ISN VIDEO LEGACY PROJECT

DR. ROSCO (IKE) ROBINSON
INTERVIEW WITH DR. STEVE HEBERT

 


SH: It is a privilege and honor to interview on behalf of the International Society of Nephrology Professor Rosco R. Robinson. Dr. Robinson. Maybe you could start by telling us what led to your interest in medicine?

RR: Well without being too long winded about it Steve, I had not planned to go into medicine until I was a senior in college. I had planned to be a lawyer, had been enrolled in Law school and my mother had always wanted me to be a physician, I had resisted that. And my father died in my senior year in college and the family gathered at the funeral and they were all physicians, uncles, aunts, and cousins and they said, "You need to be a doctor." They persuaded me that such should be so. So in the middle of the fall semester I dropped a course in political science and enrolled in a five-hour course in botany, because I didnít even have the minimum requirements for entry into medical school. In the next semester I took 20 hours of science and 12 or 15 the following summer after graduation from college and 20 the next fall and entered medical school the following September in 1950. I entered medical school via a circuitus route, but I have been very pleased that I made that decision. Medicine has been good to me and I hope itís beenÖI hope Iíve been good to it.

SH: How early in your medical career did you develop an interest in the kidney and what lead to that interest in the kidney?

RR: I think I first became interested in the kidney when the wife of a classmate and very good friend developed post partum acute renal failure. And we as medical students rotated sitting at her bedside and helping in her care as best we could and of course in that era hypertonic glucose solution and all sorts of things like that were used in oliguric acute renal failure. Fortunately she recovered, but it sparked an interest in things renal even in medical school and then as a senior we were required to spend three months on a preceptorship with a practicing physician. I was fortunate enough to be assigned to one of the most remarkable practitioners Iíve ever been around, whose patients came from far away even though he practiced in a very small and rural town on the banks of the Cimarron River in Oklahoma, who read constantly, tremendously well informed, was asked to give more than two or three AOA lectures at my medical school and he introduced me to the writings of Homer Smith. Believe it or not he introduced me to Homer Smithís University of Kansas lectures, which I just found fabulously intriguing and so well written and so clearly written. So like anyone else in the United States at the time and to some considerable extent abroad, Homer Smith indirectly influenced me. As well I was introduced to his extracurricular writings and it propelled a fascination with a kidney that remained. I was torn between the kidney, or something related to the kidney, and hematology only because one of my mentors in medical school, a wonderful person who had come to the University of Oklahoma from Cornell, Bob Bird, was a hematologist, an exciting person to be around, and for at least two or three years toyed with the idea of going into hematology, but the kidney won out.

SH: As your interest in nephrology and kidney disease is developed and as your early career developed, could you reflect on who the other individuals were that you respected and at most influenced your career?

RR: Well you know I went to Duke University as an intern. Eugene Stead was the chairman of the department of medicine at the time. It was a powerful department of medicine, I felt. Duke was not as widely recognized in 1954 as it is today, but it was a strong service. I was very pleased and felt very fortunate to be there and during the course of two years on the house staff, I needed to decide what sort of specialty I wished to pursue, specialty training. I thought a lot about it, toyed a bit with the hematology issue I mentioned before. I then decided to seek experience in a kidney related laboratory. At that time there really were no organized training programs in nephrology, clinical training programs. Nephrology wasnít even used as a word in the United States in 1956. There were laboratories that were doing things kidney wise. The ones that were best known at least to me were physiologically oriented and I was familiar with a little Charles D. Thomas book entitled Uremia that had been written by Stan Bradley at Columbia. It was one of the few books of which I was aware that had anything to do with the kidney other than Homer Smithís book and so I had decided that maybe I might like to spend some time with Stan Bradley who had worked with Homer Smith and had been involved in a lot of studies on renal hemodynamics, PAH secretion etc. And the alternative was Don Seldin. And a humorous little story I think is the fact that I was torn between whether I would apply to one place or the other. And I ran into John Hiccum who was at Duke at the time, head of Pulmonary and was about to leave to become the chairman of the Department of Medicine at Indiana. And I ran into him and he said, "Ike where are you going next year on a fellowship?" And I said, "Iím trying to decide between Stan Bradley and Don Seldin." And he said, "Well if you go with Don you sure better be up on your calculus." Well I donít know what kind of a mathematician Don is, but I knew I wasnít up on my calculus. So that sent me hustling to New York. And I spent a year at Columbia Presbyterian. Unfortunately, Stan was editor of the Journal of Clinical Investigation at the time, although I had a good year, we enjoyed New York a great deal, but unfortunately Stan was heavily involved at the moment in studies of spanchnic bed hemodynamics. I didnít do anything related to the kidney the entire year. I measured splanchnic blood volume and blood flow in hemorrhagic shock in dogs, and not a very productive study as a matter of fact. I mean blood flow and volume studies at different levels of PC02 in humans, but other than that I really secured no training directly relevant to the kidney during that year in New York. So you might say when I went back to Duke as a chief resident the following year I was still untrained in the world of the kidney. But, in that era, if you were interested in something a lot of self-training went into these ventures.

SH: What other individuals during this period or the few years after that that influenced your work in research and your continued interest in the kidney?

RR: Well when I returned to Duke I was rather persuaded that academic medicine was not for me. As I mentioned earlier there were many physicians in my family. Some of them kept wondering when I was going to finish my training and come home and join them in the practice of medicine? But when I went back to Duke, I fell into the hands of a very good friend, almost a contemporary of mine who had been the chief resident the year before at my return, Vic Murdock and Vic who subsequently left Duke to become a head of Nephrology at the University of Alabama, Birmingham, wasÖknew of my possible interest in the kidney, persuaded me to maintain that interest. I responded and I began to do some very simple clinical studies looking at the effects of diuretics in humans with inulin clearance, filtration rate measurements on magnesium excretion. A little paper that was subsequently published, a very simple little paper, and that was my inquiry during that year. We also looked a little bit at the effect of insulin on ADH activity and antidiuresis, the antidiuretic activity of insulin and minor studies, but maintained my interest in the kidney. But more importantly, through Vic who was looking at control of urea excretion in low protein diet with Bodley McNeilson at Duke, introduced me to Bodle. And through Bodle and Vic we had been invited, or they had been invited, to participate in the weekly journal club in Chapel Hill, which at that time was run by Lou Welt, Carl Gottschalk was there, Bill Blyth, a lot of wonderful people, Ike Taylor, very strong group of people at the time. Walt Hollander, so once a week I was privileged to track along with them to journal club in Chapel Hill. So between my minor studies as a chief resident, what time I had to do minor studies, and my contact with Bodle and Vic Murdock and the participation in the journal club, my interest in the kidney rose to new heights. And I began to think; well you know maybe I might give this a whirl. And so I did.

Part II

SH: Can you tell us about the areas of research or the specific research that you are most proud of in your career?

RR: I think there are two answers to that question Steve. I went into the Air Force at the end of my training at Duke. Itís considerable to think how I handled all of this at that time. It would be impossible today. I had wanted an assignment to the USAF Wilfred Hall Medical Center in San Antonio, which at that time, this was 1958, was under development and was scheduled to become in the United States the Air force major tutelary referral center. They were interested in establishing a dialysis unit. I had never dialyzed a patient in my life. John Hiccum, Hiccum Field in Hawaii is named for Johnís father, had maintained a very active relationship with the Air Force and through Johnís participation I was able to secure an assignment to Wilfred Hall to run the dialysis unit and establish the dialysis unit. In many, many academic health centers, dialysis or kidney related things really operated under the preview of cardiovascular area. The kidney was a subset of cardiology in this country, as was hypertension and a lot of other things and so Duke cardiology had invested in my last year at Duke a Kolf twin coil machine. I can remember Lou Welt coming over to watch it perform and I watch several dialysis at Duke, not many, maybe six or seven or eight and constructed a list of equipment, sent it to the Air Force and went to San Antonio and established the dialysis unit, the first dialysis unit at Wilfred Hall. That worked well, but before I went I also sat down and wrote a NIH research grant application submitted through my friend Vic Murdock at the University of Alabama. And so during my two years as a reservist in the Air Force I was able to conduct a series of studies while I was in the Air Force. That gave great pleasure to me. I had a lot of fun. I was fortunately left to do what I wished to do as long as I kept that dialysis unit going because in those days there were barracks of heat-stroke victims, or barracks that were maintained for heat-stroke victims and I never will forget during that tenure when, before my dialysis unit had really been established, a heat-stroke patient came in, developed acute renal failure, and Paul Techan was at Brook Army at the time. And Paul had written what in that era was a wonderful two or three papers in the Green Journal, the American Journal of Medicine, about the acute renal failure experience in Korea during the Korean War and I was very familiar with those papers. And so I referred this patient to Paul at Brook Army Medical Center. I went over to visit my patient a couple days after his transfer and I never will forget, it was the most stunning experience of my life. Here was a patient with oliguric acute renal failure, sitting up in bed, eating a steak. And he had whatever he wanted every day. He was also being dialyzed every day. And that patient was in a small series that Paul published in the Annuals of Internal Medicine of prophylactic hemodialysis. And it was a remarkable experience to me because that was still the era when if you had, one had acute renal failure, there were all sorts of things that you did, but that wasnít one of them. You certainly didnít have anything you wanted to eat you know. So that was a wonderful experience. During that two years I did a lot of things. I looked at the effect of prednisone on glucose ditration curves in the kidney and presented that work. That was my first presentation at a national meeting.

