was a samurai tradition. He shows that heís got guts, and that his sword is functional. I believe editors will do that sometimes just to show that they can decide, and there is innocent blood shed.

GE: Itís good to have power.

OB: Itís good to have power, but it should be done magnanimously.

GE: Letís see, what else do we need to talk about?

OB: Covered everything.

GE: No, I think we still have some things we have not talked about. How about your work habits? Tell us about your work habits when you were young.

OB: Well, I used to ride on my bike like Charles Kleeman to work and start very early, earlier than anyone else.

GE: Did that upset people?

OB: Yes. It always upset people. They said itís tough for them to come, they have traffic jams. In this respect I was at odds with my staff, with the nurses, with the young physicians. They didnít like the early rising.

GE: What is early?

OB: Well I always started at seven oíclock.

GE: Seven oíclock is early?

OB: Seven oíclock is.

GE: For young people it was early, but did you do any swimming before you went to work?

OB: No. I did swimming after work in summer, and lunchtime in winter, because otherwise it was too cold. I do this to this day, the swimming and the windsurfing. I think itís very edifying. The great thing about these two things is that within a very short time, within an hour, the cold water, the wind, you take out the calories. You donít have to run, to jog for three, four hours to spend the calories, and you can eat with impunity afterwards. Itís also good for your sleep. Itís good for the night-day rhythm. Also, I was gratified to see George Bush parachuting, although it was a special kind of parachute. We had to parachute three or four times a year, just to keep in shape. So I have to be in great physical shape all the time. Also, I was older than my regiment. I was ten years older than my regiment, and I had to keep up with them and a physician, a regimental physician in a paratroop regiment doesnít have an ambulance or facilities to carry things. You carry all your things with you. So I had to be in very good shape whether I wanted to or not, just to keep up with my regiment just so that I donít fall behind. So this was good, and this was a good antidote for the rigors of hospital life, and the rat race of academic life.

GE: What is your favorite outdoor sport? Is it swimming?

OB: Itís swimming and sailing and windsurfing. It was once skiing until I broke a leg in an accident. I was a very avid skier. The fringe benefit of Schrier and Kolff was that you stride both sides of the Rockies. I could this side and this side and the best part of skiing in the Northern Hemisphere is there. So skiing, and also I did ski on the little slope that there is on the Hermon Mountain.

GE: Now youíve held on to staying on the paratroopersí service longer than most people, would you say?

OB: Yes, I did stay until the mandatory age to get out.

GE: Which is?

OB: Which is like fifty.

GE: Why? You not only wanted to stay, but from what youíre saying, you carried it upon you to impose on your service at work, that tough, difficult, pushy, demandingÖ

OB: But, but, butÖ Maybe I should have stayed longer, but why mandatory, I tell you why mandatory, because the authorities are afraid, that at that age, youíve got a larger and 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 you referred to the personality of the paratrooper, I still canít figure it out.

OB: Well, itís the dedication to the bodies, the dedication to the country, the love of the outdoors, the ability to navigate by yourself. Nowadays you have the GPS. All the art of navigation is going to be lost. They could navigate by stars, they could navigate by maps, and so on, and itís this type of personality that comes in stark contrast to the "me generation" phenomenon that happens in my country too, that happens a lot here. You are the center, you do what is good for you, good for yourself and this brings fragmentation to society. If I go back to my paratrooper buddies, we had all the camaraderie of a partisan group, partisans like in the second world war. Itís a dangerous concept. There is an element of anarchy, but the beauty of it is important. The beauty of it is important. SoÖ

GE: Can we cut for a second?

Ö

GE: Whether itís the patients or whatever, if you talk a little more about anecdotes. One day I was walking, and I fellÖ

OB: I have a story with Bob Schrier.

GE: Patients. Keep Americans out of itÖ. Which story with Bob Schrier? I know the story or not know the story?

OB: No. No, no, no, no, no ,no. He was in Thailand, and he foundÖ I had a theory, and experiments to show that jaundice is a cardioinhibitor.

GE: Okay. Is that the story with Bob Schrier?

OB: And he saw it in Thailand.

GE: Oh. Why donít you tell that.

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 Sukiís 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 itís late, when the bilirubin is forty or fifty. You donít 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, with bilirubin on thirty, was like that. And he informed me, he said, "Ori, your theory is correct. Iíve seen your model in obstructive dogs. Iíve seen it in patients, and it dilated coronaries that Bob phoned me such good information, that your theory was shown in humans, and the brass of my university, "Who was this? Who was this phone call?" I said, "This was 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 and to the university people. You see, Faculty of Medicine, in the university is always like a funny son. They donít know exactly how scientific we are or not. We raise funds more than they do, they are jealous, and they donít 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.

GE: Could you give a similar anecdote from your childhood that stands out in your mind.

