History of Health Services Research Project
Interview with Avedis Donabedian
April 16, 1998
Ann Arbor, Michigan
Conducted by Edward Berkowitz
Donabedian: Yes, we are Armenian.
Berkowitz: You were born in 1919, and I'm not sure what was going on in Armenian history at that time. It was already after the disaster, right?
Donabedian: Towards the end. My father and mother were born in a small town in central Turkey, Hoghe, near the capital city, it's called Harput in Turkish. They got married there. They come fundamentally from peasant stock. Somehow my grandmother, who dabbled in health care because she was a kind of folk healer and untrained midwife, was very anxious to have her son get some education. So she sent him to a very, very good college, Euphrates College run by American missionaries. He graduated from there and did some teaching, but there was some political problem and he decided to leave everything and come to Beirut, Lebanon, to study at the American University, to study medicine, which was, I think, for him a courageous thing to do, especially since he had very little money. My mother stayed behind with two daughters, possibly three-we're not quite sure-and then the genocide started, the deportations. Sometimes they're called massacres, sometimes genocide, but basically they consisted of gathering all the more prominent Armenian men and shooting them, collecting them into a group and shooting them and burying them in mass graves. Women and children and some older men were deported, which means they were kicked out of wherever they were and sent on forced marches all the way down through the desert, through Iraq, down into Syria. Some came as far as Lebanon and Palestine. Along the way they just died-from starvation, from illness, from direct attacks, from being thrown into caves, from being pushed into water. Many, many died. The estimates are one million, a million and a half-nobody knows. My mother went through all of that. All my other family members died. My sisters died, but my mother was very brave, very tough, very resourceful, very intelligent. She hadn't gone to school at all. My father had to teach her after they got married, teach her how to read and write Armenian. But she survived. Meanwhile, my father, who was in medical school, was more or less safe, because there were no depredations or anything like that in Beirut. But there was conscription, so he was conscripted into the Turkish army. Imagine! On the one hand the Turks were killing Armenians and on the other, Armenians were conscripted into the army. He hadn't finished medicine, so he was taken in as a non- commissioned officer, and served in the army in some medical capacity. Afterwards, when the war was finished, my mother came all the way and met him. He thought she had died and suddenly she shows up. My mother says, "I arrived in the nick of time. Had I been a week later, he was going to marry a German nurse." Whether it's true or not we don't know, because my father never confirmed it. He just smiled. So, after horrendous experiences, she joined him. They decided since the war was over they'd go back to Beirut and continue my father's studies. I was born in Beirut during the second phase of the medical school experience for my dad. When he finished medical school, he went back to Palestine where he'd found a place to work and settled in a very small town, all Christian, called Ramallah, which has since become infamous, but at that time was an all-Christian, very small town. When I grew up it had only three thousand inhabitants, all Christian, surrounded by Muslims. He worked there as a village doctor, the quintessential village guru/general practitioner. Absolutely a model of the person who did everything. He was very devoted to his patients, tried hard to keep up by reading medical journals and ordering books. He had a great deal of curiosity about his art and practice, but mainly a very humane person, a very lovely person. That's where he lived all his life.
Berkowitz: And he was Christian?
Donabedian: We're all Christian. Armenians are all Christians. But we were not Orthodox, we are Protestant. My grandfather and grandmother were converted to Protestantism through the work of the missionaries in that area. So my father was a Christian and I was born a Christian and Protestant, my wife similarly. So we are Protestant Armenian Christians. The Armenians became Christian as a nation around 300 AD. Their king converted for some reason. We have suffered greatly because of our faith because we were surrounded by Moslems. We suffered a lot because we were different. We weren't Moslem nor were we Persian fire worshipers or what have you. So that's the family background. Afterwards I had two brothers born and a sister, all of them alive and well and in the United States.
Berkowitz: You yourself decided then that you'd be a doctor at some point.
Donabedian: Yes. I grew up in this little Arab town, the doctor's son, a pretty well known person. I went to a Quaker high school. First I went to a parochial school, the nuns' school. The nuns' convent was next to our house. Then I went for my secondary education to the Friends' boys' school, a Quaker school, in Ramallah.
Berkowitz: There was a Friends' school there? That's hard to believe.
Berkowitz: I don't think of them as proselytizers somehow.
