First, I want to thank the British-Lebanese Association for graciously inviting me to be your speaker tonight. This is indeed an honor and privilege that I shall cherish for years to come. Many people worked to bring this evening into reality, and I want to thank them all. However, to one person, I would like to extend very special thanks: Lisa Zakhem. Without her, I would not have been here tonight. Also, I want to thank you all for coming.
Ladies and gentlemen, I have chosen to speak to you tonight about my personal adventure as a doctor treating cancer. In exactly eight months, June 1998, it will be 30 years since I had started my journey with this disease and my war against it. At this point in a long and tedious journey, I would like to pause, and rewind the video tape. What did this adventure mean? Was anything accomplished? Were there any lessons learned? What is the message? I am not sure I have a message, but I certainly have the urge to say something. I would like to say something to the healthy and the living since I have spent a great deal of time with the sick and the dying. Indeed, it is life's irony that you come to appreciate life and understand it only when you get close to death or think you are close to it. It is painful to realize that we appreciate things only when we lose them or when we are threatened by their loss. If I have learned anything, I have certainly learned to appreciate things when I have them, and to appreciate life when I am still healthy.
My story starts in Bterram, a small village in north Lebanon. As a child, I listened attentively to the stories of my father who believed fiercely in the power of education, and I believed them all. He also believed in the power of hard work, discipline and excellence. If you had a tough time making it in school, you had a tougher time making it at home. To him, life was an opportunity to succeed, to excel, to climb the mountain, to reach the peak. He had little compassion for those who fell along the way and little mercy on those who did not try very hard. However, we were blessed by a mother with a different vision. Her's revolved around the family, including the extend family with its remote boundaries. Every one of us was extremely important and precious. She did everything with love, ease and peacefulness. She radiated happiness and joy all over the house. She made us believe that the whole world was there for us to enjoy. Although my father and mother held two distinct and different visions, I loved them both immensely, and whoever I am today, I owe to them. They are certainly the two most important people in my life and where they rest now for eternity is the most sacred site on earth for me.
I descended into the world gradually. After I finished my elementary education in my village, I went to study in a neighboring village and thereafter, in Tripoli, a city only 10 miles away. From there, I went t to the American University of Beirut, where I studied medicine. Although I had been seasoned to become a doctor, the year before I entered medical school, I hesitated to do so. I excelled academically in philosophy and literature, and entertained journeying in that direction. When my mother learned of my hesitation, she summoned me to her room and reminded me that I had promised her to study medicine, become a doctor, and take of her when she becomes old and sick.
This was true. As a child, I had suffered a great deal from seeing my mother struggle with recurrent bouts of kidney stones, and I had indeed promised her I'd become a doctor and take care of her. Unfortunately, however , after I'd become a doctor, she never developed kidney stones, and when she grew old, she developed Alzheimer's disease and I was unable to help her, not even a little bit. To help hundreds of people who suffered from cancer, and to watch my mother deteriorate day after day and not be able to do anything for her, was one of the most frustrating and painful experiences of my life.
I graduated in 1965, and immediately started my specialization in internal medicine at the University of Beirut. I was being nurtured to become a kidney specialist, but suddenly, a woman very precious and very close to me developed ovarian cancer. I accompanied her through her journey with the disease, and that experience changed the direction of my professional career forever.
At that time, there was no treatment for ovarian cancer and physicians did not discuss openly and frankly with patients those issues relating to diagnosis and therapy; much less, issues relating to life and death. That woman was left in solitude to suffer alone with her pain. Physicians came to see her rarely, and when they did, they rushed out quickly before she had a chance to ask questions. They had no answers for her questions. Because cancer was a taboo, she was left alone. She made me read Tolstoy's, The Death of Ivan Ilyich, and many times she enjoyed repeating this quotation: "Why hast Thou done all this? Why hast Thou brought me to this?" Why does Thou Torture me so? For what? He did not expect an answer, and he cried because there was no answer, and there could be none."
A few days before she died, she squeezed my hand and said: "Very soon, I will be here no more. This whole ordeal will be over. Would you, however, promise me that you will do something about this disease in the future so others will not have the pain that I have had? And should you ever become a cancer physician, would you remember that the real agony is not the physical pain, it is the non-physical". I promised, and I remembered.
June 1968 was a milestone in my professional career. I crossed the Atlantic for the first time, landed in New York City, and joined Memorial Sloan-Kettering Cancer Center. Since then, my life has been a continuing and a daily struggle to conquer a vicious enemy called Cancer. New York was too far from home. I could not go on weekends to visit family and friends in Bterram. People were different and far too tall for my taste. The culture seemed strange and cold. Many times I packed and decided to return to Beirut. Yet the challenge held me. The target was clear but the road was unknown. For me, life in New York was a mixture of sadness and excitement. I was sad because I was homesick, and I had left a younger brother who was newly diagnosed with multiple sclerosis. I wondered whether I would find him alive on my return. I saw his face in every page I read, in every patient I treated. Still, I was excited at the prospect of conquering a vicious and historical enemy; of embracing a new culture; of climbing a new mountain. At Memorial Sloan-Kettering, I studied under Dr. David Karnovsky, an intellectual giant who was to become the founder of cancer medicine. The son of a Russian immigrant, he had a panoramic mind and an imposing presence. Scientists in his audience fell silent. He spoke very little, but when he did, his words echoed far. A special and a unique relationship developed between us. I was fond of the power of his mind and the largeness of his heart. He was intrigued by me, a young small man from a small country that he had learned of only in the Bible. He constantly asked me about Lebanon, the Middle East, and family. Almost daily, we had breakfast together and debated political, philosophical, and moral issues. A bond cemented us. I was to become the son he did not have. One day, while he was writing a note, his hand shook and could not complete his sentence. He was admitted to the hospital and was soon found to have lung cancer that had spread to his brain. It was felt that his cancer was the result of his long-term exposure to the poisonous chemical Nitrogen Mustard. In the early forties, he conducted extensive research on this chemical as a potential cure for cancer. He tried to find out whether nitrogen Mustard could kill the cancer. Instead, and after years of exposure, the Mustard killed him. In the last few days of his life, I was one of the very few people by his side. I took care of his daily needs and gave him pain killers and intravenous fluids. Dr. Karnovsky was the victim of his own research. He was conquered by the disease he wanted to conquer. Before he died, he advised me not to return to Beirut immediately. "Beirut will wait," he said, "Before you return to Beirut, you must spend at least one year in Houston. You will come to know two intellectual giants who will certainly shape the future of cancer medicine, Dr. Frei and Dr. Freireich." It was extremely hard for me to spend one more year in America. I was already psychologically prepared to return to Beirut, but he was someone to whose deathbed wish I could not say no.
In Houston, I found a warmer people and climate. M.D. Anderson was then a small hospital, not among the biggest and most prestigious cancer centers it has now become. Under Drs. Frei and Freireich, I learned the art of research. By 1971, I was mentally and emotionally ready to return home and start building my dream. Just a month before I had to leave, Dr. Frei was offered the presidency of Harvard Cancer Center, the so called Dana-Farber Cancer Institute. He called me to his office and asked me to join him at Harvard. I refused. This time, there was no power on earth that could have forced me in a different direction. I wanted to go back to Beirut. Indeed, he had never heard of the latter before we met. There was no way for me to explain to him my attachment to my country, my people, and my family. At that time my commitment to my people was stronger than my commitment to science.