OB: Well, I tell you a scary one. 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, we had a flat roof of a two-story building, and I began to walk around the edge of the roof, and I never saw my father talking to me so softly. So he was the very strict father, suddenly completely changed, talking very, very, very softly, so I prolonged the walk as much asÖ "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 itís 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 say that.

GE: You cannot decide.

OB: I cannot decide. I got the more scientific side from my father and the more humane side from my mother, so itís a good blend. I got the best of both worlds. They were pioneers themselves.

GE: What would you do it you were going into nephrology today?

OB: Well I donít 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 donít know if itís too institutionalized, there is not enough pioneering spirit in it. Itís becoming like an industry, and our great first love, acid-base, mineral metabolism, volume control, itís not appreciated anymore, as much as it was in our time, maybe because there is no money in it, I donít know. So I feel somewhat at a distance from present-day nephrology. I wouldnít know if I would go into nephrology today.

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 is completely different, has completely different rules. Gravity does not exist because the particles are so small, but you cannot neglect gravity, you cannot stop teaching about gravity. So there should be balance between.

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, Iíll take eight, ten people, and Iíll say letís do it ourselves. No need for informed consent. This is how many of my experiments were done. We did it on ourselves first.

Ö

GE: Some of the experiments that you did were models in which you served as a subject. The question of self-experimentation has been an issue that a lot of people have addressed. Maybe you can narrate to us your own personal experiences? What experiment was it? How did it happen? What did you feel type of anecdotal story.

OB: Now in the concentration, dilution, and acidification experimentation, we had to have controls, so the controls were ten, fifteen normal physicians, paramedics, and we did it on ourselves, and this bypassed the question of informed consent. We also did it in immersion studies, immersion studies to the neck.

GE: Did you immerse actually yourself?

OB: Yes.

GE: How does it feel?

OB: It feels good. It feels like you do it in thermoneutral water, which is thirty-four degrees.

GE: For somebody who loves swimming it may be good, but how about the rest of us who donít have that love affair with swimming?

OB: No, itís pleasant feeling. You see I try to compare immersion in fresh water to immersion in the Dead Sea water. We had great expectations from there because that is very, very dense, but the results were opposite to what we expected, so weÖ

GE: What do you mean, the results were the opposite of what you expected?

OB: We thought that if you get tremendous diuresisÖ

GE: Öby immersing someone into the Dead Sea.

OB: You get tremendous diuresis by immersing someone in fresh water, you will get even more diuresis by immersing him in the dead sea, which is even moreÖ

GE: Öwhich is higher density.

OB: Öand then we thought that we would take cirrhotic and nephrotic patients to the Dead Sea andÖ

GE: Öcure them.

OB: Öand 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. The skin is impermeable. Because the Dead Sea is so heavy, that it acts like tourniquet. The pressure is like 90 mmHg on the lower body, and it acts like a venous tourniquet. To get immersion diuresis, you need centripetally removal of fluid and central hypovolemia, and then you get diuresis. The Dead Sea will prevent the water from going somewhere.

GE: So if someone has heart failure and he goes swimming in the Dead Sea water, he may get reduced cardiac return.

OB: Yes. You may say that.

GE: Itís good for pulmonary edema.

OB: I wouldnít say that. Donít 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 much they concentrate, dilute, acidify, what is their response to immersion, and then also we created uremia in normal people by infusing urea, and having high level of urea in the blood to see what effect it has on the kidney. We did it on ourselves.

GE: By infusingÖ

OB: Infusing urea, yes. This is not a pleasant feeling at all.

GE: You know, I drank urea. I didnít have IV urea, so I drank urea when I did my platelet studies. Thatís why I was asking you those questions.

OB: Well drinking it is different than having it IV.

GE: You want to change your mind about telling people about going into nephrology or you donít want them to go into nephrology.

OB: No. I donít say so. I donít say it. I will only say that it lost a lot of its avant-garde status, and the breakthroughs are behind us, and the breakthroughs are now in different fields. If the nephrologist 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 than that, itís less exciting in our time.

GE: Do you think nephrologists have given that up too easily? When critical care people came and started taking care of the acute problems? Do you think nephrology lost some of its flair, and attractiveness, and challenge by giving up?

OB: Nephrology lost a lot to the intensive care people, and itís their loss, I think. We shouldnít have done it; we shouldnít have allowed it; we shouldnít 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 artery stenosis?

OB: Well, they can do the renal artery stenosis, we will do the biopsies.

GE: But they are doing the biopsies also. Forty percent of kidney biopsies in the United States are being done by radiologists.

OB: Well, as long as we all sit together, and study the biopsies, we do plenty ofÖ

GE: But thatís maybe the heart of the problem. Radiologists have no devotion to the kidneys, itís just a procedure, and do you think they have an interest in studying the kidney?

OB: Well nephrologyÖ I mean radiology, imaging people, will always be in the second line. They are not directly responsible to people, they are only consultants. Itís we who see the patients. Itís we who make the decisions, so they are behind.

