The New Age
The story could have ended here. However, the events of the 2 years following my departure from the position of director of the program could not be ignored. Nor could my former close associates’ persistent urgings that I record what happened. Since it is all still recent, there is the risk of a biased judgment and for this reason, wherever possible, I have included the actual words of the relevant documents.
In reality, in this “new age” for the program, my former associates only had to follow the well-trodden path to ensure success. Well trained, they took over a transplant program that was perfectly organized, recognized, and confident in its 70 successful transplant operations. The decision was, therefore, for both my former associates to be directors, with my presence as consultant until the end of the year to support them in their first steps.
Unfortunately, this settlement was doomed to failure. Each of the interested parties felt unjustly treated, that he alone should have been selected as director and leader. The bitterness—unjustified, as I have explained—first of all united them against me during the first months of my term as consultant. Perhaps the short-sightedness of the board with its successive decisions to restrict my responsibilities spurred them on, giving them the mistaken feeling of immunity that led them to the unwise decision to suspend the program’s operations and to the questionable care of the patients.
Thus, from the first day, the change in the management of the program and an unwillingness to draw on past experience became apparent. The program was sidetracked from its philosophy, its procedures, even from its dignity. Serious mistakes were made, costly for the patients and the center’s reputation.
My tenure as special consultant had, therefore, become a thankless task, if not a misery, because of my virtual exclusion from the transplant program. My visits to the center, although daily, were brief. We managed to collate and publish the results of the 73 transplant recipients in the journal Transplantation Proceedings, with an international circulation. Under hidden school* conditions, we gave the text to a trustworthy secretary who after work and for a special remuneration agreed to type it. The paper was published in December 2009, establishing the Onassis program in the international arena for, as I wrote, its 94% survival of transplant patients in the first year and 70% after 10 years.
*Schools run in secret by Orthodox priests during the time of the Turkish Occupation in order to keep the Greek language and culture alive.
Unfortunately there followed the events of summer 2009 with the unprecedented suspension of the program’s functioning from mid-July to mid-August because of “summer vacations,” with the result that the reputation of the program and therefore the center’s was irretrievably damaged. During this period, six donors were rejected without assessment, and at least 10 grafts were made use of by European programs. At this time, there were 28 candidates on the Onassis waiting list, 19 for hearts and 9 for lungs. Six of these patients died before the end of the year without receiving a transplant. Of course, no one could be sure that the grafts, if they had remained in Greece, would have gone to these six unfortunate candidates, in the same way that no one could deny that a possible opportunity was lost to them.
The dysfunction was condemned in writing by the “Synechizo” group of transplant recipients. It was supported by the faxes of rejection sent by the transplant unit to the National Transplant Organization. They each had the same content and referred “to unwillingness to regroup the transplant team owing to summer vacations.” Then the handwritten (and therefore particularly believable) entries of the coordinators of the National Transplant Organization in the donor assessment forms were published, confirming the reason for their rejection.
The reaction of the hospital administration was complete denial or as much as possible the minimization of the importance of the misconduct. What was impressive, however, was the spasmodic way in which they reacted. The chief of staff hastened to assert in writing that “the publication aims at defaming the Onassis … based on falsified and unsubstantiated information.” The hospital director, on a different wavelength, accepted that “organs had not been harvested during the summer break,” but he attributed this “to the desire of those responsible for the program for the collective participation of all the members” of the program. After this the center’s wily legal counsel, with great agility of mind and without mentioning the substance of the matter, imputed to the person responsible for the program “a probable administrative oversight” because he “did not check” the correspondence with the National Transplant Organization. The latter, however, disagreeing with all three, claimed that “all steps were taken to assess the grafts on offer and the donors were considered to be unsuitable.” Therefore, the program “had not closed down,” the grafts were simply “not good enough.”
And this episode closed with the sending of a reassuring letter from the chairman of the board, a former university professor and failed transplant surgeon, to the patients: “The export of grafts from one country to another is a usual practice, when there is no suitable recipient in the country of origin.” The chairman’s observation is quite correct “when there is no suitable recipient.” However, during this period there were 28 active recipients on the Onassis waiting list, so that for every graft that was rejected there was more than one candidate.