Arriving in Beirut in the summer of 1971 was joy beyond words. My younger brother, whom I thought would be in a wheelchair, and whose personnel diagnosis crushed me during my whole stay in America, was healthy. The diagnosis of multiple sclerosis was false. The family was all there, happy and joyful. Lebanon was at its peak of glory and beauty. It was a dream fulfilled. At that point, the only place I wanted to be was Beirut. My dreams were big, but the resources limited.
Since nobody else wanted to deal with the cancer problem, I was soon asked to be in charge of the cancer program at the American University of Beirut. I was elected the president of the Lebanese Cancer Society. There I was, in the very place I had always wanted to be. The road was clear to me and there was little hesitation on my side to go forward. I wanted to achieve three major objectives:(1) The establishment of an excellent cancer treatment and training program at the American University of Beirut, (2) Creation of a cancer research program focusing on diseases peculiar to the Middle East and to our geographical region, and(3) Education of the public about prevention and early detection of cancer. None of these objectives was easily attainable. With every inch of progress, there was blood on the floor. Cancer was a taboo, its prevention was considered a myth, its treatment was considered an act of charlatanism. Research was considered a luxury that developing nations could not afford. More importantly, clinical research (that involved patients) was considered "experimental" and unethical. Public education about cancer was severely discouraged because of the anxiety and fear that it might produce. Twice, I was threatened with being fired from the institution. The first time, I had spent the previous night explaining on television the early signs of breast cancer. Half the women in Beirut got no sleep that night. The second time, I had treated a young man with liver cancer in an original way. The 24-year old patient was almost totally consumed by cancer, and I was faced with the option of either leaving him to die or doing something for him. I did the latter, and I introduced catheter in the blood vessel that feeds the liver. I treated him with chemical agents that I delivered through the catheter directly into the liver. This was the first time in the history of medicine that a patient with lymphoma of the liver had received treatment in this manner. The next day I was reprimanded by the administration. I was told that "experimentation" on people is unethical, and should I continue to treat the patient in this manner, I would certainly be fired. I continued the treatment and I was not fired. The reason was not out of mercy for me, but because the patient responded extremely well and was eventually cured. Interestingly enough, he married the nurse who took care of him. I will never forget how, when I summoned them before the wedding and explained how serious his condition was, and that there was no guarantee that he would be cured, her answer was clear and decisive. "Should he live only one day, I want to marry him." Today, some twenty years later, the man, the wife, and their beautiful children are all alive and well.
By 1975, I felt very well entrenched. The cancer program at the University was flourishing. The public had by now accepted cancer education as a necessary evil, and those who had thought that I was crazy and weird had acclimatized to my presence. People started to utter the word "cancer". In research, we made minor strides. We were very fortunate to identify a disease which is more or less unique to the Mediterranean countries and to the Middle East. We focused on it and we did well. Several publications appeared in highly- respected research journals, and we attracted the attention of the world to this unique and fascinating disease. The local response at the university was favorable. The administration felt that after all, we might be doing something right. By spring 1975, I felt on top of the world. I had won by now, not all, but many of the battles. All the troubles seemed now behind me.
Little did I know of the trouble that was to come: nothing less than a full scale war, probably the most cruel and barbaric war in the history of man. It was a war that devastated Lebanon and has yet to come to a concrete and complete halt. My life was turned upside down. The life of every Lebanese was turned upside down. The challenge now was no longer research, education and the conquest of disease. It had become a basic human challenge: mere survival. Very few people probably know that for approximately 15 years Beirut was shelled almost daily. Every morning, you would wake up and think that Beirut had been erased from the surface of the earth, but then you walk out and see that Beirut is still there, and people were still going to work. Everyday people slept in the shelters, and every morning they went to work out of these shelters. The distance between the workplace and the shelter was the distance between death and life. You might die at any minute, any second. It was only a question of luck. My house was only half a mile from the university, but there were five locations where I might spend the night. If the shelling was extremely severe, I slept in my academic office at the university. If it were slightly less severe and I could cross one street, I slept in my private office. If I could afford some luxury, I hid in a nearby apartment that my relatives owned. If the shelling was not insane, I might make it to my wife's aunt across the street from my house, and if things were unusually quiet, I might reach home.
Reaching home was not the end of the journey, because I had to be prepared to go down to the shelter any minute during the night. When death ruled everywhere, I moved my family out of west Beirut and started to commute between east and west Beirut. I was one of thousands of people who parked their cars daily near the national museum and walked the traditional crossing between east Beirut and west Beirut. In the evenings, I walked in the opposite direction. At any time, there were thousands of people crossing on each side and in each direction. We walked under fire. We became accustomed to the constant threat of death. People became fatalistic. They refused to allow the militias to divide the city. My students, staff, and fellows also had to commute. Every morning, we spent the first hour talking about the ordeal of crossing, and in the evening we spoke of the ordeal of returning home. While this was a daily ordeal for many, many years, it was also a daily triumph over the war. Never before in history was a city shelled so extensively for such a long time. The objective was to flatten it, but it stood erect. The objective was to divide it, but it remained unified. Never before had people been so crushed to the bone, yet they remained dignified. Never before had people had been so pressured to become alienated from each other, but they remained unified. Unity was most exemplified in the shelter. Under ruthless bombardment, people would leave their home and descend to the shelters. There, Christians, Moslems, rightists, leftists, were all one against the horror. They were all cemented by love, cemented by the fear of dying together, cemented by their refusal to accept the insanity of the war.
I remembered one day, late in the evening, being in my clinic talking to a woman with breast cancer who also happened to be my neighbor. I was trying to alleviate her anxiety and reassure her that treatment would make her well that she would survive to see her kids graduate from university. We both left my clinic at 7:30 p.m., only to be united one hour later, in the shelter, doctor and patient together with hundreds of other people from the neighborhood. Shelling outside was absolutely intense and insane and my daughter, 2 months old, was crying in my lap. She was hungry, thirsty. We had not brought milk with us down to the shelter because we thought the shelling was going to be very brief. Seeing my daughter hungry, thirsty, and frightened, I became extremely anxious. My patient, whom I was trying to reassure in my clinic a few hours earlier, came to me to assure me that I need not worry, that should the need arise, she would venture outside and bring milk and food. "After all", she said, "I would rather die from a bullet than from disease." In a matter of hours, the roles had been reversed. Earlier, I had been the doctor reassuring an anxious patient. Now, I was an anxious father reassured by a loving friend.
Life in the shelter became routine, and eventually, a pleasant one. After all, my friends and the people I loved most were there. I spent night after night in the shelter and I wrote most of my important research papers from that shelter. In Ras-Beirut Lebanese war was unique in the sense that it was not a war between the armed and the innocent. It was a war against the people, all the people of Lebanon. It was a war against the greatness of the Lebanese people. It was a war against what was special and unique, about Lebanon in the "orient". So many times I wondered during the war how I could have been destined to see so many cruelties: the cruelties of nature via a disease like cancer, and the cruelties of man via a war like the Lebanese one. As always, the big questions have no answers.
