A Modern Medical Metaphor: Rehabilitation, Restoration, and Reality

THE OPEN MIND
Host: Richard D. Heffner
Guest: Kristjan T. Ragnarsson
Title: A Modern Medical Metaphor: Rehabilitation, Restoration and Reality
VTR: 9/21/00

I’m Richard Heffner, your host on The Open Mind. And I’d like to begin today’s program by looking back at an Associated Press bulletin of February 1st, 2000. “Paralyzed people”, it read, “fooled by a televised Super Bowl ad showing actor Christopher Reeve walking, have been calling an advocacy group to find out how he was cured”. That was the bulletin. You remember that. That it was an extraordinarily dramatic television moment supposedly showing the paralyzed SPI (spinal cord injury) victim actually walking again and suddenly giving incredible hope to so many similarly paralyzed persons, their families and friends. All within eye or ear range of that hugely popular sports event.

Well, it wasn’t so, of course. And some days later Time magazine’s brilliant essayist, Charles Krauthammer, breaking a long time silence about his own condition, took strong exception to the television ad. He wrote, “I have long been reluctant to criticize Christopher Reeve. It is not easy attacking someone who suffered such a devastating injury and has carried on with spirit. Nor am I particularly keen to violate the brotherhood of the extremely unlucky, I injured my spinal cord when I was 22, and have been in a wheelchair ever since. But his Super Bowl ad was just too much. Why did he do it? To raise consciousness, he says, convinced that a cure is eminent, he wants to share the good news with the largest possible audience. “But”, Krauthammer continues, “for 28 years I have been hearing that a cure is just a few years away. Being a doctor”, he reveals, “I have discounted such nonsense, most of the spinal cord injured, however, are not doctors”. And he goes on, arguing a modern medical metaphor about rehabilitation, restoration and reality that no one is better able to examine in all of its ramifications than my guest today, a friend to both of these impressive and accomplished men, Dr. Kristjan T. Ragnarsson, the distinguished Chairman of the Department of Rehabilitation Medicine at the Mt. Sinai School of Medicine in New York City.

Dr. Ragnarsson was born in Iceland, is Chairman of the Board of Trustees of the American-Scandinavian Foundation and is known throughout the world for his work in rehabilitation. And doctor I want to begin today by asking what your own fix was on that contretemps. About the ad and about the response.

RAGNARSSON: Well, I was actually watching the Super Bowl with good friends when the ad came on. And I was surprised, a bit perplexed. But I did see the point in it, however. At least from the point of view of people are trying to promote research to find a cure for spinal cord injury. And to encourage society to supply funds to conduct that research.

HEFFNER: There is an assumption there, and that I gather is what Charles Krauthammer was concerned about … is that this is not in the by-and-by, but something fairly close.

RAGNARSSON: There was assumption of that. But I think if you are promoting research you, you can’t really be talking about finding the solution a hundred years from now. I think you have to be more upbeat and hoping that it will at least occur in your lifetime. I would say that, that the views towards research to find a cure for spinal cord injury are different now than when I started in this field, now almost 30 years ago. That there seems to be greater optimism even among the most serious of scientists that some of the developments of recent years may, at some day in the future, provide at least a partial cure.

HEFFNER: What will happen? What can happen?

RAGNARSSON: I think there are two things in the basic sciences that we hope that will happen. The first is actually that immediately after a person has injured the spinal cord that interventions, treatments that will protect the nerve tissue that has not been totally destroyed by the impact will allow at least preservation of some neurological function to allow more people to perhaps walk or, or be self-sufficient than they are now. The second thing is really … the hope that one day regeneration of nerve fibers within the central nervous system and specifically within the spinal cord can be allowed to grow and bridge the gap that has been created by the injury.

HEFFNER: is that the aspect that is most hopeful? The regeneration?

RAGNARSSON: I think it is both of those. But for people who have been injured for many years, regeneration is what they pin their hopes on. And there are certain signs that even, I must say, that most distinguished scientists think that this is now realize-able. And I can just mention the stem cell opportunities and some of the remylination techniques that have recently been described, that make it at least … give us a hope that this may happen one day. But, but as you know, the course of science is unpredictable. It … you cannot give it a timetable. One thing happens after another, and so perhaps one day we will see a solution.

HEFFNER: You say you can’t give it a timetable. Are you betting, nevertheless, not on timing, but on the notion that it will happen?