Even before these many declarations had been made, the transplant recipients took the case to the ombudsman who investigated the matter in depth. Thus, in June 2010 Professor Ioannis Sakellis presented his conclusions in person to the new board of trustees of the center: “It is reasonable for the belief to arise that the rejection of the grafts during the crucial time period was due to unwillingness to bring the transplantation team together because of summer vacations. The preservation of the smooth running and the good reputation of the OCSC weighed more than the effective investigation into the malfunctions and the search for possible responsibilities for it.”
Drawing on my experience at Baylor and the almost disastrous course of the program in 1991, I had repeatedly brought it to the attention of my subordinates that performing transplants under outside influence was bound to fail. It seems, however, that this lesson too was ignored, when in November 2009 a 56-year-old who was completely stable on long-term mechanical circulatory support was called for transplantation with a heart from a hospital in Thessaloniki. Serious doubts were expressed about the quality of the graft, as members of the team confessed later, because there were fresh blood clots in the heart chambers. The graft failed to work from the outset. The patient succumbed 2 weeks later. Why, though, had they accepted such a heart? Perhaps to make good the loss of grafts during the summer?
The last tragic development concerned a 48-year-old, the final transplant recipient during my tenure, in November 2008. He came back to the center with premature dysfunction of the graft at the end of December 2009, and it was obvious that he needed long-term mechanical circulatory support until a new heart could be found. They did not do this and the commendable efforts of their junior colleagues were not successful. The patient succumbed 2 days later and for the next 6 months I did not set foot in the center until I was appointed chairman of the board on June 30, 2010.
The conclusion, therefore, from the “new age” up to then was that in spite of my timely and laborious attempts to secure worthy successors, the program declined. It required firm ground to walk on and that would only be ensured by an administration with knowledge, independence in the making of decisions, and unshakable determination to apply them. These prerequisites were missing so that, at least for the immediate future, the new arrangement would be nothing more than the shadow of its predecessor.
Spring Without Summer
But let us return to December 2009, when my thankless term as special adviser formally came to an end. I would have resigned much sooner if I had not promised my transplant recipients that I would remain “where they could see me” until they adapted to the new regime. In view of their wishes, therefore, I agreed to stand as a candidate for the chairmanship of the center’s board, although my own personal interest in returning the center to its earlier way of working, before the two boards under Professor Ioannis Papadimitriou (2004-2010), also weighed on me. Even so, I was very hesitant because I foresaw the reactions and knew the problems first hand. In this regard, the new board was appointed 6 months later and for only 6 months, although with an explicit promise that it was a question of procedure and that the 3-year term provided for by the law would follow.
Like all boards, ours had a vision, immediate goals, and some thorny problems that it had to solve. From its foundation, the Onassis has been a private, nonprofit organization, which means autonomy and independence in the making of decisions. This, however, presupposes economic independence, which was clearly lacking all the previous years it had been operational, because of two unmoving rocks: the underpriced high-level health services on the one hand, and the excessive number of overpaid employees on the other. So, whereas the international management company KPMG had originally suggested a workforce of 450, with 55 doctors, we had taken on 750 workers and 95 doctors. This meant tightening the belt with the help of people known for their experience and responsibility in business. Such qualifications were possessed only by the Onassis Foundation, which during the previous years had been discreetly financing the maintenance and the buying of equipment without interfering with the administration.
The center’s founding law specifies an annual government grant, since there are no bequests. With this a certain balance was achieved during the first years of its operations. In 2000, salaries of nonmedical staff came to €14 million. Ten years later, the amount had skyrocketed to €34 million, an increase of 142%. Each year raises were given of 5% to 10%, with the exception of 2004 when the increases reached 20%. These impressive salaries were the result of accepting trade union demands to keep the workers happy. Unavoidably, with the productivity of the center fixed and given that the government grant remained at €8 or €9 million annually, there was a shortfall of up to €30 to €35 million each year, which the board covered by “internal loans.” In other words, they were collecting funds but instead of using the money to pay suppliers, they were channeling it into staff salaries. The suppliers became involuntary lenders, provoking the sarcastic comment of one of the hospital directors: “The Onassis belongs to its suppliers and not to the state.”
