The American Journal of Surgery (2014) 207, 315-320

Midwest Surgical Association: Presidential Address Has medical diplomacy reached an inflection point?

Stephen F. Sener, M.D.*

Section of Breast, Endocrine, and Soft Tissue Surgery, Department of Surgery, University of Southern California, 1510 San Pablo Street, Suite 412, Los Angeles, CA 90033-4612, USA

KEYWORD: Medical diplomacy; Tobacco Control; Breast Health

To my colleagues in the Midwest Surgical Association, distinguished guests, ladies, and gentlemen: thank you for the honor and privilege of serving as your president for the last year. I must also pay homage to 3 giants in the field of surgical oncology, upon whose shoulders I stand today to make my remarks: Edward F. Scanlon, M.D., Murray F. Brennan, M.D., and David P. Winchester, M.D. Without their patient guidance, I would never have had a successful career as a surgical oncologist and as an educator. I also thank my longstanding colleagues at Northwestern Univer- sity, Evanston Hospital, and the University of Southern California (USC). Their friendship has carried me through some of the interesting times that I will describe today. I am especially grateful to Susan Eisenhower, Emeritus Director of the Eisenhower Foundation, for providing the inspiration for my remarks. In a speech shegave at USC several months ago, she described 2 events which occurred 75 years ago, little known or recognized at the time but which, as they gathered momentum, reached an inflection point past which they would have endured regardless of the motivating forces behind the concepts. The year was 1938, and the news was

The authors declare no conflicts of interest. A dedication to Vladimir Zelman, M.D., Ph.D., D.Sc. Presidential address for the 56th Annual Meeting of the Midwest Surgical Association, July 30, 2013, delivered at Traverse City, Michigan. * Corresponding author. Tel.: 11-847-609-7266; fax: 11-323-865-3539. E-mail address: [email protected] Manuscript received July 16, 2013; revised manuscript August 19, 2013 Stephen F. Sener,M.D.,

0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.08.040 316 The American Journal of Surgery, Vol 207, No 3, March 2014 consumed by the coverage of Adolf Hitler and the annexation graphic detail John F. Kennedy’s belief that the ‘‘Cuban Mis- of Austria to Germany. However, in that same year, the process sile Crisis’’could have culminated in a nuclear war.2 This was of nuclear fission was identified. Interesting enough, fission a frightening time. Krushchev and Kennedy had to use all of was discovered in Germany, but it was Leo Szilard and Enrico the diplomatic maneuvers that they could conjure to prevent Fermi in the United States, who appreciated that it could be an armed conflict between the United States and the Union contained in a nuclear chain reactor and harnessed to create a of Soviet Socialist Republics, including a late night stealth uranium bomb. Within 4 years after the discovery of fission, an meeting between Soviet Ambassador Dobrynin and Robert atomic pile was functioning under Stagg Field at the University Kennedy in Washington, District of Columbia. of Chicago. From discovery until fission’s use in the atomic bomb, only 7 years had elapsed. In the same year of 1938, oil Armand Hammer, M.D., the Prototype was discovered in Saudi Arabia. And, although it took many Medical Diplomat years longer, few could argue the importance of oil as a current global geopolitical issue. So, the question that I pose today is Enter onto the stage an unlikely intermediary, Armand whether medical diplomacy has reached an inflection point, Hammer, M.D., born in 1898 in New York to Russian-born past which its importance as a global force cannot be argued. Jewish immigrants.3 His physician-father, Julius, had moved in 1875 to the Bronx, where he ran a medical practice and The Groundwork for Modern Diplomacy owned 5 drugstores. Julius was an avowed socialist, and in 1907 he met and developed a lifelong deep friendship with Vladimir Lenin. After graduating from Columbia Medical Henry Kissinger, in his book, Diplomacy, described the College in 1921, Armand used his father’s connections and origins in post-medieval history beginning in the 17th cen- his entrepreneurial skills, developed exporting pharmaceuti- tury with the French Cardinal Richelieu, who introduced cals to the newly formed Union of Soviet Socialist Republics, the modern approach to international relations.1 During to broker a deal in the Soviet Union with Lenin to send a ship- the next 2 centuries, European diplomacy was