Philip Berroll

If I couldn’t shield my son from the world, at least I could try to explain it.

By P.H.I.Berroll

The plan is to hang out with my son, helping him with his second-grade homework, before picking up his brother at an after-school program. We find a neighborhood diner – small, clean and as one would expect for a mid-weekday afternoon, almost empty. We sit in a booth, unpack his work materials, negotiate what he can eat (either chicken fingers or French fries, not both), and begin.

I’m so involved with him that at first I pay no attention to any of the noises in the background: clanking dishes, shouts from the kitchen, traffic rumbling on the street. But then another sound emerges, sharp, insistent, almost demanding to be heard.

“…talk about ‘bringing democracy.’ What [expletive]. They’ve never had a democracy in a thousand years. They need a dictator, that’s all they understand.”

It’s the table behind us. The manager has left the cash register for a few minutes to chat with a friend, though “chat” is not the operative word here. Nor is “dialogue.”

“And that [expletive] Obama, he’s so concerned about their feelings. Because he lived in Indonesia, he thinks like them. The hell with their feelings. They don’t like it, tough [expletive].”

The manager says something in response, but it’s not clear; his voice is too soft, his Greek accent too thick. In any event, he’s barely able to complete a sentence before his companion jumps back in.

“We don’t need their [expletive] oil. We’ve got enough oil underground to last more than two hundred years, did you know that? But we can’t touch it because” – he shifts to a falsetto register – ‘Oh, you’ll hurt the environment.’ What [expletive, expletive].”

My son has been doing his best to concentrate on his word-study exercise, though he has shot a few surreptitious glances over his shoulder. Now he leans toward me.

“Daddy,” he whispers, “that man said the ________ word,” referring to it by its first letter.

“I know. Just focus on your work.”

In terms of his vocabulary, I am not concerned about my son’s innocence. He’s heard the word numerous times. His year-and-a-half-older brother has become quite fond of it, and repeats it – only at home, thankfully – whenever he feels like getting a rise out of his parents.

But I want to protect him, not from the man’s politics – though I disagree with everything he’s saying – but his worldview. Bleak, nihilistic, Manichean;I’ve met his type before, usually at night and after a few drinks.  The message never varies. Big fish eat little fish, money talks, nothing will every change. Optimism and idealism are for fools and suckers.

“…blames the rich for everything. Hey, you got your winners, and you got your losers. That’s how it is. Stop whining.”

He finally leaves when the cashier tires of his rants and goes back to work. I wonder: How did he get to this point? I understand the lure of cynicism, especially for middle-aged (like myself) and older men. Age and painful experience teach us to be hard-headed realists, to accept that the world often works in ways we don’t like.  But realism is not the same thing as sour, ugly misanthropy.

I feel like covering my son’s ears, or at least explaining to him why this fellow is not to be believed. I want to protect him from contracting the man’s disease.

I know – it’s futile to think I can shield him from everything noxious and destructive in the world. It’s even counterproductive, like those antibacterial soaps that kill so many germs they leave children more vulnerable to infection. Exposure to a little dirt, a bit of ugliness, is not a bad thing; it can ultimately leave them tougher, more resilient.

We all know this; as men, we’re supposed to know this, yes, even we modern, sensitive dads. We still feel that primal impulse to impart the message that life is not always gentle or pretty. It’s a tough world, son. Right. But a hopeless world?

At bedtime, in their darkened room, my son gives his brother a full report.

“And he said something about Indonesia… Daddy, you remember what he said?” The mother of one of his best friends is Indonesian.

“I’m not sure,” I lie.

He mentions seeing the man pass a cop as he left the diner. “Why didn’t the policeman arrest him?”

I explain, in as kid-friendly a manner as possible, the First Amendment.

“You mean you can even say the ________ word?”

I explain, as best I can, the current norms about inappropriate language. “Does that make sense?”

“Yeah,” they say, sounding satisfied if not entirely convinced.

We say our goodnights, and I leave the room. For a moment, I contemplate what they might encounter in the next day, or year. I’m already thinking how I can make sense of it for them.

Recently, in the space of three days, two different people said to me – in the course of an otherwise unexceptional conversation, apropos of nothing – that they had dreams of being a writer. Both of them are in their fifties, which meant they’ve been doing something else for the better part of three decades (but hey, no one remains with the same company anymore, so why stick with the same profession?).

Those of you who are writers probably know what came next: the questions. Those questions. The exact wording varies, but the gist is always the same. How do you get started? Do you have to go to school? How do you decide what to write about? Why are there no people of color on “Game of Thrones”(trick question, just to see if you were paying attention)? Essentially, these are all like strands in a child’s drawing of the sun — leading back to the center, to the more basic question: “Can anybody do it?”

In a way, I find this kind of flattering. Most people don’t get those kinds of queries, after all. You know what you have to do to be a doctor, or a lawyer, or an athlete or an actor. You know what’s involved in working in someone else’s business or starting your own. The path is clear, the signs along the way well-marked.

Writing, on the other hand – professional writing, that is, as opposed to composing an e-mail or a grocery list – is shrouded in a kind of cosmic mystery. Everyone realizes that it’s not just a matter of scratching letters on a sheet of paper, or tapping the keys in a certain order. But what else? Writers themselves are no help; they’re happy to talk about their work routine (“I get up every morning at five, drink a few shots of vodka, play two tennis matches and then sit down at the computer”) but rarely if ever about the actual work process, and only infrequently about what made them decide to get into this crazy business in the first place.

So what does it take to write professionally? Can any idiot do it?

The best answer I can give is that there is no answer – no single answer, that is, that could be applied to every writer in every time and place.

We all start from the same point: learning a language – its rules and standards, formalities and slang; how to use it to present basic facts, to embellish and add color, to convey our happiness, sadness, anger. We “practice” every day, on school assignments, letters/e-mails, birthday cards, Post-Its. And unless there is a baby or someone else who can’t easily communicate in our lives, we come to take it all for granted.  We don’t think about how we form our words any more than we consider how we tie our shoes – we just do it.

But some people go a step further. They see how words, sentences, paragraphs can be strung together for grander purposes: to tell a story, make an argument, describe an experience or a person. Something in their lives compels them to do the same. Maybe they’ve lived through a horrific experience (war, forced migration, an abusive childhood) and are obsessed with telling the world what they saw and felt. Maybe they enjoy reading or listening to other people’s stories and decide to make up their own. Maybe they want to recount the past or describe the present of their city, region or country. (Carlos Fuentes  was inspired by hearing his grandmothers’ tales of old Mexico; “my two grannies,” he said, “[were] the two authors of my books, really.”) In my case, I was pissed off – at my parents, my teachers, my government, the world – and saw writing as a way of exposing the shallowness, hypocrisy and false values that I found all around me, and blah blah blah (yes, I was a teenager).

And if you turn out to be one of those people, what then?

Then you write whenever, wherever you can. You jot down notes, ideas, lines of dialogue, character sketches, and file them away for future use. You might start with short stories or poetry or essays, or jump right in with a novel or play. Often you take courses, either at college or grad school or on your own, not to learn how to write – remember, you already know that – but to get an understanding of what works and what doesn’t. You familiarize yourself with different styles, borrowing (o.k., stealing) just enough to escape detection. Slowly, gradually, you settle on the style – the voice – with which you’re most comfortable.