In the mid eighties, it became clear that many of our patients could no longer reach Beirut to receive treatment at the university, and consequently, we established a satellite program at a small hospital in Byblos, some forty miles north of Beirut. I would leave Beirut every Thursday and spend Thursday and Friday in Byblos, returning on Saturday to Beirut. This became a routine. One night, alone in my beach house in Byblos, I heard a knock on the door. It was two o'clock in the morning. The telephone was out that day and I thought someday was trying to reach me by phone and could not, thus he came in person. I opened the door, but could not believe what I saw. A uniformed and bearded young man whom I did not recognize was standing in my face. He hugged me emotionally and reminded me that he was a patient I had treated for testicular cancer few years earlier. Now, he was cured and is a member of one of the militias. He had come by sea from West Beirut in a tiny boat to advise me not to return to Beirut the next day. His militia planned to kidnap me on my way back and he was to execute the plan. This was an attempt by his militia to recapture their hostages from rightists in the Christian area. At that time, my brother was minister of foreign affairs and this young man's militia had reasoned that pressure on my brother would put pressure on the president of the Republic. He, in turn, would then force the rightist militia in East Beirut to liberate the hostages from west Beirut. Rather than returning to Beirut the next day, I decided to leave the country. I reasoned to myself that as a physician devoted to preventing disease, I now needed to prevent a catastrophe. As the father of three very young children, and the husband of a young wife, the risk was too high.
In January 1987, I left Beirut for Houston. The journey was traumatic and painful. I had made this trip before many times, but this time was different. This time I had left a country that I thought I would never see again, and I had left family and friends that I thought I would not see again. I flew in a helicopter from Beirut to Cyprus, and as the plane went farther from the mountain of Lebanon, I went farther from my reality. It was like being peeled off from your own skin. By the time I arrived to Houston, I felt as if I had been split in two halves, the physical half in Houston and the other half still remained in Lebanon.
Upon Rejoining the M.D. Anderson Cancer Center, the institution felt almost like home to me. I had a courtesy staff member for many years and many of the students that I had trained in Beirut were already entrenched at the institution. Most of the faculty members there were very close friends of mine. I found myself back in the mainstream of cancer research again. I shall never forget the kindness, warmth, and support that my friends at M.D. Anderson and Houston gave me when I first arrived. Each tried to help in one way or another. I felt like a cancer patient. As the cancer patient is threatened by death, I was threatened by losing myself. It took me time to recover from the shock, to readjust to the new realities and harsh realities. I was no longer in my own country. The dream has shrunk to a simple ambition: peaceful existence. I, a physician who spent his life reassuring cancer patients, raising their morale, boosting their egos, expanding their hopes, was surrounded by friends and colleagues trying to do the same, but to no avail. The wound was very deep. The healing was very slow.
One year later, my friends at Memorial Sloan-Kettering must have realized my agony and wanted to cheer me up. The institution chose me as the distinguished alumnus of that year. This meant that I had to go to New York and give a talk on the research I had done in Beirut. I did, and at the end of the lecture, a very close friend of mine came to me and asked me whether I could find a job in Houston. He could not see eye to eye with his boss and wanted a new challenge. I returned to Houston and after a month I found him the job he wanted. But when I called him to tell him the good news, he asked me to wait one more week, because something new had come up. When he realized how angry I was with him, he reassured me that should this "new thing" come to fruition, I would be very happy.
A week later, my secretary came into my office to inform me that somebody on the phone was trying to kid me: "He says he is calling from the White House." I took the phone. It was Burt's voice. "Have you heard the news?" he asked. "What news?" I responded. "I am in the White House" he said. "What could you possibly be doing there?" I responded. "President Bush has asked me to be his personal physician." "Has he lost his mind?" I said. Burt was nobody else but Dr. Burton Lee, who was to become the man closest to President Bush.
That telephone conversation was the beginning of a new phase and a new direction in my life. He asked me to serve on one of the committees he chaired. In three weeks, I was at the White House shaking hands with the most powerful people in the world. When I went back to Houston, I told my wife, that indeed, it had taken a big shock, the White House, to lift me out of my depression. This new era of medical politics was certainly very educational to me. All my life, I had been focused on cancer. This was a new challenge. America's focus was now on health care for all, and the rights of the American people to receive the best possible healthcare. During this period I learned how interrelated and how deep is the relationship between politics and health, and what a myth is the division between the professional and the politician. I became convinced that professionals should become involved in the political process and it is naive to think that politics is the responsibility of politicians alone.
With my new experience in healthcare and government in America, I became a marketable item and in 1991, I was offered the directorship of the cancer program at St. Luke's Episcopal Hospital, where I am today. I did not hesitate to accept the job. This was a new challenge. But this time, I had recovered at least partially from the trauma of Lebanon. I was totally immersed in cancer research and in healthcare. Now I had an offer to be in the driver's seat and take the steering wheel. Here was the challenge of discovering new drugs in cancer, the challenge of genetic restructuring, and the potential of gene treatment. Here was the challenge of understanding the immune system, and how we could potentially manipulate it to conquer cancer and other diseases. Here, the new challenge of understanding the new epidemic, the new plague, AIDS, and how it eventually produces cancer, the challenge of eventually conquering both diseases, salvaging millions of lives and alleviating enormous human suffering and pain. These, I thought, are the real battles. This is real war, man against disease, rather than man against man. By now, the boundaries of my vision were no more Lebanon and the Middle East. The boundaries had widened to encompass the whole world and all mankind.
At this stage in a long journey riddled with frustrations and disappointments, I feel I am the luckiest man on earth. I have been fortunate to have been in front trenches fighting disease, helping people, serving the sick. The question, though, you may ask is "what is in this journey for you?" "What message may we take home tonight?" My message is simple. You cannot attain joy without pain, you cannot make progress without failure, and you cannot go forward without having a few backs.
It has been a long and a bumpy road on which joy was mixed with pain, yet at every point the pain overwhelmed the joy. At no time, however, did I feel I was pursuing the wrong direction, and at all times I was at peace with myself. My greatest joy come in curing patients, in turning them from being threatened by death to being welcomed by life, in salvaging them from the claws of despair to the joy of hope.
Many people have spoken of the joy of giving and the different forms of giving. Giving is certainly beautiful in every way, but it is most beautiful when you give what is most precious in life, and that is life itself. I shall never forget how a 13-year old Lebanese girl came to see me with cancer after her family was told by a prestigious cancer center in America that her disease would kill her. Her father slept under her bed, as she was his only child, to make sure that she kept breathing all night. He told me that one day, should she die, he would rather die, too, because his life without her would be hell. How can I possibly describe to you the joy of seeing her now at the age of 32, a graduate of the most prestigious London schools in engineering, and married to a man from this city.
How can I describe my joy when I'm reunited in Houston with a friend of mine, of my age, and from my village, in Houston, 8000 miles away from home, 35 years later? She, a patient with advanced ovarian cancer, and I, a cancer specialist in an American hospital? She came to tell me that should she die any way, she wishes to die at my hands. Now, five years later, she is alive, free of disease and enjoying a normal life. Whenever I experience a moment of despair, I always remember the words of the Koran, "The one who cures one human, cures all humanity."