dominated ment of surplus American wheat to the Union of Soviet So- by Great Britain, which was responsible for the concept cialist Republics. While living there in the 1920s, Hammer of the balance of power. In the latter 19th century, Austria’s brought medical supplies to assist in a typhus epidemic, Metternich reconstructed Europe, and shortly thereafter developed a large business manufacturing pens and pencils Germany’s Bismarck dismantled it, reshaping European di- for use in the Soviet Union, and even convinced Henry plomacy into a very hard proposition of power politics. Ford to create a plant in the Union of Soviet Socialist Repub- But, it is post-World War II history that laid the lics to manufacture the ‘‘Fordson’’ tractor. groundwork for the modern concept of medical diplomacy. When he returned to the United States in 1930, Hammer When the Soviets launched Sputnik in October 1957, Krush- participated in a diverse array of business endeavors, chev actually believed that a serious change had occurred in including investing in US oil production efforts. He subse- the balance of power between countries of socialism and quently parlayed these investments into a controlling interest capitalism, in favor of the socialist nations. He sought to of Occidental Petroleum Company. In the midst of these translate this perceived change into a diplomatic advantage; engagements, he met and developed a longtime friendship his target was Berlin. During 1958, Krushchev delivered with Al Gore, Sr, Senator from Tennessee. Throughout his a series of ultimatums, challenging the formal arrangement life Hammer continued personal and business relationships between the United States, France, Great Britain, and the and had significant cache with leaders in the Soviet Union, Union of Soviet Socialist Republics for the control of Berlin. including Krushchev. The relationship between Hammer, By the time John F. Kennedy took office in January 1961, Krushchev, and Gore Sr played a significant role in nearly 3 years had passed and nothing had happened in Ber- brokering the 1961 summit meeting between Krushchev lin, reducing the credibility of Krushchev’s threats. Howev- and Kennedy in Vienna (Vladimir Zelman, M.D., June 2013, er, with the Kennedy Administration’s failure to overthrow University of Southern California, Los Angeles, CA, per- Castro in Cuba and its indecision regarding intervention in sonal communication). Laos, Krushchev viewed Kennedy as weak. At a meeting In his later years, Hammer traveled extensively, working with Kennedy in June 1961 in Vienna at the Hotel Imperial, for peace between the United States and Communist Krushchev issued his final ultimatum regarding Berlin, countries. In my opinion, Hammer must be regarded as which began the most intense period of confrontation of the post-World War II prototype medical diplomat. The the Cold War. On August 13, 1961, West Berliners awoke Hammer story will come back around later. to find that a true ‘‘Berlin Crisis’’ existed, as a barbed-wire fence had been built around the entire city, isolating the So- viet sector from those occupied by the 3 Western countries. Medical Diplomacy During the Second Half of This huge dilemma was followed on October 16, 1962 with the 20th Century photographic evidence, convincingly demonstrating that the Soviets had placed missiles with nuclear warheads in Cuba. In In subsequent years, a number of organizations arose, his book, Thirteen Days, Robert F. Kennedy described in which took up the cause of international humanitarian S.F. Sener Medical diplomacy 317 medical missions. Perhaps the first and best organized was of this advocacy movement was the passage of the Federal Medecins Sans Frontieres (MSF) (aka Doctors Without Aviation Act with the Durbin Amendment in 1988, making Borders), founded by Bernard Kouchner and Raymond Borel domestic air flights of ,2 hours smoke-free (http://www. in 1971, in response to Biafran secession during the Nigerian smokefreeairlines.com/historynosmoking.html). During the Civil War (http://www.msf.org). This small group of French next year, Senator Frank Lautenberg (D-NJ) took the battle physicians and journalists was motivated by the belief that to the Senate to make longer flights smoke-free. And after all people have the right to medical care, and that their needs years of internal debate, Delta Airlines took the bold step supercede border considerations. MSF’s first mission was in to make all flights worldwide smoke-free in 1995. Managua, Nicaragua, where a 1972 earthquake killed be- Shortly after the Surgeon