Then the real fun starts: making a living. Again, one size absolutely does not fit all.  Some people take “writing jobs” – journalist, teacher, copywriter. Often these become their primary careers, whether or not they do other kinds of writing on the side, and there’s no shame in that. Others go into fields that have nothing whatever to do with what they love; they learn to carve out time to write on lunch breaks, evenings, weekends, etc.  And some get by on temp jobs, or grants, or loans from friends or relatives. I make no judgment on any of these strategies, having tried them all. Whatever works.

Meanwhile, you search for people to look at your writing, and to pay you for it. And search, and search.  I won’t bore you with what we did in the pre-Web era; suffice it to say that it involved dead cats, voodoo dolls and incantations in Latin. The point is that now there is no excuse for not searching, not when you can click your way to lists of agents, editors, publishers, magazines, newspapers, academic journals, etc. Then, of course, all you have to do is determine which of these are scams, dead ends or a bad match for you.

Well, not all. There remains one more hump to get over – the King Kong, the Godzilla, the Moby-Dick of humps, really. It takes the form of a neat, polite e-mail or letter with some version of the following message: “This just isn’t for us. But thanks for thinking of us, and good luck in the future.”

The first time this happens, you’ll probably howl with pain, for you cannot avoid that knife-in-the-gut feeling. You will also have a sense of bewilderment – “How could they not like it? Can’t they appreciate the time and effort, love and skill that went into its crafting?” After a few more such rejections, you learn to deal with it; you have to. Hopefully a few of the rejectors are kind enough to mention what they thought was lacking, the areas that could be improved. If several of them harp on the same thing, you can safely assume they’re worth taking seriously. So you fix what needs to be fixed.

And you keep going. You become your own toughest, most cold-blooded editor, cutting out that wonderful description or dialogue exchange if it doesn’t serve the overall story. You try to find a subject that no one else has really covered, or a theme that no one has dealt with in quite the same way. You join online or in-person groups, attend conferences, locate that friend of an acquaintance of an ex-roommate who is rumored to be in publishing… network, network, NETWORK. You do whatever you can in the service of two goals: to make your writing as clean, fresh and compelling as possible, and to get it in front of anyone who can possibly help you.

Having done all this – guess what? There is still no guarantee that you will have any success – that’s “success” as in “making a steady living from your writing.” That is what separates the pro from the amateur. So ten people buying your self-published book on Amazon, or several hundred reading your blog, doesn’t count. You must see the dinero on a regular basis.

And even if you do, that’s not the same as being a Major Author, the kind whose name becomes a noun – “I’m reading the latest ____________ right now.” You may just become a perfectly respectable working writer, churning out your articles or your books or your screenplays or your rhymed couplets year after year.

Which is perfectly fine. Because you’ve reached the point where it’s not about the fame, or the money, or getting out your Important Message. It’s just something that you have to do, something you can’t imagine not doing.

And the good news: you can keep doing it long after your friends have stopped being accountants or dentists or management consultants or whatever. You can do it as long as your brain and fingers are in good working order. “Writer’s don’t retire,” declared Andy Rooney, a few weeks before his death.

If you get to that point, then we can truly say: Welcome to the club, you beautiful idiot.

By P.H.I.Berroll

Around 7:30 a.m., the men gather in the chilling December air at the corner of South 5^th Street and Bedford Avenue, next to the Williamsburg Bridge overpass, as they do every morning.  There are about 30 of them, ranging in age from twentysomething to early fifties.  Some stand alone; others cluster in small groups, chatting, making jokes.  But everyone keeps an eye on the street, watching the cars, vans, and pickup trucks that pass by — and waiting for the occasional vehicle that slows down.

The men are part of a sad tradition in American labor — the shape-up crew.  For generations, the unemployed have clustered on particular street corners in American cities, hoping to get a day-labor job for a couple of hours or even better, several days.  Because most of them do not possess a special craft or skill, they are of little interest to unions or conventional employment agencies, and so are left to their own devices.

At the height of the Depression, most shape-up crews were made up of native-born Americans.  Today, the crews are almost entirely composed of immigrants, legal and otherwise.  Mexican-dominated crews have long been common to Southern California.  Here in Greenpoint, two of the men waiting by the bridge are African-American and several are Latino, but most have emigrated from Poland or the former Soviet Union.

Zygmunt “Zygi” Lemond, a stocky, friendly man of 43, came from Poland — he is vague about the exact year, but it was some time after the fall of the country’s Communist regime in 1989.  Drawn to Greenpoint by its large Polish community, Zygi has lived for almost a year in a homeless shelter on Bedford and Atlantic Avenues, about half a mile south.

Wearing a patterned jacket, hightop sneakers and a painter’s cap, he is dressed a bit more colorfully than the others.  (Even more bizarre is a younger man who looks like a college student, wearing a backpack, a Walkman — and rollerblades.)  Zygi’s background is also unconventional.  Trained as a musician, he left Poland when he realized that work would be harder to come by in a capitalist society — “How many dance bands do you need?” he asks rhetorically.

But Zygi felt that the American music business, while equally competitive, offered more opportunity.  And he does on occasion play bass guitar with a band, working New Jersey towns such as Linden, Garfield, or Passaic, which have large Polish neighborhoods.  He plays both nightclubs and social events — weddings, christenings, baby showers.

But it’s not enough to make a living.  So every morning, he is out on the corner, looking for construction or warehouse jobs or “painting, sometimes.”  The pay isn’t great, but it’s better than minimum-wage — at least $6 an hour, and as much as $10 for more strenuous construction or demolition work.

The real problem is the length and frequency of the jobs.  When asked if he gets much work, Zygi makes a face and says only, “It’s not regular.”  Some of his jobs have been as short as two to three hours, but none have been longer than two days.  “Yesterday,” he says, “I worked nine hours, in a warehouse.”  He usually stays on the corner until noon before giving up for the day.

At one point, a station wagon pulls up, with two men in the front seat.  Everyone clusters around, gesticulating, talking in two or three languages, as those with better English translate for their friends.  Zygi joins in for a few minutes, then walks away.  Eventually, no one else decides to get in the car, and the men drive off.

Zygi explains that the men offered to pay $6 an hour for extensive wiring and carpentry work on a building that they were renovating — but were honest enough to mention that the building was unheated.  “For a job like that,” he says, “it’s got to be at least $10.”

Not everyone can afford to be so choosy.  Down the block, on the other side of the overpass, another group of East Europeans have staked out their own patch of turf.  One of them, Sasha, a Ukrainian immigrant who has been in the U.S. for three months, says with a laugh that he does “everything.”  Another in the group, Tibor, who comes from Bulgaria, lists his skills as “welder, electrician… and I put down tiles.”  They are less easily discouraged than Zygi — they usually stay on the street until 2 or 3 p.m.

At his end of the block, Zygi sniffs that there are “too many Russians out here” — some days, in fact, they outnumber the Poles.  Is he voicing ancient resentments, given the history of relations between Russia and Poland?   More likely, it’s a matter of numbers.  The more men on the block competing for jobs, the less chance any of them has of getting one.

Occasionally, Zygi says, the competition gets ugly.  When an employer announces two openings and four (or more) men are gathered around his car, push can literally come to shove.  But the disputes are generally forgotten, or at least set aside, by the following day.  The men have to face each other every morning, and holding grudges is a waste of energy.