But probably the thing that has been most associated with me were some studies that colleagues and I did in patients who had what was thought to be benign proteinurea. We used a very qualitative classification of asymptomatic proteinurea that we labeled fixed and reproducible autositic proteinurea because almost all the time when you sought it out it was there in the upright position. Renal biopsy was still relatively new and we biopsied almost 60 such patients and then continued to follow them. And I participated in those follow-up studies over a 20-year period and just recently a 30-year follow-up. People still, who are now in the Air Force, completed most of those patients and that study was probably the most widely quoted and maybe the one that was most associated with me. But I think the one that Iím most proud of was one in which I was scooped. I had decided to get into renal micropuncture. It was going to have to be self-taught. I had a medical student at Duke who dropped out a year of school to spend that year in my laboratory. I sent him to Dallas to work with Floyd Rector and learn what he could about the technique. Itís curious that I would do that when Carl and Bill Lassiter were only ten miles away, but thatís the way we did it. Jim came back and we set up a micropuncture lab and for reasons that I will never fully understand except for the fact that I had been doing other studies on ammonia excretion with another close colleague and good friend in Duke GI, Gene Owen, and we had been looking in renal uptake of amino acids in various forms of acidosis and what have you in human and interested in ammonia excretion and production. And that led to an interest in ammonia and Carl Ulrich had published an ultra-micro method for measuring ammonia. A very tough method I might add. But we finally thought that we had it well enough in hand that we could apply it and we did. In the first series of studies really demonstrated I think the net addition of ammonia to the collecting duct. No question about that. I was excited about that finding. Theyíve only come from across the loop I felt. But just before my paper when in Gerich Dietrich had one on the same subject so we were scooped. But I was always proud of that study even though we were scooped. It certainly was done independently and it was a lot of work and a tough drill in that era.

SH: Ike, could you tell us more about the early years in the development of nephrology at Duke in the nephrology division and maybe reflect a bit and put it in context on what was happening in American nephrology during that period.

RR: I went back to Duke in 1960 out of the Air Force after my two years of service, which I had enjoyed very much and first began to work with Gene Owen. Gene had earlier developed an interest in ammonia metabolism in general because of his interest in the liver and we really I thought made a great partnership. Duke had no official, divisional organization in nephrology. I donít remember even being aware of the fact the Hamburger had organized, or was organizing, what was to become the first International Congress of Nephrology the same year I returned to Duke. My first recollection of an ISN Congress was the Prague Congress in 1963 when I was still a very junior member of the Duke faculty. I like to say that when I looked below the academic ladder there was no one there. And I remember there was aÖmaybe perhaps, I donít remember exactly the source of funding, but there was an NIH organizational support for travel grants to the Prague meeting, which one could apply.

I applied unsuccessfully so I didnít make the Prague meeting. And nephrology wasnít even a word in this country. At least it was not one that had surfaced in my awareness. When I returned to Duke, it was not clear what my role would be. I returned as a clinical investigator in the VA, in the Durham VA hospital. There was no formal structure. I resumed my contact with Bodel and Bodel and I did several things together that focused on urea on the most part and regulation of urea excretion. It was a wonderful training period for me. Another colleague at Duke who had come during my absence in the Air Force was Dick Portwood who had research laboratory training with Don Seldin in Dallas. And it was unclear whether Dick was going to lead the development of nephrology or not. At the time I felt it was my interest to really remain focused in the laboratory and I did my best to do that and resisted as much as I could being drawn into clinical work at the time, while Dick was pretty much doing the dialyses that needed to be done at that time. Dick and I did some studies in the chicken looking at tubular secretion in that animal model and also looking at urea production by the chicken kidney and that was fun. Dick subsequently decided that leadership of an academic division was not what he wished to do and Dr. Stead, Jean Stead came to me and asked me in 1961-62 if I would get together or begin to think about doing whatever Duke would do in the kidney. A little bit later he came to me and suggested that there were things going on in Seattle that we needed to know about. This was probably a year or two after the first chronic dialysis in Seattle burst on the scene in 1960. I had identified my first fellow, Charles "Chuck" Hayes, who had returned to Duke and I talked with Chuck. And Chuck went to Seattle and spent, I donít remember how long, some several weeks in Seattle and came back to Duke and put us in the dialysis business, chronic dialysis business, very successfully. IÖby 1962 or 63, the word nephrology was being to be battered around and I give a lot of credit to Hombergeís choice of that word and itís application to the first International Congress. There are some who say that Homberge coined that word. Thatís not so, but he certainly popularized it and used it extensively. The French renamed their society to the French Society of Nephrology. It became a very popular word so I just decided to put on our letterhead, Division of Nephrology. I didnít ask anyone if I could do that I just did it. I think that period of time in the United States was an exciting period. Oh you know renal biopsies had burst on the scene, percutaneous renal biopsy in the prone position had literally burst on the scene in 1954. Renal biopsies were being performed. People were learning things about renal morphology that had not been existent before. The physiology business was booming. Renal micropuncture was current and choice and at least in the United States and I again think because of Homer Smithís tremendous influence on our world in that era, I think that leadership of this entire effort was mainly physiologically oriented with some wonderful people, wonderful biomedical scientists, who were also many of them good clinicians. And they set the stage for what was to follow. In the early 60ís, and I was largely unaware of this, I being a very junior at the time, but there was a lot of struggling for leadership I think within the various groups. The first organization in this country of which Iím aware of was the American Society for Artificial Internal Organs, which held itís first meeting I believe in 1950. It obviously began thinking of artificial organs, but it later became very involved in dialysis and that involvement grew exponentially after the introduction of chronic dialysis in 1960. And as you know the old Nephrosis Foundation, which had originally been populated largely by pediatricians who were interested in childhood nephrosis, evolved with a few bumps and turns into what is today the National Kidney Foundation, but not without some political machinations that were a struggle for some. And it really was not until 1966 that the American Society of Nephrology was founded and the first meeting was not held until 1967.