General’s report was issued, tween 10,000 and 30,000 people. MSF received the 1999 tobacco consumption in the United States began to drop Nobel Peace Prize in recognition of continued efforts to pro- significantly from its peak of 200 packs per capita per vide medical care in acute crises and to raise international year.9,10 But, it was not until 1990 that age-adjusted lung awareness of humanitarian disasters. Last year, over 26,000 cancer death rates began to fall in men. With the implemen- volunteer medical professionals and water/sanitation engi- tation of comprehensive tobacco control programs, the per neers provided medical aid in over 60 countries, funded for capita annual consumption in the United States dropped the most part by individual private donors. even further, with greater declines in states with strong pro- Another example is the Bill and Melinda Gates Foun- grams, such as Massachusetts and California.11 The lung dation, which was founded in 1994 and is the largest private cancer death rate among US women, who began regular foundation in the world, with an endowment of over cigarette smoking later than men, has just peaked nation- $36 billion ($28 billion from Bill Gates; http://www. wide and has begun to decrease in California. gatesfoundation.org). In 19 short years, the Foundation has grown into 3 grant-making programs, including Global Health, Global Development, and US-based grants. The The Framework Convention on Tobacco Global Health program funds service grants in AIDS, infec- Control tious diseases, and immunizations, among others. The Global Development program funds financial services for But, the tobacco industry realized that there was a huge the poor, agricultural improvement, and earthquake relief. international market for their products, and systematic saturation with private–public collaborations marked the steep growth of tobacco consumption worldwide in the Public Health Efforts to Control Tobacco 1990s. Fueled by the success of the antitobacco movement in Perhaps the most sustained and largest global public the United States, the global response of international health effort to date has been the attempt to control the use of tobacco advocates was to become more organized into a tobacco products. King James I provided royal opposition to confederation through The World Conference on Tobacco the new addiction as early as 1604, describing smoking as ‘‘a or Health (WCTOH). But, it was a master stroke of custom loathsome to the eye, hateful to the nose, and diplomacy by Ruth Roemer, Allyn Taylor, and Judith dangerous to the lungs.’’4 Even though the relationship be- Mackay, when their proposal for a multilateral treaty tween smoking and lung cancer was described in Germany regarding tobacco control was adopted as a conference in the 1930s, it was not until Sir Richard Doll (United resolution at the 9th World Conference on Tobacco or Kingdom) in 1950 and the subsequent Hammond–Horn Health in 1994.12 The next year, the World Health Assem- Study (United States of America) put a fine point on the bly resolved to create an instrument adopted by the United causal link between the two, that worldwide efforts at to- Nations calling for an international convention on tobacco bacco control began.5–7 In 1964, the US Surgeon General, control, the Framework Convention Alliance. When Gro Luther Terry, M.D., released the first report of the Surgeon Harlem Brundtland, a Norwegian physician, was elected di- General’s Advisory Committee on Smoking and Health, rector general of the World Health Organization in 1998, which concluded that cigarette smoking was a cause of there was finally enough diplomatic momentum that the lung cancer.8 Shortly thereafter, the US Congress adopted World Health Organization fully supported the concept of the Federal Cigarette Labeling and Advertising Act of 1965 a binding multilateral treaty on tobacco control, the Frame- and the Public Health Cigarette Smoking Act of 1969. These work Convention on Tobacco Control (FCTC). Negotia- laws required health warnings on cigarette packages and tions for the treaty began in 1999 and were most notable banned cigarette advertising in the broadcasting media. To- for the unprecedented inclusion of nongovernment organi- bacco control advocates quickly banned together from gov- zations throughout the drafting processes. As a past na- ernment agencies and nongovernment voluntary health tional president of the ACS, I am proud to say that organizations, such as the American Cancer Society (ACS), members of the ACS, such as Thomas Glynn, were instru- to form the National Interagency Council on Smoking and mental in forging a concept, which represents the present Health. Multipronged, comprehensive tobacco control pol- day pinnacle of diplomacy on behalf of global public icies were then developed. One of the most visible successes health. 318 The American Journal of Surgery, Vol 207, No 3, March 2014