From time to time, two uniformed policemen in a squad car circle the block, keeping an eye on the group.  But the men are careful to stay on their best behavior.  Until several months ago, the group had been gathering a few blocks away, at the intersection of Wallabout Street and Kent Avenue; they were chased away by the police, after local residents complained that some of the men were drinking in public and throwing bottles and other garbage on the street.  Zygi confirms the charges, although he personally claims innocence.

Now another car pulls over.  Before Zygi takes three steps in his direction, the Latino driver picks the first three men who approach, and drives away.  Zygi shrugs, takes a cigarette from a Marlboro pack, and lights up.

Most of the employers, Zygi says, are Latinos or Orthodox or Hasidic Jews.  The latter, he says, are sometimes a problem because they prefer to pay him in cash, off the books, in order to avoid paying social security taxes.  He would rather get a check.  “If you’re paid cash,” he says, “it could be as low as $3 an hour.  A check, if it’s six, you still keep $3.75 after taxes and Social Security.”

Zygi is familiar with the current American political debate about welfare and unemployment.  He has heard the claims that there are plenty of available jobs for any able-bodied worker who is willing to look hard enough.  (In New York, Gov. George Pataki recently announced plans to cut state welfare rolls by 25 percent.)

But Zygi prefers not to take sides in this argument; he will only speak of his own feelings and experience.  Welfare, he says, is not for him, but he does not judge anyone who takes that route.

What Zygi really wants is the chance to leave the corner for good.  He says he knows of “some people in the summer who go to upstate New York.  They get regular factory jobs and they don’t come back.”  And Zygi himself has an application in at a factory on Java Street, a few blocks north.

For now, though, he remains under the bridge, waiting for another car to pull up to the curb.

“Every day,” he says, “it’s the same situation.”
 

Originally published in Brooklyn-Queens Waterfront Week weekly newspaper, 1995.

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By P.H.I.Berroll

Dr. Valentin Fuster’s workday begins at 5:00 am – but for the first fifteen minutes, he does absolutely nothing except think about the hours ahead of him. “Basically I program the day in terms of priorities,” he says, “to be sure that when I start, I know exactly where I am.”

For Dr. Fuster, the Director of Mount Sinai Heart, this approach makes perfect sense. The 67-year-old cardiologist has a load of responsibilities – as doctor, teacher, researcher, administrator and activist – that would tax the strength of many younger men. Yet he maintains his energy and his equilibrium through a mindset that is equal parts optimistic and pragmatic, detail-oriented and focused on the broader view. And despite a stunning record of achievements, honors and high-level positions, he is a modest, unpretentious man who considers himself “lucky.”

At Mount Sinai, Dr. Fuster presides over a dynamic program whose innovations in technology and research have placed it in the forefront of the cardiology field. At the same time, his interests and advocacy are global in scope. A former president of both the American Heart Association and the World Heart Federation, he is currently President for Science of the National Centre for Cardiovascular Research in his native Spain (where he spends part of each week), serves as Chair of the Committee on Preventing the Global Epidemic of Cardiovascular Disease for the Institute of Medicine (IOM), the health arm of the National Academy of Sciences, and is in demand worldwide as a speaker and advisor on medical, cardiological and related issues.

“I just want to be on the frontline – this is where I am the best,” he says. “My affinity is for dealing with the issues very pragmatically, and getting results.”

Dr. Fuster spent twelve years at the Mayo Clinic before joining Mount Sinai in 1982 as chief of the cardiology division. After a four-year hiatus in the early 1990’s when he headed the cardiac unit at Boston’s Massachusetts General Hospital, he returned to New York to be director of Mount Sinai’s Zena and Michael A. Wiener Cardiovascular Institute and later, director of the Marie-Josèe and Henry Kravis Center for Cardiovascular Health. In 2006, when the two entities were merged to form Mount Sinai Heart, Dr. Fuster was the logical choice to be its first leader.

When he talks about Mount Sinai Heart, Dr. Fuster emphasizes a number of aspects. The institute is noteworthy for integrating three disciplines – molecular cardiology, regenerative cardiology and cardiac imaging – but the doctor also praises “the integration of research, clinically applied research and clinical care.” Equally important, in his view, is that “this is a healthcare system, not a doctors’ system… we value tremendously nurses, nurse practitioners and technical people, who are very involved in what we do. We also include students who participate in projects – they are extremely helpful. And I think this is what makes this place very unique.”

He also speaks proudly of Mount Sinai’s openness to a diverse patient clientele. “This was controversial at the beginning, when we started,” he says, “but I don’t think it is anymore. I’ll never forget one day when [philanthropist] Laurance Rockefeller was sitting in the waiting area along with an ailing lady with a big hat from Harlem and he said, “I’ve never seen something more spectacular – this is absolutely fantastic what you have achieved here.”

“A Disease of Modern Times”

Dr. Fuster is serving at a critical juncture for the field of cardiology – a time, he says, when “there are so many advances, and at the same time, an epidemic.” The statistics are daunting: one in three American adults (80 million people) has one or more types of cardiovascular disease; it is the leading cause of death among women; 17 million people die from it each year around the world. And Dr. Fuster notes that it is a scourge of fairly recent origin – “Centuries ago, autopsies showed very little coronary disease. So it’s a disease of modern times.”

He is blunt in his assessment of how “modern times” have contributed to the problem:

“Of the six risk factors that lead to the disease, two we can call ‘mechanical.’ One of these is obesity, and the other is high blood pressure – a disease of the modern world, of tension, of stress – and obesity and blood pressure go together. There are two chemical problems, non-Type 1diabetes and high cholesterol, which have a lot to do with obesity. And two more factors are extremely modern: smoking and lack of exercise. All of this represents 95 percent of the epidemic.”

His studies and experience have made Dr. Fuster a passionate advocate for preventive medicine – and not just in regard to cardiovascular disease.

“I love this country,” he says, “but the concept of prevention is not part of the culture here – the feeling is, ‘It’s not going to happen to me.’ So we have prolonged life two years per decade by treating disease – but we are not preventing it. As a result, people are dying later, but at the same time, the amount of disease is increasing. This is extremely costly. For example, the cost of treating cardiovascular disease in 2006 was over $300 billion; ten years before, it was one-third of that. If you understand that you’re spending three times the amount of money as ten years ago, you can trust that the health system will break. It will not be possible to continue like this.

“What we have to do,” he continues, “is understand that preventing disease will make a significant difference. Let’s say, for instance, that we’re treating two twin brothers – one at the time he develops an infarction and the other, preventing the risk factors that may lead to the infarction – for a period of ten years. The cost of treating the infarction is four times the cost of preventing the infarction. You cannot get away from the fact that quality of life, preventing events, is very important economically.”

Learning Globally, Acting Locally

To drive home this message, Mount Sinai Heart is conducting a number of research projects in the developing world. “We have to go to this part of the world as quickly as possible,” says Dr. Fuster, “in time to help prevent what we are experiencing in Western countries – but also because developing countries can actually help nations like the United States by teaching us a lot that we do not know.”

Indeed, Dr. Fuster becomes especially energized when talking about Mount Sinai Heart’s international projects, which include an initiative in Rwanda – in collaboration with world-renowned economist Dr. Jeffrey Sachs – to help rural villagers combat cardiac disease by reducing their cholesterol and blood pressure, and a project involving 6,000 Colombian children aged three to seven, using the Spanish-language version of “Sesame Street” to teach them the importance of good health.

