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Dr. Salvatierra

In their own words:

Transplantation has been very important to me. I’ve always been interested in patients and particularly patients that, you know, have a more difficult time. So certainly, it influenced what I did in terms of patient care, in terms of research, in terms of public policy like the National Organ Transplant Act. But what I enjoyed [about ASTS] is the camaraderie and the interactions with other transplant surgeons and other people in the field, both in a non and also professional basis.

Biography:

Oscar Salvatierra, MD, has spent most of his professional medical career at the University of California, San Francisco and Stanford University. A founding member of the ASTS, Dr. Salvatierra served as the Society President from 1983 - 1984, a time when significant efforts were required to appropriately develop the National Organ Transplant Act and to organize transplantation surgery throughout the United States. In addition to many efforts at engaging the Federal Government, Dr. Salvatierra formulated the Ethics Committee for our Society and refined its membership requirements. Through all of his work for societal issues in transplantation, Dr. Salvatierra has always remained clinically active, with a special interest in pediatric kidney transplantation which he directed at Stanford University. He has served in leadership positions in numerous organizations and including UNOS and the Transplantation Society.

Transcript:

Oscar Salvatierra: I’m Oscar Salvatierra and most of my career has been at University of California, San Francisco, 19 years, and now I’m in my 14th year at Stanford University. I first got interested in transplantation I think in my residency. When there were these huge bathtub dialysis machines and there was a need for access to the vascular system and I used to put in all the shunts because nobody wanted to do it. And then when I went to Vietnam I was a combat surgeon in Vietnam. When I went to Vietnam, I saw a number of renal failure cases that, you know, piqued my interest so when I came back I actually went into private practice for two years because had had it with major institutions, but found that that wasn’t really where I wanted to be. I think I had more of an academic bent and then went to UCSF. I applied for a transplant fellowship that was under Fred Belzer and Samuel Koontz. Fred Belzer who really was the pioneer in the preservation solutions and Sam Koontz who was a remarkable surgeon scientist and also had a lot to do with the legislation that in 1972 the social security amendments where, which brought about the end-stage renal disease program under Medicare. Before then you had to have cash on the table for either dialysis or transplantation.

…for our patients. Next, I think in terms of credit for what was happening was Mel Williams and Mel Williams was very much concerned about the wastage of organs for one thing and also that the organs were being shipped overseas. In fact, we have chronicled the first 20 years of transplantation, but just looking at some of those considerations early on, of course this will be deleted right here, I guess.

To underscore the point of what was happening with organs after procurement, this is data from the Southeastern Organ Procurement Foundation for the year ’83-’84, 930 kidneys were procured by the center and 266 were exported to other countries from the United States. And then there was also a wastage and this was the point that Mel Williams was strongly portraying. Now, at that time and I followed, so Mel Williams was the ninth president and you know, as you look at our society, every year you build upon the previous year and one of the most tremendous aspects of our society, especially in those early days was a collegiality amongst all its members. I mean, I’m sure the same prevails today, but it was a much smaller membership so we were very much in communication with each other.

So at the beginning, or towards the end of Mel’s presidency, you know, I continued his work and it went off into actually developing legislation to address some of our problems. And this involved numerous interactions with Albert Gore. I know, myself in the year of my presidency, made 14 trips to Washington, in part for testimonies, in part to visit with senators and representatives. Now, at that time the, in terms of congress the House of Representatives was democratic and the senate was republican. So I ended up, I mean, personally going and visiting with about two-thirds of the senators to try to develop some understanding of our issues, but I mean, this took time. You worked with a lot, not only did you work with the elected representatives, but the staff was really important.

Now to make a, not to go through all aspects of this, but to get down to what the legislation did, it did six things. It established the organ procurement in transplantation network and that was to contract with the private national entity to coordinate the distribution of organs, to maximize utilization of organs and also to set policy for organ transplantation. Now, after review of a number of bids the award to act as an organ procurement and transplantation network, that award was given to UNOS. The other thing that it did, and this was really very important, it established regional organ procurement organizations. At that time, for example, there might be a transplant center at one end of the city, another transplant center at another end of the city and both were competing with each other at a number of hospitals. You know, and it wasn’t the best thing for public relations or trying to develop a real acceptance of organ transplantation in trying to promote organ donation. So the setting up of these organ, procurement organizations, I think, was very important because it, I think, coordinated our procurement efforts, but most importantly the mandate was that you had to procure all organs, not just kidney organs. You had to have to procure all organs. So this part of the legislation, I think, as a very part of the legislation because as soon as it was in, in law, what happened was that there was a hidden benefit to the legislation which was de facto by so having these organ procurement organizations, de factor heart and liver transplantation were essentially not experimental anymore. It established a scientific registry and this was important for several reasons. Number one, for, to promote research. I mean in getting back to what this registry was, it was a compulsory registry so in terms of credibility or validity of the data from that registry, since it was a compulsory registry where data had to be submitted on every patient and this was sort of a requirement for certification of the transplant centers, it provided good data and therefore, and this was what was intended, and data that would be used for research purposes, but also for establishment of policy. In regards to policy, there was a real systematic approach. Anyone could submit some recommendation, but there had to be rationale and there had to be evidence to support that policy change.