So during that early period in the 60ís, most investigators in this country were totally committed to well established and very prestigious annual meetings. The Atlantic City meetings, the Federation meetings and to their relevant journals, the American Journal of Physiology, the Journal of Clinical Investigation and had no or limited interest in new journals they thought. There were enough meetings, there were enough journals and these were quality events and therefore we didnít need any new societies, including an American of Nephrology. So the other organization that was active in all this was the renal section of the Council on circulation of the American Heart Association, which in the early 60ís, and Iím sure of the dates, was chaired by John Merrill at Harvard and for reasons that Iíve never fully understood, John was a bit of an outsider when as viewed by the more physiologically oriented leadership at the time. I donít know whether it was because of his early and very forceful and wonderful involvement with the rotating drum kidney and as spectacular I think even today. If you go back and read them series of papers in the JCI the output of his work and even in that area know if you interned at the Brigham you had a month on the artificial kidney rotation. It was so new and so spectacular and what have you. But John was a march to his own drum. I thought it was a wonderful drum. I thought the world of John Merrill. When he had struck a very early association with John Hombroge. They met during a visit in Paris. John Merrill was on leave in Cambridge I believe it was and took some time to visit Hombroge in Paris in 1953. And because John spoke fluent French they struck up a very close personal friendship that existed until Johnís death. So John Merrillís association with the French was very close. And another person in that time, a little later in the same category, would be Norm Maxell from Cedar Sinai at UCLA who also was very close to the people in Paris at the time. Anyway, I was largely unaware in the early 60ís of all these shenanigans about whose organization was going to represent nephrology. Keep in mind Steve, there wasnít even a textbook of nephrology in 62 or 63. And the first textbook of note in the country obviously was the one that Morey Strauss and Lou Welt put together and I donít remember the first year that it appeared, but it was later. I can even remember as confident youngster talking to some of my contemporaries, you know we ought to get together and write a textbook about all this business. There wasnít one. So the division of nephrology, I accepted Dr. Steadís offer to develop a division of nephrology and we had to carve out from existing services what we would do clinically. Operating a dialysis program came with the territory. Couldnít do anything about that. We wanted to do something about it and did. It led us into transplantation. Duke did not; we did our first transplant in 1965. Had a great time with, Ernie Amous had been recruited to Duke and Bernard was a leading histocompatability type who made many contributions to understanding that. And with Del Stickle and Jim Glen and our group, which by then had grown to include Jim Clapp, Tom Andrioli, Craig Tisher joined us a bit later, and Caulie Gunnells, we felt we were really developing a full service nephrology group with all the things. For a long time, all of the renal arteriography in Duke medical center was done by our group with our own reasons until one day Dr. Stead came to me and said, "Ike. Weíre getting a new chief of radiology who wants to get into invasive radiology and wants to do the arteriography and weíve all agreed that he can, but you can continue to do them, you just canít charge for them anymore." So we sort of drifted out of the business of doing renal arteriographs. But I think of no time that was more exciting than the 60ís. There was so much going on. Transplantation was bursting upon the scene, histocompatability testing was beginning to come on board, immunosuppressive thinking, I mean immunosuppressive treatment; when you think about it you know 6MP really didnít hit the scene until 1960 or 61 and what an impact it had. You know we donít today, but let me tell you we thought about it a lot then.

So it was a good time. I remember the first meeting of the American Society in Los Angeles. Neal Bricker was the first president, wonderful friend. I just thought it was the best meeting Iíd ever attended. I thought it was so exciting. I was so pleased that nephrology was coming together and we were having a meeting. And follow the year after, the Washington, the third Washington meeting, which was the Third International Congress of Nephrology that Bob Berliner and George Schreiner had run effectively. It had been a very strong meeting. It had attracted over, oh gee over 2,000. It was really the first of the large meetings and did a wonderful job of putting it on. It was a superior meeting I thought surrounded by a lot of social events. And parenthetically I think it also set the pace for some issues that were to surround and to some extent plague subsequent Congresses for years. Remember, there were 75 invited speakers at the Washington meeting who participated in a large number of symposia as there were largely state-of-the-art symposia, whatís going on in this area or that. Iíd say they were sort of continuing education or update kinds of talks. And only about a third of the free communications were presented orally there. I donít think there were poster sessions at that time. I think itís very difficult to have a tri-annual meeting and expect that first presentations of cutting-edge discoveries are going to wait three years to be presented. And therefore, it meant from the very beginning the International Congresses would tend to be heavily weighed with reviews and state-of-the-art sorts of things, which I think meant that that fact plus the infrequency of the meetings meant that this meeting from the very beginning was not destined to become a place where one wanted to first present oneís results. The prestigious meetings in the United States still occupied that platform. Itís a problem that has I think plagued the Congresses for some time and also has set in place the business that if you, especially in the United States, a feeling that gee, if you went to an International Congress, somebody needed to pay your way, or you need to be an invited speaker or maybe you might not go. I think that was too bad too. I think it really sort of hamstrung a bit the organization of the format unless one just accepted the purpose of these meetings is really to provide an inventory of whatís going on in nephrology in the year in which the Congress is held, which is not a bad objective when you look at it in that way.

SH: Look at and tell us about your initial involvement, other than a participant and spectator, but an involvement in the International Society of Nephrology and in particular involvement with the Societyís journal, Kidney International.

RR:I can tell you that for the first decade of the Societyís existence one did not know how one became a member of the International Society of Nephrology. One of the controversies I now know within itís executive committee and leadership in the 60ís was whether the Society would be an elitist society in which membership would be extended to those with certain qualifications. The first meeting in Avignon in 1960 was by invitation only. And that was Hombergeís view. There were others that felt that membership should be more open as is the case today in the American Society of Nephrology for example. And that debate existed throughout the 60ís. The first constitution provided for two kinds of memberships. 1. You could become a member through a participating national society of which there were very few in 1960, The Italian Society, The Swedish Society, The Renal Association in the UK, The French Society. I think that was about it at the time in Europe, nothing in the United States.

The Japanese Society held itís first meeting in 1959 and so itís still unclear by what criteria membership in a national societies would be evaluated, whether a national society would just provide a list of itís members and therefore were a member of the ISN. And then you could become an individual member if you existed in a country that had no national society, but the process was terribly complicated. It had to be approved by the general assembly or some such organization, would have taken months for that to wind its way through. And I donít think that anybody understood all that. I can remember for a time thinking that if you subscribed to Nephron, which had its first issue in 1964 as the societyís journal, that you were a member. That wasnít the case. Dues and subscription were not coupled but I didnít know. I didnít think much of the International Society. The only thing that I knew that it did, which was the only thing that it did, were to hold these congresses every three years and was that sufficient to make someone wish to be a member because you didnít have to be a member to go to the Congress as events later developed. And so I really didnít know much about the International Society until I got a phone call in the spring of 1971 from Neil Bricker who unbeknownst to me was the treasurer of the International Society of Nephrology. And he said, "Ike. How would you like to be the editor of Nephron?" Well, nothing had ever entered my mind of that sort. And I was sort of surprised and I said, "Nephron has two editors, Gabriel Richet in Paris and George Schreiner in Washington, DC and another wonderful fellow named John Domo would was really carrying the bulk of the load in Paris and deserves great credit for his contributions to Nephron. I said to Neil, "Let me think about it and Iíll get back to you." Well I thought about it and Iíd talked to the people in my group and concluded that I wanted to learn more about it. So I called Neil back and I said, "Yes, Iíd like to know more about it." And he said, "Could you meet with me and Hugh de Wardener," who was president of the ISN at the time, "and the representative of a publishing company, a German publishing company Springer-Verlag, at JFK Airport in New York?" At that time I was on the board of the directors of the American Heart Association and been chairman of what had now become the renal kidney council of the American Heart Association, and weíd meet him at the time when I had to go the New York anyway for that meeting. I remember we met at an empty dinning room at a rather grungy airport hotel and I was so impressed by Hugh de Wardener who flew over that morning and flew back that night because to me, Iíd only been to Europe once or at maybe at most twice in my life and if you went to Europe, my gosh, you going and coming in a day was unheard of, but I was very impressed by Hugh. And so they explained to me the background at that meeting. I had a view of Nephron. I knew that Nephron had not been accepted in the United States. John Merrill campaigned vigorously for American support unsuccessfully. A wonderful symposium issue dedicated to Dr. Pitts, I think was a spectacular issue that was presented to him by the way at a ceremony at the Stockholm Congress. But it really had not been accepted. Nephron was not receiving quality manuscripts from people and I felt the same way about it. I felt Nephron was a past journal that had really not made it. I wanted my things, our things in the American Journal of Physiology or the JCI or wherever. So I was very concerned about that and I was very concerned whether or not my counterparts would support a journal. Hugh de Wardener, when he became president of the ISN, because of a terrible relationship with S. Carger the publisher of Nephron, which effectively meant that the society had no financial control over its journal, which effectively meant that the publisher served as the societyís treasurer and which effectively meant that because as the Journal grew, as Nephron grew, publishing expenses went up and there was never any profit to be returned to the society. So there were tense times between the society and the publisher, but the ISN had no money.