Donabedian: They were there to do good, to educate people, and through their example creating social consciousness and open-mindedness. They were not proselytizing but at least trying to influence people along those lines. They were pretty successful. I think everybody who studied there was in some way touched by this openness and willingness to accept differences. They are the original people who accepted diversity, would say a good Moslem is just as good as a good Christian or a good Jew and so on. So it was both in terms of the ideology and the education a very good experience. When I finished high school, I didn't know what to do. There was nothing to do. What could one do in Palestine in those days? You could be a pharmacist, you could be a dentist, you could be a doctor. There weren't many choices, so I decided I would be a doctor. I don't think it was a very reasoned choice. My father was a doctor; I became a doctor. My brother was afraid of blood so he became an engineer. I was afraid of blood as well, but I became a doctor.
Berkowitz: So you went to where your father had gone?
Donabedian: I went to Beirut and I became a doctor.
Berkowitz: Beirut, I'd guess, was a very cosmopolitan place.
Donabedian: Beirut was very cosmopolitan, yes, and you met all kinds of people from all over the world. 'Twas a lovely town, not so large as now, still some open spaces. Some trees, groves. It was a very nice, elegant, quiet kind of life. Much changed since then. It was fun. I enjoyed my years in Beirut. I met Dorothy there and later we married.
Donabedian: The American University was also a mission, but I am not sure what mission, whether Presbyterian or Congregational, but it was originally a missionary school. They were not proselytizing either, but they hoped that through their example they would show good Christian works and what a good Christian life was like. And I think they demonstrated that amply in many ways. But later on the religious content or the background of the people who taught and the content of the education disappeared. When I first was there, we used to have chapel every day. We'd go to chapel and have somebody talk, maybe a moral message of some kind, but then that also disappeared and it became more or less secular and lost its kind of missionary flavor-which was never very marked during the years I was there. Previous to that perhaps it was more marked.
Berkowitz: What kind of doctor did you study to be?
Berkowitz: Was the word "internist" used then or just "general medicine."
Donabedian: Probably it was. Yes, I think there were internists. There were specialists in the world of medicine. This was in 1944. There were specialties everywhere else, but the university itself did not prepare certified specialists. Graduates chose to concentrate on pediatrics or internal medicine and, of course, we had surgery and gynecology. So the university, the medical school and especially the hospital was organized around specialties. Most students spent maybe a year or two in one of these specialties but did not qualify as specialists. To be a specialist you had to come to the United States and take further training, pass the exams and so on.
Donabedian: Palestine was oriented towards England, but the American University was American and oriented towards the United States. There was also a French medical school and, of course, the graduates of the French medical school went to France to do medicine.
Berkowitz: Did you think you were going to go back to the town and become a doctor, take over from your father? What sort of a doctor did you think you were going to be?
Donabedian: I couldn't imagine myself becoming a specialist, I thought. Any specialty was simply too narrow. I mean, to see children all the time-whatever. I couldn't choose anything that was more narrow than medicine in general, so I became a generalist and a physician. I went back to my father's town, my town, Ramallah, and wasted a little time here and there not deciding for sure what to do. Finally I became a doctor at a mission hospital in Jerusalem, the English Mission Hospital. I stayed there for a year or two and then decided that I needed some specialty. I woke up to the necessity to have some expertise in some field. Not that I would be a specialist, but I wanted to be a little more expert in one area. And I chose pediatrics. So I went to England, as you said, because I was in Palestine. My chief at the English Mission Hospital arranged for me to go to England. I spent six months there and came back not a specialist but with a slightly added interest in pediatrics.
Berkowitz: It must have been interesting to you. England was pretty down and out then, just rebuilding.
Donabedian: Yes. England was down and out. We went on a troop ship and came back on a troop ship. Not very pleasant accommodations. Women were separate, so Dorothy was in a big cabin for women and I was with men. We had to rough it, but it was fun and exciting. We were young. In England I stayed in a missionary hostel, which was very nice as well. We had rationing and there was no fruit, but we were privileged because the moment we got there they gave us a big book of coupons. We had many more things we could buy than the local people did. We bought a lot of things and brought them back. So it was a lot of fun. So I went back and wanted to start my own practice. When I was just about going to start, the war broke out and everything went to pot.
Berkowitz: Which war was this?
Donabedian: I was going to say I rented a clinic and started.
Donabedian: Back in Jerusalem where the English Mission Hospital was. We lived in Jerusalem with my wife for a while. Of course, Ramallah is very near, it's about eight miles to the north, so I could go home and have Mother's food and whatnot and then come back. We lived on the grounds of the Hospital in an apartment which was given to us by the Hospital. That was another pleasant year. I was going to break away from the Hospital and start my own private practice. War broke out. We left because things were becoming pretty difficult. We were hoping that soon we would be able to go back, but it was never possible to go back. The place where I was going to have my office was destroyed, was shelled. We lost everything, property, furniture, books-everything. So we stayed in Beirut. I had to start from the beginning in Beirut. I got a job at the university. Anything anybody didn't want to do, I was asked to do.