There has also been rewards in treating patients who were never cured, because in every patient, no matter how advanced and how severe the disease is, you can help alleviate suffering, decrease pain, and instill hope. At no point in time have I kept silent in the face of dying; I always have a word to say, a ray of hope to instill. And believe me, to the sick, money, power, prestige, and glamour lose all significance. They are totally replaced by compassion, caring, loving, and sharing.
My pain, my greatest pain, was in losing patients, in seeing people I loved and cared for dwindle and die. Thirty years of battling cancer, and yet my skin remains thin. Every time a patient died, a part of me died with him. And it wasn't painful only when an individual patient was lost; it was even more painful when I also lost his whole family. To appreciate physicians when they succeed is natural and instinctive, but it takes a depth of sophistication, education, and civilization for people to appreciate physicians when they fail.
Pain is not confined to losing patients, it is also experienced in seeing them suffer and agonize. Love has a big price. It does not entail only giving, but also sharing pain with others and absorbing that pain. Love is like an immense lake to which all the rivers eventually run to tranquility and peace. To provide love, you need to spend time, a lot of time. It takes little time to treat diseases, but it takes a lot of time to treat people.
This is where modern Western medicine has failed. It has yet to realize that medicine is not the science of curing disease, but it is also the art of treating people. Modern medicine has failed to recognize that physicians never treat diseases; they always treat people who have diseases. In spite of the advancements in technology and in science, medicine will certainly fail, should physicians lose compassion, caring, and the ability of loving. If I could pinpoint one major problem with the West, it is this: the failure of the West to see in man what is invisible. Somehow, we have become entangled with the mania of quantitating and measuring things. Anything that cannot be measured and quantified and logged in the computer does not exist and should be ignored. Let me say that one conclusion I've reached in my long journey is my strong belief that what is most important in man defies quantification and defies measurement. It also defies computers and technology. The greatest component of man is the immeasurable one. How could you possibly measure goodness, compassion, loving, caring, giving? How could you possibly measure fear, agony, pain, frustration? To understand man, we need to dismantle ourselves from the mania of quantification.
There was great joy in research, and in the discovery of new knowledge. A greater joy is translating this new knowledge to better treatment of human diseases and reducing human suffering and pain. The excitement in research has been central to my personal life. It was a boundless joy when in the early 70's, we and other colleagues discovered how repeated and chronic infection in the small intestine may eventually lead to cancer, and how this cancer could start as a relatively benign process before it became malignant; and also, how we were able to reverse the benign phase of that process with simple antibiotics before it had the chance to become malignant. These simple concepts, ridiculed in the early 70's, are now the cornerstones of chemoprevention (the new art of reversing the malignant process), a new discipline in modern cancer research. Also, these concepts are essential for the understanding of the relationship between infection and cancer, and the process by which cancer may evolve from a totally benign process to eventually a process which overwhelms the body.
What a joy it was when we succeeded in modifying and taming an extremely toxic drug like Cisplatinum. This was a drug which was considered of little use because of its injury to the kidneys. After several years of research, we succeeded in making it far less toxic and more useful. Millions of people all over the world benefit from treatment by this drug as a result of our research. Let me now hasten to emphasize that in research, you never do anything alone. You are always part of a team. I never did anything significant alone. I was always part of a team. The credit for everything I have done should never be given to me, it should always be given to the team. Great things in life could not be accomplished without teamwork. This is as true in medicine as it is in science and politics. People who have never learned how to work in a team will forever be left behind in the progress of civilization because very little can achieved by individuals who can not work within a team.
At last, let me capture the moment to thank all those I worked with and worked under. In particular, I would like to extend my very special thanks to my students, who were always the source of my joy and the source of my optimism. Also, let me reiterate to all young researchers all over the world, that research is not a story about success. It is primarily a story about failure. It is a story about failing most of the time and succeeding sometimes. It is the story of accepting failure in order to achieve success. In the beginning of my professional career, failure in research was very traumatic and was very personal to me. Now, after thirty years, I have realized that failure is a necessary component of success. You cannot succeed if you are not ready to fail. Those who fear failure can never make progress. People must accept failure as a given for going forward. Failure should be considered an opportunity to refuel, to reassess, to gain momentum, and to go onward again. It should never be an excuse to go backward. To my great surprise, I have also learned that failure is extremely useful, it teaches you humility, a virtue which is necessary for making progress, a virtue which is necessary for making you a great student of science.
Ladies and gentlemen, this was my story, my adventure with cancer: a story of joy mixed with pain. But how about your story, your concerns, your worries? One of your concerns, of course, is your health. You may all know that health is a great gift - a gift from heaven. However, you may not know that staying healthy is a great challenge and this challenge is your responsibility. To remain healthy is not merely a question of destiny and genetics but it is also a question of responsibility and commitment. I cannot understand why one would work hard to succeed but work less hard to remain healthy. What does success mean if you lose health? The reason most people do not appreciate the responsibility to preserve health is because health education is, at best, poor.
Here is the most sacred and most important basic human right: the right to life; the right to health, the right to remain healthy and the right to be treated properly, should you become sick. The authors of the U.N. Declaration of Human Rights ignored this right. This is where citizens fail: in demanding from their government their basic right and their most important, the right to health. It is the responsibility of the government to provide all of what it takes for prevention of disease, all what it takes for making proper diagnosis of disease, and all measures to ensure that all citizens receive the best treatment when they become sick. In my opinion, this responsibility is the prime responsibility of government. There is nothing more sacred and more important for the government to provide to its citizens, than the dignity of health. The right to remain healthy entails promotion of public health education programs. It entails introducing health education into schools; incorporating health as a major function of government and making the media engaged in educating the public about health . The right of the sick to receive the best treatment is not only the responsibility of physicians, but it is also the responsibility of community and government. I'm sure you are aware of the debate in the West in regard to the access to medical care, the right to be treated when you are sick. Nobody argues with this right; it is a sacred right, which is almost totally ignored, is the quality of care you receive once you have access to care? People fail to appreciate that access without quality means very little. What we are witnessing now is the slaughter of quality at the expense of access. This has happened because governments do not understand what healthcare is. In every profession, quality is the borderline between mediocrity and excellence, between good and bad. But in medicine, quality is the borderline between life and death. It is tragic and ever ironic to see how in spite of advancement in knowledge and technology, the quality of medical care in Europe and in America is deteriorating, and unless we make some serious and painful decisions, this deterioration will result in disaster. The major victim of this deterioration in quality is the patient himself. It is you and I. It is all of us.
This is about health. And I agree with you that health alone is not enough to make one happy. Health alone is not enough to erase your sorrows and your pain. How about your dreams and your daily struggle to reach somewhere? Don't we all want to climb the mountain? Don't we all want to go upstairs and reach the peak? And what is the peak? I must tell you, with all honesty that unfortunately, many people pay very expensively to climb these stairs. They sell parts of themselves, part of their integrity in their march upwards. Every step they climb, they sell a part of themselves. When they reach the peak, they discover that they have already sold everything they had, that they have lost their integrity and their self-respect. And now, they can't neither enjoy the peak nor maintain it. To enjoy the peak, you have to be the master of your destiny, and to be the master of your destiny, you have to grasp your reality, you have to have integrity, you have to be your own real self. Those who sell themselves cheaply have nothing to be proud of at the end of their journey. Also, let me tell you, that the mountain and the peak exist only in your imagination. They do not exist in reality. The road to happiness is not upwards; it is inwards. Happiness is a journey that does not end up at some peak, some mountain; it is a journey that does end within yourself. It is a journey that will end with peace, satisfaction, and pride within your soul. The peak is not outside; it is certainly inside.