In another project, on the Caribbean island of Grenada, Dr. Fuster’s researchers are forming peer groups among local residents who smoke or suffer from hypertension or obesity to see whether group members can help each other develop healthier lifestyles. “The point we are trying to make,” says Dr. Fuster, “is that adults only change for two reasons: peer pressure, or the law. In Grenada, we are checking the peer pressure hypothesis.”

“The Principle of the Four T’s”

Dr. Fuster is proud of Mount Sinai Heart’s growing reputation – in U.S. News & World Report’s “America’s Best Hospitals” survey in 2009, Mount Sinai was ranked 18^th in the category of Heart and Heart Surgery, up from 41^st the previous year. “This jump took place because we are doing things that are very advanced,” he says, “in terms of technology, in terms of what we do globally. And I can predict another jump next year.”

He also expects future breakthroughs from the institute in bioimaging – “You’ll be able to see physiological processes, not just anatomy and structure, how the body works, how the mind works” – and genetics.

For now, Dr. Fuster continues to juggle his myriad interests and involvements through what he calls “the principle of the four T’s – Time to reflect, discovering your Talents, Transmitting positive feelings, and Tutoring… I have two tutors, top people in the fields in which I’m interested, who can tell whether what I’m doing is right or wrong.”

And he is always finding ways to make a positive contribution to both his adopted country and his native land. He speaks with pride about bringing cardiology trainees to his wife’s home town in Spain each year, where he gives a lecture on the latest developments in the field “in the town’s movie theater – it’s like [the Italian film] Cinema Paradiso.”

“My life,” he says, “is really about giving back… because of how lucky I have been.”

Originally published in Mount Sinai Science & Medicine magazine, 2010. 

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As we reach the outskirts of San José, I look out the window of our tour bus to see a majestic mountain range, its peaks literally touching the clouds… and in the foreground, an ugly strip of fast-food joints and used car lots that wouldn’t be out of place in northern New Jersey.

We’re traveling from San José, Costa Rica’s capital city, to the northern Sarapiquí region. Our 21-member group includes seven Latin America-based staff members who helpfully show the rest of us the ropes regarding local conditions and culture. We learn that the gap between rich and poor is less stark than in other parts of the region, but the issue that challenges much of Central America — how to reconcile economic development with environmental preservation — is present here as well. That challenge is symbolized by the view from my window: how far will the KFC’s intrude on the mountains?

After driving through the beautiful, 200,000-acre Braulio Carrillo National Park — and a wildlife corridor to which the Rainforest Alliance contributed funding — we cross the Rio Sucio (“Dirty River”), so named because it is stained yellow from iron ore mineral deposits, and enter Sarapiquí.

 We arrive at the Guayacán banana farm, one of several in the region owned by Chiquita — our host, Oscar, identifies himself as “manager of corporate responsibility” for the giant company. In the past, such a title would have seemed like a bad joke. But as he leads us on a tour of the farm, Oscar emphasizes how much things have changed.

Chiquita, he says, now makes every effort to safeguard the health and well-being of the more than 120 workers on the farm (most of whom come from neighboring Nicaragua) — which is one reason why Guayacán has earned Rainforest Alliance certification. The use of dangerous pesticides and herbicides has been cut back, but some chemicals are still used… so workers have their blood tested every three months to make sure their bodies have not absorbed too much pesticide (if they have, they cannot work at the farm until their levels go down). Those workers in particularly close contact with pesticides wear surgical masks, and soap and water is readily available at all times.

“Before the Rainforest Alliance came here, not only did workers have no protection, they would also eat on the job,” says our tour guide, Hector Brénes, an auditor for the Rainforest Alliance’s agriculture program. “So they would be touching the product, getting pesticide on their hands… then touching their food.”

The work is hard; nothing can change that fact. After hiking through the banana groves in the midday heat, I feel drained. I can only imagine what it must be like for these men, through day after day of climbing, cutting and lifting. (Oscar tells us that the workers wear shin guards when hacking bananas off the trees… because sometimes, when taking a big swing with the machete, the motion carries them forward and they can’t hold up before slashing themselves in the leg.)

The difference is that unlike in the past, Chiquita is taking pains to ensure that the men’s long-term health is not sacrificed … and that they are fairly compensated for their efforts. The workers (including the women who package the bananas for shipping) earn $14 – 17 a day — 15 percent higher than the Costa Rican minimum wage of just over $10 — and they are unionized.

After leaving Guayacán, our next stop is the Hotel Gavilán Rio Sarapiquí, a sustainable eco-lodge where we will be spending the next two nights. Never having been to such a place, I don’t know what to expect in the way of creature comforts — and I prepare for a few days of “roughing it.”

As it turns out, no worries on that score. The Gavilán is charming, low-key and quite comfortable — I’ve stayed in American motels that were far less pleasant. Advertised as “a beautiful and simple place… offered without preservatives,” the 17-year-old lodge caters to birdwatchers (more than 100 different bird species have been spotted in the vicinity), hikers and other nature-oriented tourists.

The rooms where we sleep are in long, bungalow-like structures; each room is cooled by a large ceiling fan rather than an energy-devouring a/c unit (energy conservation being a big part of sustainability). Every room also has a short biblical verse posted on the door — mine is Todo hombre sea pronto para oir, tardo para hablar y todo para enojarse, which translates to: “Everyone should be quick to listen, slow to speak and slow to become angry.” (James 1:19.)

We eat three meals a day at a long table on a shaded patio next to the main house. Costa Rican cuisine is not fancy, but quite filling — our hosts make sure that no one goes away hungry. Food staples are used with imagination: we have arroz con frijoles with every meal, but for breakfast, it’s made with spices that make it a pleasing accompaniment to the eggs, fruit, and other dishes that are laid out, buffet style, for us to sample.

During our stay, we make a trip to Finca Bosque, a flower farm operated by Plantas y Flores Ornamentales, one of Costa Rica’s leading tropical flower and fresh fern producers, which recently earned Rainforest Alliance certification. Plantas y Flores exports close to 4,500 tons of flowers each year to the U.S. and Canada for the “special occasion” flower market.

Flower cultivation seems less grueling than banana farming, but there can still be risks to farm workers from overuse of pesticides. German Céspedes, the farm’s operations manager, explains how Plantas y Flores uses innovative methods to minimize chemical use and protect the environment, including the use of organic compost and other biologically-derived methods.

We’re very impressed by his presentation… and by our walking tour, which takes us through row after row of flowers at every stage of development, from bud to full bloom. And the visit ends with a nice surprise: each member of our party is presented with a bouquet of lovely red roses.

On the final day of the trip, we say goodbye to the Gavilán and head south, winding slowly through the mountains (the phrase “hairpin turns” was invented for a road like this), with a brief stop at the charming Cascada de la Paz (Waterfall of Peace). Then it’s on to our last visit: Finca Rosa Blanca, an eco-lodge/coffee farm.

Our guide here is the owner, Glenn Jampol. Glenn informs us that guests at Rosa Blanca, Costa Rica’s first “boutique hotel,” are served coffee made from beans grown on the adjoining farm… and that the staff takes every opportunity to educate them about sustainable coffee production.

As he walks us across the farm’s hilly terrain, Glenn talks about the innovative practices used at Rosa Blanca. For example, most of the workers live in the area (which is unusual on Costa Rican coffee farms) — that way, he says, “they can keep the money they earn here in the community.” And as at Guayacán and Finca Bosque, pesticide use is kept to a minimum.

