Autobiography: A Clinician's Odyssey
You can't go home again -- Thomas Wolfe (1940)
It was a Sunday morning, and I was looking at the Sunday newspaper comics page with the console radio in the back-ground. Suddenly, I heard explosive sounds like thunder or fireworks. I ran out into the yard after my alarmed parents, looked up, and saw a Japanese Zero flying low enough that I could see the pilot's face. I did not know then, of course, what was happening, but years later, I learned that the planes had approached Oahu from the north, the part of the island where we lived at that time, bombed the Kaneohe Naval Air Station first, then flew low to avoid radar, and then up over the Koolau range in a sur-prise attack on Pearl Harbor on the south. The date: December 7, 1941.
I was 5 years old. We lived in a sugar plantation town; my father worked in the fields. The first doctor I remember was Dr Charles Black, who cared for my pneumonia at the Kahuku hospital. It was a country childhood, flying kites my father made, bathing in the hot Japanese public baths, waving to the sugarcane trains passing by, and watching Hopalong Cassidy, Roy Rogers, Gene Autry, as well as the original Bambi movies. I was only aware there was a war from the newsreels that usually preceded the main feature film, the blackouts, paper and tin can drives, and the bomb shelter we had to dig in our yard, and that my mother worked for the United Service Organizations (USO).
My parents had emigrated to the Territory of Hawaii from Dingras, Ilocos Norte in the Philippines during the great depression to seek a better life. They were part of the successive waves of workers that the sugar and pineapple plantations (founded by descendants of New England missionaries) recruited from Asia to work in the fields, starting in the late 19th century, even before the Kingdom, and then the Republic, of Hawaii was annexed as a Territory by the United States. This was the multiethnic, multicultural, multireligious, multicolored, warm, and sunny environment into which I was born and within which I grew up.
We moved to Honolulu shortly thereafter. I remember climbing coconut trees in the Iolani Palace grounds for fresh coconut juice, roller skating on the sidewalks of the Federal tax building, playing hide and seek in the Kawaia-hao Church (the Westminster Abbey of Hawaii) cemetery grounds, and picnicking and swimming at Ala Moana, the large city beach park on the edge of the Waikiki area. I shined shoes for sailors in port when they spent leave time on Hotel Street. On the day Franklin Delano Roosevelt died, I sold newspapers shouting "Extra! Extra," then added the headlines.
Up to the fifth grade, I attended Cathedral School, where the Brothers of Mary tried to convince me to enter the priesthood, and where the whole school learned how to sing the Latin High Mass. My parents divorced during this time, and my father returned to the Philippines. My mother later remarried, and we moved to another sugar plantation town, Aiea, today a western suburb of the city of Honolulu.
We first lived in post -- World War II United States Navy barracks housing, because my stepfather, who had been in the Army Air Force and graduated from San Jose State College in California, found a civil service position working for the US Navy at Pearl Harbor that paid better than a public school teacher's salary. When sugarcane land in the hills above Aiea opened up for residential development, my family bought a lot, built a house, just below CINC-PAC (Commander in Chief of the Pacific, Headquarters). The US Navy housing in the valley below where we had lived was leveled, and today, it is the site of Aloha Stadium, where the annual National Football League Pro Bowl is played every February.
Up through the ninth grade, I was steeped in "local" culture -- walking barefoot or with zoris (the original flip-flops), talking "pidgin," hiking in the mountains for mountain apples and guavas, and a summer job picking pineapples.
I had always thought I would return to Hawaii to practice after training. To my disappointment, pediatricians I visited in Honolulu painted a poor picture of success for such a new specialty and were not encouraging. So, when I was offered a position with Dr Lombroso in the seizure unit, I accepted.
The seizure unit was an exciting place to start a career. Besides Dr Lombroso (see Figure 2C), my colleagues were Giuseppe Erba, Frank Duffy, and Kuna Abroms. The neurosurgeons we worked with were Donald Matson and John Shillito, 2 superb technical surgeons as well as warm human beings. The unit also included a psychologist, social worker, as well as the EEG technologists. Under Dr Lombroso's leadership, its organization was a forerunner of what later came to be called Comprehensive Epilepsy Centers.
We ran an epilepsy fellowship, which attracted many from around the world -- Natalio Fejerman from Buenos Aires, Toru Kurokawa, and Genjiro Hirose from Japan, Nicole Symann-Louette from Belgium, Norberto Alvarez from Argentina, and many others. The seizure unit also had an EEG technologist training program, in which we also taught.
These were the early days of surgery for epilepsy, before computed tomography (CT) and magnetic resonance imaging (MRI) brain scans. We developed our Wada test protocol based on the Montreal Neurological Institute's approach, thanks to Giuseppe Erba and his wife, Valeria, a neuropsychologist, who had trained with Brenda Milner. The EEG technology support was superb, led by Carol Van Velzer, John Barry, and Nancy Logowitz.
The other big project I instituted, with the invaluable help and advice of Peter Wolff, Chief of Research Psychiatry at Children's Hospital (see Figure 2D), was the Learning Disabilities (LD) Clinic. The concepts of "minimal brain damage" and "minimal brain dysfunction" had evolved from the observations of hyperactive children with known brain damage, as in cerebral palsy or encephalitis. School systems were becoming aware of children with specific learning disabilities, having been prodded by a new law in Massachusetts, Chapter 766, which was the forerunner of PL 94-142, the education for all handicapped law.