RAGNARSSON: I am betting on that it will happen. Absolutely. I hope it will be in my lifetime and hopefully soon in my lifetime. But I, I sometimes take the … use the sample that, that … with respect to science … is that when you find a solution, it doesn’t come from one source, but it comes from many sources. And the sample I sometimes give to my patients is that if … the most powerful man in the world, two hundred years ago, and I assume that was Napoleon would have called all his best scientists together and told them that he would like to, say, have a radio or a television set … since we’re here in a television studio … they could not have done it in his lifetime. But scientific knowledge cumulating over the next century made it possible. I think the same thing will happen when it comes to cure of injuries to the central nervous system. But I can’t tell you how soon it’s gunna happen.

HEFFNER: But you know, in reading about some of the … I’m not going call them miracles, but some of the wonders you have performed in your own rehabilitation work … a football player who is so badly injured and yet walks again. You’ve made the point that what is so important here is that we be, at all times, in a physical condition …

RAGNARSSON: Yes.

HEFFNER: … that will make us susceptible to the kind of rehabilitation work that you’re doing now.

RAGNARSSON: Well, I believe that. I believe that people who are in good health, physically and mentally, are better able to meet any challenge, including a sudden disability that falls up on them because of an accident or perhaps because of disease. That if they are in good shape and are mentally, not prepared, but … for that kind of event … but are able to cope with it emotionally with support from the families. I think they will ultimately show better results than the others.

HEFFNER: But you seem to be saying that in this country, I would suspect it’s not true in Scandinavia … but you can comment on that, but that in this country instead of being better and better prepared, we’re not doing very well.

RAGNARSSON: Well, I think that people … people all over the world are the same. And I think that the conditions of Western civilization … people who live in the Western civilization are pretty similar. People tend to be overweight, under exercised and not prepared to adversities. And so I don’t think there’s a huge difference between this country and, and Europe, for example, or Scandinavia, for that matter. I believe that it’s up to individuals mostly. And their support system to do well after a catastrophe strikes.

HEFFNER: Well, you mentioned before that perhaps 30 years ago, you would not be as optimistic about the possibilities as you are now of reclaiming our bodies. How do you feel on that score about our physical conditions?

RAGNARSSON: Well I think that the data show that by and large the population is gaining more weight and even though there is interest in physical exercise, I think that it’s limited to too few people. And I think that even if we have a President’s Council on Physical Fitness, I think that it is not promoted enough. But then I am, of course, given my background, I’m a spokesman for physical exercise.

HEFFNER: Because of your Scandinavian origins?

RAGNARSSON: No, I think mostly because as a physician of physical medicine and rehabilitation … one of the reasons I entered this field was that I felt that physical exercise as a therapeutic modality was underestimated. And, in a similar way, as in the 60s when I went to medical school, there was nothing on nutrition or diet and there was nothing on physical exercise and now we know that those two factors are … have a huge impact on our health. Not only in the present, but also in the future.

HEFFNER: But do they have a huge impact upon the practice of medicine?

RAGNARSSON: No. They generally do not.

HEFFNER: And how do you account for that dichotomy?

RAGNARSSON: I think that to change people’s life style both with diet and exercise takes self-motivation. It is really not any body that can force a person to, to change life styles and adopt healthier eating and exercise habits. But rather that people have to find it among themselves to do it, with some encouragement, and as you say, strong encouragement from health care professionals and society.

HEFFNER: Is … or are health care professionals providing that “egging on” that you would like to see?

RAGNARSSON: Not as a rule. I think individuals do that, but I think, by and large they do not.

HEFFNER: And how do you explain that?

RAGNARSSON: Well, there is no money in it for one thing. And …

HEFFNER: What do you mean?

RAGNARSSON: I don’t think that, that .. If you prescribe a physical exercise for a person, you know, it doesn’t bring in the same thing as a big operation, or expensive medications. And the same thing with modifying the diet is that there is no part of the health care industry that stands much to gain from it.

HEFFNER: How would … how would … you know, I’m surprised. Not … cynicism isn’t the word because … however little we know each other, I know you’re not cynical, quite the contrary … you could not do the work you do. But that seems like such a strange thing to say about people who have taken an oath to devote their lives to, to healing.

RAGNARSSON: Yes. No, I think doctors … by the way doctors themselves usually adhere to a sensible diet and exercise regularly. More so than the population at large. But they don’t always carry that message to the patients. I would certainly like to have them do that more often. None of them would ever, I think, or at least very few would ever say to their patients, “do not eat healthy and do not exercise”. They would encourage them to do it if asked. I’m not convinced that they make that a habit in the same way as they check blood pressure.