One of the secrets I have learned about achieving the peak is to understand what joy is about, and to appreciate that the greatest joy is derived from giving, not from taking. One of the major problems in the West now is that children grow up in a cultural climate where giving is irrelevant. The young are being told every day how to make it, how to acquire wealth, how to gain power, how to make money. The question many people ask every day is, "what is in it for me?" The most popular formula now in America is that "I love you because I need you." Those who have the courage and vision to reverse the formula to "I need you because I love you," are ridiculed and are considered naive. It is my conviction that the philosophy of considering yourself the center of the universe, believing that you have the right to exploit everything and everybody to your personal benefit, does not lead to happiness and joy. What leads to happiness and joy is to give, and to give generously. To give not only of your money and your time and your power, but also of yourself. To give is to share joy and pain, to be part of all, and in particular, a part of the weak and underprivileged. Kahlil Gibran, the Lebanese poet, was right when he said, "Do not say that God is in my heart, but say I'm in the heart of God." Thus I say, to be in the hearts of people, you have to have the people in your heart.
During thirty years of intense debate with a killer, I have come to believe in the oneness of all mankind, in the goodness of all people. Most importantly, however, I have come to believe in the enormous power of love. But what about the power of knowledge? I must remind you that I am a student of science and I'm also a believer in knowledge. I believe Bertrand Russell, the English philosopher and one of the most important thinkers of the 20th century, was right when he said, "Knowledge and love should be inseparable, either one alone is dangerous." This is absolutely true, but with the advancement of science and the enormous weight of knowledge, I feel that love is being crushed and is being progressively diminished. I'm worried about the potential survival of love in a world which is becoming more and more in the grasp of science and technology. This, in my opinion, will constitute the major challenge for the 21st century. My fear, my greatest fear, is that someday, one day science may crush love; the mind may crush the heart. Let us not let this day come. A world without a beating loving heart, is a world without a soul, a life without a meaning, a life not worth of living.
Ladies and gentlemen, with all my heart, I thank you again, and may God bless you all, put light in your souls, infuse love in your hearts.
I'm delighted to be with you tonight and to share with you this beautiful evening. Also, I feel privileged to be asked to speak to you and I'm very thankful to the organizing committee and to Mr. Ayoub for inviting me.
Today, I'm going to focus on my experience as a physician, and more specifically, as a cancer physician, and how this experience has helped me shape a new vision and a new philosophy towards life. This philosophy is not based on the abstract, it is based on the harsh realities of life; it is based on a real and intense personal experience with disease, pain, suffering, agony, dying, and death.
I was born on July 13, 1941 in a small village called, Bterram, of El Koura District of North Lebanon. My horoscope is cancer. In that very same year, Memorial-Sloan Kettering Cancer Center, where I was to go later in life and study, was also established. I received my elementary education at the Elementary School in Bterram. Thereafter, I studied at the Bishmizeen High School and in Tripoli. At the age of 16, I joined the American University of Beirut and I graduated from its medical school in June, 1965. Before I entered medical school, I majored in Philosophy. I did not study medicine because I thought it was a good, prestigious, and glamorous job. I went to medical school with the objective of helping the sick, and with the deep conviction that medicine is not a job, but a noble mission. The early 60's were the days of ideology and idealism in Lebanon. At that time, I was a young, idealistic and a pure student. After graduating from medical school, I did three years of training in internal medicine. At the same time, I was studying philosophy at the American University of Beirut, and I was also teaching biology at the Lebanese University. I decided to study cancer in 1966. That decision was based on a painful personal experience with a friend who died of cancer. At the same time, I felt that in those days, cancer was treated only by ignoring it. People who developed cancer then, were left to suffer with pain and die with indignity. In June, 1968, I arrived in New York to study at the Memorial-Sloan Kettering Cancer Center. I was convinced that within the coming forty years, cancer would be conquered. I was wrong. At that time, Memorial-Sloan Kettering was the Mecca of cancer therapy. And thus, I was privileged to treat many famous, rich, and powerful people. It was there where I discovered that being famous and rich does not mean being happy. After spending two years at Memorial, I went South for a third year of training at the M.D. Anderson Cancer Center in Houston, Texas, which eventually, has become my professional home in America. In 1971, I returned to Beirut with the objective of establishing the best cancer treatment and research center for the Middle East. When this was done, war erupted in Beirut. In the early days of the war in Beirut, nobody ever dreamt that this war would last sixteen full years; but it did, and I lived in Beirut through the war. Thus, it was my destiny to witness the cruelty of nature via a disease like cancer for forty years; and also to witness the cruelty of man via a war in Lebanon for sixteen years. I left my beloved City, Beirut, for the last time in 1985 and I was forced to come to America in January of 1987, where I joined M.D. Anderson Cancer Center. Since 1991, I have been in charge of the cancer research program at St. Luke's Episcopal Hospital in Houston, Texas. I'm here tonight to tell you of the lessons I have learned from this experience; with disease and with war.
Lesson #1: Life is a privilege, not a given. Life begins with an accident of biology. We are here by accident and not by design. Being here is a privilege that was given to us, and not a privilege that we have earned. We are also here for a specific period of time and eventually, we wither and die. The challenge is to make maximum use of this privilege. Enjoy life, carve some depth and some meaningfulness into it, carve a path and a mission worthy of you, think about the wonders of life and the universe, and the millions of questions that remain without answers as to the origin, direction, and fate of the universe. We are tiny little things in this unlimited and infinite universe, yet, each one of us is an infinite universe by himself/herself. Whatever direction you take; whether it is space or biology, the line will be infinite. Joy, in my opinion, is the essence of life. To achieve joy, you have to achieve peace with the world and peace with yourself. My advice here, is to enjoy every day of your life. To do that vertically and in depth, and not horizontally and superficially. Your joy should be part of the joy of the world and part of a noble mission.
Lesson #2: Health is the greatest gift. Although health is determined to a large extent, by genetic factors, the greatest wealth that you may achieve is to maintain that health. It is true that the inheritance of your genes was not done by your choice, but it is also true tht it's your choice and your responsibility to maintain your health. Many diseases are preventable, and if not, are treatable. The most important basic right to man, is the right to medical care, because this right is the first step towards good health. Without health, there is very little that could be achieved in life. Health is the major cornerstone for living, and living well, and with meaning. Most people understand their rights to freedom, liberty, education, and other basic needs, but very few people appreciate their rights to health. The keys to health include the following:
- Public health education. You do not realize your basic rights in health, because you are not educated about health. It's only when people get educated about these rights, that they become aware of their significance. Health education is a major key to health. It is time to incorporate health education in our school and college curricula. It is no longer permissible for a woman to graduate from college without knowing some basic information about cancer of the breast. The difference between knowing this information and not knowing it, is the difference between life and death.