Berkowitz: Did your parents also go to Beirut?
Donabedian: No, my father and mother remained in Ramallah. Ramallah was safe. It was in the Jordanian part of Palestine. In the partition, Ramallah was on the Arab side, so they stayed there. It was ruled by Jordan. I'm not quite sure when that was lost, but I don't think they were ever citizens of Israel, my father and mother.
Berkowitz: I don't have a good feel for that time.
Donabedian: I don't have a good feel for it either because I was away. But they suffered nothing. My father and mother didn't lose anything. My father had property in Jerusalem, and he lost that, of course, but in Ramallah itself they were safe. Had we gone to Ramallah, we would have been all right as well, but we decided to go to Beirut because my wife's parents were in Beirut. And we were due for a holiday, in any case, so we packed a suitcase and went to Beirut. We thought in a week or two the dust would settle and then we'd come back, to Ramallah, Jerusalem or wherever. We didn't realize it was going be for good.
Berkowitz: So then you were at the American University of Beirut. Would you now consider yourself an academic or were you still a doctor, a practitioner?
Donabedian: At the American University in Beirut, I was mainly a practitioner when I returned. I did some teaching, but it was not in medicine. I did some teaching in physiology. I did some teaching in pharmacology. I worked in the dermatology clinic. They needed somebody to teach nutrition. I was willing. Anything that nobody else wanted to do, I would do. I did all kinds of things. But my main job was taking care of patients, students; I was a college doctor taking care of students. We also took care of faculty, we also took care of workers. We had a little something that we would now call an HMO, actually, a little health plan. We had a little building that we called an infirmary and I was the doctor at the infirmary. Later I was director of the Student Health Service, or called the University Health Service because we also took care of faculty and workers. Nobody paid any fees; it was financed by the university. We had access to the hospital. It was an ideal practice situation. After some years in that capacity, I decided there were things I didn't know. I didn't know how to run an infirmary. I knew nothing about administration. I didn't know how to keep track of supplies. I did not know how to make budgets. I knew nothing about the administrative work I was supposed to do as administrator of the University Health Service. I am a doctor, period. So I decided I had to learn, but I didn't know how you learned. I also had a professional interest in infectious diseases and the way that infectious diseases spread amongst students. We had a population we cared for and therefore we could see the pattern of illness and how people got ill, often with the same disease. And the same disease general diagnostic category showing very interesting patterns. Mrs. Smith would get sick and then we'd have fifty people like Mrs. Smith. We'd call it Mrs. Smith's disease. We didn't know what they were doing, not in books. But there were very interesting patterns of illness and subtle variations. I said, "I want to understand more about this," so I went to the dean and said, "Look. There are two things I don't understand. What are these 'things' that are spreading in this population, and I want to understand how to run the clinic." He said, "You have to go to the School of Public Health. The dean of the School of Public Health is visiting Beirut. I've arranged for an appointment." So I went and described to him what I wanted.
Donabedian: Yes. He said, "You have to come to Harvard and you have to study epidemiology and health services administration." I didn't know what epidemiology was, I didn't know what health services administration was, but I did want to go to the United States. That's for sure. And I also wanted to work. So I got a scholarship from Point Four, they used to call it, and came to Harvard. My wife got a scholarship at Boston University and continued her nursing studies. So that's how we came to the United States.
Berkowitz: So you actually went to Boston. Did you think, "I'm going to stay in the United States or I think I want to go back"?
Donabedian: I was hoping I would stay.
Berkowitz: What was the reason for that?
Donabedian: First reason, political uncertainty. You must remember that my parents were refugees in the Middle East, and they never really belonged, Armenians. We are treated in all honor-my father was a doctor-but we were still not one of the people. So I said, "Twice is enough." They were refugees; we became refugees. I became a Palestinian refugee. I had ration cards. I used to get rations because I was a refugee in Lebanon. And I said, "I think it's going to happen again. My children will become refugees again. Enough is enough. In the United States they'd be more or less settled." In particular, I knew that there was really no place for Christians in that part of the world. If you are a Jew, you belong to Israel. If you are a Moslem Arab, you belong to the Moslem Arab population. If you are a Christian Arab, you could claim affiliation to the Arabs even though the Moslems don't really fully accept Christian Arabs as fully Arabs. But I am not an Arab. I'm not a Jew. I am an Armenian Christian. I am not a Moslem. So I felt that there was no future for people like me, and I think events subsequently proved me to be right, unfortunately. And I decided I would come to the United States, the land of diversity. Then there were professional reasons. There was simply more opportunity. I didn't want to be tied to one university and therefore whatever they said I should do I was supposed to do. If I were upset, there was nowhere else to go except the same university, one place. So I decided I'll go to the United States and I'll be more free to move around, to do what I want.
