"Disappointments in one’s life are an opportunity for growth. I attempted to deal with frustrations and disappointments in an administrative way. Okay, so we have a problem. What is the solution? Okay, so you are bringing me a problem to my office. What is the solution? And if there is no solution, then you have to get it out of your desk. But yes, I can think of 20 disappointments but probably I can think of a hundred blessings that I have had in transplantation and in Puerto Rico."
Eduardo A. Santiago-Delpin, MD, MS, is the founding director of the organ transplantation program in Puerto Rico. Raised and educated in Puerto Rico, Dr. Santiago-Delpin completed general surgical training there before taking a transplant surgical fellowship position at the University of Minnesota. While earning a Masters Degree at Minnesota, Dr. Santiago-Delpin honed his skills in immunology as well as transplantation surgery so that he could establish a science-based organ transplant program in his native Puerto Rico. His vision to bring modern transplant services to his home was ultimately realized as effective clinical, research, and outreach efforts evolved through the 1970s and 80s in San Juan, Puerto Rico. Dr. Santiago-Delpin has been a career-long ASTS member and was the founding member of the Latin American Transplant Registry, The Pan-American Society for Dialysis and Transplantation, and the Transplantation Society of Latin America and the Caribbean. He is the author of Organ Transplantation, the first book in Spanish on the topic. Dr. Santiago-Delpin has over 350 published papers and abstracts and serves as the Distinguished Professor of Surgery at the University of Puerto Rico.
Dr. Santiago-Delpin: I am Eduardo Santiago-Delpin, founding and current director of transplantation at Auxilio Mutuo Hospital and University of Puerto Rico Medical School, and also director of the immunogenetics laboratory.
Interviewer: Transplantation surgery.
Dr. Santiago Delpin: I first became interested in transplantation surgery because I was interested in immunology. And that was so fascinating in the early ’60s when I was doing my medical school and later on in my residence, and it was such an unknown and exciting field.
And you could go into immunology either in cancer immunology or in transplant immunology. One at that time was very destructive, and the other was constructive and reconstructive, so that’s the way I eased my way in, in the late ’60s and the early ’70s when I trained.
Interviewer: Tell us about your training, perhaps just a brief comment about your residency and then the Minnesota years.
Dr. Santiago Delpin: I was so fortunate to go to Minnesota. Minnesota seemed to be a tradition for us, because my mentor, a very famous local cardiac surgeon, trained in Minnesota in the late ’40s and early ’50s, in the heyday of cardiac surgery and later transplantation. So it was sort of natural to go there.
It sort of coincided then that Minnesota was probably the most exciting place to go in the early ’70s, so I was very fortunate to go and train with John Najarian and Dick Simmons, who were my mentors. But at the time there was not only the direct mentors, but also the environment in Minnesota. There was Bob Good and there was Edmond Yunis and there was Carl Kjellstrand, very fine researchers also.
So simultaneously I had the training in transplantation and immunology, which I wanted, but also they guided me through the steps to become an academic surgeon.
Interviewer: Let’s do just a little bit more history about you; you grew up in Puerto Rico.
Dr. Santiago Delpin: Yeah.
Interviewer: You trained there, I think, as well?
Dr. Santiago Delpin: Yeah.
Interviewer: And then went to Minnesota, so you went back to Puerto Rico to start a transplant program.
Dr. Santiago Delpin: I grew up in Puerto Rico and went to the public university and then to the medical school, and I did my surgery at the University Hospital. There didn’t seem to be very many options at the time, and something that I learned from having an extra training in Minnesota was that now with my fellows, they have a training with me in transplantation surgery and immunology, but also a period afterwards for what I call “finishing school.”
Then I came back to Puerto Rico to set up a transplant program. I had studied all of my life with scholarships, so not only did I feel a debt, but there was also a need for which I felt responsible. So I trained in 1970 to 1972, I had a master’s degree also in experimental surgery and immunology. And subsequent to that, I came back and started my own program.
Interviewer: Tell us how starting a single program from scratch was, in those days.
Dr. Santiago Delpin: The thing is that it’s not only starting a program the way we see this in the States. I came back with my eyes full of stars and feeling that I could do kidneys the next day and then livers and then pancreases and then help other people to develop cardiac surgery and then go to my little mouse lab and do immunology. It was not to be.
There was no infrastructure, very minimal immunology, no research in immunology. And even though there had been a very early experience in one of our local towns with 18 or 20 kidney transplants, it was not done under the umbrella and with the infrastructure of a program, meaning a team, so they had stopped. By the time I came back, they had stopped.