- The second key is the availability of good medicine. When you are sick, you do not need only medicine, you need good medicine. Quality is the key in medicine, without it, there is no medicine. When you need a doctor, go to the best. After being in medicine for forty-six years, I can honestly tell you that when I'm sick, I'd rather see a physician who is knowledgeable and would charge me $1,000., rather than a physician who is not knowledgeable and who would not charge me at all. One great lesson that I have learned from my experience with medicine, is that I would rather pay with dollars, rather than with blood and life. America is now embarking on an adventure in medical care, that will eventually lead nowhere, but to a scandal. You must have heard a great deal in the last three years of cost-effectiveness; cutting costs, accessibility to medical care and managed care. All this will eventually lead to a major victim, quality. Without it, American medicine will plunge to levels unimaginable and undesirable.
- Medicine and politics are intertwined. Without moral and courageous politicians, it will be difficult to institute the real health policies we need. The 21st Century is on our doors and yet, even in America, people are allowed to buy severely toxic and addictive substances like tobacco. Politicians know that every year, tobacco kills three million people all over the world. It is the influence of industry, money, and lack of courage that make them unwilling to take radical moves to stop this crime against humanity. Politicians know that dumping nuclear and chemical waste on the shores of the Mediterranean, the Pacific, and other shores of the developing world, will eventually lead to hundreds of diseases in these areas. They do so for financial reasons, without the slightest respect for the moral implications involved. It is Khalil Gibran, the Lebanese poet and author who said, "If you kill one person, you are a criminal; if you kill a nation, you are a hero." One would add now, if you kill many nations, you are a super hero. In regard to health, my advice is, if you are healthy, try to maintain it; if you are not, seek the best medicine.
Lesson #3: Disease, not man, is the major enemy of man. There is no enemy that belittles man like disease. There is no enemy that humiliates man like disease. In the last twenty Centuries of recorded history, man has waged war against man. Shall we dream that man in the 21st Century will at least start to transcend this level of vision to a higher one where all mankind will unite against a major enemy called disease? The real enemies to man at the moment are: AIDS, cancer, heart disease, and infectious diseases. Man may not be convinced that disease is his major enemy until, (and hopefully, we will never witness that), a global outbreak of infectious disease occurs. I have little doubt that twenty Centuries from today, man would look at us as primitive people who believed in nationalism, primitive people divided by boundaries of geography and political ideologies. It is only a pity that man continues to devise technology and science in order to kill man. All over the world, nations invest in technology and ideology to fight other men, rather than in major programs for healthcare and education. I would only hope that eventually, man would mature enough to realize that man is his brother, not his enemy, and that the real enemy is disease.
Lesson #4: Love, not power is the greatest force in the world. Although I deal with the body, with the concrete, with the visible, my experience with diseease has led me to believe that it is love and not power which is the greatest force in the world. Without love, there is little meaning and there is little joy. It is indeed love that makes life worth living. It is unfortunate that in America love has been reduced to its pure physical component. This is indeed a tragedy. The breakdown of love is responsible for the breakdown of the family and the breakdown of friendships, and the breakdown of moral values in America. It is this fierce philosophy of materialism in America that I'm afraid will eventually lead to the collapse of American civilization. America can win the whole world by technology, science, and war, but it will lose the major war, if it does not win the battle inside America. Children are being taught every day, that the index of success is material wealth; at any cost. Values and moral directives are being eroded for the sake of accumulating more wealth. To love your parent, to love your grandparent, to love your brother, to love your friends, to love people is a basic need. The major motto of America now is "I love you because I need you". We need to make a major effort to reverse this motto for another motto which says, "I need you because I love you". Without love, there is no joy and without joy, there is not much sense in being and in living.
One of the greatest joys is giving. The major emphasis in America today is on taking, and not giving. It is the joy of taking; it is the joy of promoting the self. Everything is now centered on the self. What is in it for me is the motto. It is time to teach our children and to teach in schools, the art of giving, the art of selflessness. It is only when you extend yourself to your friends and to others, that you experience real joy. I was personally privileged to experience the joy of giving the best that you could ever give, and that is life. There is no joy which is superior to giving life. That should be the reward of the physician.
Lesson #5: The triangle of glamour, money, and power is poison. I have been privileged to see during my professional career, a large number of people who have been plagued with this triangle. And I have seen how sad and miserable they are. Most people work very hard to achieve this triangle, and once achieved, they realize that it is a mirage. Power, money, and glamour are wild horses, if you do not know how to reign them in, you will eventually fall off their backs. It takes character to reign in these wild horses. Power is poisonous and corruptive, unless you are really powerful from the inside and you realize that it should be used for the service of others. Money is dizzying, unless it is used to help people. Glamour is toxic to the brain, unless accepted with humor and humility. It is only when you get close to death, you realize what life is about, and the depth of the meaning of being alive. It is only when you get close to death, you see and you see very clearly, that power, money, and glamour are at the periphery rather than the core of being.
Lesson #6: Courage is the fuel of life. What I have learned from my patients is courage. It takes a lot of courage to fight disease and despair. In cancer, where treatment is intense, prolonged and sometimes, physically and emotionally mutilating; only those who had courage to go through a difficult journey achieved cure. This is also true of life; only those who have courage to face life and its cruelties will eventually make it. When you see cancer patients struggling with pain and agony; and suffering with dignity and courage, how dare you not have the courage to say the truth; how dare you not have the courage to live by your beliefs; how dare you not have the courage to stand up and refuse to accept what is unacceptable; how dare you not have courage and be yourself?
Lesson #7: Perseverance is the key to success. No cancer patient would have made it to cure without perseverance. And no cancer researcher would have achieved a breakthrough without perseverance. Those who give in easily, fall off in the beginning of the journey. Only those who work hard and persevere reach the end of the line. To my mind, the three essentials for success are: hard work, perseverance, and courage. Genius comes second to these three essentials. In my daily work and fight against disease and death, it always takes perseverance on my side and perseverance on the side of the patient, to achieve cure. Patients who give up, die. Physicians who cannot endure, fall. The key test to determination is perseverance.
Lesson #8: Arrogance is sickness, humility is power. I have learned humility from my experience with cancer research. Research taught me how little I know; and how infinite is that, that I do not know. I have also learned how important it is to change my mind. Those who are arrogant and who think that they know almost everything will never make progress and will never achieve anything. The truth needs humility; progress needs the ability to change your mind constantly and adjust to new realities. I want to dare to tell you tonight that the major objective of science and research is really not to discover the truth and new realities, as much as it is to train the mind and make it malleable and innovative. The objective of science is to eradicate arrogance, since arrogance is a disease which plagues the human spirit and human mind. I was most arrogant when I was a chief resident of medicine in 1968 in Beirut. As I matured in research, the arrogance in me has decreased steadily. The more I have learned about cancer and disease, the more I have realized how little my knowledge is, and how vast the unknown remains. The deeper you plunge into research, the greater becomes your wonder about the world, the universe and the creation. Whether you study the cell or the universe, both are immense and limitless. How can you not be humble when you realize how little you are in this boundless universe? How can you not be humble when you realize that the cell which is the smallest structural unit of the living is also boundless, immense, and limitless.