Like our other hosts, Glenn emphasizes that the welfare of his workers is as important to him as the quality (and quantity) of his product. It’s a sea-change from the days of the tough patron (boss) who saw the workers as easily replaceable and therefore expendable. But Glenn also notes that most farms in Costa Rica are required to take good care of their employees — the country has some of the strongest labor laws in the region.

As we return to San José, I reflect on what we have seen. Guayacán, Finca Bosque, the Gavilán and Rosa Blanca are all striking examples of what sustainable farming and tourism can accomplish; sadly, however, too many of their competitors are less enlightened. In order for these three enterprises and others like them to succeed, we must continue to spread the word that everyone — business, consumers, workers and the environment — benefits when farms and hotels choose the path of sustainability.

– Philip Berroll

Originally written for Rainforest Alliance blog,

http://www.rainforest-alliance.org/blog, 2008.

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Laparoscopic surgery pioneer, educator, researcher – Dr. Celia Divino wears many hats, but still keeps her equilibrium.

By P.H.I.Berroll

While chatting with a visitor in her office, Celia Divino picks up a tiny plastic rake and slowly pulls it back and forth across a miniature sandbox on her desk.

“It’s a Japanese garden,” Dr. Divino explains. “When you’re stressed out, you rake it and it relaxes you. It’s kind of Zen.”

It’s easy to see how Dr. Divino would be interested in stress reduction. Her life is a kind of tightrope walk, balancing a dizzying array of responsibilities.  A pioneer in minimally invasive gastrointestinal and hernia procedures, she was one of the first practitioners to perform laparoscopic hernia surgery. And while maintaining an active surgical practice, she also serves as  Chief of Mount Sinai’s Division of General Surgery; Professor of Surgery at Mount Sinai Medical School; Program Director of the General Surgery Residency Program… and head of the groundbreaking Surgical Simulation Center (SSC), where both new and experienced surgeons learn cutting-edge robotic surgery techniques.

“When I was in medical school,” she recalls, “it was my dream to be what was called a “triple threat” – a person who does research, teaches and has an active practice. I feel fortunate to be able to do all three.”

In her work, Dr. Divino also engages in another kind of balancing act: while teaching and advocating for innovative surgical procedures, she firmly believes that no new technique should be introduced without taking issues such as patient safety and quality of care into account.

“With any new procedure, I think that people should resist a bit when they have doubts regarding safety – after all, we’re doctors, we don’t want to endanger our patients,” she says. “So there has to be quality control, and appropriate credentialing. Not everybody can just go out there and start doing this.”

From ‘Heresy’ to Standard Procedure

How does Dr. Divino keep her equilibrium? By conserving her energy, keeping her sense of humor – and practicing a kind of synergy, where her experience in one area complements and enriches her work in another.

For example, take her position at the SSC, a state-of-the-art facility where both surgical trainees and experienced surgeons can learn and practice techniques using a “virtual surgery” construct – working at a computer-based tabletop, manipulating robotic instruments as in an actual operation, while  monitoring their progress in the digital image of the “patient” on a screen. It’s a process with many similarities to minimally invasive surgery; and there is a clear overlap between Dr. Divino’s advocacy for the center, her role as an educator, her quality-control concerns and her experience performing minimally invasive surgeries such as the groundbreaking hernia procedure.

“There were a lot of pioneers across the country, but I particularly focused my interest on many aspects of hernia surgery – not just inguinal [groin] hernias but ventral [abdominal] hernias,” she recalls. “I looked into it from a more academic standpoint; I did a lot of studies on it, on the durability, safety, and outcomes of this procedure. And I still have an interest in pushing the envelope and trying to see if there are other efficient ways of doing the surgery, with better outcomes.”

She cites several advantages for laparoscopic hernia surgery over traditional procedures: “With a laparoscopic procedure, you have a smaller incision than in open surgery. You still have a dissection, of course, but with much less pulling and tearing, so there’s considerably less trauma.  And the recovery time, the possibility of wound infection, the durability – all are much better.”

Dr. Divino makes a similar case for laparascopic methods in her other major field of interest, gastrointestinal surgery.

“For gastrectomies, small bowel resections, colon resections for both benign and cancerous growths – you have the same differences in technique and in the effect on the patient,” she says. “Or look at cholecystectomy [gallbladder removal] – that’s a three, four day hospital stay if you do an open procedure. As recently as 1992, people thought the idea of doing it in such a way that the patient could go home the same day was crazy – it was heresy. But we’ve since proven that when you do it laparoscopically, it’s a four hour stay in the recovery room. Colon cancer, gastric cancer, small bowel cancer, all of them can now be approached using minimally invasive techniques with the same outcomes in terms of survival and adequacy of resection. And that is really important.”

Not surprisingly, Dr. Divino has often encountered initial objections to new techniques – and not only on the grounds of patient safety.

“It can be harder for people who have done it a certain way to adapt to what is quite a steep learning curve,” she observes. “Do you want to start from scratch again when you’re able to do this and you’ve been doing it safely for 20 years? But I think our responsibility as leaders in the field is to reassure them – to say, ‘I don’t care if you’re at this stage of your career, you can still learn it if you want to.’”

It’s in that spirit that she declares the SSC “open to everybody – not only to train new doctors, but also those who have been in the profession for some time.”

“You Have To Take Ownership of Your Patients”

Dr. Divino feels that in one regard, the current generation of surgical students does have an advantage: their experience with video games gives them a leg up.

“One of the most difficult things in doing laparoscopic surgery is that it’s you can only work in two dimensions, as opposed to three-dimensional when you’re doing open surgery,” she explains. “In laparoscopy, you have at the most 4 degrees of freedom – you go this way or that way, or up, or down. You can’t turn the instruments around there because it’s a fulcrum.

“But kids who do video games, they’re playing in two dimensions,” she continues,  “so it’s second nature to them. Studies have shown that kids who play video games have better hand-eye coordination. Even my son, who naturally has done the Wii, the Xbox, etc., has been asking to use a surgical simulator to prove to me that he would be good with it,” she says with a hearty laugh. “And I’m like, ‘We’re not having a simulator at home!’”

The educational process has changed in other ways since she began teaching. “The mass of knowledge is expanding, but we have less time to teach it in the hospital because of the regulations that have been put in,” she notes. “Interns can’t work more than 16 hours at a stretch or have too many calls. You have to supplement their operating room experience because they can’t stay there all night long anymore. So you think of innovative ways to get the message across. When we teach our curriculum, we actually give them web-based modules and reading materials to study. We are also able to teleconference our teaching conferences to other hospitals, so they don’t have to physically be here. And on balance, I think it’s for the best.”

Again, she emphasizes the importance of patient safety and the quality of care. “There’s a lot more emphasis on those factors – it’s always been there, but now there are a lot more requirements and oversight,” she says. “It’s no longer that cowboy mentality of residents operating by themselves, making crazy decisions. And that has to play a part in education.”

But there are also some unchanging lessons that Dr. Divino has always imparted to her students.

“First of all, don’t lose track of why you’re here, and that’s the patients; they come first. Two – and this goes hand-in-hand with number one – you have to take ownership of your patients. Make sure that nothing falls through the cracks, and that all the people on your team know what’s going on. Three, you have to have a passion for what you do, or else you’re not going to do a good job. Fourth, keep on learning, whether it’s on the floor or by reading. Fifth, always maintain a certain amount of professionalism, whether it’s not wearing jeans on a Saturday even if you’re so tempted, or always being respectful of the patient’s race or religion, or the way you talk to your colleagues on a different service. And finally, before you do anything, stop and think. Because medical errors are unforgivable – and if you just stop and think for a moment, it may save a patient.”