So I had to do a little, what they call today, strategy planning. I guess that was intuitive, and then say, “Okay, hello, I need to get a group together in the three key elements: surgery, donor surgery, tissue typing, and of course organ preservation. So we started at the only place that that could be done at the time. But it took me five years to do the first transplant, to train the people.
Here I have to say that when you are trained in transplantation, I knew how to sew in a kidney. I knew how to do an experiment. Maybe I knew how to write a competitive grant. But I did not know what you need to know from all points of view: personnel, infrastructure, budgeting, planning, training, certifications, etc.
So then I had help, I had mentorship, if I may interrupt myself. It’s not a one-shot deal. It continues for a life. And I know that I still can consult with my mentors when things I have not met before need their experience. But anyway, I was going to mention that I had the help also of Gene Pierce, also a Chronicle awardee, who I can truly say was one of my godfathers. The other person who helped me in organization, especially through the years, was Felix Rappaport, in addition to Dick Simmons and John Najarian and mentor Joshua Miller, who also helped us out a lot.
But essentially what we did was get the whole group together, train them, do dry runs and then do the first transplant, which is now 34 years down the line with a good creatinine and reminding me always that he was a very brave person, because no one wanted to be transplanted. No one wanted to be the first one.
Interviewer: Tell us a little bit about organ donation in Puerto Rico, that’s been one of your triumphs.
Dr. Santiago Delpin: You can see organ donation as a vector with multiple side vectors. And one thing, and this is my experience in Latin America, that it has to do with attitude or culture only, and I thought so myself. But it has to do with a number of other things, including education. So during the beginning, we had one to two donors per million population; we were one of the lowest in the nation. And about half-way through in Latin America, I tried everything. But I could not get the whole thing to work, because I could not get the funding to have an organ procurement organization.
So to make a long story short, after being one of the persons involved in the partnership for organ donation in the States, and after visiting Spain on a number of occasions to see their success, I incorporated two key elements. The key element was train your requestor. And it has to be a culturally sensitive requestor, something that Clive Callendar has demonstrated with the African American population in the States.
Number two, not all Hispanics are the same. The accent tells you that you are either from Cuban extraction, Puerto Rican extraction, Central American, South American and so on. And in that final moment of death, the grieving family will close themselves and exclude everyone who is not kin. So they will interpret non-kin if you are not speaking with the same accent or with the same cultural nuances.
So we invited LifeLink to Puerto Rico. I had been a very good friend of Donna Shires for many years, from the late ’60s and ’70s, and they came and tried out. And so from two per million per year, we went up to 30 per million per year with one year, which one year was second to Spain only. It sort of leveled off at 120 donors per year, and it makes you busy.
Now that has a spin-off and that is that your infrastructure is not ready for that really sharp increase. So we had to scramble and get the infrastructure par with the donation success we were having.
Interviewer: Once transplantation got off the ground, certainly by the early ’90s, you were doing a considerable number of transplants. Tell us what your daily life was like at that time.
Dr. Santiago Delpin: My other great benefit or blessing has been to be associated with a great team. So Zuma Gonzalez, my Co-Director, and Luis Morales, they have shared with me after the ’80s, so they took up a lot of the strain that allowed me to hold on other areas which needed attention. For example, the deanship of biomedical sciences, the graduate school, and I was chair for a while of the Department of Surgery.
But still, it was a full-time job, the involvement with transplantation with our level of production. And with the need to continuously monitor all of the aspects for quality was a full-time job for 12-14 hours a day, like all transplant surgeons.
Interviewer: What do you remember in the early days about the ASTS and your involvement?
Dr. Santiago Delpin: I was very early involved in both TTS, The Transplantation Society, and ASTS. I remember going to the early meetings. My name is not in the initial charter, something that I have talked to Oscar Salvatierra about. But I was involved in the very early days. So we were a very small group with a very large heart and a lot of involvement in academic surgery and the quality issues.
More than a reactive organization, it was a scientific organization and eventually the focus became education. I held several positions in ASTS and the same with TTS. And with what was called the International Society for Organ Sharing also. So the Society has grown with the issues. And one of the things that size has not interrupted is its flexibility. So as new issues have come along, they have been extremely—not vocal, but active—in getting a balance.
If in the beginning it was difficult to start a program from scratch, now there are different difficulties. You are faced not only with the issue of donation, you are also faced with the issue of micro-oversight, which can distract all of your staff from what you have to do, which is transplant a good, sizable number and get good results. And if you are an academic program, then a focus on your research and your other responsibility, getting academic surgeons and academic nephrologists out in the field—in my case not only locally, but for the Caribbean and Latin America as well.