I remember that in 1972 in Mexico City at the Mexico City Congress, the societyís coffers may have contained $6,000 or something. It was pitifully small amount of money. And I have a copy of a wonderful letter from Jean Louie Fumpbrentano what replied to an earlier president of the ISN, Claus Bruin from Denmark that said, "You know, if you have no money you are a beggar. What can we do?" Well, Hugh de Wardener decided it was time for drastic change. And although Hugh has subsequently been criticized by some for his methods, I think in retrospect it has been proven that he was correct and I think he made the right decisions. He decided that if he could not renegotiate the contract with Carger and if he could not expand the editorial board with influential leadership in North America that he would have to seek a new publisher and a new contract. He was unsuccessful in his attempt to negotiate a new contract with Carger, which led him to visit Heidelberg and Springer. He was impressed by them and felt that they would help us get under way appropriately with a much more favorable contract. It was learned that the title Nephron belonged to Carger, not the society, another example of the ownerless terms of that first contract. So Hugh had decided that Springer should be the publisher and that we would start this new journal and he suggested the name Kidney, which was fine to me. And I said after our meeting at JFK, "Let me go home and think about this and I will get back to both of you." I was inclined to do it, no question about it, but before I did one more thing I wanted to know what people in the United States thought about this venture. I spend two days on the telephone. I called everybody I knew in American nephrology. And I laid it out to them. I said, "If we do this thing, are you guys going to help out, because if you tell me your not sure, or if you tell me your going to send everything to the AJP, or what-have-you and if your not going to let us have a little of it, then I have no interest in getting involved." And I turned to several people to help me assemble what I hoped would be an editorial board that would send a strong signal about interest and support for the venture and felt that I was getting enough reassurances, although I didnít get enough reassurances from everybody. But I think my contemporaries who were in my age group were very supportive and subsequently that generally has proven to be the case. So I called Neil back and said, "O.K. Iíll do it." And thatís the way it all began. It was a very interesting time. Craig Tisher agreed to be the associate editor and Claude Amiel in Paris, who I had not met, did not know, but had been suggested by Richet, was going to run a Paris office, although it was very clear in contrast to the earlier arrangement with Nephron that there was only one editor and the editor would be based in the United States and the associate editor in Paris was playing a supportive role helping with the review of manuscripts and that sort of thing. It was an arrangement that worked very well for me and I think itís worked very well for subsequent editors of KI. But it has certainly smoothed some of the lines of communication. Now I mentioned earlier that Hugh had been criticized for some of his approaches to resolution of this. Keep in mind the society had no money. It had no financial support to call a meeting of the executive committee, the council, or anything else. And Hugh had had two meeting, one in the Atlantic City area in 1971 and one in London later when he assembled as many people as he could, but there was some people on the executive committee who were left out who subsequently felt that was inappropriate and that Hugh had been a little forward if you will in the way that he made these kinds of decisions. Perhaps there may be some truth to that, but it was a form of forwardship if you will that looking back on it I think was appropriate and turned out well actually. And that was true perhaps. They had first approached Morey Strauss and asked Morey Strauss to become the editor of KI. Morey was very attached to Little Brown a very fine publisher, but based on in the United States.

And Hugh felt that because of the internationality of this journal that it needed to be associated with an international based publisher, which led to Springer-Verlag, which had a New York office in addition to its home base in Berlin and Heidelberg. So for that reason they reluctantly turned away from Morey and that led to Neilís call to me. Hugh de Wardener did not know me. I had never met Hugh de Wardener. He operated I think solely on Neil Brickerís recommendation and I am not sure why Neil turned to me. I certainly was not an established editor. I never edited anything and, but Neil did and so I did agree to take on the task. Craig had to go to England that summer, the summer of 71. We had to get an issue together by January of 72. Six months we had. And Craig happened to have to go to England anyway. He was in the process of buying an electron microscope and he wanted to do some things in connection with that purpose in Britain and he took a couple days off and visited Richet in Paris and that was our first official contact with the French office. I always felt badly that George for some reason felt that he had been, George Shreiner, had not been kept fully informed of all of these discussions as he should have been. There was debate as to whether that was so or not. Iím not privy to who was right or who was wrong in that debate. But the other decision that Hugh made that was to stir controversy that lasted for another four or five years was whether or not dues should be coupled with subscriptions. It my view strongly held that a successful journal would provide a very appropriate magnet for the attraction of membership in the society. I did not feel that just a tri-annual congress was sufficient to do that. Didnít have to be a member to go to the congresses. And because no one knew how you were even a member, at least I didnít know how you became a member of the ISN, at least it would clarify that as well. And so it was decided to couple dues with subscription. Well as you can imagine that there were parts of the world who had been paying $2 for dues or a small amount, I think it subsequently went up to $3 and maybe a little more, I donít remember or know exactly, and they didnít have to subscribe to Nephron. Now you have the first combined subscription for the journal, a monthly journal not a bi-monthly journal as Nephron was, with membership was $30. That was quite a jump coupled with the fact that the decision was not felt to have been made on the part of some in the most democratic way led to some controversy that was to surround the journal. The other major problem at the beginning is that the society had the most tortured process for individual membership. You had to be sponsored by two members, an application had to be submitted to the Secretary General. When I came on board in 71 the Secretary General was Herman Via Riel in Mexico City. Postal communication in Mexico City was not the best. Herman would process the applications, the names had to be forwarded to the treasurer in New York and the treasurer would then forward the name to the publisher. After six months of this a subscription would begin and sometimes it was longer than that. It was a terrible system. The most inefficient administrative structure I believe Iíve ever seen. Now without getting into all the details and thanks to Neil Brickerís leadership and he was a very strong supporter and very important player in that period. Very important. I donít believe that KI could have begun to have done the things that I hope people think it has now done, has done, and is doing had it not been for the strong support that came from Neil during his 10 years as treasurer of the society. And his help and support and of course from Hugh de Wardener as the president. Thatís the way it all began.

Part IV

SH: Ike, can you tell us how Kidney International got its name?

RR: Thatís a funny story. Hugh de Wardener had signed the contract with Springer-Verlag before the JFK meeting and in his prior discussions, unsuccessful discussions to renegotiate the contract with Nephron between the society and S. Carger it became clear that the ownership of the name Nephron belonged to Carger not the society and that the journal was going to have to have a new name and Hugh de Wardener suggested Kidney. When that word got out, the National Kidney Foundation in the United States had a fine educational newsletter that was called The Kidney and they felt that this new publication of the ISN would conflict with theirs and asked that we choose another name. A good friend Dick Freeman in Rochester, New York, was then active in NKF affairs and I called Dick and told him of my dilemma and wondered if there was any way to work around it and he came up with the suggestion that I thought was just spectacular. "Why donít you insert in very small letters the word "International" below the word Kidney in large letters and weíll call the journal "Kidney International." Well I sort of thought it sounded like a gambling casino, but anyway it stuck and it certainly reflected the intended internationality of the journal. So with that name we were off and running.

SH: The importance of the journal to the society is certainly without question and itís contributed tremendously in many ways to the health of both financially and scientifically to the society. I think our listeners would be interested in your reflections on the early days of the development of the journal. What were the thoughts that went through your mind about which way the journal should go, what should be in the journal, the international components to the journal, and then later on how you view the journal as contributing to the health of the society?

RR: Oh my goodness Steve. Those early years were fraught with hazard and opportunity. I donít think that I would have ever made it without Craig Tisher. Craig was the assistant editor based in Durham. Claude Amial in Paris had been suggested by Richet as someone to operate the Paris office although it was very clear in contrast to Nephron that all editorial responsibility and decision-making would be based in my office. But Claude Amial as time went by not only a very good friend, but also a wonderful assistant and associate editor in Paris. Keep in mind that the journalÖthat we took over the journal in effectively July of 1971 and were being asked to produce an issue in January of 1972. We had to move very rapidly. John Domond in Paris who had been the assistant editor for Nephron very graciously forwarded with the approval of the authors a number of manuscripts to us from Paris, which could be considered for inclusion in the first issue. But most importantly, I got on the telephone and solicited my friends who were very supportive. And I donít remember, but I know that first issue contains a paper by Larry Yearly and a paper by Floyd Rector and what have you. We made it, but for those first few months as submissions were beginning to pick up and beginning to rise on their own, it was really hand to mouth. There were many days when Craig and I wouldÖwe did all the copy editing ourselves and the editorial office was given a magnanimous sum of $8,000 a year to operate. There were no editorial stipends although later we were able to pay a small amount; the assistant editorís retroactive to the beginning of the journal.

