The Story of the Howard University Transplant Center (A Project of the People) Clive 0. Callender, MD and Patricia A. Spaulding, BS Washington, DC
It took almost two years for Howard University Hospital to receive certification as a kidney transplant hospital under the federal government's end-stage renal disease program, although Howard had a transplant program that was comparable to many in the country. By the time the Department of Health, Education, and Welfare approved Howard's program, many successful transplants had already been carried out there, largely on indigent patients who probably could not have received transplants elsewhere or on patients whose chances of survival, because of other complications, were so risky that other hospitals had turned them down. At first the high cost of these operations had to be absorbed by the University since the government reimbursed only those hospitals which had an approved transplant program. Howard has now received reimbursement (payments of more than $500,000) for its transplants because its certification was granted retroactive to July 1, 1973, when the federal program was started. So the Transplant Center is now enabled, and committed, to provide the best possible transplant care to the Washington, D.C. community which, incidentally, has one of the highest incidences of kidney failure in the country. Howard University Hospital has been approved by the Department of Health, Education, and Welfare (HEW) as a Kidney Transplant Center under the federal government's end-stage renal disease program. The HEW certification, coming almost two years after Howard first applied for it, is the
From the Departments of Surgery and University Relations and Publications, Howard University Medical Center, Washington, D.C. Requests for reprints should be addressed to Dr. Clive 0. Callender, Department of Surgery, Howard University Medical Center, 2041 Georgia Avenue, NW, Washington, D.C. 20060.
direct consequence of the hard work of many Howard University employees and friends. Howard first applied for temporary certification in 1973 immediately after the passage of federal legislation HR-1. HR-1 authorized the Social Security Administration to develop a program which would provide kidney transplant and dialysis for any United States citizen in need of them, despite the patient's inability to pay the exorbitant costs involved. HR-1 provides for federal payment for such treatment, but only to certified transplant centers. According to HEW guidelines set up
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 8, 1977
by a Steering Committee comprised of the Regional Medical Program Services and the Joint Commission on Accreditation of Hospitals, the temporary certification was to be effective until HEW could identify the hospitals in an area capable of providing the most advanced diagnosis and treatment techniques and methods for end-stage kidney diseases. The Committee proposed that there be one kidney transplant center per every two million people in the United States. This meant that Washington could eventually have only two centers. The HEW guidelines, however, did not stipulate the number of centers which could receive temporary certification. Even though more transplants were done there in 1974 than in other civilian hospitals in the area, no on-site evaluation was ever done at Howard to determine whether or not its kidney program was one of the most advanced. Although Howard qualified for temporary certification according to the guidelines, which state that consideration for certification be given to those hopsitals that had made commitments to develop kidney transplant programs prior to the passage of HR-1, its request was turned down and no specific reason was given for not granting the certification. A "grandfather" clause in the guidelines provided for interim certification to those hospitals which had already performed at least one kidney transplant (Georgetown and George Washington). Georgetown, George Washington, and the Hospital Center all received certification in 1973, although federal 565
officials later declared that the Hospital Center's certification was granted in error because it had not performed kidney transplants prior to HR-1. It is hard to state precisely when the idea of transplant activity first began at Howard but, in 1964, Dr. William E. Matory of the Department of Surgery performed the first animal kidney transplant and also was first to use the artificial kidney in dogs in Howard's Surgical Research Laboratory. Following a period of preceptorship in the dialysis unit at the Washington Veterans Administration Hospital in 1966, Dr. Matory initiated the hemodialysis program at Howard University. He initiated the use of arteriovenous shunts in patients needing chronic dialysis in 1969. This pioneering work then served as the foundation for the kidney transplant activity which was to follow. The work begun by Dr. Matory was continued by Dr. Oswald Warner, a thoracic and cardiovascular surgeon, who returned to the Howard University faculty in July 1970. It was he who mastered the problems of vascular access which allows patients with kidney failure to be kept alive on the artificial kidney. No less important was the pioneering work of nephrologists, Dr. Edward Chappelle, Dr. Adrian Hoston, and Dr. Martin Dillard, all of whom were on the Howard University staff and who developed and sophisticated the hemodialysis program. These doctors fought to have Howard University participate in the planning of a regional transplant program even before the University had a transplant surgeon. Dr. Burke Syphax and Dr. LaSalle D. Leffall, Jr., former chairman and present chairman of the Department of Surgery, respectively; Dr. Charles S. Ireland, Dr. Vincent J. Roux, hospital director and medical director, respectively; and Dr. Carlton P. Alexis, vice president for health affairs, were key figures in the development of the kidney transplant program at Howard
University. In 1971, Dr. Clive 0. Callender, who was Howard's chief surgical resident in 1968-1969, was sent to the foremost kidney transplant center in the world at the University of Minnesota to train as a Clinical Transplant Fellow. In July 1973, he returned as transplant director at the Howard University Hospital which was then Freed566