Interviewer: Tell us about the development of the Pan-American Transplantation Society.
Dr. Santiago Delpin: Okay. Organized Latin American activities started very early, but in 1977, in a cafeteria with Latin American friends, we started asking each other “What is happening in Latin America?” Remember this is before the internet, this is before email. This is before fax, we didn’t know. So we looked around, we wrote to some friends, and there wasn’t very much going on as far as organizations.
In 1980, the Latin American Society of Transplantation was founded. But then again, because of difficulties with the mail and communication, it was limited to the Southern Cone. So we developed a society, the Pan-American Society of Dialysis and Transplantation. Why dialysis? Because in Latin America you cannot separate them.
So in 1985, we founded the society. But the formal organization was in 1987. And from there on, rather than a competition or even a complement, we were working too separated for a region which is not culturally so different. So with help of our Argentinian friends, we developed the goal of fusing both societies into one. And that is another achievement in 1999. We founded the Society for Transplantation of Latin America and the Caribbean.
There was a small, preliminary attempt which led to that fusion, and that was the need for information. So together with a very good Brazilian colleague, we founded the Latin American Transplant Registry in 1989. From then on, we have published 13 or 14 reports, 30 papers. And it’s still a good registry, with over 170,000 transplants reported already.
Then the books, that was also a unifying factor. There was no transplant book in Spanish. There was no internet. Communication happened by sharing journals from the respective universities, so we decided to write a book with a Mexican colleague, Dr. Octavio Ruiz, who was also a very fine pioneer in transplantation in Mexico and also a general in the Mexican Army.
We wrote a book. We edited the first book back in 1987. It was sold out, to our surprise, because it was in Spanish, and there was a huge need for that information. Subsequently we did a second edition, totally different, written mostly by the pioneers of transplantation in Latin America. That was in 1999. That was the second transplant book, and that sold out, too. So right now we are working on a third edition in Spanish.
Interviewer: Can you point to any significant international roles that the ASTS has? I know there are some international members and Puerto Rico is sort of a bridge to other nations for America. Fully American, of course, but this bridge is something I think we all recognize. So could we start by simply talking about Latin American members of the ASTS that are not Puerto Rican, that are from other countries?
Dr. Santiago Delpin: The ASTS opened its doors to international members. And I think it was done very smoothly through the years, with two venues. First, by selecting international corresponding members and honorary members, but also because ASTS members trained many people from around the world and especially from Latin America. So I think it was very natural for those, not only loyalty, but in recognition of the quality, especially the Congresses, to eventually attempt integration to the ASTS.
Now there’s an unfounded feeling sometimes that the ASTS meetings may compete with other international meetings of stature. I don’t think so. I think they complement each other beautifully. And having been a member of most international transplant societies, I can say that Latin American surgeons, and especially transplant nephrologists, are highly attracted to the ASTS/AST Congresses.
I think that the contribution in education is seen not only in direct training and in the Congresses, but also making young members and a beautiful slide presentation in the academic clout that the ASTS has.
Interviewer: Have you had any disappointments in Puerto Rico with transplantation?
Dr. Santiago Delpin: Disappointments in one’s life are an opportunity for growth. I attempted to deal with frustrations and disappointments in an administrative way. Okay, so we have a problem. What is the solution? Okay, so you are bringing me a problem to my office. What is the solution? And if there is no solution, then you have to get it out of your desk.
But yes, I can think of 20 disappointments but probably I can think of a hundred blessings that I have had in transplantation and in Puerto Rico.
Interviewer: Give us an example of one of the things you would have wanted to do, but have not been able to do.
Dr. Santiago Delpin: My starry eyes were incompatible with the cultural realities of Latin America, basically Latin American personality. So I would have wanted to do kidneys in the mid-’70s; actually it was 1977, close. And followed by livers very quickly and by pancreases and by hearts. The growth has been slow. I would have liked organ donation to have been faster, but it was not to be. It needed a cultural transformation made possible by the concerted effort of a team, a dedicated team, specifically for organ donation.
I would have wanted to do more research; I have done research, of course. And have my share of publications and scientific papers. But I would have wanted a more molecularly based research faster, encapsulation, for example, of cells.
We were working with cells and the old Amicon membranes and crazy glue early in the ’70s. But to pursue that full-time and get to the successes that we are seeing published these days, it would have taken an immense amount of effort, money and time and that effort had to go into clinical service.