Much of the groundwork for economic justification of have tested the feasibility of guideline implementation in the FCTC was done by the World Bank, which asserted that Ukraine, Ghana, Columbia, and Israel. The last of these tobacco control would not harm evolving economies.13 feasibility studies identified that the current breast cancer Despite the vigorous attempts of the tobacco industry and screening program in Israel is a model for other middle- the International Tobacco Growers’ Association to thwart income countries in South America and Eastern Europe. the efforts of the drafters of the FCTC, the treaty was adop- Beginning in the mid- to late-1990s, the ACS began a ted by the World Health Assembly in 2003. It is the first more deliberate engagement in international activities, even United Nations Treaty to address a public health issue, of- though the original articles of confederation dating back to fering the best chance to globally address tobacco control, 1913 had mandated a commitment to global health and it will continue to generate tobacco control advocacy in problems. The ACS realized that tobacco control had to every country in the world. The FCTC became an interna- be waged on a global scale. But, it also recognized that tional law in 2005 when 40 countries had ratified it. cancer is a disease without borders. With current interna- Currently, 168 countries have signed and ratified the tional migration and travel patterns, the United States has FCTC, representing 86% of the world’s population. Alas, absorbed the world’s cancer problems. In 2000, there were the United States is one of the 9 countries, which have 6 million deaths worldwide from cancer. Murray and signed but not ratified the treaty, as neither Presidents Lopez19 have estimated that by 2020 that number will Bush nor Obama have had the political will to send the have doubled, with 75% of all cancer deaths occurring in treaty to the Senate for ratification. The major provisions the developing world, the countries least equipped to deal of the FCTC were designed to address cross-border issues with them. The international program was designed to build and include an advertising ban, health warning labels, pro- capacity for cancer control in the countries with the greatest tection from second-hand smoke, a ban on sale to minors, need and where ACS could have the most impact. and legislation to control smuggling of tobacco products.14 I was a member of the volunteer group, which pushed the international agenda for the ACS. My first foray into humanitarian medical missions began in the mid-1990s, Nongovernment Organizations and when Mickhail Tolstykh, then a medical student at Moscow Worldwide Breast Health Programs State University, visited me at Evanston Hospital, North- western University, for an elective rotation. One thing led to On a different but contemporary track, advocacy for another, and in May 1999 a 7-member surgical team spent international breast health programs was supported by US- the first week of several over the ensuing years at the based nongovernment voluntary health organizations, such Central Clinical Railroad Hospital Semashko, Moscow as Susan G. Komen for the Cure and the ACS. Breast State University. Although we were exhilarated by helping cancer is the most common cancer in women in the a relatively small number of individual patients, we were developing world. It is also the most likely reason that a frustrated by our inability to help the Russian surgeons woman will die of cancer anywhere in the world, except the accomplish systematic change to medical care in Russia. United States.15 Between 1990 and 2010 in the United This, and subsequent similar experiences in Latvia and States, the age-adjusted death rate from breast cancer drop- India, taught me a valuable lesson. In order to have the ped 33% because of a combination of utilization of opportunity to make significant change in a country’s health improved detection techniques and better adjuvant ther- care delivery system, one must have access to both the apy.16 But, in developing countries, most women with medical and political leadership. So, when Dr Guangwei breast cancer present with locally