Lesson #9: Do not sell yourself for success. Most people look at success and progress as a ladder that they have to climb, and unfortunately, every step they climb, some sell parts of themselves to others to make the step. By the time they arrive at the top, they have already sold everything they had, and whatever they had achieved of material wealth, power, fame, and image, will be totally meaningless and empty. If I have a message for you tonight, it is to beg you not to ever lose yourself. Climbing the stairs should not be made at the expense of selling yourself. The greatest mistake you could ever make is to lose yourself for the sake of accumulating wealth or brightening your image. Neither wealth nor image would have meaning without "yourself". At the end of the day you go back home and you will be alone; And if you had sold yourself, you would be a terribly lonely and miserable person.
Lesson #10: The ladder of progress is only a mirage. If I have learned anything from my experience and journey, it is that this imaginary ladder of progress is nothing but a mirage. The journey that you have to make in life is not upwards; it is inwards. It is not a journey to achieve something outside you, it is a journey to achieve something inside you. It is a journey to recapture yourself. The ultimate objective of life is to be at peace with yourself; to be respectful of yourself; to be proud of yourself and to be in joy with the world. If you do not realize that, at the end of the fight, at the end of the journey, and at the end of the day, you will regret it tremendously.
Ladies and gentlemen.....I would like to apologize to you for this sermon, but I thought you might be interested in knowing what a man who has been at war with disease, cancer, and death for forty years, has to say. I thought you might be interested in seeing the other side of the coin. You always have the opportunity to hear the healthy, the successful, and the powerful speak. But I come here to you to speak out of pain and out of my experience with disease. I'm somebody who has seen the other side of life. I thank God for showing me the light, for curing me from the common diseases of man: greed, power, money, and glamour; and above all, for giving me the strength to serve the weak, the sick, and the dying.
I must tell you that my journey with disease has been very enriching. It made me closer to my elements. It has taught me that the greatest joy is in giving; It has taught me that the greatest power is in serving. May God give you the power to see, the courage to believe, and the gift of living the life which is worthy of your living.
Forty Years of Experience with Cancer
What Have I Learned?
- The joy of being.
- The importance of health.
- Love as the greatest force.
- Courage to face disease.
- Perseverance as the key to success.
- Research teaches you that you know so little; teaches you humility.
- Disease is a major enemy of man.
- Lack of public health education.
- The myth of money, fame, power triangle.
- The joy of giving, rather than the joy of taking.
- The need for love rather than love for need.
- When you struggle to go upstairs, do not lose yourself. The stairs are a mirage. Do not feel criticism. Don't let praise go to your head. Do not let success corrupt you.
- Don't take life or health for granted; Enjoy every minute.
What are the latest developments, the latest research as far as cancer is concerned, and what are the latest treatment methods?
While progress is steadily being made, it is certainly not fast enough. I wish we could have a drug tomorrow that would cure all cancers. However, I do not believe this will happen in the foreseeable future. Progress so far has been gradual, but is definitely going in the right direction. It is important to emphasize that right now, we are able to cure 40%-50% of all cancer patients if these patients are given the proper treatment. The tragedy is that more than 90% of cancer patients all over the world do not receive appropriate treatment, and this is why the results of the treatment of cancer have not been very impressive. The key to the proper treatment of cancer is to provide patients with access to cancer experts who work in institutions or programs where group consultations and teamwork are feasible. Cancer cannot be treated by one single doctor; it needs a team of doctors who work together as one single entity, in harmony, to provide the best care. Also, you need the supportive measures. This means that you have to have a very high-level pathology service to provide the right diagnosis. You also need to have a very sophisticated diagnostic radiology facility where patients can undergo the most modern imaging technology. This simply means that it is not enough to have a great doctor; you have to have a great system, a great network of cancer experts and network of supportive systems for diagnosis and treatment. This scientific climate is available only in a few centers in the world.
How close is the link between cancer and infection, and which infections can cause cancer? Which types of cancer are caused by infections?
By now, there is little doubt that some chronic infections may cause cancer. H.Pylori in the stomach is associated with higher incidence of stomach cancer, including lymphomas and adenocarcinoma. There is little doubt that schistosomiasis infection in the bladder causes bladder cancer. This is why bladder cancer is the most common cancer in Egypt. Also, there is a strong suspicion that Hepatitis (infection of the liver) would eventually cause cancer of the liver.
What about cancer vaccines. When will the first cancer vaccine be on the market according to you? Can you give a date, like in 10-20 years?
I cannot give a specific date, but vaccine therapy remains in the experimental phase. At this point in time, there is no vaccine which is used in the actual treatment for cancer. There are different experimental protocols evaluating vaccines, but at this point in time, they do not have vaccines available for the treatment of cancer. I would expect that vaccines would be more important in the prevention of cancer rather than its treatment.
Gene therapy and stem cell transplantation seem to be very promising. Do you think that treating cancer will be much more easier in the future, when these methods are developed?
I have no doubt that treating cancer in the future will be much easier and the results will continue to improve. Stem cell transplantation has a very promising role in the treatment of cancer, so does gene therapy. At this point in time, bone marrow transplantation has been shown to be very effective in the treatment of leukemias and some lymphomas. Gene therapy, however, remains in the experimental phase.
Why is there an increase in cancer cases? What are the major reasons for cancer?
The most important cause for cancer is tobacco smoking. Smoking kills four million people every year all over the world. There is no war in the history of man that has killed as many people. There are of course, many other reasons like exposure to asbestos, extensive exposure to sunlight and exposure to radiation.
How do you see the future as far as cancer is concerned?
I believe the future is very promising, but progress in cancer will continue to be step-wise. The speed of progress is going to be log rhythmic, and research is going extremely fast. Within ten years, I am almost certain that most cancer diseases will be treatable and many of them will be like any other chronic illness like diabetes and hypertension.
What are the most important factors that determine the cure of a patient?
Cure depends on three major factors:
- The nature of the cancer
- How advanced is the cancer in the body
- Whether the treatment of the cancer was appropriate or not
In your opinion, what is the cornerstone of excellence in cancer care?
The basic cornerstone is scientific knowledge. Without updated state of the art scientific knowledge, you cannot build a treatment program. However, because of the recent explosion in scientific knowledge relating to the treatment of cancer, it has become of utmost importance that doctors who treat cancer seek group consultations because there is not one single expert in cancer who knows everything about the disease. Therefore, treatment has to be designed by a group of cancer experts rather than by one single expert. Although I graduated from the two most prestigious cancer centers in America (Sloan-Kettering Cancer Center and M.D. Anderson Cancer Center), and I was on the faculty of M.D. Anderson as a professor of cancer treatment and research until 1991, and I have been in academic medicine and research for 36 years, I still feel that I cannot make the final treatment plan on a patient without a group consultation. Group consultation provides the cornerstone for guaranteeing the fact that the patient is receiving state of the art treatment.
In spite of this progress in cancer research and cancer treatment, I have heard you say many times that cancer medicine in America is in a crisis. Why is that?
I have told you that scientific knowledge is the cornerstone of treatment in cancer and in any disease. However, scientific knowledge, though necessary by itself is not sufficient. In cancer, the patient needs far more than scientific knowledge concerning the treatment of the disease. I believe that when we treat cancer, we need to remember that we are not treating the disease in vacuum; we are treating a human being who has the disease. These two philosophies are very different and demand different strategies. I believe in the latter. However, the latter demands a lot of time, a lot of care, and a lot of giving from oneself. In addition to scientific knowledge, what the cancer patients mostly need is love and care. They need to be treated by a doctor and medical staff who love them and come to know them very well as an individual, and who want to give them the best care in the world. It is not enough to give the scientific knowledge; because without love and care, the patient will not receive the absolute appropriate care.
