The eternal triangle of a sound health system

A misfiled application steered Bill Kissick away from his dream job and into the world of health policy.

The ongoing drama of Bill Kissick’s life involves a triangle, not of romance, but of health policy. The three sides of Kissick’s triangle are access, quality and cost containment. “I can deliver any one of these three by compromising one or both of the other two,” said Kissick.

William L. Kissick, M.D. ’57, M.P.H. ’59, Dr.Ph. ’61, has been puzzling over his triangle’s three sides since he began his professional life in Washington, in 1961. He was planning to start his dream job at the National Institutes of Health (NIH), assisting in the lab of future Nobel laureate Baruch S. Blumberg, M.D. Thanks to a misfiled application, the young physician ended up not at the NIH, but at the office of the Surgeon General, where he was assigned to work on a health insurance plan for elderly Americans. With a further nudge from what he calls “The Princes of Serendip,” Kissick became one of the authors of Medicare. In the 18 months that he worked on the program, Kissick got a crash course in the art of the possible from Wilbur J. Cohen, then assistant secretary of health, education and welfare.

By the time Kissick arrived in Washington, Cohen had survived almost three decades in government in administrations of various political persuasions, beginning with President Franklin Delano Roosevelt. Cohen, one of the architects of the New Deal, had proposed that it include national pensions and health insurance. The pensions came to pass when Roosevelt signed Social Security into law in 1935. “FDR dropped the health care idea, but Wilbur didn’t,” Kissick said. Thirty years later, after President Lyndon Johnson signed Medicare legislation, Cohen told the young physician, “If you choose to continue working in health policy, you must learn to appreciate delayed gratification.”

His old mentor, were he alive, would be angered by the recent changes in Medicare, particularly the privatization of the program, said Kissick. He brands the new legislation entirely “political” and attributes it to the lobbying strength of the pharmaceutical and insurance industries. For example, under the new legislation, Medicare will no longer use its enormous purchasing power to negotiate prescription drug prices. The lost savings further compromise Medicare’s financial stability, Kissick said.

Not that Kissick—who is the George Seckel Pepper Professor Emeritus of Public Health and Preventive Medicine at the University of Pennsylvania School of Medicine, professor emeritus at the Wharton School and Penn’s School of Nursing and visiting professor emeritus of health policy and management at the Yale School of Public Health—considers the original legislation he helped write to be perfect. As Kissick sees it, the drafters made three serious mistakes. They dramatically underestimated the growth of the elderly population and the sophistication of medical technologies that would become available in ensuing years. Perhaps most importantly, they did not count on rising patient expectations.

Those expectations are discussed at length in Kissick’s Medicine’s Dilemmas: Infinite Needs Versus Finite Resources (Yale University Press, 1994), currently in revision. “No society has sufficient resources to provide all the health services its population could utilize,” Kissick explained. “We all expect the ultimate in health care.”

In the 1970s Kissick took a sabbatical in the United Kingdom, where he had an eye-opening conversation with a man who was wearing a bilateral truss. Kissick advised him to have surgery for his hernia.

“I intend to,” the Englishman answered. “I’m waiting.”

“How long have you been waiting?” Kissick asked.

“Five years.”

“That’s appalling!”

“My neighbor has been waiting for six,” the man replied.

The British system relies on citizens’ willingness to wait. “Ignore the queue and the system collapses,” said Kissick. He finds it unlikely that Americans would patiently wait years for surgery.

“Health care transcends the biomedical sciences. It’s a cultural affair,” Kissick said. In a vast and populous country like the United States, where it is difficult to define a single culture, he suggests that health care plans organized by states are more viable than a single-payer federal system.

But state-by-state health care is by no means a panacea, Kissick cautions. “The more I read, the more confused I get,” he said. But he is not giving up on the idea of a health policy that serves America well, despite his perplexing triangle. “By the time I finish the revision of my book, hopefully, I’ll have some idea,” he said. (He’s also counting on more than 150 physicians who have graduated from an M.B.A. program in health care management he and a Wharton colleague established there in 1968. “They are now challenged to address the issues,” Kissick said.)

Kissick’s model of perseverance is his wife, Priscilla, who in 1982 founded and directed the first Medicare-approved hospice program, which became part of the University of Pennsylvania Health System in 1998. The Kissicks met at a Yale tea when he was a medical student and she was at the School of Nursing. Kissick committed the social error of turning up at the refined white-glove affair run by faculty wives with several friends, all dressed in khakis and laughing and joking as if they were on their way to The Game. Spotting her future husband, Priscilla Dillingham remarked to a friend, “Somebody needs to straighten that guy out.”

The Kissicks, who have three sons and a daughter, recently celebrated their 48th wedding anniversary. According to Kissick, “She still hasn’t given up trying to straighten me out.”