HEFFNER: How do you bring that about? Like the checking of blood pressure.

RAGNARSSON: I think it has to start early in the education of certainly doctors, but I think it should also be part of the education of all people starting in elementary school and continuing throughout high school and college. Not just going to the gym and participating in competitive sports, but actually learn about the benefits of both proper eating habits and exercising regularly.

HEFFNER: When the Kennedys were in the White House there was a feeling that exercise was of enormous importance. They exercised. Is there any area now, is there any, is there any entrance into this notion, is there any way we can bring to the public’s attention something that you seem to think is perhaps getting worse …

RAGNARSSON: Well, I think …

HEFFNER: … rather than getting better.

RAGNARSSON: … I think my and my colleagues in the field of physical medicine and rehabilitation generally make physical exercise part of the fundamental approaches, you know. Ordinarily, however, it’s with specific ailments like people that show up with back pain of some reason. The solution for that is, frequently, physical conditioning … improving your physical condition through physical exercise. And then at the same time, talking to those about dietary needs. This is often times, the first thing we think about before we prescribe drugs, for example. And certainly much before we even think surgery, unless there are clear cut indications for that.

HEFFNER: Preventative medicine seems not to be a … all that much of a concern perhaps first for our insurance companies or medical insurance.

RAGNARSSON: Well I think it has changed a little bit. Actually I think the managed care companies who, at least those that insure large population … took some interest in preventative medicine. Not that they want to pay for it very much, but at least they, they promoted physical exercise and proper eating habits. And some of them actually were able to tell the subscribers that they could get discounts at some fitness facilities. Or discounts at some sporting goods stores for running shoes and hoping that they would pick up on better patterns of lifestyle. And I think that was positive.

HEFFNER: But you don’t think that it is word about very much of a change in our eating habits, in our exercise habits.

RAGNARSSON: I have not seen that. I think that there is a certain portion of the population that exercise regularly, but too many that do not.

HEFFNER: What about doctors themselves?

RAGNARSSON: Yeah, doctors themselves. I think generally try to exercise regularly as a whole group, and certainly recognize the benefits of it.

HEFFNER: Now, going back to the question of miracles, or advances in science … what needs to be done to shorten the period before we may well see the kinds of advances that you’ve posited.

RAGNARSSON: Well, I think there are … if you’re talking about spinal cord injuries specifically, then I that there is a two pronged approach to it. First of all we know what works now to improve function … namely rehabilitation. But on the other hand we are not, don’t understand quite well how all the treatments or rehabilitation, that it has to offer, how it works. And I think that there’s still room for improvement there. And, and there have been some significant developments in the last 20 years using the high technology devices. Using developments in other fields of science and applying it to the people with disabilities. And that, indeed, has … I think made measurable progress. But still research in that field needs more funding. The other thing is, we need to find a cure and I think actually the solution is not going to come out of one laboratory, or single inventor or something of that sort. I think there’s going to be a world-wide effort of multiple scientists in numerous laboratories who work … if I can use the metaphor … brick and brick at a time to build a whole cathedral of understanding so we can find the solution. So I think the, the resource funding frankly has to increase for this. And it has been very limited. And I think that, you know, because science follows the money as well as sometimes money follows science. But, there has to be more for it. And I think that there is interest among the public and the politicians who control the flow of money into research … seem to be sensitive to that right now. But not enough.

HEFFNER: There seemed to have been a time, some years back, when, unless I’m mistaken there was more interest in the Congress in this approach to medicine. Am I wrong that it took something like the Christopher Reeve accident to rekindle.

RAGNARSSON: Well the unfortunate thing for most people with disabilities is that if often times takes a celebrity to raise the level of awareness in society and among politicians. And so it’s true that at first after and then a couple years after Christopher Reeve was injured there was a great rise in interest. And I must say that he has followed up on this well. His foundation, I think has make major appeal to the public and so there has been an inflow of private money to his foundation and that has been channeled directly into, into science. With very little overhead. So that is encouraging. And at the same time they have been advocating in Congress for more support. I can’t say that it has materialized big style, and that’s disappointing. But, but I hope that one day we’ll reap the fruit of his effort.

HEFFNER: Has it materialized “big style” elsewhere in the world?