GE: But they are the ones who are being paid. The procedure is what generates the money that is necessary to stay in the war.

OB: WellÖ

GE: Maybe you donít 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 paid more, and transplantation paid more, and the role of the nephrologist in transplantation should be more.

GE: All right. Iíll read this again, and then I will pose the question.

Ö

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 1960ís, 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 homeostasis, at the site which is close to what was then the biblical Sodom and Gomorrah.

Since then, he has continued to do good work, under adverse conditions, and contributed to the understanding of the homeostatic process of the kidney. Upon completion of his service, he went to Cedar Sinai, in Los Angeles, for his first formal exposure to a Nephrology training program in the United States. There, he worked with Chuck Kleeman, himself a student of John Peters, and one of the founders of American nephrology and world leaders in the study of metabolism. Over the years, Ori expanded on his exposure to American nephrology training programs, by intermittently spending time at Georgetown, University of Utah, University of Colorado, Yale, and State University of New York in Stonybrook. He did this while establishing the first nephrology program in Northern Israel at the Rambam Hospital in Haifa, where he was chief of nephrology from 1959 to 1993. In the process, he founded the renal transplant program that performed the first cadaveric renal transplant in Israel in 1965. At the broader level, and again under the leadership of Professor Ehrlich he helped in the establishment of the Faculty of Medicine at the Technion Israel Institute of Technology in Haifa in 1971, becoming dean of its medical faculty in 1983. In 1985, he was appointed Annie Chutick Professor of Medicine, a title he still holds. In 1993, he retired from his administrative responsibilities to devote himself to research as head of the Rebecca Chutick Crush Syndrome Center in Haifa. His work there has made him a sought after world 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 RTA, function of the post-transplant kidney, divalent ion metabolism, and obstructive nephropathy. Most of his work has centered on human clinical research, using readily available techniques, and always focused on questions raised at the bedside. In fact, it is at the bedside that the unique attributes of Ori are most evident, as a first-rate physician, and teacher. He is worshipped by his patients, and adored by his students, and trainees. This is based as much on his vast medical knowledge, which he shares freely, as his uniquely warm personality, which endears him to anyone who comes in contact with him. It is this that has also made him a sought after friend and colleague of the international nephrology community. It is a special pleasure for me to conduct this interview of Ori Better, for the Video Legacy Program of the International Society of Nephrology.

I would like to begin the interview at the start of your career, by asking, "Why did you go to medicine, and why did you choose nephrology in the first place?"

GE: Anything else you want to say? You still have time, and there is tape.

OB: Let them stop it for a minute, and let me think.

Well, now I am part of the establishment itself, because the Minister of Health put me in a supervisory position to oversee live transplants. There was lots of abuse of live transplants in Israel, kidneys being bought and sold, and there was outcry in the newspaper. So in order to regulate it, to supervise this, they made a committee of four or five people, and I am sitting on it, and every live transplant that will be done in Israel will need my signature. So here at a ripe age, Iím about to regulate the industry, so to say. Iím also advisor to our home front command, which does all the search and rescue operations and excavation of casualties under the rubble because what we talked about was only the medical aspects, the engineering part of it and the logistics, the search and the dogs, all this huge effort, we are just one part of it, so I am advising to them, and I am part of their exercises. So this is it, I think.

GE: Are you part of the establishment? The rest of us who have remained advocates of the patient still have to face the shortage of organs for the number of patients who are awaiting transplantation. Do you have any thoughts on how to handle that problem? Obviously the issue that you are looking at, buying and selling organs, is a solution. Ethical or not is another question. But the problem persists. Do you have any thoughts on how to handle that problem?

OB: Well you know that there are enough cadavers, except that we canít reach them. Some countries like Belgium and Austria are the most advanced. They require that everyone that dies in the hospital, or arrived dead on admission, and has not said something to the contrary in his will you can remove the kidneys. I think we should go in this direction, and have legislation like they have. Iím really sorry that Jews who are so clever couldnít do it better, or find better legislation, and I envy the Catholics in Austria. They have got such advanced situation. They can take almost any kidney they 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 the army, they complained itís difficult to conduct battles because the CNN factor. When I do it, sooner or later, there will be CNN in the morgue seeing me doing it, so the time really has passed. So I believe in education and in making more public awareness, but I feel sorry for every live kidney that is taken out. It leaves scar, it leaves morbidity, even though I donít buy Brennerís theory that reduction of nephron mass isnít detrimental. I know of live donors who died. There are cases, underpublicized but there are, and there is morbidity, and these people are really the wage earners of big families. So on top of the family they are now handicapped with pain and so on and so forth. We should do less, than we do. We should encourage cadaver transplants.

GE: So you are in concept, not very supportive of live transplants.

OB: I frown upon it, and Iím glad we did the first cadaver transplant and not the first live. Live is permissive, permissive attitude.

I have a last statement. Sometimes when we 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, "Donít say that, you donít know what a great miracle it is. Let him urinate."