—Colleen Shaddox

Familiar Faces

Hunting the secrets of the cell in San Francisco, and game fish across the globe

John D. Baxter, M.D. ’66, HS ’68, has an imposing presence. At 64, he is a tall, strongly built man with shaggy hair, an affable Kentucky drawl and a passion for the specialized hunt. As often as he can, he packs his gear and heads for Alaska, the Seychelles or the South Pacific to go fishing. He goes after marlin, tarpon, bonefish, trout, salmon and sailfish, and if you want to see him beam, ask him about the five world records he holds. But Baxter doesn’t go out with powerhouse rods and tackle; that would be too easy. No, he goes after the biggest fish in the sea with only a fly rod and delicate test line, tools requiring an artist’s touch.

“I love Alaska,” Baxter says, kicking back in his office at the University of California, San Francisco (UCSF), campus. “And I’m very passionate about my fishing.”

For the past three decades, Baxter has also passionately devoted himself to another specialized hunt: he has been trying to decipher the delicate mechanisms by which hormones, proteins and receptors interact inside our cells. Here, too, he has bagged some impressive trophies. In 1977, he, Peter H. Seeburg, Ph.D., Howard M. Goodman, Ph.D., and John Shine, Ph.D., were the first to isolate and clone the human growth gene. That led to the creation of the first synthetic drug to stimulate growth in children of short stature. It also led to drugs that increase milk production in dairy cows. Then Baxter and a UCSF research colleague, Robert J. Fletterick, Ph.D., became the first to reveal what a nuclear receptor looks like when it is binding to a hormone, a breakthrough that led to new structures in drug design. In 2003, in recognition of his pioneering research, Baxter was named to the National Academy of Sciences.

Now he believes he may be on to his biggest catch yet. Working with Thomas S. Scanlan, Ph.D., another colleague at UCSF, Baxter has developed GC-1, a new compound that is showing great promise in preventing and treating high cholesterol, heart attack and stroke. By working on multiple sites in the liver, GC-1 could prove far more effective in lowering cholesterol than the statins that most doctors prescribe today. Baxter says it also shows promise in reducing obesity and diabetes, especially the highly prevalent type 2 form.

“This compound is about 1,000 times more potent than the statins,” Baxter says. “It will not replace the statins. If it works out, it will probably be used in conjunction with the statins. It attacks a different part of the cholesterol pathway, so they’d work phenomenally well together.”

If GC-1 does fulfill its promise, it will crown for Baxter a lifelong quest. He was born and raised in Lexington, Ky., and did his undergraduate work at the University of Kentucky on an athletic scholarship, majoring in chemistry and graduating Phi Beta Kappa. When he entered Yale in 1962, it was quite a shock: “Even though I had a good education at Kentucky, I was not prepared for the Ivy League. I had a significant adjustment, adapting to the Eastern intellectual establishment. I thought my Kentucky accent was just fine, but that was not the prevailing view at Yale.”

Baxter struggled in his first two years, but then he found his legs, thanks in large measure to Philip K. Bondy, M.D., the head of endocrinology. “He was a wonderful mentor,” Baxter recalls. “By the time I graduated in 1966, Dr. Bondy was head of medicine. So I elected to stay on at Yale and do an internship and residency in internal medicine.”

Yale left a deep imprint on Baxter. “When I look back, the most wonderful thing about Yale was that it was patient. I struggled and Yale put up with me. And I’ll forever be indebted to Yale for that,” Baxter says. “And I could not have gotten better training. Once I got out and mingled with the guys who went to Harvard, Johns Hopkins, wherever, we guys who came out of Yale were quite competitive.”

After leaving Yale in 1968, Baxter joined the National Institutes of Health and began probing the inner workings of nuclear receptors. In 1970 he went west to UCSF, where his work on receptors led him into the field of human growth hormones. After he and his colleagues cloned the human growth gene, Baxter teamed with Fletterick to show how hormones bind to their thyroid receptor proteins. “That has had all kinds of implications for helping us design things that ultimately become pharmaceuticals. It has really paid off.” In 1979, Baxter was named chief of endocrinology at UCSF and director of the UCSF Metabolic Research Unit, and continues today to lead a team of researchers.

Baxter was among the first university researchers to create biotech startup companies. Not everyone approved. “At a time when interactions with industry were highly controversial in the university setting, John started biotech companies, several of which were very successful,” says Jan-Åke Gustafsson, Ph.D., M.D., professor and chair of medical nutrition at the Karolinska Institute in Stockholm. “Although he received scorn from his academic colleagues, John kept working in new directions and thereby substantially contributed to modernizing the thinking in academia.”

Bert W. O’Malley, M.D., professor and chair of molecular and cellular biology at Baylor College of Medicine in Houston, says that even greater renown for Baxter may be in the offing. “Although GC-1 is not being tested on humans yet, it looks very promising,” O’Malley says. “It could rival or exceed the importance of John’s work with human growth hormone.”