advanced or metastatic Xu, the president of the Chinese Anti-Cancer Association, disease. In that setting, one does not need a mammogram approached the ACS and me, as president of the ACS, to find a breast cancer; a program on breast awareness about the possibility of creating a screening program for and clinical exam will suffice in the early phase of a detec- breast cancer in China, I was especially encouraged by tion program. the active involvement in the project by Wu Yi, then In 2002, under the auspices of Susan G. Komen for the Vice-Premier of China. Cure, Benjamin Anderson, M.D., and Leslie Sullivan In the early 2000s, it was realized that there was a founded the Breast Health Global Initiative (BHGI), which bimodal age distribution for breast cancer in China, with has become internationally recognized for leading the peaks in women in their 30s and 60s, and an increasing global movement toward clinical improvement and imple- incidence in urban women. And yet, there was no mentation of ‘‘best practices’’ for breast cancer.17 Over the organized screening program for early detection. After past decade, BHGI has produced model approaches for numerous exploratory and planning meetings, an ACS consensus guidelines, which are comprehensive, resource- delegation, composed of internationally known experts in stratified, and evidence-based.18 The objective was to effec- breast cancer screening, joined members of the Chinese tively detect, diagnose, and treat breast cancer in low- and medical and political hierarchy in an International Forum middle-resource countries. These guidelines were the out- on Breast Cancer in Beijing in February 2005 to finalize comes of 5 global summits and were produced with exten- plans for a nationwide breast screening program. The sive worldwide scientific collaboration. BHGI pilot projects result was the One Million Women Breast Cancer S.F. Sener Medical diplomacy 319

Screening Project, launched in Spring 2005, with the research program in Moscow as chief of anesthesiology and primary objectives of establishing national breast cancer critical care under the auspices of the Russian Academy of screeningguidelinesinChinaandcreatingaplatformfor Sciences Institute of Neurology/Neurosurgery to study ce- clinical research in breast cancer detection. We realized rebral blood flow auto-regulation and brain metabolism. that there would probably never be another randomized Here is where the Hammer story comes back around. In clinical trial of screening for breast cancer in the United 1976, Armand Hammer was visiting Moscow and became States. And so, any further advances in screening research ill with an intense respiratory virus. Dr Zelman cared for Dr would most likely have to be done outside of the United Hammer in a critical care unit, and subsequently Dr Zelman States. This was to have been the largest screening was brought to the United States as Dr Hammer’s personal program to date comparing mammography with ultra- physician. After completing a US residency in Anesthesi- sound. Because of the large fraction of young women with ology, Dr Zelman joined the faculty at USC, where he has breastcancerinChina,womenaged35to70yearswereto served in various leadership capacities in his department to be screened 4 times between 2005 and 2010. Eighty this day. However, Vladimir has maintained the especially mobile vans, equipped with mammogram and ultrasound strong ties that he established within the Russian Academy units, were created for use in 5 urban areas. All digital of Sciences and the medical establishment. He is renowned images were stored in a PACS unit in Beijing, there was and revered in Russia for his active participation in central review of pathology slides, and further diagnostic humanitarian medical missions, including the Chernobyl workups were completed in the cancer hospitals to which nuclear power plant catastrophe with Dr Hammer in 1986, the vans were attached. Top Chinese government leader- earthquake in Armenia, and gas pipeline explosion in ship saw this project as a focal point for change. Bashkortostan, Russia. He has most recently been a key In May 2006, as the program was accelerating, another intellectual influence in the development of Skolkovo, a surgical team representing the ACS and Evanston North- unique model of private–public collaboration with the western Healthcare went to Beijing Cancer Hospital for Russian Academy of Sciences to develop a national basic Chinese–American Surgical Oncology Week, hosted by Dr science research program in Russia. Jin Gu, vice president of