Berkowitz: So after you were at Harvard where you got your degree in 1955, you were MD, MPH, and you were in the United States. Were you thinking of being an academic?
Donabedian: No. I come to the United States, I need a sponsor. I talked to the people at the School of Public Health and said, "I want to come to the United States." They were very unhappy with me because they trained me to go back and help my people. And I said, "I don't fit there. There really is no future for people like me." My professor, my major professor and advisor, was also a refugee from Germany, a Christian whose family was Jewish and at one point they had switched. He had experienced persecution in Germany, and he understood my situation.
Berkowitz: What was his name?
Donabedian: Franz Goldmann. So he introduced me to somebody by the name of Leonard Rosenfeld who eventually agreed to sponsor me to come back to the United States and work for him in a research project. He was looking for research assistants. And I agreed. I came to the United States and I stopped being an academic doctor, stopped being a clinic physician; I became a non-clinician doctor who was working on a research project with Dr. Rosenfeld, who was also an MD but had not been practicing for a long while. Once you get into the research area, that puts you in touch with academic circles. I went to the New York Medical College after that project as a teacher of epidemiology and "social medicine," perhaps you would call it. Then I was recruited to the University of Michigan to teach health care administration and I became an academic doctor. I don't really practice medicine.
Berkowitz: Did you practice at all after 1956?
Donabedian: I didn't practice medicine in the United States. I wasn't sufficiently qualified. I was not a specialist. I didn't have a board membership. I could have made a good family physician, but I decided-well, it just happened that I became involved. I came here to do research, and from research I got interested in academic things and stumbled into academia, more or less. I never planned to do what I do now. When I came to this country I didn't know what Blue Cross or Blue Shield was. I didn't know anything, nothing, a total ignoramus.
Berkowitz: So who was-you know the expression-who was your rabbi that taught you these things?
Donabedian: Well, the dean at Harvard, as I said, told me I had to study epidemiology. That was very influential. The health care administration person was Franz Goldmann, who had done a lot of work in the field in Germany and had written several books. He was very well respected, so he became, in a sense, my initial rabbi. Then working with Rosenfeld, Rosenfeld became initially the most important person in my life in terms of shaping my interests and training me in the health services research area.
Berkowitz: He was with the project in Boston that you were working on?
Donabedian: He was head of this project in Boston to evaluate the quality of the various areas of care in Boston. He was supposed to develop a method for evaluating care in the community. He chose certain topics from which one could infer what the quality of care was like. One topic was prenatal care. I worked on that more than anything else. Another area was symptoms, asking people whether they had certain symptoms during the previous six months, and whether they wanted to get care for those symptoms, and whether they did in fact get care. From that an index was developed of symptoms that were not cared for even though there was recognition of the symptom and the wish to have care. Another part of the study was follow-up of chronically ill patients discharged from hospitals. What happens to them in the community? I worked a little bit on that also. We send them out. Where do they go? How are they cared for? Another index was the study of samples of patients from several kinds of hospitals and review of their records to see whether the care conformed to certain standards of quality. That was my initial exposure to the field of quality assurance.
Donabedian: When you're a new immigrant, you don't really know who's funding what. I don't know. Probably it was government funding. Actually Rosenfeld had received money from the Commonwealth Fund in a previous project.
Donabedian: Everybody who was anybody in the public health field in Boston had some remote affiliation with Harvard, including me. I even later became a lecturer at Harvard's School of Public Health, which is just nothing, an honorific title. So he would teach at Harvard, but, then, so did everybody else. He was a kind of auxiliary Harvard-connected person. That whole circle of people in the Harvard-connected hospitals and in the research establishment in some way or another were related to the Harvard family, a Harvard extended family. But as far as the real core of Harvard, very few people were permitted to be in that.
Berkowitz: They very tightly held that.
Donabedian: Really tightly held.
Berkowitz: Looking at your papers a bit, I'm struck by how statistical they are in a heuristic sort of way. You don't run regressions, but you have lots of these little summation signs and series and so on, very advanced medical notation. Did you learn that at Harvard as time went on?