Dr. Divino also wants her students to be knowledgeable on the subject of global health.  Born and raised in the Philippines – she came to the United States to study at University of California-Davis and UC-Berkeley – Dr. Divino is acutely aware of the differences between healthcare in the West and in the developing world. Under her leadership, surgical trainees have traveled to communities in Southeast Asia, Haiti and elsewhere to teach and help set up healthcare programs, and all senior surgical residents participate in a month-long surgical rotation in the Dominican Republic.

“Having come from that culture, I think our goal should be sustainability,” she says. “We try to go there and train the surgeons, the local people, not to do it our way, but to improve how they do it, or teach how we do it so that they’re able to do it on their own. We don’t convince them that the way to do it is using these fancy machines, because nobody there can afford them.”

The Unfinished Revolution

For all her pioneering efforts in surgical research and development, Dr. Divino has also broken new ground in another sense: as a female surgeon and surgical educator in what had long been a male-dominated bastion of medicine.

She considers it to be “revolutionary, unbelievable”  how much things have changed since she began her medical career. And while acknowledging that “there’s still a long way to go for female surgeons – we have plenty who are assistant professors, but very few who are at the tenured, full professor level,” Dr. Divino also notes that “45 to 50 percent of the applicants to surgical residency are very, qualified women from the best medical schools, some more qualified than the men. It used to be maybe 20 percent. The number of women in the American College of Surgeons, the number of women in residency programs – they’ve all gone up.”

But in her view, the rest of the country is just following Mount Sinai’s lead. “We were always ahead of the curve here,” she says, “because of Dr. Arthur Aufses [Chair of the Department of Surgery from 1974-1996], who was one of the trailblazers in bringing in a lot of women.”

Dr. Aufses, who is currently Professor of Surgery and Professor of Health Policy in Mount Sinai School of Medicine, agrees with Dr. Divino’s assessment.  “About a third of the surgical students at the medical school are women,” he notes.  “That’s real progress – though when you consider that for many, many years we’ve had 50% or more women overall as medical students, we’ve still got a ways to go to make it really equal in surgery.”

And Dr. Aufses is not surprised by the success of his former protégée.

“Every once in a while, you see somebody and you know they’re going to be a star,” he says. “She was destined to be a star from the beginning.”

“A sense of shared humanity” motivates Dr. David Nichols.

By P.H.I.Berroll

In the course of his career, David Nichols, M.D., has had no shortage of honors and acclaim. Still, upon hearing that he would receive Mount Sinai’s Saul Horowitz, Jr. Memorial Award, Dr. Nichols says he reacted with “a combination of tremendous thrill and total disbelief – because I did not expect to win.”

For all his modesty, it’s easy to see why Dr. Nichols, who is vice dean for education and professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, was chosen for this honor.

The award was established in 1978 – the year after Dr. Nichols graduated from Mount Sinai School of Medicine – in memory of longtime trustee Saul Horowitz, Jr., who played a major role in the construction of the school’s facilities. It is given to alumni who have made “significant contributions as a teacher, investigator, and/or practitioner in the field of medicine.” By any definition, Dr. Nichols meets this standard.

A specialist in pediatric intensive care, Dr. Nichols has taught at Johns Hopkins for nearly three decades. He has served as director of Johns Hopkins Hospital’s Division of Pediatric Critical Care and its Pediatric Intensive Care Unit (PICU). Dr. Nichols has also trained and mentored more than 50 postdoctoral fellows, written more than 80 professional journal articles and abstracts and edited numerous textbooks on pediatric critical care medicine.

Dr. Nichols credits Mount Sinai with providing the foundation for his career. “It was a very supportive and engaging learning environment,” he says, “and it gave me a commitment to excellence. It also taught me the importance of putting the patient first.”

From Berlin to Baltimore

Dr. Nichols’ path to Mount Sinai took some unusual turns. Born in Virginia, he spent much of his childhood in Berlin, where his father, an English professor and Fulbright scholar, served as director of that city’s Freie University.After graduating from Yale with a degree in molecular biophysics and biochemistry, “I decided that I was ready for a somewhat bigger city than New Haven – and of course, nothing can compete with New York.”

It was while at Mount Sinai that Dr. Nichols chose to go into pediatrics. “I believethat it’s very important for a doctor to enjoy being around a given type of patient,” he says. “And I just loved being around children. I felt committed to and passionate about caring for them.”

That passion took Dr. Nichols even further: while doing his internship and residency at Children’s Hospital of Philadelphia, he decided to specialize in pediatric intensive care.

“There is a tremendous immediacy and energy in that situation,” he says. “All of your training, knowledge and expertise is focused on this one sick child, and you know that if you and your team can pull together to provide the right care, this child will have a chance at growing up. It’s part of what makes medicine in general and pediatrics in particular such a noble profession.

“Most of the time,” he continues, “the children bounce back, and you’re able to watch the joy, the gratitude and the relief on the faces of the family members. When it doesn’t work out, and you have to convey bad news to a family and maybe even grieve with them – that’s a moment that no parent would ever want to face. But it’s also one that exposes our common humanity, the idea that we’re all in this together. And I think it’s that sense of a shared humanity that bonds doctors and patients and families.”

That same “sense of a shared humanity” spurred Dr. Nichols to join a major overseas initiative: last year, he was involved in setting up a medical school in the Malaysian city of Serdang.The facility,Perdana University Graduate School of Medicine, is a public-private partnership for which Johns Hopkins and Ireland’s Royal College of Surgeons are helping to provide courses. Dr. Nichols describes the experience as “a wonderful, exciting journey.”

“The Next Big Challenge”

At Johns Hopkins, Dr. Nichols has worked to provide students with the same high-quality education that he received at Mount Sinai. Under his leadership, the university undertook a major updating of its medical school curriculum.

While he considers American medical education to be “probably the best in the world,” Dr. Nichols sees room for improvement in several areas: a greater emphasis on recent scientific discoveries such as genome sequencing; more inter-professional education involving doctors, nurses and other healthcare personnel; and increased use of simulation technology.

The most crucial need, he feels, is for research into the link between physicians’ education and training and patient outcomes. “We have to find a way to prove the assumption that a doctor who’s been well trained and educated will provide better care,” says Dr. Nichols, “and for poorly functioning teams, to determine what about the training and preparation of team members could have been done better.”

“That is the next big challenge in medicine,” he adds. “If there’s any task that I would like to take on in the rest of my career, it’s that one.”

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Drs. Andrew Hecht and Sean McCance work on the cutting edge of minimally invasive back surgery.

By P.H.I.Berroll

For Sean McCance, one of the biggest innovations in his field, spinal surgery, over the last ten years has been the XLIF cage. XLIF, or lateral lumbar interbody fusion, is a minimally invasive surgical procedure performed through the patient’s side, in order to avoid the major back muscles. The cage, a small rectangular-shaped device, is inserted between the patient’s vertebrae to provide support.

“The cage is put into a very small incision,” Dr. McCance explains, “through a special tubular retractor that allows you to get a large implant into in a small space. The older approach, with a large incision, tended to cause muscle denervation [the interruption of nerve impulses to the muscles] and lead to out-pouching of the abdominal wall and maybe some scar pain. But with this technique, there’s less scarring, less risk of side effects. It can be used for older scoliosis patients who can’t tolerate a big open surgery, and can save younger patients the morbidity of a big incision.”