But apart from the vision and the goals of the new board of trustees, there were the difficult problems that touched the moral existence of the center and were an indicator of the integrity and courage of the new administration. Immediately after the presentation of the report by the ombudsman, the board appointed a three-member committee whose report, after an exhaustive investigation and many depositions, concluded:
The offered grafts were rejected owing to a failure to regroup the transplant team because of summer vacations.
At least ten (10) grafts were lost.
No graft was assessed.
An attempt was made by the administration of the OCSC, the general director and the legal counsel not to attribute particular responsibility to those in charge.
The board was given misleading information … and there was an attempt to reassign blame to individuals who were lower down in the hierarchy.
The Parthian shot, however, was fired by the chief of staff and this is to his credit. In spite of his original declaration that the whole affair amounted to “defamation” of the Onassis, he stated categorically to the investigative committee that the grafts were not used “because the transplant team could not be assembled” and also that “the program should not have been shut down.”
Shortly afterward the report of the health inspectors was made public, and this confirmed that the faxes rejecting the grafts “were dictated” by the head of the program, as the three coordinators had testified, something he himself had denied in his own deposition. Furthermore, the report, casting doubt on the accuracy of the medical facts that had been declared, recommended that “the correct person to rule on these events is the public prosecutor of the Athens Magistrates’ Court.”
To sum up, therefore, the three audits—by the ombudsman, the Ministry of Health, and the investigative committee of the center’s board—did not leave the slightest doubt that the program really did close and the grafts were really lost. After the publication of the findings, my former deputy in charge of the program submitted his resignation and it was accepted.
During its short term in office, the board managed to achieve the goals of the previous months, if not years. It reduced general expenditures by 18%. It reduced by a third the outlay on drugs, introducing generics and abolishing the exorbitantly expensive “boutique” antibiotics. With the help of the Onassis Foundation, it added four cardiac surgery beds to the ICU, increasing the productivity and the income of the center by €4.7 million annually. Michalis Papadakis, head of the department of organization and information systems, contributed greatly to the achievement of these goals. Evidence came to light about productivity (number of operations annually), surgical efficiency (length of operations), and safety (mortality indices) of the heart surgeons. Similar information came to light about the implantation of assist devices and the use of disposables by the invasive cardiologists.
The scene for the real confrontation was set in January 2011 when the union, in the middle of the economic crisis, demanded “an increase of 5% on the basic wages” and, to cap it all, the outrageous—and macabre—request for “an allowance of €100 for the laying out of the dead.” The crisis broke in February when the board voted for a reduction of allowances to the amount of €9.4 million in view of the new collective work contract. It was also decided to cut €2 million from the doctors, mainly for reasons of equality.
Government Intervention
In spite of the disputes, now a daily occurrence, I could not help noticing the obvious indifference of the Ministry of Health to developments at the center. Between November 2010 and March 2011, I sent six letters to the minister and a further five to the general secretary, “on all matters” but with particular emphasis on the economic.
The mystery of the ministerial indifference was solved toward the end of March 2011 at the two meetings of the 50-member Parliamentary Committee on Social Affairs, chaired by our former cardiology director, Demetris Kremastinos, who was also a member of Parliament. They were programmed following the announcement by Minister of Health Andreas Loverdos to the press that he was being pressured by “conflicting” recommendations about the center, which was “collapsing” under economic difficulties and administrative errors, “while he himself was caught up in the “usual Greek blackmail.” One wonders how it is possible for a minister to be blackmailed, and by whom? It was just shadow boxing.
Two days before the first meeting—March 23rd—I sent a very detailed memorandum to Chairman Kremastinos about the center’s chronic problems—as old as the hills—about the measures taken by the previous boards, and about those we were planning to take, so that the members of the Parliamentary Committee would be informed in good time. It was all there: the numbers, diagrams, statistics, for anyone who wanted to know.