Donabedian: Have you read my papers or somebody else's?
Berkowitz: Did someone help you?
Donabedian: Oh, no, no. There's only one paper, I think, but that's because I collaborated with an economist. The major ideas of the paper are mine. The conceptual apparatus is mine, but in order to present it in a way that is respected by economists, I had to work with an economist who was formerly my student, and all those things come from him. I don't understand any of that stuff, but I do understand the fundamental concepts which I developed myself. Basically the ideas are very simple. It's when you try to provide the statistical and economic expression that you have to have somebody who knows how to run those. I have studied statistics, but it's very low level statistics, mainly descriptive, simple analytic. I did study statistics and I was much impressed by them. It's a way of thinking about the world; that was quite an important influence in my intellectual development, which I acquired at Harvard-as was epidemiology and the concepts of epidemiology. These two were very important perspectives, which colored a lot of my own thinking, a descriptive, intuitive type of thinking about health care. Basically I was trying to put things together. I had no background in psychology, in sociology. I had no background in any of the basic disciplines except medicine. Therefore I had to invent things of my own. It was a lot of fun. I had a wonderful time. Not knowing my limitations, simply saying, "This fits with this, this fits with that. Hey, I can see relationships here where people haven't seen the relationships. If I put this this way it would begin to work. If I arrange it that way it makes sense." It was this kind of seat-of-the-pants type exploration.
Berkowitz: It occurs to me that you're sort a of double outsider, aren't you? You're a foreigner and you're also not practicing, which seems to me that you could look at the thing rather differently.
Donabedian: I'm a double outsider in terms of seeing the value foundations of the health care system. I'm an outsider and, therefore, I can see how these "natives" think. It's very strange. These "natives" have really very strange ways of looking at things. I struggled with that. What are the value givens that seem to run this system? Why is it the way it is? So I developed this "libertarian" and "egalitarian" kind of model. If you're an egalitarian this is how you think about health care. If you're a libertarian this is how you think. What are the ways of putting these together? From that point of view, being an outsider was extremely helpful. I'm not as good as Lafayette at writing, but it's a kind of Lafayette-esque kind of experience. You come here and everything is strange. It doesn't make sense. And yet it does make sense once you understand what some of the historical background is and what the givens are, what are the values. That was a lot of fun to write.
Berkowitz: One of the things that struck me looking at your vita, was that, unlike people in this field, you have fewer collaborative papers. There are many more singly written papers, many more first author papers. As you say, they seem to be almost essays. That's an interesting style of working, which must have been unlike your colleagues who were doing these vastly collaborative things.
Donabedian: In those days it was more common than it is now. Now it's impossible. I did collaborate. When I collaborated usually it was with my students. Basically I was trying to give them a chance to publish something in the literature. But I did everything myself. Every paper that I reviewed, I have read, sometimes many times. Nobody did anything for me. I read everything, I wrote everything longhand, I typed. It's all done by me, a kind of artisan's work. Most of it, almost all of it is like that. Yes, I think that's a good observation. I enjoyed it too much to have somebody else do it for me, and I can't trust somebody reviewing a paper for me because you learn through reading the paper. That's the process by which-like an archaeologist-you discover things. You read another paper, you read another paper and take notes and then say, "Hey, there's something here...this belongs to this, this belongs to this...there's something lacking..." Synthesis is going on in your head, a rearrangement of things so that finally light breaks through and you say, "This is the way, this is it." Nobody can do that for me. If I had somebody else doing it for me, I'd find nothing. I would find that I would simply describe things. I'd say, "Of fifty papers, twenty of them use this terminology, thirty of them use this terminology." You know you have papers like that. There's no real synthesis, no real progress, simply a description of very superficial aspects of the papers. The most important part of my work is reading the papers and thinking about them.
Donabedian: Intuiting, exactly. At first nothing happens for the first five or six papers, and then there are things on the side going on. Two pages on readings and one of comments on the readings and then they get cut up and put together. I tell you, I have fun. It's lots of fun-when it works, when that moment of illumination comes: "Where did it come from? How did that happen? I didn't know these things. Where did this come from? I didn't know I knew these things."