Dr. McCance, who is Co-Director of Spine Surgery in the Leni and Peter W. May Department of Orthopaedics, regards the XLIF cage as a major advance in his field – and a paradigm for his mission as a surgeon: “To perform the same or better surgery through a smaller incision.”

Indeed, this is the primary goal of Dr. McCance and his co-director, Dr. Andrew Hecht, who have led Mount Sinai’s spinal surgery program since 2005. For both practitioners, minimally invasive surgery has become a key component of their work. They are in the forefront of a wave of innovation that has revolutionized spinal surgery – to the point where procedures once considered high-risk are now commonly performed on both elite professional athletes and people in less physically stressful lines of work.

“Minimally invasive techniques have had a very positive impact of on our field in the last decade,” says Dr. McCance. “They’ve given us the ability to address a broader array of pathologies with less morbidity.”

The Extraordinary Tube

In addition to his work at Mount Sinai, Dr. Hecht is the spine surgical consultant to the New York Jets, the New York Islanders and numerous collegiate teams. This has given him a unique perspective on the growing popularity of minimally invasive spinal surgery, first with big-name athletes – this past May, Indianapolis Colts quarterback Peyton Manning had a microdiscectomy, which is performed through a one- to one-and-a-half-inch incision in the lower back, to relieve the pain of a pinched nerve – and now with the general public. “A lot of these techniques,” he says, “are applicable to many different groups of patients.”

Like Dr. McCance, he speaks with great enthusiasm about the use of tubular retractors – which he says “have enabled us to do some very extraordinary things” – in several types of lumbar and pelvic surgery.

Tubular retractors enable surgeons to enhance their view of the spine without the invasiveness of traditional surgery. “Instead of making a larger incision and dissecting all the way down to the spine,” Dr. Hecht explains, “we make a small incision and through a series of dilators, insert what is basically a tube. Then, with the use of a microscope, we’re able to look down the axis of this tube and see things that we normally see with open surgery. Some of these tubes at the very bottom are able to be expanded or dilated further to improve visibility.

“This allows us to avoid the extensive dissection, the tissue exposure, of open spine surgery. You’re minimizing the muscle damage, shortening the length of stay, and minimizing the post-operative pain, particularly in the short term. The patient can be out of the hospital and getting on with his life much more quickly.”

Dr. Hecht also cites prosthetic cervical disc replacement, used to treat patients suffering from herniated discs, as “a very advantageous development.” He and the other members of his team, Sheeraz Qureshi, M.D. and Samuel Cho, M.D., have frequently performed this procedure.

“It’s a big advantage over traditional fusion treatments, where the disc is removed and the surgeon performs a fusion with a bone graft and a titanium anterior fixation plate,” he says. “With prosthetic replacement, motion is preserved – patients can start moving right away, they don’t need to wear a brace. As a result, we don’t worry about problems such as muscle atrophy above or below the area where they would have had a fusion.”

From Cages to Proteins

In addition to the XLIF cage, Dr. McCance speaks highly of a similar device, the self-distracting cage (“distract” in this context means to separate or spread apart) – which, he says, “allows us to do ‘more with less.’

“When we put this cage into the spine,” he explains, “it allows us to elevate the space and restore height to the vertebrae with less maneuvering and tissue manipulation than with older technologies – because the cage itself actually jacks up, almost like a car jack. So you don’t have to do a lot of opening, spreading, etc. to expand the space, which makes it safer for the surrounding neural tissues.”

One tool about which both Dr. Hecht and Dr. McCance are enthusiastic is neither a device nor a procedure, but a substance: Bone morphogenetic protein (BMP), a molecule which can literally grow bone.

Dr. McCance, who calls himself “the largest user of BMP at Mount Sinai,” says, “It can be used as a replacement for iliac crest [a major segment of the group of bones around the pelvis, from which bone material is often used in grafts], and studies suggest that it holds up just as well. So it’s been a step forward in saving some patients the need to harvest their own bone.”

Dr. Hecht concurs: “We’re able to achieve a solid fusion through a tiny incision, only a centimeter or two long, by inserting BMP, where in the past you’d have these massive incisions. For certain types of patients, this is a very effective treatment.”

The two surgeons are closely following the development of other minimally invasive techniques that could prove useful in their work. For example, Dr. McCance predicts that more surgeons will be inserting screws in the spine percutaneously [through wires and tubes] during procedures, rather than the traditional approach of insertion through an incision.

“So if you have a sick patient who maybe can’t tolerate a full open surgery, you can do part of it percutaneously and part of it open,” he says. “That’s another minimally invasive technique that potentially is a step forward for patients.”

Dr. Hecht and Dr. McCance both feel that minimally invasive surgery has enhanced the success of their practice – and the personal satisfaction they take from their work.

“For both cervical and lumbar surgery, we’ve showed a substantial ability to help people,” says Dr. Hecht. “Mount Sinai has one of the largest spine services in Manhattan, and has emphasized treating patients with all kinds of spinal disorders, and trying to get them back to a full life. I think the kinds of surgeries we’re doing, and the outcomes we’re having, are testament to that.”

Originally published in Mount Sinai Science & Medicine magazine, 2012.

By P.H.I.Berroll

It’s one thing to research and develop a new surgical procedure. It’s quite another to put it into practice, over and over again. The surgeons of Mount Sinai have been leaders in the use of the DaVinci robotic system and other minimally invasive techniques. Here, three of them talk about how those innovations have impacted their work.

Dr. Eric M. Genden is no stranger to innovative surgical procedures – he was the first surgeon in the United States to perform a jaw transplant. So it’s not surprising that he has been a pioneer of robotic surgery in his field of specialty, cancers of the head and neck. “It’s made a remarkable impact on our ability to take care of patients with these cancers,” says Dr. Genden, “without making large incisions and doing surgeries that take up a huge amount of time and resources.” Dr. Genden, the Chairman of the Department of Otolaryngology and Chief of the Division of Head and Neck Oncology, performed his first robotic surgery in 2006 and has since done close to 250 such procedures. The biggest advantage of the robotic procedure, he says, is its relative simplicity: “In the typical open surgery, patients have to undergo a 12-to-14-hour procedure to get to the tumor, and they’re usually in the hospital for 10 to 12 days. Using the robot, we’re able to remove the tumor in about two hours – and patients usually go home the next day, eating and drinking and swallowing.” Dr. Genden notes that the robotic technique “is being adapted widely, not only across the U.S. but now in Europe and Asia – because people are seeing that this has a tremendous impact on both the quality of patient outcomes and the cost of care.”

As Chief of the Surgery Department’s Division of Metabolic, Endocrine and Minimally Invasive Surgery, Dr. William B. Inabnet III leads a team that has done more laparoscopic surgeries than at any other hospital in New York City. Dr. Inabnet himself performed the first robotic thyroidectomy at Mount Sinai in 2010, and is a strong advocate of both robotic and non-robotic minimally invasive procedures to remove part or all of a diseased thyroid gland. In the most common procedure, a laparoscope with a tiny, high-definition video camera is inserted into the incision made by the surgeon, so that he and his team can have a bigger, clearer view of the operation on a television screen – “which promotes teamwork,” says Dr. Inabnet, “and greatly improves patient safety.” There is also a cosmetic advantage: The patient is left with a one-to-two-inch scar on the front of the neck, as opposed to four to six inches in a traditional operation. Dr. Inabnet is so impressed with the procedure that he has posted a video of it on Facebook (www.facebook.com/msthyroid), and looks forward to its becoming more common. “Every year,” he notes, “we graduate two endocrine laparoscopic surgery fellows who know these techniques. We’re training the next generation.”