The LD Clinic became an intellectually stimulating multidisciplinary forum, an inspiration for research ideas, as well as a diagnostic service, because of the newness of the field and the caliber of people involved -- Jeanne Chall's reading research group at the Harvard Graduate School of Education, mathematicians from Massachusetts Institute of Technology (MIT), Maria Marolda, a math specialist and educator from Simmons College, neuropsychologists, Natalie Solle and Jane Holmes, Tony Bashir, Speech and Language pathologist -- all being critically questioned by Peter Wolff, and organized by our able coordinator, Rose Dashefsky. The staffings usually involved invited special educators from the schools, so our findings could be translated into practical approaches in the classroom. When I finally left Children's Hospital, I recruited an old colleague, Martha Denckla, to administer the program.
One of my most memorable learning experiences was the yearlong participation in the Reading Forum of the White House Conference on Children, consisting of about a dozen experts -- university reading researchers, the superintendent of the Chicago public schools, the executive director of the International Reading Association (IRA), and others, which culminated in our presentation in Washington, DC in December 1970 on recommendations on how to improve literacy and remediation of reading disabilities in the nation's schools. This occasion was the nearest I have ever come to becoming a producer of a play. The various forums had been asked to present their findings and recommendations in novel ways. I arranged for a then little known improvisational theatre group from Cambridge, Massachusetts, The Proposition, to perform a one-act playlet, which they improvised from our written report and verbal suggestions. It was a hit. Some members of the group, Judy Kahn, Jane Curtin, and Josh Mostel, went on to performing careers in television and Broadway.
My more significant early career papers from my Children's Hospital days were the first description of acute confusional migraine, an early clinical differentiation in gelastic epilepsy, the paper that brought to attention what was later to be called Landau-Kleffner syndrome, and a clinical paper on what was later to be neuraminidase type 1 deficiency.
Working on the Board of the ICNA was another enjoy-able, professionally enhancing experience (see Figure 6). It was first-hand experience of the globalization of medicine -- meeting child neurologists from the developing and developed world in their countries, advancing professional education and training, and using internet communications technology, for information transfer particularly in the developing world, as in the establishment of a child neurology knowledge environment.
By far, the most exciting research collaboration during the Jeddah years was with Christopher Walsh's neurogenetics research team and lab at Harvard Medical School. The main project was the search for autism susceptibility genes, through Chris's NIH-funded research grant. He decided to take a different approach than most researchers who were doing whole genome scans in families in North America and Europe. He reasoned that with the kind of population in the Middle East -- consanguineous parents, large families, many with more than 1 affected child, that the chances of finding such genes in a population was much greater, using homozygosity mapping, even though the genetics of autism is complex and non-Mendelian. Soher Balkhy, developmental pediatrician, and I essentially were case-finders, participating the way clinicians can do in genetic studies, by making sure the phenotypes were tight. The results have recently been published. Other more traditional studies involved finding mutated genes in congenital brain malformations and microcephaly vera, working with Ganesh Mochida from Chris's lab and MGH.
The Jeddah years ended with me reluctantly assuming administrative duties that I did not seek or relish, but despite which I learned things I otherwise would not have. I wound up chairing the Department of Pediatrics (see Figure 7) for 2 years, and the Research Center for about a year. My task was made especially difficult, because, it turns out ironically, as with the restrictions of managed care in the United States, which I thought I had escaped, the hospital was facing financial shortfalls, and we had to do more with less.
Oh beautiful for spacious skies for amber waves of grain for purple mountains majesties above the fruited plain -- Katherine Lee Bates
North Falmouth on Cape Cod has been our safe harbor since 1990, a refuge for the family to sit out Operation Desert Storm, the site for the McInnis Open, our annual family reunion centered around a best-ball golf tournament, and the place to which I have returned to downshift into a country doc lifestyle, doing part-time practice as a member of the Neurology Department, Pediatric Neurology division, at MGH. My improbable odyssey would not have been possible without the opportunities for quality education in superb institutions.
I feel fortunate to have witnessed first hand, from coast to coast, the transformation of the Kingdom of Saudi Arabia (KSA), from its concentration on internal development of infrastructure during the post-oil boom days of the 1970s and 1980s, to its assertive entrance into the Middle East peace process with the King Abdullah Peace Initiative of 2002, subsequently adopted by the Arab League, and welcomed by Israeli leaders during the United Nations General Assembly meeting, November 2008. I came to admire a society with a growing, educated middle class that saw the need to modernize rapidly and become more open, without losing its cultural and religious values, doing it in fits and starts, but nevertheless, progressing. I am forever grateful to my colleagues in Riyadh and Jeddah, both physicians and residents, as well as nurses, secretaries and other ancillary staff too numerous to mention, for making me feel at home in their professional community and helping establish pediatric neurology as a specialty in the country. I am indebted to the numerous patients and families for whom I was fortunate enough to care for, who reinforced an often underappreciated fact by outsiders to whom Saudi society seems impervious, about universal values, that the prime social unit in Middle Eastern society is the family, nuclear and extended, and that children are cherished.