As it later became clear from the positions taken by the members, the memorandum we had sent was circulated only a few minutes before the beginning of the meeting. This harmed the assessment of the facts but it was beneficial for the minister as well as for the chairman of the committee when they reached the stage of making arbitrary and to a large extent false statements. The members of Parliament, in their turn, without the restraint of having heard “both sides of the story” and not having read the memorandum containing the exact details, restricted themselves to repeating irresponsibly what they had heard from the trade unionists. And what hadn’t they heard! Unfortunately, the proceedings did not permit intervention—in this case rebuttals of the monstrosities we had heard. But I did have the opportunity to point out that the essence of the problems was that “the days of the fat cows” had passed. Furthermore, I emphasized that the contentiousness of the employees was due to the fact that they did not want to be faced with a board that had an opinion and above all the will to enforce its decisions.
However, the meeting was dominated by the speech of Antonis Papadimitriou, president of the Onassis Foundation. After referring to his continuing practical interest in the center, he commented on the criticism of the Onassis as a hospital as well as on the criticism of the current chairman: “He is not, of course, responsible for the misfortunes of the hospital for the last 15 years.” In conclusion he added: “I am not Dr. Alivizatos’ advocate, as the Onassis Foundation introduced and voted on his retirement because of his age.“
In the limited time I was allowed at the end, I again underlined the fact that the committee had been misinformed and criticized the impassioned comments from members and trade unionists. I repeated that the battle against our administration was happening because it stood in the way of interests and because it had shown that it could make decisions. Addressing the unionists, doctors, and employees, who were listening in embarrassment, I said: “You are doing enormous damage to the hospital with what you have said and it will come back to haunt you.”
The discussion was closed by Nikos Karafolas, president of “Synechizo”, who expressed his anger and sadness over what we had heard, assuming responsibility for reporting publicly the program’s malfunction during the summer of 2009. He finished by saying: “With the arrival of Alivizatos, a program was created with a 70% 5-year survival … while other similar attempts had a 50% mortality in the operating room.”
In his letter dismissing the board, a month later, the minister again referred to a “board declaration” to justify his action. There never was a “declaration,” only an information leaflet for the staff of the center concerning the possible delay in the payment of salaries.
And to put the record straight, there really was not enough cash, and salaries were paid in two installments, following a written explanation by the head of financial services Zoe Gamalia, who courageously declared that “this amount … was insufficient to cover salaries.”
In spite of the botched scenario for the change of the board, I do not blame the politicians, even when they are doctors. First and foremost they are politicians and then doctors. They listen attentively to the wishes and desires of their clientele and act accordingly. Neither do I blame the trade unionists, doctors, or employees, who in this case were used as a battering ram.
Those I really blame are my former colleagues, the so-called “silent majority” who did not stand up to the trade unionists’ downward slope of distortion of the facts. They knew about the center’s efforts to be independent and to reorganize but did nothing.
But why? We all know the answer. Because they are weighed down by centuries of teaching to make haste slowly until they can first see which way the scales are tipping. The most important thing is not to be among the “losers.” This is the mentality that my first chief, Yannis Boudouris, called “petty politics” and that my father more elegantly dubbed “going with the flow.” And so the Onassis returned to its orbit around the Ministry of Health, and the familiar landscape of the “peace” with the union was restored!
As I wrote in an article in May 1976 for the newspaper Eleftherotypia, quoting a respected teacher: “He who plans to sow in infertile soil must do so even if he is sure that the first year it will be wasted.” The exhortation was of the great Gerasimos Alivizatos.
Ten Years
The gods know future things.
Of what’s to come the wise perceive
things about to happen.
While in the street outside
the people hear nothing whatsoever.
—“Wise men perceive,” C. P. Cavafy
In the introduction to the last chapter, I wrote that when events are recent, “there is the risk of a biased judgment” when they are recounted. I also mentioned the criticism that the transplant program “was sidetracked from its philosophy, its procedures, even from its class.”
Altogether, 10 years have gone by since the passing of the baton to my former subordinates, and the period is long enough, I think, for a sober assessment of the facts and the drawing of conclusions helpful for the future.