There were many days when we dropped finally completed copy edit to manuscripts to the publisher at the last possible moment before the deadline and we might have received an accepted manuscript the day before that rounded out the issue. That first year we received about 225 full-length, original manuscripts and the acceptance rate was the highest ever in that first year, as I remember something around 40-44%, which was unusual. Thereafter it never approached that level. It remained usually in the neighborhood of around 30%. At the beginning I felt very strongly that the journal needed to me, I wanted it to be multi-disciplinary. I wanted it to accommodate work from all of the kidney relevant disciplines, whether that be biochemistry, or physiology, or pathology, clinical medicine or what have you. And most importantly it had to reflect the international sponsorship of the society. That meant in those early years that on more than one occasion we had to edit and help rewrite manuscripts from countries whose native language was other than English because I can tell you Steve from a lot of experience with that kind of effort, thereís nothing more difficult than to try to write a cogent manuscript in a language other than oneís own. So I have great respect for those wonderful researchers all over the world who today are working very hard to put their manuscripts in proper English. We also wanted the journal to be of high standard, wanted it to be quality irrespective of geographical origin. And that was very important to us. Its backbone would be original, full-length manuscript and interestingly, I recognized at the time, the political leadership in the United States was very physiologically oriented. And I felt that if the journal was going to be successful in the States, which Nephron had not been, that we were going to have to attract a certain amount of material from the leadership group that was physiologically oriented. Now that posed a real challenge for us. That meant that if we began with a clinical journal, I hazarded a guess that we would never attract their science. So that meant at the beginning in a very deliberate way we perhaps if there was any bias in the selection of materials it canted toward accommodating good, bench oriented science from good laboratories in the United States. And in the early years there was some criticism that perhaps the journal did not obtain sufficient clinical material. We never accepted case reports for example and good clinical material was hard to find. As time went on we were able to begin to intersperse good clinical writing in the midst of science once we had established a base in the community that said, "Look. They really want this to be a good journal. They want high quality material and weíre going to help provide them with that." My friends and colleagues were wonderfully supportive and we received our fair share of material that would have been competitively placed in other good American journals. We worried a lot about circulation in the first year obviously. I canít for the life of me remember just how we solicited member subscribers in that first year. I assume that we must have had a mailing list of some sort announcing the journal and hoping that people would wish to subscribe. Subscribe they did. And by the end of the first year the circulation had reached approximately 2,200, which was wildly beyond our initial expectations. I donít know what the circulation of the journal is today, but it certainly approaches 10,000 and has been very successful. The first yearís operation was at a loss. Our agreement with the publisher was that they had to recoup their initial startup cost and from that point on we would share equally in the profit if there was one with the publisher. I donít remember exactly how long that took, but the first two or three years of operation were at a loss, it took that long before the journal turned profitable. Springer-Verlag recouped their loss and then we began to share in the profit. Neil Bricker had a wonderful slide that he showed, I think in Montreal in 1978, which showed how bankrupt the society was when he took over as treasurer.

I think there was something like $5-6,000 in the treasurer and then the treasurerís deposit seems to rise exponentially over time and of course all of that or most of it was due mainly to contributions of profit from the journal. In the early days Springer was a wonderful publisher to work with, very responsive. The journal was printed initially in Germany, then moved to England, then moved to the States. In either instance the journal was shipped in bulk via air either to the United States from Europe or vise versa and then mailed. After it was moved to the United States and printed in this country, we airmailed the journal in bulk to Amsterdam and then it was mailed to European subscribers. Japan remained a problem. In that first year about 8-9% of the total circulation was Japanese, by far the most in Asia including either Australia or New Zealand. It took some time before we could work out a system that would distribute the journal promptly to Japanese subscribers who were even then becoming increasingly important to the success of the journal and to biological science in general.

SH: Could you reflect maybe a bit more on the contribution of the journal to the overall science of the society? As you look back on not only your years, but subsequently the involvement of the journal scientifically, how you would view the journal as you look back on it as to its scientific contributions to nephrology?

RR: I think the journalÖ(canít make out. A break in the taping). Like many Americans I thought at the beginning or I questioned whether we needed another journal. I was very pleased with the journals we had. I think most Americans were. We were skeptical as to whether or not there was a sufficient amount of good material to justify a new journal, another journal. My goodness, when one looks at the plethora of nephrology journals today and literature and the number of books in nephrology, there clearly is a market. Now I donít think all journals are of the same quality. I would like to think that KI has remained and is a high quality journal. I think that most would view it that way in the field. I like to think that itís the leading journal in its field. Its competitive with indeed today the American Journal of Nephrology in my view, itís become successful, but its major contribution certainly to the society, was that it was the centerpiece in my opinion of societal programs for some time. I think it still is the anchor on which all else rests. Economically, if for no other reason, because today the journal is enormously profitable. And in that first decade of its existence, the only real programs that the society mounted were its tri-annual congresses and the journal. And I felt that the journal because the society was so amorphous and it was so difficult to govern and there was so much disagreement on almost every issue in those early days that it just became, there wasnít room for anything else. Scientifically I think that the journal today has finally reached in most fields, not every field, the journal has never accommodated as much transplantation and transplantation biology as I would have liked. It does well in physiology. It does well in morphology. It does well in clinical nephrology. But there are small areas, genetics I would say there is still work to be done, but it has moved a long way toward to what had been my original objective namely the creation of a multidisciplinary journal in nephrology that would accommodate any kind of research quality relevant to the kidney. Its very size today speaks a lot of words to anyone who looks at the journal. Itís a large journal. Submissions are over those we saw initially. Iím very pleased with, and I think itís contributed to, I donít think thereís any question as to whether itís contributed to both the scientific stature of the society and contributed to the dissemination of knowledge in the future.

Now what is the future of journals in general in the era of the Internet and the web and a host of other things? And I think you know weíve, Tom Andriolli who succeeded me as editor took the journal into computer based programming and that was a major contribution then, but we need to look ahead and ask ourselves what of the future and that future is not completely clear to me at least today.

SH: Ike, one of the areas of controversy, at least Iím told, was the coupling of society dues to receiving the journal. I think our listeners would be interested in having your thoughts about this controversy and how it was resolved.

RR: Steve, I think we need to begin at the beginning. Hugh de Wardener was president. Hugh is a decisive, action oriented fellow. He was persuaded that something had to be done about the Carger contract, which led to something having to be done about the journal. The society had no money. In his view there was no money to call a meeting of the executive committee. He did on two occasions assemble as many as he could who could afford to travel on their own hook. But the decisions that derived from those meetings were viewed as unofficial by others who were not there perhaps appropriately and that therefore Hugh had acted unilaterally without proper credentialing and there is some truth to that. In my own view as things have turned out the society owes Hugh a great debt of gratitude for his courage and leadership in that era. Many of the council, the executive committee was spread all over the world. They only met once every three years at a tri-annual congress. They were variously informed about the nuances of the issues because of their distance and the poor communication within the society, which had a very limited administrative structure. So that was the background and Hugh felt that for a number of reasons that dues should be coupled because as I have said earlier the journal would serve as a magnet for membership. We could keep the membership list straight etc. There were a number of reasons for that. When that action was brought out, Hugh de Wardener was followed by Pricilla Kincaid-Smith as the president and Pricilla was deluged by complaints especially from those in developing countries who complained about the $30 per year for dues and subscription. They felt that it was too high and that people couldnít afford it and thereís truth to that. Thereís no question that in parts of the world $30 to subscribe to a journal is quite a challenge. Pricilla attempted to respond to that concern because I felt and she too felt that dues and subscriptions should be uncoupled and that subscription to the journal should be an option of the individual and not a requirement and she made quite a strong case on the behalf of that issue. Neil and Hugh and I and others were equally firm in our belief that dues needed to be coupled. And that issue rankled. Pricilla attempted to resolve it with a mail ballot of the executive committee and the major of the executive voted to uncouple dues and subscription by mail ballot. But those who voted for uncoupling were generally people very distant from the epicenter of action so to speak during Hughís presidency and not totally informed to the pros and cons of coupling verses uncoupling. Things festered along until finally in the fall I believe it was of 1973 a meeting was held in London. Pricilla was there, George Schreiner was there, Lou Welt was there, Don Seldin was there, Neil, Hugh de Wardener and me, a number of other people. Those are some who I remember and after a lot of debate and discussion, it was good meeting I felt, a resolution was passed that basically said that for the time being dues would remain coupled, but that we would continue to examine the issue.

Part V

And it wasnít until 1978, six years after the journal had been launched at the Montreal Congress and the adoption of a revised constitution and bylaws that coupling was written into the bylaws and the matter was put to rest once and for all. But it was a chapter of the societyís history that certainly accommodated some dissention within the ranks so to speak. And in fairness to Pricilla I think Pricilla had a point, thought she had a good point. She defended it vigorously and I have some understanding of the challenges. Later as you know as the journal became more established, more economically sound; the society was able to do many things that made the journal more accessible to those in developing countries who wished to subscribe to the journal. A group of people could get together and subscribe to one journal for as many as ten people or what have you, which made it much more affordable. So the society has always been sensitive to the needs of individuals from developing countries, but it took some time before the society felt it was sufficiently stable and economically sound to be able to share the journal in that manner with those in developing countries.