People at large do not appreciate the big difference between giving a good treatment and good care. Good care means far more than giving good treatment. It means that you attend to the patient as a person; you attend to his fears, his concerns, to his images of death, dying and pain. You attend to the most divine and sacred essence of the person. This is why I have always believed that the relationship between the cancer doctor and his patient should almost be divine. There is no relationship among human beings which is more divine than the relationship between two persons, one threatened by death and the doctor struggling to salvage him from death. Love is a very important component of the patient's care.
Is there anything else that good care entails?
Of course, a lot of other things:
- The patient needs to be monitored almost daily. These patients are fragile and they need to be examined and seen almost daily, to make sure they do not develop fatal complications like bleeding and/or a very low blood count that predisposes them to infection and possible death. Also, chemotherapy may produce major side effects. If these side effects are not addressed in a preventive and prophylactic manner on a daily basis, major health problems and complications may occur You simply cannot put a patient on chemotherapy and ask him/her to come and see you once a week. Good care demands more than that.
- Good care also demands continuity of care. Therefore, patients need to be seen on Saturdays, Sundays and holidays. Disease does not take a vacation and you cannot be in charge of patients if you do not provide them with daily care. At Salem Oncology Centre, we are open every day and we have staff that is on-call 24 hours a day, 7 days a week, 52 weeks a year. Any discontinuation of care could be disastrous. Diseases do not take weekends off and do not celebrate holidays.
- Also, one of the important issues in cancer care is that the patient receives therapy at the hands of the same doctors, nurses, and the paramedical staff every day. Cancer patients cannot afford to have different doctors every few weeks because this will certainly cause a lot of turbulence in the continuity and quality of care. It is also important that the patient receives therapy at the hands of the same nurses and staff, so if any complication occurs at night and he calls, the voice that he hears on the other side of the phone is a familiar voice who knows the patient extremely well and can immediately diagnose the problem and recommend the exact and precise treatment for it.
- The emergency outreach program. One of the major issues in cancer therapy is the fact that if the patient develops a major problem at 2:00 o'clock in the morning and somehow could not come to the emergency room at the hospital, there are very few programs which are available in America and the rest of the world where the facility would send a nurse or a doctor to the hotel or apartment where the patient is staying. I am proud to say that at our facility, should the patient call at 2:00 o'clock in the morning and there is an emergency problem, one of my staff will immediately be dispatched to where the patient is staying and will deliver the treatment at that specific location. I know of several patients who died because they were too sick to come to the emergency room at night, and the hospital had no outreach program to dispatch medical professionals to see them at their hotels or apartments.
All the above emphasize the importance of having a dedicated team of medical professionals who take care of the patient daily, without interruption and the delivery of care 24 hours a day. This component of therapy is of utmost importance. I know of patients who receive the best treatment in the world, but who eventually died because the care component of therapy was not good enough. Therefore, I reemphasize again that excellent care is far more than excellent treatment. This is where, in my opinion, in big academic American institutions, these institutions may fail to provide what I consider the best care because they do not have enough medical and health professionals to attend to the overall needs of the cancer patients.
Why, in your opinion, this kind of care not delivered?
The answer is simply because this kind of care is very time-consuming and demands a lot of medical staff, and both of these issues are very expensive.
One of the challenges to American medicine is to allocate adequate time for patients. This is a problem because insurance reimbursement policies do not consider time in their equation. In a consultation, whether you see a patient for 5 minutes or 5 hours makes little difference. Therefore, with the reimbursement climate in America, doctors are forced to see a large number of patients to make ends meet. This leaves very little time for the doctor to allocate to every single patient. Also, because of cost containment strategies in America, physicians, hospitals and medical facilities are trying to cut down on costs, and this eventually leads to inadequate staff to attend to all the needs of the patient.
An additional important factor is that doctors in America are not trained in attending to the psychological and emotional issues associated with disease. It has not been clearly understood yet, that treating a human being takes far more than treating the disease that he has. The doctor has to be very sophisticated in the art of communication with the patient and should allocate a lot of time to lift the patient's spirits and educate him about his disease. We always have to tell the patient and family the truth, but there is delicate balance between telling the truth and maintaining good morals and spirits in the patient. In my opinion, at no point in time should the patient be stripped of hope. I believe there is always hope. I have treated many patients where I felt that the cure rate was zero percent and I have seen these patients ten years later. We should never forget that when we talk about the future, we are building our arguments and assertions on research done in the past, and sometimes we forget that new drugs may emerge as the patient lives on. I can easily say that in my lifetime, I have seen more than 100 patients where, when I started therapy, the chance for cure was zero and eventually new drugs emerged and the patient was lucky to live long enough to receive these agents and achieve cure. This is why I emphasize that the patient should never be stripped of hope.
Dr. Salem, I know you are of Lebanese origin. How do you feel being of Lebanese origin and being a very important doctor in America? You are in the last three editions of the America's Top Doctors.
I believe being of Lebanese origin has been a great advantage for me. Being from the Mediterranean world, I brought with me several weapons that I used daily. I brought with me the human warmth, the compassion, the ability to embrace the patient as a family member and the ability to give him of myself and of my time. Although I believe these traits are present all over the world, they are of special importance in the Mediterranean culture where I come from. Also, being of Mediterranean origin, I understand the world outside America much better. I know Europe extremely well and I understand the European mind. Also, I understand the Latin mind. Coming from the Mediterranean world has been a great advantage in practicing medicine in America because when you practice medicine, you have also to understand the culture of the patient you are treating. Dealing with the sick takes far more than science and knowledge. You have to understand his mind, his philosophy, his mythology, and his culture.
Also, as you well know, diseases and patterns of diseases change from one geographical area to the other. Being, of course, from the Mediterranean world, I understand more Mediterranean diseases. Take, for example, one cancer like lymphoma. This cancer has a very different pattern in the Mediterranean than the pattern in America. I devoted a good part of my life to researching a specific kind of lymphoma that afflicts the small intestine and exists only in the Middle East and the Mediterranean shores. Also, for example, lymphoma in bone is common in the Mediterranean world, but is extremely uncommon in the West. So being of Mediterranean origin is a great advantage for me to treat, here in America, people who come from the Mediterranean countries.
Dr. Salem, can you single out one achievement you have made at Salem Oncology Centre?
Probably, the most single achievement I have made here at Salem Oncology Centre is the fact that we have succeeded (my staff and I), in providing a facility which is the closest possible to home for the patient. Patients love to come to our facility daily because they love the nurses who take care of them and they feel very much at home here. Above all, they feel they are loved and cared for. We not only care for their medical needs, but we also care for other needs, including the family's needs. Patients from all over the world, Christians, Muslims, Jews, Buddhists, and Atheists come to this facility and get bonded by love. I am a great believer in the universality of man because I have seen patients who come from Argentina who are not any different, in essence, from those who come from Turkey and those who come from Turkey are not different from those who come from Mexico. All humans want to be loved, want to feel secure and they do not want to die.