RAGNARSSON: Elsewhere in the world … I would not say so. There are a handful of … less than half a dozen laboratories in Europe that focus on this … mostly in Switzerland and in Sweden. And they have had some remarkable research findings. In Israel I might add also … at the Weitzman Institute in Israel. But, but I think there are disappointingly few elsewhere in the world. So once again I believe the United States has to take a lead in this field as in so many others.

HEFFNER: Does it show signs of being willing to do so?

RAGNARSSON: I think that there are individuals … individual leaders who, who have shown signs of that. But too often it’s lip service.

HEFFNER: What’s the kind of research, what’s the level of research. What do you mean by research in this area?

RAGNARSSON: Well, what I mean is follow up the findings that have been promising so far. And I would mention, as I did before, the stem cell research. These very primitive nerve cells, if you will, that can basically develop into almost any cell within the nervous system. These come from fetuses that are usually spontaneously aborted. But they are harvested and then they are used. I think that, that the promise of this research is extremely exciting. I must admit that I’m not a basic scientist so I can’t discuss the details of it. But what I know makes me excited and it makes me excited that my scientists, my colleagues not only here in New York but elsewhere in the world who, who have a deeper understanding on the scientific value of this … they are excited. And that tells me a lot.

HEFFNER: Is the opposition to stem cell research hindering this kind of work?

RAGNARSSON: Well, I think Congress has just recently addressed this, and I think that they’re looking at it favorably. There are some people because of their fundamental religious beliefs who are against it. And I sympathize with them, but on the other hand, being a physician, I … my sympathy is with continuing with the stem cell research. And I do not think that this ever mean sacrificing life at any stage.

HEFFNER: Where is most of the research being done in this country?

RAGNARSSON: Well, there are several universities and … but frankly experts in stem cell research are now … there’s a shortage of them. And …

HEFFNER: Afraid of the political opposition?

RAGNARSSON: Perhaps. I don’t know about that. I think frankly there have not just been enough who have received adequate training to take on major research projects.

HEFFNER: And what do you think is going to happen now? You say there’s some movement …

RAGNARSSON: I … I

HEFFNER: … in the Congress.

RAGNARSSON: I think if the political hurdles can be overcome, that if, if Congress and the National Institute of Health then follows up with funding for this research, I think that there are benefits that cannot be predicted today, but I think they will be enormous. And not just with spinal cord injury, but a number of other conditions as well.

HEFFNER: Bionic man is the result?

RAGNARSSON: Oh, I don’t think so. I think this will be, this will be a regular human being, but just with, just with … using modern science to compliment for losses that have occurred.

HEFFNER: To what end … we just have a couple of minutes left. Doctor, to what end … what will you and your fellow scientists, clinicians bring to us? Eternal life?

RAGNARSSON: No, I don’t think … I think every animal, including the human being, has like a programmed life span. But I think it can be greater than what we are now expecting.

HEFFNER: Is it unfair to say … “greater” … what do you mean “greater”, how much “greater”?

RAGNARSSON: Well, people say that the human being can live well beyond a hundred years. Providing that you can control the different diseases. But ultimately I think the system will break down, so “eternal life” is not for us.

HEFFNER: Why do you say “ultimately …” … seriously, why do you say “ultimately it will …”. Is this out of religious conviction, philosophical …

RAGNARSSON: No, I think it’s biological. Religiously I believe in eternal life. Frankly. But, but on a biological sense I do not.

HEFFNER: Would you explain that?

RAGNARSSON: I think frankly that the new biological being is programmed to last that long, and I think that certainly today … is at least beyond us scientists to take it any further or even understand it.

HEFFNER: At this table Dan Callahan has frequently come and said “the damn trouble is that the doctors and the scientists want to spend so much money doing this basic research. Do you have any program with the expenditure of money? To keep us going 100 years perhaps? Longer?

RAGNARSSON: Well, I think I, I have some trouble with that.. I think, I think there are societal issues that have to be resolved here. And that is, for example, just with the care of the elderly. And to what extent that expensive gear should continue.

As you know , it’s at that … more than half of all the expenditure that we, as individual use in the last six months of life of your life.

HEFFNER: Would you “limit”?

RAGNARSSON: I would not limit it because I don’t know what the last six months are.

HEFFNER: That’s an interesting point. It’s a point we should take up again …

RAGNARSSON: [Laughter]

HEFFNER: … thank you so much for joining me again on The Open Mind.

RAGNARSSON: It certainly is my pleasure and honor.

HEFFNER: Thank you.

RAGNARSSON: Thank you so much.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.