Beijing Cancer Hospital. The So, it was no surprise that, when the wife of the chancellor goal was to highlight the advantages of breast cancer of St Petersburg University ruptured a cerebral aneurysm screening for patient care, demonstrating breast conserving some years ago, Dr Zelman was called to her aid. She and sentinel node procedures, ultimately creating a shared survived, neurologically intact. Today, that lady is Svetlana learning environment for US and Chinese surgeons, Medvedev, and her husband is Dmitry Medvedev, who went anesthesiologists, and nurses. Alas, however, with the on from chancellor of St Petersburg University to become the retirement of Dr Xu and Vice-Premier Wu Yi, the breast president of Russia. Dr Zelman has maintained a close screening program was privatized and lost momentum. personal relationship with the Medvedevs. When Mrs Another tough lesson learned: programs designed to Medvedev was deciding how to create a legacy program as change systems and cultures require sustained medical wife of the Russian president, she sought counsel from Dr and political leadership. Zelman. As I had recently moved from Northwestern University to USC, Dr Zelman was aware of the past ACS history and interest of Dr Christy Russell and me in interna- Vladimir Zelman, M.D., Ph.D., D.Sc., an tional cancer control programs. We recommended that Mrs Enduring Model of Medical Diplomacy Medvedev establish a national breast cancer screening pro- gram and Human Papilloma Virus (HPV) immunization/ And, now I turn to the man for whom this piece is cervical cancer detection programs, based on the high dedicated, Dr Vladimir Zelman. incidence of breast and cervical cancer in Russian women. Like many Jewish families in Eastern Europe in the early Finally, with all of the previous lessons learned during 1940s, he fled Ukraine, went to Uzbekistan, and eventually international medical missions, it was apparent that we had settled in Siberia (Vladimir Zelman, M.D., June 2013, Los come full circle in Russia. This was the missing link in our Angeles, CA, personal communication). Vladimir grew up attempts to establish a breast cancer screening program in there and obtained his M.D. from Novosibirsk State Medical Russia in the late 1990s-access to what we hoped was Institute in 1959. Early student research work under the sustained medical and political leadership. Drs Zelman, guidance of prominent Russian scientists gave Dr Zelman a Russell, and I embarked on a series of conversations with unique opportunity to prepare himself for a successful career Mrs Medvedev, which to date have resulted in a pilot in clinical and laboratory research. He became interested in demonstration mammogram project and the provision of anesthesiology and was closely involved in developing new HPV vaccinations in St Petersburg, robust discussions clinical strategies aimed at brain protection during open heart regarding the inclusion of vaccination for young boys and procedures. His publications in this field led him to national girls in the Russian national vaccination program, and plans recognition in the Soviet Union. He was also a pioneer in for a rehabilitation program after breast cancer treatment. developing a helicopter air ambulance transport system in Everyone who knows Dr Zelman remains amazed at the Northern Siberia. He was then recruited in 1969 to direct a depth of his contacts and understanding of international 320 The American Journal of Surgery, Vol 207, No 3, March 2014 medical diplomacy. He has my personal gratitude for a life 6. Doll R, Hill AB. Smoking and carcinoma of the lung: preliminary of service as a very powerful force for good. Here is a man report. Br Med J 1950;2:739–48. who is not interested in money or glory, just in proving that 7. Hammond EC, Horn D. Smoking and death rates-report of forty-four months of follow-up of 187,783 men. II. Death rates by cause. he is serious about changing the world. JAMA 1958;166:1294–308. 8. Terry L. United States Surgeon General’s Advisory Committee on Quo Vadit? Smoking and Health. ‘‘Smoking and Health.’’ Office of the Surgeon General, US Public Health Service; 1964. 9. US Mortality Public Use Tapes, 1960–2000, and US Mortality Vol- So, has medical diplomacy reached an inflection point? ume, 1930-1959, National Center for Health Statistics, Centers for Will people like Vladimir Zelman take up the torch in the Disease Control and Prevention, 2002. next generation? All we have to do is look around us in July 10. Cigarette consumption. 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