On March 29th 2012, Minister A. Loverdos sat in on a board meeting that took leadership of the program away from A. Baïraktaris and appointed as acting director P. Sfyrakis, who held that position until the end of 2015. The new head of the program devoted himself zealously to his duties, performing 17 transplants with a total mortality of 27.7% for that year. It was clear that again under the pressure of producing “numbers,” the program accepted second-rate grafts, which I had told my subordinates ad nauseam to avoid. No one in his right mind would have given a peripatetic 34-year-old mother and candidate a graft that had been battered with inotropes in the ICU for 21 days and from a donor colonized by a “panresistant” organism. Needless to say, the result was both predictable and devastating. Transplantation means having the patient alive 10 and 20 years later.
Results improved in the following couple of years. However, during this period, 11 patients of the “Old Guard” (1996-2008) succumbed, leaving unanswered questions regarding their loss. These thoughts I encapsulated in a letter to the new chairman of the board, drawing the attention to the high perioperative mortality but mainly to the losses due to the relaxation of the long-term post-operative follow up of the patients. Not unexpectedly, my letter to the chairman, received no reply.
In coming in 2016, the new board showed its true colors, both symbolically and actually. In February, without warning or explanation, the 70 photographs of the transplant recipients of the first period, 1996-2008, were taken down. The subjects of the photos had been particularly proud of them, since under each one, without mentioning names, there was a brief history of the illness and the origin of the graft. When I asked about it, I received the answer that the administration was looking for a better, more dignified space to display the photographs, which, needless to say, was never found.
Survival : Two Periods
A different survival
after
the change of the guard.
Beyond the symbolism, the new management of the center was trying to deliver a message. At the same time, there began indoctrination in the philosophy that would distinguish the new from the old. This concerned the participation of all, since transplantation does not require any special skill, knowledge, or dedication! Initially, two transplants were carried out in January and March 2016, without anything untoward happening. . During the third case at the beginning of April in the same year, however, the shaky foundation of this disastrous mentality became apparent. The novice transplant surgeon sent to a nearby hospital, where the ischemia time for the graft would not be more than an hour, botched the preservation and the patient required extracorporeal membrane oxygenator support. The transplanted lady remained hospitalized at the center because of a multitude of complications for the next 6 months. At least she lived to be discharged.
The next two patients were not so lucky. The first, a 60-year-old man who was operated on in June 2016, died on the table after a marathon procedure, because the otherwise capable cardiac surgeon who now only had a “faint recollection” of transplants. Thus, the patient succumbed during surgery. Three months later, there followed the loss of a 15-year-old with an excellent graft. Instead of assigning the anesthesiologist expert in handling this problem, the “on-call” person was entrusted with the anesthesia, in keeping within the framework of everyone does everything. Thus, suddenly everything clotted up, pump, tubes, and patient, who died on mechanical circulatory support.
After this second failure and the exposure in the press, the team was reorganized with younger, trained people (two of them are my disciples) with an immediate improvement of results. So, it was indisputably proved that everyone does NOT do everything, that transplantation requires hard training, knowledge, and dedication. With a great effort, the 10-year results were collated. It should not be forgotten that the program data are no longer reported to the International Society of Heart and Lung Transplantation.
It is not necessary for one to be a specialist to understand that the survival of the second period (2009-2018) falls 15% short of that of the first (1996-2008). It should be noted that in the world of transplantation, a difference of 5% in survival also determines the classification of one program as exceptional as opposed to another which is average.
To start with, the perioperative mortality was almost three times greater (14.3% vs. 5.4% earlier on). Also, a total of 37 patients died in the second period, including 18 transplants from the first period (from 1996 to 2008). In essence, 37 patients perished in the 10 years 2009-2018 versus only 8 in the 12 years 1996-2008. So much for irresponsible changes of leadership for the sake of “reform” through the infusion of unproven “new blood,” discarding knowledge, experience, and dedication.
The Price of “Reform”
Heart transplantation at the Onassis Cardiac Surgery Center (1996-2018).
Losses before and after the change of leadership.