SH: One of your other many contributions to the society was your society presidency. Iíd ask you if you would if you would reflect a bit on your society presidency and the contributions that you made during this period. Some of the changes that you wanted to make that may have happened and maybe others that may not have happened, but I think we all would be interested in your thoughts about that period.

RR: I followed Claus Turell as president of the society and by that time the society had begun to launch a number of additional programs that brought added luster to the society. The International Fellowship Program was up and running doing well. Claude Amiel had done a beautiful job of shepherding it along subsequently followed by Jan Weening in Amsterdam. The forefronts conferences that Gerhard Geibicht ran for so well for so long were wonderful editions. The society was beginning to ask itself what it could do to support the development of nephrology in developing countries. Gabriel Richet during his presidency had launched a group of seminars and actually Don Seldin during his had held one as well. These were meetings in developing countries that were canted towards individuals there. So there were a number of programs that were developing and doing well and offered great promise of extending the purview of the society beyond just an elitist group of individuals practicing high science with high standards and we were pleased by that. So looking at what I might do, it seemed to me that among others things the societyís congresses needed a look. Theyíd been held every three years since the beginning. It meant that their formats were more or less the same. They were heavily laden with what I might call topical reviews, state of the art presentations either in symposia or plenary lectures. I had never felt that the free communications sessions always accommodated the first presentation of discovery. I felt that their programs needed a hard look and maybe their frequency. Keep in mind that by 1990 when I became president, I think thatís right; there were meetings all over the world. There were national societies everyplace. There were regional societies, European societies, EDTA, the Asian Pacific Society, the Latin American Society, not to say anything about the innumerable National societies. One didnít have to look very far to find a nephrology meeting to attend. International Congresses were no longer the only International meeting.

The American Society of Nephrology Meeting had developed into a wonderful scientific meeting, which scientifically at least was on its way of becoming an International meeting and I felt therefore we had to take a look at the format and structure of the Congresses. And one derivative of that was length of service on the council. You know I really looking back on it think itís ridiculous for me to have been a member of the executive committee of the International Society of Nephrology from 1971 to 1995. Thatís 24 years. Thatís an incredible length of service in the leadership of a society and can only mean that there were a lot of good people who didnít have a chance to serve or participate. And since terms of office were geared to these tri-annual congresses I felt that we perhaps might hold them more frequently, but hold them in association with a regional meeting that was going to occur anyway, that would occur anyway. We would do away with a meeting. We might make a better meeting hopefully every so often when we met in association with a regional society. I set that process in motion not understanding at first how political it would become. It took a big selling job to a lot of folk who wanted to know what our motive was. My motive was very simple. I just wished to do away if you will with the tri-annual congresses by strengthening them in combination with a meeting with another society. The first societies that volunteered for that were the Asian Pacific Society and the Australian Society when we met in Sydney and held the Congress there. The council and the executive committee, the ISN approved the recommendations and so that meeting was scheduled in combination with those two societies. Weíve just have the meeting with association with the Latin American Society in Buenos Aires and then of course the big meeting coming up almost two years from now will be a conjoint meeting with the American Society of Nephrology in San Francisco under Tom Andriolliís presidency. So I think and I hope that that system works. I think that it has effectively done away and has seen to that and with a lot of help from Barry Brenner who helped chair a couple of retreats which looked at all of the societyís programs and asked a number of questions. I had two retreats at the beginning of my presidency with as many members of the executive committee that could be assembled and the council. One in Florida and Barry held one in Canada. And the outcome of that led to increasing the frequency of the ISN meetings, but also recommending that we take a look at the format. So that led to the adoption of what has to become the "Theme Format", which was first tried in Jerusalem during my meeting and basically that said that each Congress would not necessary try to cover the waterfront of the entire field in terms of invited speakers and what have you, but that certain themes would be identified and focused on in depth and that that theme might conceivably run all week on each day of the Congress however long it lasted and that therefore one could move sequentially from relevant basic science to relevant clinical understandings as one moved through that theme. It hadnít quite worked out that way in some meetings I think largely because organizing committees and program committees find it incredibly difficult not to accommodate everything especially if its good and thereís some merit to that. And it get very hard with free communications to say, "Well, weíre not going to accept any free communications except those that deal with acute renal failure," or whatever happens to be the nature of the theme. So I do think it was successful. I felt that the, I was admittedly close to the scene and what have you. I thought that the Jerusalem meeting was a very successful venture in that way and Joe deserves a lot of credit for bringing that off. The Buenos Aires meeting and the Sydney meeting as well adopted a modified theme format and I think that was a contribution.

It also meant that now you were no longer a member of the council for nine years after election and since your term of office is geared to the frequency of the Congresses that reduced the length of service of a councilor from nine to six year and I thought that was a good derivative of that decision. So turnover is more frequent among the leadership and I think that exposes more people with an opportunity to play a role in the societies programs. Now the second area where I made an entry, but not as much as one as I would have liked. Previous presidents had all appropriated money for ventures in developing countries. And I felt very strongly that an International Society, that there was one thing that we could do and should be doing, that no other society in the world was equipped to do and that was assist in whatever way possible the growth and development of nephrology in countries that were less fortunate in the West or Japan or what have you. And so I had identified central Europe as an area of special interest on my part. I didnít get to do as much as I would have liked, but I have been very pleased that John Dirks and Barry Brenner and Bob Schrier and other subsequently have picked up whatís now a phonemically to coin a word called the "COMGAN" program and extended the societyís purview extensively into developing countries all around the world. And I think thatís a function that this society can do uniquely and very, very well. And Iíve been pleased to see that program take off and go.

SH: Iíd like to go back for just a minute and get your thoughts in regard to the journal particularly with the, after your ten years as editor the transferring of that editorship to Dr. Thomas Andriolli.

RR: Well of course Tom Andriolli and I have been friends and colleagues for a long time since Tom came to Duke as an intern in 1960. I was very pleased when after Richet who was then the president that Tom was selected as my successor. Tom has done a wonderful job, yes by good support as I was. I mentioned earlier that Craig Tisher was a tower of strength in the first five or so years of the journalís life and he was followed ably by Vince Dennis. Vince was just a trooper all the way. Wonderful job. Quite bench oriented scientist and he was a wonderful helper and more than a helper. Vince was perfectly capable of operating a journal himself and did. When I came to Vanderbilt in 1981 I still was editing the journal and Vince and I had a little bit of a complicated circumstance where we had to pass manuscripts back and forth between Durham and Nashville with some frequency. The system worked well and I donít think we lost much time at all. Richet recognized that the journal should be transferred in due course. I certainly was beginning to think it was time. Iíd edited the journal for the first 13 years I think it was and transferred the journal to Tom at the beginning of 1985. That transition I think smoothly and well. Tom was then in Houston and one can only look at the success under Tomís leadership to know that he was the right choice, he was in the right place at the right time, and did the right job. Saulo Klahr has the journal now and I have been equally pleased with what Saulo has done. So the society has been pretty fortunate I think to have two good successive editors. You know I can also remember another component part of the journal. I was very nervous when Jordi Coen who was then in Boston, called me with a suggestion that perhaps the journal might accommodate a piece that was nowhere less, but yet different from the CPC format in the New England Journal of Medicine that would be a case presentation and discussion in a scholarly way. And we proposed that that might be called Nephrology Forum, which you know is now a very important part of the journal.

I donít remember the year I was approached exactly, but it may have been in the late 70ís and I worried that the journal had sufficiently established its reputation in science based publication not insertion of something that clearly had a clinical bent, would send a signal that the journal was changing, that the journal would, whether or not this venture would drive away materials that might have otherwise been submitted to us because KI was now becoming "more clinical". Yet at the same time the overwhelming majority of subscribers to this journal are clinically oriented people. Overwhelmingly. And therefore I was very nervous about it. As things have turned out I shouldnít have been at all. It probably has become the single most popular feature of the journal. Jordi and his colleagues, John Harrington who runs it still today, Jerry Casser has just done a wonderful job with that program. Jerry I think had drop out when he became editor of the New England Journal. Itís had an incredible run and itís not an easy thing to put those things together and again reflect internationality and both Harringtion and Coen have done a wonderful job of doing that. So Iím looking back on it, it was the right decision at the right time although it was one I entered into with some nervousness at the time.