Donabedian: What happened-again, your earlier question, "Who was your rabbi?"-I had been fortunate in having some friends who sort of sponsored me. When our project in Boston ended, Rosenfeld, who was my boss and with whom I had a very good relationship, came to Detroit to help establish and run what would later be called an HMO, a plan for the United Automobile Workers, a prepaid group plan as they used to call it at that time. Axelrod was in charge of the medical care or health administration or medical economics program at the University of Michigan and he was recruiting. He was looking for somebody, and Rosenfeld told him, "I know just the kind of man you want, Avedis Donabedian. He is at present working at New York Medical College teaching epidemiology and social medicine. He's the one you need to get." So Axelrod showed up and said, "Would you come to Michigan?" So, I came to Michigan. First of all, it was a day like this, just beautiful. Spring had sprung, there's a campus. You know I grew up academically at the University in Beirut, which is an absolutely beautiful campus overlooking the Mediterranean. So here's a campus, students are going back and forth, young women and young men with their satchels and books, the faculty-the whole paraphernalia of a university. And their library, mainly, was the library of the National Academy of Medicine. So I said, "I don't care what they do to me. I'd come here no matter what they gave me." And they gave me more money, so we came here. I was asked to teach "medical care administration," so-called. I'd never taught any. I went to the library and lived there for about a year and learned my craft.
Berkowitz: I see. Medical care administration.
Donabedian: You'd call it administration. The unit in which I was was called " medical economics" and it wasn't a department. It became a department later. What we were teaching was called "medical care," and there was a section in the Public Health Association which was called the medical care section, and we people who were involved in this, which was then regarded as socialized medicine, were called "medical careniks." Medical care was the kind of generic name for what we were doing, what we were teaching, which later became medical care administration, health services research, policy. I don't even know what the name of our department is now because it has changed so often.
Berkowitz: Who were some of the others that were there at Michigan with you? Health economists or health administrators?
Donabedian: There were no health economists when I joined this unit. Actually, this unit was somewhat different from other units because it had some other-than-doctors. Other units had mainly MDS who had somehow developed an interest in this. They were amateurs in the field who had somehow strayed from the core of medicine into these periphery. But this department did have, because of the leadership of the person who started this unit, Nathan Sinai.
Berkowitz: Yes, I've heard a lot of him. That's the name of your professorship, isn't it, Nathan Sinai?
Donabedian: Nathan Sinai was a veterinary doctor, surgeon, who participated in the initial study run by the Committee for the Costs of Medical Care with Falk and others. These are the fathers. Sinai hired a social psychologist, he hired an economist so we had one of each. But we had nothing in management or business. It was mainly medical care, which is a kind of-it's not really a discipline. I don't know what it is, medical care. It was largely descriptive. How the health care system is organized in the United States. What are the strong points? What are the weak points? What do you think should be done to make it better, to improve access to medical care, to improve the quality of medical care? It has no peculiar disciplinary base. These people I mentioned were supposedly going to use their disciplinary backgrounds to provide a better understanding of health care phenomena and to help solve problems in the health care field, to bring these disciplinary perspectives to bear on these phenomena of health care. The people, if I mentioned them, they would mean nothing to you because unfortunately this experiment failed. The people who were supposed to do what was expected of them didn't really accomplish much: Charles Metzner, the social psychologist and methodologist, Benjamin Darsky, the sociologist, and Kent Winter, the economist.
Berkowitz: You're right, I don't know any of the names.
Donabedian: It didn't make much of an impact. We mentioned the sociologist, the economist, and the social psychologist. Subsequently, we added, in the person of Feingold, a political scientist. Then we added a real economist, someone more expert in economics, whose name was Sy Berki. He came from Hungary. He's since deceased. And another economist, McLaughlin. Then people from organizational behavior and, for a while, Bob Kahn actually was connected with our department. We had managers. Gradually there was a shift from first of all the purely descriptive, non-disciplinary approach, kind of heuristic approach to health care. Then various disciplines tried to interject, were invited to interject their disciplinary backgrounds and expertise and perspective into this field. There was a major emphasis on policy, health care policy and then later on health care management. Our program became a program in management to a large extent. I think now the two major perspectives that are to some degree in competition with that are the social welfare and social policy perspective on the one hand and the managerial/business-oriented/private enterprise perspective on the other. It is not clear how the balance is going to play out.
Berkowitz: That's a pretty common dilemma in academia, especially in schools of public health.
Donabedian: Yes, yes. I think the trend is more and more towards economic models to explain what's going on.
Donabedian: Oh, yes. I was very deeply involved in that. They would call on me to go to Washington to give a lecture on one thing or another, but I don't have a stomach for politics. I'm not interested in politics. I couldn't be partisan. I saw my task as saying, "Well, on the one hand this, on the other hand this. You could look at it from here, from there." That's useless in politics. I testified once before a Congressional committee, and after we testified I asked the people who invited me how it went. He said, "You have no ax to grind. Everybody else has something, but you seem to have nothing." When they asked me to appear on TV I said, "No, I cannot." "Will you come on TV. We're going to have somebody from the Medical Association and you would present..." I said, "No, I cannot present the other point of view. There's no way you could make me present any particular point of view. I'm a professor and I'm not happy until I present every point of view I can think of." I work with government agencies, of course, the Veterans' Administration, lots of things but maybe at a kind of technical professional level, research level, policy level, not getting involved in the politics.