In spite of the grave mistakes committed by the management of the transplant program since 2009, no one ever felt obliged to explain and certainly not to apologize for the inexcusable waste of human life. Obviously, the managers were too proud to admit fault. This brings to mind the pithy comment made by the distinguished Captain T. H. Dyer, US Navy, that there is no greater insult for individuals with limited horizons and unbridled ambition than to be proved wrong in their predictions.
Legacy
This year marked the 30th anniversary of the opening of the Onassis Cardiac Center. Many, so many, things happened in these years that it is impossible to fit them all into what from the outset was intended to be a brief account.
The first, although mentioned only in a whisper, concerned the tragic lack of communication between the original board of trustees and the new directors who would come from abroad. With exceptional perception and shrewdness, this had been pinpointed by the first hospital director, the late Antonis Kontaratos. He called it a “problem of the difference in culture between Greece and America leading to an inability to communicate.” Pessimism about lack of infrastructure was shared by other colleagues from abroad, and so the board set out on an informal shopping spree among the cardiac surgeons of Athens to see who would be willing “to make a start.” This resulted in the resignation of the first to be appointed, Professor C. Anagnostopoulos, in January 1993. There followed the assigning of coordinating duties to anesthesiologist Lila Papadimitriou, which led to the resignation at the beginning of June 1993 of the most renowned anesthesiologist of that time, Tasos Triantaphyllou, the close associate of the pioneer in lung transplants, Joel Cooper. Fortunately for the center, director Stephanos Geroulanos had already taken up his position and was working feverishly to prepare the ICU. Thus, in June 1993 my colleague and friend, Alkis Michalis, bravely inaugurated the cardiac surgical activity of the center. In the fall, the respected cardiac surgeon, Georgios Palatianos, started work as a director.
The years 1996 and 1997 were overshadowed by the very acrimonious dispute, even reported in the press, between the director of cardiology, D. Kremastinos, and his deputy, when the former resumed his duties after his term in office as a government minister, and the latter demanded that he should be the only one responsible for his own patients. The matter spiraled out of control, splitting the medical personnel and costing the writer his close friendship with the deputy director.
The years 1996 to 2001 were taken up by the efforts to organize the transplant program in the face of competition for grafts from the Evangelismos and the Papanikolaou hospitals, and with the lack of referrals of patients from other institutions, especially the university ones. It should not be forgotten that the Onassis had been accused, even on television, of being elitist and was subject to general dislike. From its own internal resources, therefore, those few transplants were performed which kept the program alive until it finally rose to dominance. In 2003, the two other programs were obliged to disband. I believe that, apart from the withdrawal of their worthy founders, the results of 30% survival at 5 years were not particularly encouraging for the continuation of the efforts of their successors. *
*Although the first heart transplant in Greece took place at the Hygeia Hospital, the track record of its program was not included in the statistics of the Ministry of Health in 2001.
A new obstacle appeared, quite unnecessarily, with the drawing up and passing of the law regarding transplantation and the creation of the National Transplant Organization. The work of this committee under the highly respected Professor G. Koumantos will remain in the annals of history as a model of wisdom, conscientiousness, and detail. It was also modern, since it took into consideration the relevant guidelines of the European Union. The law, apart from the fact that it established brain death, which forms the cornerstone of the donation of organs, instated an unbiased system of managing and allocating the graft to the rightful recipient. This caused new reactions from the transplantation establishment. These disagreements, as usually happens, were reported in the press and public opinion reacted in the familiar way: with complete lack of trust in the medical establishment, which led to a dramatic fall in organ donation. Thus, in 2001, the index of organ donation fell to just 3.6 donors per million. It was the collateral damage of the medical dispute.
The next major upset that has already been exhaustively analyzed was the “civil war”, as I call it, with my in every way worthy pediatric cardiac surgeon colleague. It lasted from 2000 to 2007, when he left the center. The conclusion to be drawn from this dispute is that indecisiveness is worse than a wrong decision.