SH: One of the other features of the journal is the symposium issues or special issues. Maybe you could reflect a bit on that as a component to the journal.

RR:I tried to make it clear at the beginning. I was absolutely besieged with requests to publish proceedings of various meetings. I think the one thing that helped make the journal attractive in the early years was the solicitation of abstract publication from national societies. You know for a long time we published all the ASN abstracts until the ASN started itís own journal. The EDTA abstracts of other meetings of other national societies. I think that added to the attractiveness of the journal, but there were some who felt that was not a good step. I can remember Jack Orloft saying to me, "Youíre going to do what? Youíre going to publish those abstract? Are you going to be an abstract journal?" he said. But politically I know it was the right move and added to its eventual success. The other question Steve was what?

SH: The special issues or symposium issue.

RR:Oh, as I said I was just deluged with requests to publish proceedings of various meeting around. The papers that were submitted to those meetings were of very uneven quality. I finally agreed to do it on condition that it was made clear to all submitters that their paper would not necessary be accepted, that it might be edited for clarification if nothing else, but they would not be peer reviewed. At least the early supplements were not subjected to peer review and I tried to make that clear to the readership that these were basically proceedings. Now thatís not necessarily true of invited symposia. The responsibility of the review of invited symposia issues where someone would say, "Gee, weíd love to have a paper from you Steve in this symposia on whatever." The responsibility of that was the guest editor. The guest editor wished to subject his solicited manuscripts to peer review that was his prerogative, but the editorial office would not do that. We would assume that the submissions of those supplements, those symposia, had been appropriately reviewed to a satisfaction of the guest editor and thatís the process that we adhered to during my tenure. Iíd donít know whether Tom or Saulo had subsequently modified that. The world usually requires modification as we go along so I suspect that they have modified that approach to some degree.

SH: I know this may be a difficult question for you to answer because of your so many contributions to the society, but which of those contributions as you look back in reflect on them are you most proud?

RR:Oh I donít think there is any question that KI is the thing of which Iím most proud. I think in retrospect KI has been a very successful publishing venture. Like all medical publishing I think that itís style and format and future in this era remains to be protected and examined and maybe reestablished. I donít clearly understand the future of medical publishing, where itís exactly headed although change is in the air. I think itís clearly something though that I am proud of. I was ready for a change. I always had a short attention span and whether it was teaching or doctoring or researching or editing or administering or whatever and I was ready to do something different. The editorship of KI came along at just the right time for me. It was a bit of a surprise in retrospect. I had no prior editorial experience. I didnít know Hugh de Wardener, Hugh de Wardener didnít know me. I didnít know Richet, he didnít know me. I didnít know Claude Amial, he didnít know me. All of this happened on Neil Brickerís recommendation I think. I was stunned when the telephone rang one day and Neil says, "Would you like to be editor of Nephron?" Nothing had ever entered my mind. I was a subscriber to Nephron, O.K. journal; I didnít think it was a superior journal. I was absolutely stunned. But I warmed to the idea and then Craig and I just, I mean I put hours into that journal initially, long hours. And itÖIíd like to think that it established a journal as a credible venture. And I felt equally strongly that an editor, that an author needs an advocate and yet anyone is in a position to become an advocate of the author itís the editor. I felt that in this country where we pay homage every day to peer review for lack of a better system, that sometimes we may tend to over do it just a bit as well. Editors, their job in my view is to be sure if he or she can, that thereís balance between the comments of a referee and the points that the author is attempting to make with the design of his or her study or whatever. Thatís no easy task. I would like to think that I worked hard at that and there were several occasions when I thought referees were unfair and I said so. And I would say so to the referee, try to, and explain to the author. But you know Steve, at least I found there are almost no manuscripts that are submitted suitable for publication in the form in which they are first received. I will bet you that the number of original manuscripts published in KI during my tenure that required no change as a consequence of review were minimal. Now those changes may have been minimal themselves or minor or what have you, but a pristine manuscript is a wonderful thing to behold an occasionally one comes along, but they really are very unusual for the most part, at least I always found it so. I think that some people have said to me in the past that it was obvious that I had read each manuscript and I did read each manuscript and I worried over those manuscripts. As I became more experienced and more efficient at this there are also some manuscripts at the bottom of the pile that you just know are not going to make it. I mean from the reviews, from just a cursory glance, and I came to the point where I didnít spend a lot of time with those manuscripts. I spent a lot of time with those that I thought were on the fence especially and just pleasured in the fact when one came along that clearly wasnít on the fence, but just needed some minor tune up before acceptance. I enjoyed editing. I found it fun. I liked it. There was a side of me that hated to relinquish the editorship of the journal to Tom even though I knew it was time. My responsibilities at Vanderbilt had grown tremendously.

You know when I first came to Vanderbilt I thought I could continue to edit the journal, I could continue to make rounds, and I could continue to do all the things Iíd been doing at Duke.

Well also in the last four or five years of my Duke life, Iíd held a major administrative appointment parallel with my nephrology appointment. It soon became clear to me that I wasnít going to be able to do that, well at least I didnít feel comfortable doing at Vanderbilt. And so gradually, by the time I been at Vanderbilt for five or six years, I was beginning to distance myself a little bit from teaching rounds and the journal went to Tom and involving myself in Vanderbilt became my full-time job.

Part VI

SH: Your contributions certainly to Vanderbilt University and to American medicine and nephrology have been immense. Your role as the administrative and spiritual leader as the Vice-Chancellor allowed you to shape a major University as well as the contribution to the overall direction of certainly American medicine. I thought we might conclude by having a bit of your thoughts about where nephrology and where medicine has come during your career and where you think its heading in its future. I know itís a difficult question and one has to be a soothsayer to answer the later, but I think we would all be interested to hear your thoughts.

RR: I pledged my life to Vanderbilt. I had danced on a political stage in nephrology, I had headed a nephrology board, Iíd been president of the American Society, I was about to become president of the International Society, I had done all the things in nephrology that I had wished to do. I had edited what I felt was itís best journal. So I decided that I would confine my activities to doing what I could do to support the development of a very fine American school and its associated medical center. I feel that that the job is never done when one takes on a task of that sort. When I left my post at Vanderbilt recently I could name many, many things that were undone and yet needed to be done. On the other hand Iíd like to think that the institution prospered during my 16-year tenure at its helm and I think it did by any objective criterion that one tried to lay upon it. And I think that Vanderbilt is today on the threshold of being able to go to the next plateau wherever that may be. Itís been great fun for me. Iíve enjoyed it. But if you have a job that you like you must be able to take pleasure in successes of other people. I think that is very important and you better hope that you have selected the right people, at least 75% of the time, for very key positions. I donít know anybody who makes it 100%, but I think weíve been fortunate and attracted some wonderful folk. As to where medicine is headed: Steve, medicine in this country is undergoingÖthe delivery of healthcare is undergoing enormous change. Itís had tremendous and dynamic impact on academic health centers including our own. Some have prospered more than others. I just have to believe that the interests of the patient will bear out in the end. I have to believe that quality will bear out in the end. And I believe that in this county, you know weíve never been able to address what I perceive to be the true drivers of the cost of healthcare, which started all of this and one is what I call too much good medicine. My wife and I were at a party recently and we were the youngest people there, and I bet you that everyone at that party had seen a doctor in the previous two weeks, and probably half of them had a pace maker, and that all comes at very high cost. Iím not saying that we shouldnít do it, but weíre one of the few countries in the world that has not really been able to come to grips with those kinds of costs.

Second is high technology and itís costs and the third, that I think is unique to the United States, is the enormous appetite of the American people for anything connected to health. If you open a new fitness center theyíre there tomorrow. But manage-care is here and weíre going to live with it and I think we are now beginning to see a little bit of a turnaround in the approach to manage-care companies, but it certainly brought a totally different view into American academic medical centers. And fortunately or unfortunately weíre going to have to accommodate to. Weíre more conscious of our costs than we were. Weíre more conscious for the need of administrative systems. But I have great faith and Iím very optimistic. I really do believe that good people will bring good benefit to good patients in the end. And Iím hopeful that that will be the case.

SH: Finally Ike, one of the things I know in your philosophy and in your actions has been very important to you is the training of young people. Iíd like to get your reflections on the societyís role and functions in training fellows and training people in our subspecialty.