Prostatectomy – the removal of a diseased prostate gland – has long been considered one of the riskiest of medical procedures; because the prostate is surrounded by nerves which control sexual and excretory functions, the slightest error can leave a patient both impotent and incontinent. But through the use of robotics, Dr. David B. Samadi has been able to perform close to 2,200 prostatectomies at Mount Sinai, with amazing results: “97 percent of patients retain continence,” he says, “85 percent, sexual function. 95 percent stay only one night in the hospital. Pain is minimal.” As Chief of Robotics and Minimally Invasive Surgery at Mount Sinai, Dr. Samadi, a urologist, performs almost 15 robotic prostatectomies a week, using a procedure he has named with the acronym SMART (Samadi Modified Advanced Robotic Technique). The main advantages of the technique, he says, are the ability of the DaVinci system to handle the prostate without disturbing “the delicate, sensitive nerves” around it, and to give him a clear, precise view. “In open surgery, you use ‘the touch factor’ because you can’t see the detail of the procedure,” he notes. “With the SMART technique, I can see the detail – so I can perform a precise operation.”

Originally published in Mount Sinai Science & Medicine magazine, 2012.

By P.H.I.Berroll

Say you’re a New Yorker whose friends or relatives from outside the U.S. are planning to visit. You’d love to put them up in your Manhattan apartment, but unfortunately, like many Manhattanites you barely have enough space for your own family.

So you try to think of other options for your guests. A hotel?  Manhattan has some of the most expensive hotels in Western civilization, with nightly rates of four figures not uncommon.  Even cheaper hotel rooms (and “hotel” in this case could mean a converted town house or apartment building) can go for as much as $300/night. A motel? Those are often located near the city’s three airports – where the sounds of airline takeoffs and landings have disrupted many a traveler’s sleep – and in other less-than-desirable locations where getting to Manhattan involves  a lengthy and often crowded commute.

In the past few years, however, some innovative entrepreneurs – combining the DIY esthetic with the growing “frugal traveler” movement – have introduced new lodging options to put the traveler near the heart of the city without busting his budget.

The most well-established of these is San Francisco-based Airbnb, which enables “hosts” – apartment owners or renters – to offer their homes as low-cost tourist accommodations. Travelers can browse listings (which include photos as well as “reviews” from previous guests) in over 19,000 cities in 190 countries, and contact hosts with any questions before booking a space…   for as little as a day, or as much as a month. It’s a new twist on the bed-and-breakfast concept, though unlike traditional b&bs, the host may not be on the premises and guests often have to provide their own food. But on the upside, the traveler gets a clean, safe, conveniently located place to stay, at nightly rates ranging from the low $80’s to less than $150.

Airbnb is the brainchild of three young entrepreneurs, Brian Chesky, Nathan Blecharczyk and Joe Gebbia. Chesky and Gebbia, who met as students at the Rhode Island School of Design, were sharing an apartment in San Francisco in 2007 when they had their “aha” moment: Hearing that many attendees at an upcoming design conference had no place to stay – all the local hotels were completely booked – they offered their apartment as an informal bed-and-breakfast.

The experience worked out so well that after taking on Blecharczyk as a partner, they decided to expand their one-time act of kindness into an ongoing business operation – both to make money and in Chesky’s words, “to disrupt the [hospitality] industry” with their new approach. (Chesky, the CEO, is so dedicated to the concept that he gave up his apartment last year and has since been staying in renters’ homes “to grasp the full impact and experience of Airbnb.”)

Not surprisingly, the success of Airbnb has inspired several imitators, including iStopOver, which is based in Canada, and Italy-based Wimdu. There are also other sites offering different alternatives to traditional hotel booking: HostelWorld enables users to book stays at hostels in New York and 112 other U.S. cities as well as in 180 different countries, while CouchSurfing is a kind of exchange program where members can stay in the homes of locals in other countries and open their own homes to visitors from abroad.

But Airbnb has the greatest number of listings for New York City – more than 6,000 as of this writing – and Chesky professes to be unfazed by the competition: “They may borrow our concept or copy our designs, but the keystone of Airbnb is the community behind it – and the relationships our community fosters can’t be replicated.”

There is one drawback to the Airbnb system for New York City hosts:  officially, the business is operating in a legal limbo.

In 2010, the New York State Legislature passed a law (which went into effect in May of this year) entitled “Clarifies Provisions Relating to Occupancy of Class A Multiple Dwellings.” In plain English, the law makes it illegal for a paying guest to stay in another person’s apartment for less than 30 consecutive days if their host is not also living in the apartment. The law was passed in response to complaints from apartment dwellers and coop and condo boards about “absentee owners” who bought or rented multiple apartments not for their own use, but as tourist lodging – a violation of the rules in many NYC apartment buildings.

The problem is that there is no way for law enforcement to distinguish between those multiple-unit owners and the single-apartment hosts of Airbnb. Hosts who stay in an apartment at the same time as their guests are not affected, but those who take in guests while living elsewhere are at least technically breaking the law.

To date, however, there have been no arrests or prosecutions under the law, and local Airbnb hosts aren’t worried. As Rachel, a renter in Chelsea – for personal reasons she prefers not to use her last name – observes, “It’s not like the city or the state has the money to hire ‘real estate cops.’”

Airbnb has also had to deal with the fallout from an incident in June, in which a San Francisco host returned from an out-of-town trip to find that her guests had ransacked and looted her apartment. It was the first such occurrence in the company’s history, and while Airbnb worked with the police to catch the offenders, it was a wake-up call to Chesky and his partners. “For two million nights, we’d seen this as a case study demonstrating that people are fundamentally good,” says Chesky. “We were devastated.”

But the company took steps to tighten security, including designing enhanced tools to verify user profiles and creating an “education center” to provide hosts with safety tips. They also began offering a guarantee of $50,000 to reimburse hosts in cases of theft or vandalism.

According to Chesky, their business has not suffered – “In fact,” he says, “we have received thousands of e-mails from users who told me that they still believed in our service” – and he anticipates continued growth for Airbnb in the foreseeable future.

Indeed, Airbnb consistently gets high marks from users, not only for the low prices but also for something more intangible: the chance for visitors to immerse themselves in the life of the city. Airbnb guests often speak of how staying in an apartment enabled them to experience the “real” New York, as opposed to the isolation of a typical hotel. “I love being able to feel like I’m living in a neighborhood,” says Sara, a traveler from Vancouver, “rather than dropping into a tourist zone.”

It’s an experience that Airbnb hosts are happy to provide. “I don’t think we’re cutting into the large mass of people who want maid service every day and don’t care if they have a kitchen,” says Rachel. “But if you want a kitchen and don’t need a maid, then why would you reserve for $375 per night at the Times Square Residence Inn instead of $125 at my apartment?”

Here are the websites for the lodging services mentioned in this article:

Airbnb                                      www.airbnb.com

iStopOver                                 www.istopover.com

Wimdu                                      www.wimdu.com

HostelWorld                             www.hostelworld.com

CouchSurfing                           www.couchsurfing.org

Originally published in New York International magazine, 2011.

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