The years 2004 to 2009 were marked by the disagreement with the board of Professor Ioannis Papadimitriou over his insistence on advertising all the senior positions, again causing upheaval, pointless discussions, and uncertainty for the medical staff. Up to that point, the center was running smoothly and productively in all departments and, in American folk wisdom: “If it ain’t broke, don’t fix it.” It showed unequivocally his lack of favor for the transplant program from that time on. In addition, it established the arbitrary “retirement age,” nonexistent up to then in the bylaws, with no thought for the continued contribution to the center of the knowledge, experience, and talent of those who were slated to leave, which is exactly what happens with pensioners in the civil service. Obviously he did not believe in the development and final prevalence of a heart transplant patient program, contrary to his previous spectacularly failed attempts to create a liver transplant program.
It would, however, be unjust to consign all the responsibility to Professor Ioannis Papadimitriou’s decision. The participation of the Onassis Foundation in the unanimous decision is shown by the minutes of the center’s board meeting of December 2006. As I have already mentioned, no one knew about it until December 2008 when I was told in front of the whole board that my candidacy for appointment renewal was “null and void” because of the existence of a “retirement age.” As for the relevant proceedings of 2006, as I pointed out, their existence had only recently been discovered (2017). The decision of December 2006 regarding “retirement age” would turn out to be of cataclysmic importance for the subsequent course of the center. It marked the abandonment of the private character specified by the founding law and essentially its turning over to the state. These I consider to be the major crises of the 25 years.
In conclusion, I wish to pay tribute to three leaders whose acquaintance and cooperation make me really proud. I have already mentioned the late Georgios Koumantos, who twice gave essential help to the transplant program. The first time was when he recommended the well-known expert in administrative law, Christos Politis, thanks to whom the threatened break-up of the program was “frozen” for 2 years. A little later, as vice president of the National Transplant Organization, he foiled the attempt to revive the question of a separate pediatric transplant program and to discuss, completely out of context, the relevant document of the Onassis board to the Ministry of Health.
Chronologically, the second leader, from the sphere of medicine this time, was Professor Kostas Stephanis. I have mentioned previously the perspicacity and terseness of his pronouncements, products of an unusual mental capacity. However, I really admired him in March 2004 when, as minister of health and 2 days before the end of his tenure, he had the courage to reverse a previous decision of the center’s board under his chairmanship, in November 2001, on the basis of which the program was going to split into two competitive subgroups.
The third great man during the 20 years of my sojourn in Greece was the president of the Onassis Foundation, Stelios Papadimitriou (father of the present Foundation president). I had always declared that the reason for my return to Greece was the Onassis and also that I considered my real employer to be the Foundation and not the amateur chairmen or the civil servant apparatchiks of the board.
Thus, I am pleased to recall the anticipation, perhaps even a certain awe, that we all felt when Stelios Papadimitriou entered the conference hall, full of life, challenging, exuding gravitas, carefully weighing his words. Although he was never very friendly toward me during my early years at the center, I think because of my unbending stance about pediatric transplants, in 2004 he understood what was at stake and radically changed his attitude. I had the opportunity to say goodbye to him a few weeks before he died in November 2005. I still remember the affability with which he said: “Sit down, Dr. Alivizatos, you are more than an associate, you are a friend.” And turning to his associates he said: “You know, Dr. Alivizatos reminds me of myself when I was young, a fighter and persistent as he is.”
These were the three most worthwhile Greeks that I came to know after my return in 1996. They had something in common: the supreme virtue of being able to recognize and correct a mistake, which requires integrity, the ability for self-criticism, and above all self-assurance. They were the antidote to the Laistrygonians and the Cyclops waiting for me in Ithaca, mentioned in the preface.
Since my retirement I have been repeatedly asked two questions: Do I regret coming back to Greece? and Did my compatriots deserve the sacrifice, medical, social, and financial, especially after their ungrateful behavior? The answer to the first question is always “No,” because I was, so to speak, programmed to return some day, fulfilling the family tradition of distinction through service. The answer to the second question is also “No, they didn’t,” and this is what prompted me to take American citizenship, embracing the country of freedom of thought, meritocracy, and the tradition of hard work, which I identified with. This was a tribute to a society that offered me training and the opportunity to create three transplant programs, the pride of my professional life. However, I do feel a real satisfaction now after having gone through the difficult 10-year period “without the pleadings and complaints of cowards,” exactly as the Alexandrian poet, C. P. Cavafy, commanded.