RR: The answer to that can come quick and easily. Iím very proud of the International Fellowship program. Itís one of the societyís strongest programs. Itís been enormously successful and although we havenít always been successful at returning a trainee to their home country of origin, we have been sufficiently successful and I think we can take great pride in the fact that many, many, many international ISN fellows have returned to their home country. I think itís a wonderful way to expand science and clinical nephrology into developing countries and the society has been wonderfully adapted at attempting to do that. Their now well over 100 fellows who have been through the program, its and exciting program, itís a good program and its one in which the society can take great pride. Iíve taken great pride in watching it develop and again as is all other programs is because good people have taken good charge of it and run it, Claude Amiel, Jan Weening etc.

SH: Thank you for your many contributions to both American medicine, international medicine and nephrology to the International Society of Nephrology and thank you for sharing your thoughts about your early career, your many, many contributions to our field and our society and our society as well of nephrology is all the richer for your having served us very well. Thank you.

Steve, let me try and amplify on the five points that you asked me about. First was your question about Duke nephrology. When Dr. Stead asked me to begin to assemble what became a division of nephrology, he didnít suggest what it should be named. I simply chose the word nephrology, I was attracted to it and I might add that I first became acquainted with the use of that word when I became aware of the First Meeting of the International Society of Nephrology in Avignon in 1960. I chose my own title. I called myself, "Director of the division of Nephrology", and it was a title that I chose. The first person to join our group at Duke was Caulie Gunnells. Caulie was a consummate clinician and he spent his first few years in our group measuring plasma rennin activity in a variety of clinical circumstances using the spirally cut rabbit aortic strip methodology. Very effectively I might add. To my knowledge, Caulie was the first person to demonstrate an increase in plasma rennin activity during acute rejection of a homograft following an allograft following transplantation. It was published in the New England Journal of Medicine. The next person to join our group at Duke was Jim Clapp. Jim Clapp was the first person to micropuncture the dog.

I was privileged to be associated with Jim in studies that were attempting to identify the sites of action of diuretics such as ethacrynic acid, furosemide, and chlorothiazide, and we felt that we had successfully delineated a proximal site of action for the two loop diuretics that I mentioned. Jim and Caulie were followed by other very capable people, Tom Andiolli, Craig Tisher, Vince Dennis, certainly deserve the mention. In addition, others in our group over time included Chuck Hayes who led our formation of a dialysis unit and our entry into that field, Bill Stead in medical informatics, Bill Yeager who is still at Duke, Cleaves Bennet who brought to us the technique of helium-glow spectrophotometry, Bob Harris, Steve Grossman, Bob Gutman, all very, very fine people. We had an eclectic group at Duke, a large group. I donít remember the exact number, but more that 70 or so fellows. Craig of course was using morphological techniques; Chuck Hayes was the first person to demonstrate that chronic renal disease was associated with increased fecal potassium excretion. Bill Stead in informatics, Caulie in hypertension, and all and all a very eclectic group. Vince Dennis utilizing the isolated perfuse tubule and interested in mechanisms of phosphate absorption. It was a good group and a very exciting time for us.

You also asked me to expand on other programs of the International Society that I might have failed to mention. I think its fair to say that the first presidents of the society, the early presidents of the society, were mainly concerned with putting a new constitution and bylaws in place, establishing the need for the Congresses and bringing them about, making them happen, and establishing the societyís journal, which as you know early on was Nephron. I think that it was in Hugh de Wardenerís presidency when KI was established and I think that you would agree that his main contribution during his presidency led to the creation of Kidney International, which I feel has been enormously successful. Hugh was followed by Pricilla Kincaid-Smith and one of the things that Pricilla did, of course she got caught up in the terrific conflict over the coupling of dues and subscription, the additional thing she did, I believe Pricilla was the first person to reach out and sponsor International Meetings under the eaves of the International Society. One I remember she sponsored was on hypertension, another one was on urinary tract infection and I believe that both of these were published as supplements to Kidney International, but Pricilla deserves the credit for extending the purview of the society into those kinds of activities. Later following Pricilla, Gabriel Richet to my recollection was the first president of the society to establish symposia in developing countries. He held two symposia, one in Tunnis and another in Lima, Peru, which I participated in by the way and subsequently, each president of the International Society is appropriated a certain amount of money to continue the sponsorship of continuing education type symposia in developing countries. In my own presidency I held one in Poland as central Europe was beginning to emerge from its period behind the Iron Curtain. Forefronts were established I believe during the presidency of perhaps Don Seldin. I participated in the first one, which was on molecular biology. At that time I felt very, very, strongly that nephrology was slow to apply the techniques and concepts of molecular biology to its problems. We constructed the first forefronts conference under the leadership of Dell Granner, Harry Jacobson and held it in North Carolina and invited many, many, basic scientist from outside nephrology who could begin to talk about the emerging and in fact the emerged field of molecular biology.

Now many investigators based in nephrology have begun to apply those techniques, but at that time nephrology was relatively under represented.

Other ISN programs, I had mentioned earlier the International Fellowship Program and its success. Klaus Thurau  deserves credit for establishing what he termed the "Commissions". We had commissions, which were special study groups. One of the most successful has been the Commission on Acute Renal Failure headed by Kim Solez, at least initially, in Canada which in addition to many of its programs also sponsored a rapid response team, one that could involve itself and support the provision of emergency medical care in various crisis around the world, and thatís been a very successful program. Then last and not least, I think that more recently under Bob Schrierís leadership, our interest in developing countries and John Dirks and Barry Brenner have done a wonderful job of beginning to extend the purview of the International Society into developing countries under the rubric of what has come to be called the "COMGAN" program, which is the commission on nephrology in developing countries. And the format for those commissions had been set in place earlier by Klaus Thurau .

My views of the development of the American Society of Nephrology may be of interest. For many years, in all of the early years, and in fact up and through my presidency of the American Society of Nephrology in 1981-82, the main and sole purpose of the American Society was to hold the best scientific meeting that it could arrange. It resisted in those early days extending its activities into other areas. Of course now the American Society has involved itself in many other kinds of programs. Looking back on it I think that the founders of the society and the early presidents were very, very wise to restrict their activities, to simply holding the best scientific meeting that they could. I think that had they permitting the society to involve itself in a number of other issues from the beginning whether it be politics or policy development or whether it be continuing medical education programs or a host of other kinds of programs now embedded in the fabric of the American Society, I think it might have run the risk of weakening the development of the strong scientific program that we now see today. That tradition was set in place early on, maintained and nurtured and I believe facilitated what has now emerged as an exceedingly strong scientific meeting.

You asked me earlier in the hall before we began this taping just what I thought my personal rewards and benefits had been of my long association on the executive committee of the International Society of Nephrology and my editorship of Kidney International. I think thatís a very easy question for me to answer. In a simple word it was the establishment of many, many friendships around the world, friendships that continue today. Noticeable I would include all of the past-presidents of the International Society from Hugh de Wardener, to Gabriel Richet. Gabriel Richet and I at the moment are involved in what is perhaps an amateurish attempt to write a history of the International Society. Claude Amiel, both Ann and I became very close to Claude and Ginette Amiel over the years. I consider Gabriel and Claude among my two best friends. A host of others over the years.

Its really been a pleasure for me to get to know a lot of fine, productive, contributing people from around the world, Stewart Cameron, a host of others that could be named. One other that influenced me as a young person very much, even though I never trained with him was Don Seldin. When I was in the Air Force I just by accident happened to be officed next to Norm Caplin. Iíd been a chief resident at Duke, Norm had been Don Seldinís chief resident at Dallas, both of us went into the Air Force at same time, our offices were located next door to each other and one day Norm had asked me, we were both in San Antonio at the USAF Wilfred Hall Medical Center and Norma had asked me if I wanted to go across the city to Brook Army Medical Center and listen to his old boss conduct grand rounds? And I said sure. And thatís exactly how I met Don Seldin. Don Seldin was interested in our studies of patients with fixed and reproducible static proteinuria and arranged for our biopsy samples to be examined by Charles Ashworth, who was at the time the chairman of the department of Pathology at Southwestern Medical School in Dallas. I made arrangements to fix the tissue in osmium tetroxide in San Antonio. A military aircraft flew the sample to the navel air station in Dallas where they were transported to the medical school. Charles Ashworth finished the staining and preparation of the samples and performed the electronmicroscopy on those samples. Don Seldin has remained a good friend, a close friend, a supporter of mine and of the International Society and Kidney International. He has had a wonderful influence on me as he has had on many, many other people. My time and my associations with the society have been wonderful and very, very rewarding.