Very importantly another thing that the scientific registry did, with the data that it provided certainly validated the claims that we had that transplantation particularly heart/liver, heart/lung, what have you were not experimental. The other thing it did, it prohibited organ purchases. In other words prohibited commercialization of organs, it established a task force of transplantation, and the reason the task force came about was there were actually four bills, two in the house of representatives and two in the senate. And the best bill was one that Gore put up and it was known as the Gore Bill. However, the senate wasn’t so agreeable to some of the provisions of the Gore bill and on their version wanted a task force. One of the things that was in the Gore Bill was a provision to help subsidize the prescriptions for Cyclosporine. So all the other provisions of the Gore Bill went through except and for that you had the task force. The task force met a number of times, it met under the leadership of Olga Jonasson and one of its recommendations was that Cyclosporine should be reimbursed. And, I mean which, by legislation later on that was provided for. There was also a bone marrow registration demonstration and study, but to show you how difficult it was I just want to read this, you know, and maybe finish with this.

The bill passed the House of Representatives almost unanimously. It was 396 to 6. It passed the senate almost unanimously, but we could not convene a conference committee and in order to try to bring this about and this was probably the most difficult part of all, but this will give you, I just want to read a few passages, I just want to read a letter that I wrote to President Reagan which pretty much outlines what the issues were at that time.

I am writing this letter to follow up on my letter of July 30th. And I wrote this September 6th. This is 1984. And the legislation was signed into law in October of 194. I began working on this with my presidency which was 1983, May 1983 to May 1984, H.M. Lee succeeded me as president and he asked me to continue with this, you know, until it was finished. I write this letter, it’s a follow up of my letter of July 30th, and to again request your assistance in assuring that some of our citizens who need organ transplants are not denied an opportunity to improve and save their lives. More specifically, transplantation legislation has been referred to a congressional joint conference committee approximately 2-1/2 months ago. However, our society’s concern with reports of a reluctance to allow this committee to convene. There is tremendous urgency to our request for you to exert your influence and leadership in obtaining an earlier meeting of this committee since congress will only be in session for approximately four more weeks before the elections. Nothing really happened until there was only one week, a little over one week before that session of congress ended and if that session of congress ended without legislation you would have to start again in 1985. So, what we did is on Friday before that last week, announced a press conference for Monday where we would have the media and kind of detail what was happening, you know, for the public to be aware that here there was almost unanimous consent by both houses, although the senate bill was much weaker, and yet couldn’t convene a conference committee for something that was really important and would be addressing a major public health issue in the United States.

So announced that on Friday and on Monday the conference committee convened before and so we cancelled the press conference. But just very briefly, the failure, just skipping down here, the failure to pass meaningful transplantation legislation with a provision to help needy patients receive Cyclosporine and so forth, there is a real fairness issue when one considers a statement of Ambassador Jean Kirkpatrick at the Republican, and the recent Republican Convention. In her address, she indicated that this present administration is spending more on foreign aid than any other previous government. It seems as though there could be a double standard in giving a large amount of aid to non-citizens while some of our own desperate citizens in comparison are being placed at a low priority level for consideration. Likewise, as you yourself stated in a radio address approximately two weeks ago, one of the goals of your administration was to advance science and technology. This is a laudable goal, but the current position of some members of the administration and Senator Hatch provides a major contradiction to this goal. While we have become world leaders in the field of transplantation, our society is having major difficulties in making transplantation under optimum

Immunosuppression available to patients despite the fact that this is the only fair humanitarian approach that can be taken. And as I indicated on that last week, it did go to conference, it was passed and, so it’s public law 98507, passed, signed into law by Reagan, October 19, 1984 and then I got a letter from the White House after the signing of that legislation.

Goran Klintmalm: There’s one last question I would like to get from you and that’s the one about perhaps, you know, how has transplantation affected your life? If you could quickly try and set that up.

Oscar Salvatierra: On the 20th anniversary of our society I, with the help of Kelly Ann Lumb went to our archives as they existed and put together a history of the first 20 years of organ transplantation. What it contains is a history of our society, it includes the transcript of the first business meeting of the society, word for word. It talks about the growth of our society and I mentioned before we started with 127 members and so forth and then it has recollections of all the presidents up until that time during their terms. In addition, it has the presidential addresses of all the presidents up until that time and it talks on various other aspects that the society has promoted, for example, the accreditation of training programs which John Najarian was responsible for, and the bit about the politics. It talks about the National Organ Transplant Act.

Goran Klintmalm: Can you tell us how transplantation impacted your life?

Oscar Salvatierra: Transplantation has been very important to me. I’ve always been interested in patients and particularly patients that, you know, have a more difficult time. So certainly it influenced what I did in terms of patient care, in terms of research, in terms of public policy like the National Organ Transplant Act, but what I enjoyed the most and this is, you know, a plus for this society, I think, is it really, really what I enjoyed the most is the camaraderie and the interactions with other transplant surgeons and other people in the field, both in a non and also professional basis.

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