Berkowitz: How about professional politics? Like these people who were involved in starting the Association for Health Services Research and that sort of thing. You were not a part of that? You're an individualist.
Donabedian: When I first started, they made me chairman of the education committee-or the program committee-of the APHA [American Public Health Association], and after three years of that and always being criticized, I said, "No more." I worked with the Institute of Medicine on one or two of their projects and decided that wasn't for me.
Berkowitz: You were a very early member of the Institute of Medicine, maybe 1971, in the second class.
Donabedian: I think the first time it was opened up to a large group. At first it was a little group of 10 or 12. I was in the first 300.
Donabedian: There were. One of my former students was on the inside of that.
Berkowitz: Who was that?
Donabedian: Mitch Greenlick. I always suspected that he proposed my name. How he got in there, I don't know. At that time Mitch Greenlick and a few students were beginning to get known. I received a letter from somewhere, I think the American Public Health Association, some agency, and it said, "We have these new people who are in our field. We have recruited such-and-such." The people who were members of the committee were my students. And then they said, "And there are the younger people whom we'd like to invite like Avedis Donabedian." That was funny. These are my students; what are they talking about? So I probably was known by some and totally unknown to many. It took me a long time really. It took me about 10 years before my ideas became popular. Though they became popular, I always insist it was being misrepresented, that I did not say what they say I did, and so on.
Berkowitz: Talking about your ideas becoming popular, you say the quality one caught on, but the others did not quite catch on.
Donabedian: It did not catch on in a general population. My students continued to use these models and they have also been applied, as for example, in Mexico, where one of my students became very prominent in health care reform and used these paradigms, these ways of thinking, extensively and very successfully. So within a narrow compass, they have been noted and used. I was talking before on a method of working and what drives one to work and saying that I am looking for understanding even when one does not have the opportunity, nor does one have the need or the desire to be personally involved in bringing about change but merely in presenting to others certain ideas. I was going to say, there's a certain aesthetic in this. If it is produced and it looks beautiful, looks persuasive and looks elegant, then you can give it a visual representation that's beautiful, symmetrical. At the same time if certain things are missing, you can see that. "There should be something here," and you begin to work on that and put it in. I had had experience as follows in using these models. People come to me with research problems or something they want to do and I say, "Well, let's see. We can think about this in the following way," and I use whatever I have produced and it works. Where they have been properly applied, they do provide understanding and illumination, and they improve the probability of finding the right solutions. I have no solutions; nowhere in my work does it say, "This is how you should do things." But everywhere in my work is the admonition, implied or explicit, "This is a good way of thinking about these problems. I think you'll do much better if you think this way. It's a more systematic, more organized way of thinking and taking into account all the important variables that bear on the decision that you are going to make." That's basically what I have claimed for myself.
Berkowitz: You mentioned Mexico. You seem to have a lot of Hispanic connections in your work.
Donabedian: That has to do with one of my best students, the one who understood me the best. There were times when I was very discouraged because it looked as if nobody understood me. Nobody thought that anything I said was of any value. "What's all this? It's too theoretical. It means nothing, it applies to nothing. We don't know what to do with it." And lo and behold, I got this student from Mexico. His name is Julio Frank. They made sense to him immediately, and he made me feel maybe I'm not that off the map as I think I am. Here's somebody who's intelligent who thinks it makes sense.
Berkowitz: So you were simpático.
Donabedian: We were very simpático and he helped me. I helped him understand things that had bothered him which he couldn't understand. He was a physician and had thought about these things. He was at a loss how to make sense of things. I helped him, and by observing that I was helping him, I helped myself believe that I had the right ideas because they were helpful to this guy. He was brilliant. He became in a sense-he was my student-more of a colleague than a student. Subsequently, when he went to Mexico he was very well connected there and he could do things. He established a center for health services research, for example, and he did the whole center and its program around my paradigms. I would go there every year and meet with a group of colleagues and listen to what they were doing, give advice. That's the way my connection with Mexico started and has continued. And then some friends, some people totally unknown to me, in Spain met me at one of the international conferences and talked to me. They said, "We want to establish a foundation in Spain to study health care quality and other aspects of health care policy and evaluation, and we'd like to give this organization your name." Well, I didn't believe it when they said your name. I didn't think that they would name it after me, but lo and behold they did, the Avedis Donabedian Foundation. It was quite a surprise. Through that I have made many friends in Spain proper.