In conversation, John Baxter comes across as a man fulfilled. For the past 40 years he has been married to Lee, his Kentucky sweetheart, and the couple has two grown daughters. Clearly, though, Baxter is a man who still dreams of sailing distant seas and hooking even bigger fish, and right now those dreams are riding on the wings of GC-1. “You go to medical school to be a doctor and make a difference. If this thing could ever work and not be bad for some unforeseen toxicity, that would be a very satisfying thing.”

—Paul Chutkow

Turning the tide of AIDS in New Haven, in a collaborative style

When Yale College turned him away as an applicant in 1961, it came as a shock to Matthew F. Lopes Jr., M.P.H. ’77. He’d grown up at Yale, living at the Elizabethan Club on College Street, where his father was the steward. Lopes naively assumed that Yale, the only school he’d applied to, would accept him.

He applied again to Yale College after a stint as an Army cryptographer during the Vietnam War. After another rejection, he argued his case at the admissions office and ultimately was accepted.

Today, Lopes is the coordinator for AIDS services for the New Haven Health Department, where he oversees a staff of 17 who deliver education, outreach and care to New Haven’s HIV-positive community. He chose a career in public health after his plans to become a physician didn’t pan out. Nearing graduation from the combined M.D./M.P.H. program at the medical school in 1977, he had written his thesis on Reye syndrome, completed his course work for his M.P.H. and finished all but two semesters of medical school. After several attempts and near misses, however, he failed to pass his medical boards. He graduated from Yale with an M.P.H.

“The world doesn’t necessarily stop because you don’t get everything you want,” he said. “I’m living testimony to the fact that you can survive not passing your boards and still be involved in medicine or practice public health.”

Lopes had chosen the combined program because he wanted to practice medicine in an urban environment and he felt he would need a public health background. As it turned out, public health was probably the better choice for him, because it gives him the opportunity to deliver health care to a larger segment of the population than he could were he in private medicine. “In public health we see a lot more people and have a better impact in some respects,” he said. “A lot of people with HIV/AIDS need primary care and supportive services, and we have the models to make it work.”

Lopes came to the city’s health department after working as an epidemiology consultant at the state health department, a hospital administrative intern at the state’s Department of Mental Health and a minority recruiter at the School of Public Health. He joined the city’s AIDS division in 1993, about three years after the city initiated its groundbreaking needle exchange program. Lopes has kept the program going, sending a van out five days a week to sites around the city where people can exchange used syringes for new ones and receive support services such as drug treatment referrals and HIV counseling and testing. With intravenous drug users accounting for 48 percent of New Haven’s AIDS cases, Lopes believes the program is essential to fighting the spread of HIV/AIDS. He shuffles resources to fund it, since federal support is not available. “We try to meet people where they are and bring them to where we want them to be, without being judgmental,” he said.

When Lopes joined the health department at the height of the AIDS epidemic, there were almost 280 new cases reported that year in New Haven; today there are about 80. But there are 680 HIV/AIDS patients and their families in New Haven who receive care through the New Haven HIV/AIDS Case Management Consortium, and delivering that care can be complicated. Lopes, with the support of community-based organizations, has built an infrastructure with funds from the Ryan White care Act, a federal program designed to help provide care for HIV/AIDS patients and their families. He coordinates HIV/AIDS case management for the city of New Haven through another consortium of five community agencies (including the AIDS Interfaith Network and Hill Health Center), and oversees the health department’s outreach and education efforts, HIV counseling and testing, and drug treatment referral. He is also the coordinator of the Mayor’s Task Force on AIDS, whose mission is to foster community response to the HIV epidemic and raise awareness of AIDS at the local, state and federal levels. “We’ve built a huge network of collaboration,” he said, referring to the myriad agencies and officials involved in the fight against AIDS.

Although the number of new cases of HIV continues to decline, the Centers for Disease Control and Prevention estimates that 25 percent of those infected may not know they harbor the virus. Lopes sees his mission as finding those people and getting them tested and into treatment. To do that, he has looked at new ways of reaching people who are at risk, those who engage in intravenous drug use and unprotected sex. In an effort to address New Haven’s needs, Lopes has introduced flex hours so that his staff can start and end their day later, when they have a better chance of connecting with residents who need services; some of the agencies in the consortium have extended their hours as well. His department’s outreach efforts include visiting drug sites, beauty parlors and even soccer fields on the weekends to help disseminate information, as well as running peer education groups with teens and going into schools to promote harm reduction. In addition, Lopes organizes community-level interventions, such as World AIDS Day, which took place at Center Church on the Green on December 1 last year.

At 61, Lopes shows no signs of slowing down, although retirement isn’t far off. He and his wife, Evelyn, an artist, plan to retire to either Brazil or Costa Rica in about four years. Lopes is undaunted at the prospect of picking up and starting over in a foreign country; over the course of his lifetime he has learned Spanish, Portuguese, French, Japanese and German. “I’m nosy and I like languages,” he said, “so I could live anywhere.”

—Jill Max


			Originally published in Yale Medicine, Spring 2005. Copyright © 2005 Yale University School of Medicine. All rights reserved.