Interviewer: You and I are about the same age. Tell me what you do every day? What is your day like?
Dr. Santiago Delpin: The day is busy; it is interesting, but it is very busy. It’s filled with the transplant clinics, meetings with administration, dictation, surgery, of course. But we have a team, so we share a lot of the responsibilities. With the micro-oversight that we were talking about a few moments ago, you need to be much more involved in tracking things. Tracking cannot be left to the automatic systems. You have to track, otherwise you get into problems.
We have an ASTS-approved transplant fellowship, so we have to deal with that and tend to that. We have two residents; we have nephrology fellows, medical students, and a full-time research fellow. So that takes also part of the time. We try to take tea every day in the afternoon with a research fellow, and try to have lunch every day with the staff and discuss patients and discuss administration and discuss other events or benchmarking activities that can help our program.
Interviewer: We’ve covered a lot of ground. Is there something that you would like to say in addition to what you’ve already talked about, maybe your family or how the church has affected organ donation, other cultural things?
Dr. Santiago Delpin: There is a misunderstanding regarding the cultural effect on organ donation. There is indeed a cultural factor. But I think that the experience in Puerto Rico has shown that if you attend very closely to education, it’s not public education, it’s not the masses, it is the physicians. The ICU personnel, the operating room personnel, anesthesia, neurosurgeons, that will help override the cultural donations.
Religion helps; unexpectedly, it helps. Most religions, as you know, and I think the transplant community knows, will endorse an organ donation and help out. But of course that needs tending also by your local OPO. They have to visit them and tell them what the story is.
Regarding the world vision, it’s been such a thrill to be in transplantation. You see, transplantation in the ’60s and ’70s and up to today, I guess, was in the position where cardiac surgery was in the ’50s and GI surgery before, and thyroid surgery at the beginning of the century. So it is not experimental anymore. But it is still highly exciting and that is because of the immunology.
That is because of the immunology, and having been involved in both, I have been one of the witnesses, as you have been, of the shift from plain guessing or study of phenomenon, to the molecular basis with first names and last names for virtually hundreds and hundreds of molecules. That is very exciting. And to see the way that all of the molecules are integrated continuously, and to try to, with a smile, override, convince, and persuade without doing damage to the person, that has taken a lot of art.
Regarding the current issues, of course, is donation and the different solutions or options that we have in the future. And we need to be very active in making decisions with those options.
The micro-management distracts too much. And one personal concern that I have, and that I try to be aware of continuously in this current, young cadre of transplant surgeons, is to make sure that immunology, nephrology, tissue typing, and organ preservation are part of the curriculum. So that we continue to endorse and support and foster the true hybrid person that our generation—I’m a second-generation transplanter—have enjoyed so much, rather than a plain operation only.
Interviewer: Let’s cone it down to what you see as the future of transplantation in the Commonwealth of Puerto Rico. And then close with a personal comment about what transplantation has meant to you and your family. You mentioned you kids as we were talking off-camera and so….
Dr. Santiago Delpin: The future of transplantation not only in Puerto Rico, but worldwide, will be conditioned to a worldwide effort at prevention. And when we look at the people who go into end-stage organ disease, there is such a high percent of preventable conditions, that is number one.
Number two, there should come a time in which this new generation of genetic surgeons, if you will, will take an early precondition and alter the course of many of the diseases that us transplanters do. So eventually it will not be the huge problem that it is right now.
On the other hand, the immunology field will continue. We thought we knew at one time, we think we know now. But every single immunological journal comes out with more and more interactions of the molecules and the genes. And now with epigenetics, which is such an exciting field, we think there will be no end.
The question about how it affects family life, it does indeed affect family life. There is no question, especially in circumstances where you’re starting a program and in circumstances where you have to continuously monitor the, if you will, cultural and the society pulse. The hospital pulse in your institution, not fighting for space or whatever, that is part of anyone’s work and job. But the fact that you have to continue, your system has to continue to be in charge because still it is not part of mainstream hospital life. It still needs attention and tending.
And it affects family life; there is less time. You have to convince yourself that it’s quality time that you have to give. But in the end, given certain circumstances, they can be part of the joy of transplantation if they become part of what you do. I have always said that one of the critical issues in the success of marriages and families, given that there is love, of course, as the platform, is communication, commitment, and compatibility.
And the compatibility you have or you don’t, but communication and commitment you can. So family, wife, children, and the other members of your family have to have the same importance as your professional life. How you do it, you have to become a miracle worker, but they have to be both at the same level of commitment.
[End of audio]