Berkowitz: Do you speak Spanish?
Donabedian: I can read but speaking is impossible. I can't make head nor tail of it. But I am interested in Spanish literature. I love to read Spanish. There's a reinforcement that helps me stay close to Spanish literature.
Berkowitz: So that's another culture that is a Christian culture that was very much informed by the Moslem culture.
Donabedian: That's what attracts me a lot about southern Spain where we've visited several times, the Jewish-I speak a little Hebrew and I can read Hebrew with dots-and Arabic, of course, and the Christian. The intermixing of these three cultures is fascinating to me and I love it. I enjoy myself a lot reading about these things. That comes from personal experience with all three cultures. Almost all the patients at the English Mission Hospital were Jewish. It was a mission to the Jews, to convert the Jews. Of course, we never converted anyone, but I got to speak pretty good medical Hebrew. "Where does it hurt? Do you have good bowel movements?" I read the Bible and now I'm reading the Haggadah. I love Hebrew. It's very similar to Arabic in many ways. I love Arabic.
Berkowitz: What language did you speak as a boy?
Donabedian: Two languages, Armenian at home and Arabic outside, on the street. This was an Arab town, so I was bilingual. But I've forgotten much of my Arabic and also the Armenian. Basically I speak English most of the time, but I'm now trying very hard to strengthen my Armenian. Dorothy and I read Armenian every day, and English and French. On my own I read Spanish.
Berkowitz: The French is from Beirut?
Berkowitz: This is my last question. Now that you're retired, do you keep working on these projects?
Donabedian: Mainly I have lectured. I've done one or two things during my retirement. Probably the major work I did was for the Institute of Medicine. That had to do with what do we know about the effectiveness of quality assurance. I think that's one of my major pieces of work. Again, they use this technique of commissioning various people to write papers. There ten or twenty of them I know, and those chose a few of those papers to be published. They were published together in a little paperback.
Berkowitz: Which one is this now? Is this about their history? You have a piece in this. That's a small paper, that one, a different one.
Donabedian: That's a nice paper but it's nothing special. No, the other one is I think-what should I say? I have this certain degree of arrogance that says there's nothing has been done like it, nothing could be done like it in the next 50 years. I don't think I've done anything better than that in my life. But it's so abstract, so esoteric. Maybe it's so wrongheaded, I don't know.
Berkowitz: Do you use computers?
Donabedian: No, no, I don't know anything about computers. I write everything longhand.
Berkowitz: This is the one paper, I know, "A Quarter Century of Work on Quality Care."
Donabedian: That's in homage to my friends. This other is a, I think, very important one.
Berkowitz: Which one, "Continuity and Change in the Quest for Care"?
Berkowitz: So you've done that since you retired?
Donabedian: I think so.
Berkowitz: When did you retire?
Berkowitz: I think that's a good place for us to stop. Thank you very much.
American Public Health Association 12
American University 1 3 5
Student Health Service see University Health Service 5
Association for Health Services Research 12
Avedis Donabedian Foundation 13
Beirut 1 3 4 5 10 14
Berki, Sy 11
Blue Cross 7
Blue Shield 7
Boston University 6
Committee for the Costs of Medical Care 10
Commonwealth Fund 7 8
Community Health Care 7
Darsky, Benjamin 11
England 3 4
English Mission Hospital 4 14
Euphrates College 1
Frank, Julio 13
General medicine 3
Goldmann, Franz 6 7
Greenlick, Mitch 12
Harvard University 5 6 7 8
School of Public Health 5 6 8
Health Care Policy 10 11 12 13
Health Statistics 8
Hospital administration 5 7 10
Institute of Medicine 12 14
Jerusalem 4 5
Kahn, Bob 11
Lebanon 1 6
Medical Economics 10
Metzner, Charles 11
Mexico 12 13
Michigan, University of 1 7 9 10 11 12
Missionary work 2
National Academy of Medicine 10
New York Medical College 7 10
Palestine 1 2 3 4
Quality Assurance 7 14
Ramallah (Palestine) 1 2 4 5
Rosenfeld, Leonard 6 7 10
Sinai, Nathan 10
Snyder, John 6
Spain 13 14
United Automobile Workers 10
University Health Service 5
Veterans' Administration 11
Winter, Kent 11
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