men's Hospital. His return occurred at the same time that the federal government had stepped into kidney transplant activity. The initial refusal of certification to Howard as a transplant center was viewed with some pessimism and many felt that there was little likelihood that Howard would ever receive approval. Fortunately, this was not the view of the administrators of the hospital who endorsed this embryonic transplant program without reservation. Upon Dr. Callender's return, the support given him by the hospital's administrators, the nursing administration, the chairman of the Department of Surgery, and the Department of Anesthesiology was invaluable. The initial planning and training of the transplant team were assisted in great measure by the procurement of a $500 grant from the Kidney Foundation, and a $20,000 grant from the Regional Medical Program. This money was used to assist in the training of the nursing and surgical transplant teams. Particularly important at this stage was the cooperation of Maude Jennings, associate director of Nursing, in charge of the operating room; Thomasina Wigfall, head nurse of the Annex Operating Room; Gwendolyn Webster, associate director of Nursing; and Alice Naughton, director of Nursing. The initial phases required the cooperative efforts of these nurses as well as the nursing teams on the wards. Here, Charlotte Reid and Geneva Greene, head nurses on the renal units, played vital roles in the development of the Transplant Service. Of equal importance were the services provided by the hospital security guards in the procurement of organs from other hospitals. These services were provided under the leadership of Captain Roy Williams. No less important was the role of the environmentalists in assuring that the rooms were appropriately cleaned and sterilized in the wards as well as in the operating rooms. This general cooperation was typical in every department that was called upon to assist the transplant team in its development. The role of the urological team, as provided by Dr. George Jones and Dr. Aaron Jackson, was overwhelming. With the foundation having been laid and the preparatory operations having been performed, the first transplant was performed on January 28,
1974. Scottie Leftwridge, age 38, who today works for Howard University Hospital, was the first transplant recipient. He is alive and well after more than three years. The first kidney obtained for renal allotransplantation at Howard was provided through a collaborative organ-sharing program from the Bethesda Naval Hospital. The cooperation of the Bethesda Naval Hospital Transplant Team, headed by Dr. Ron Filo, was vital to the success of this transplantation endeavor as the kidney had to be preserved for about 36 hours prior to the transplant. Bethesda Naval Hospital sent the kidney to Howard in a kidney-preserving machine. The first kidney transplant at the old Freedmen's Hospital was followed by many others. In April 1975, Freedman's Hospital was closed and its facilities were moved to the new 500-bed, ultramodern Howard University Hospital. Two unusual transplants for Howard University Hospital took place in February and September 1975. In February 1975, two brothers traveled from India to Howard where one brother gave a kidney to the other whose kidneys had ceased to function. The hospital donated its services as well as the services of the dialysis and transplant teams and used the operation as a teaching case for its medical students. Today, both brothers are alive and well. On September 30, 1975, Howard's first transplant on caucasians was performed on a brother and sister who had identical matches. Both were in their 50's. The brother, who was the recipient, had been refused by a Cleveland clinic on ground that he was too old and too sick to receive a kidney transplant since he suffered from extreme arteriosclerosis. He was brought to the Howard University Hospital and was felt to be a high-risk candidate, but nonetheless, one who should be given the opportunity for a renal transplant if he was willing to accept the risk. He was willing and stated that he would do anything to improve the quality of his life, even at the risk of death. Without guarantee and with informed consent, he and his sister underwent the transplant operations. Both are alive and well as of this writing (June 1977). Since Howard's first transplant in January 1974, 37 patients have rec eived 43 kidney transplants.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 8, 1977
Twenty-six of these patients are alive, 19 with functional kidneys. Our oneyear cadaver donor/recipient survival and function rates are 75 percent and 60 percent, respectively. These are above the national average for whites of 70 percent and 50 percent, in spite of recent reports indicating that the one-year survival of kidney transplants for blacks is 33 percent. Seventy-five percent of the kidneys donated are from cadavers. Much of the hospital's success with cadaver kidneys can be attributed to the use of antilymphocyte globulin, which helps fight rejection of the new organ by the transplanted patients. Howard was the first hospital in this area to use the drug and is now conducting research to further refine its use. The Department of Pharmacy, under the direction of Mr. James C. Burgess and Mr. Robert L. Malone, was helpful in obtaining and using this experimental drug. Howard also uses group therapy as a form of rehabilitation for its transplant patients. The Center employs a rehabilitation counselor and a social worker, both of whom work with the patients before and after surgery in an effort to assist them in adjusting to the psychological effect of having someone else's kidney - often a problem with such patients. In the group therapy sessions, patients help each other in their adjustments after surgery as well as during the preoperative waiting period. The transplant expertise is provided by a team consisting of three nephrologists, three transplant surgeons, a pediatric surgeon, three general surgeons, a transplant social worker, vocational and rehabilitation counselors, dietitians, and dialysis and nephrology nurses. This breadth of expertise gives the capability of transplanting other organs such as the pancreas and liver. In spite of its initial success, the transplant program continued to function unsanctioned until Dr. George Jones, Chief of the Division of Urology and Dr. Jesse Barber,, Chief of the Division of Neurosurgery became involved in its fight for certification. They petitioned supporters of Howard University, at all levels, to make them aware of the transplant activity at the University and of the injustices that Howard was suffering in not being certified. The persons who were involved in consulting and communica-
ting with the Department of Health, Education, and Welfare and the local press regarding the unfair treatment of the hospital were: Senator Edward Brooke (R-Mass); Congresswoman Shirley Chisholm (D-NY); Congressman Carl D. Perkins (D-Ky); Congressman Walter Fauntroy (D-DC); Congressman Louis Stokes (D-Ohio); Senator Edward M. Kennedy (D-Mass); Congressman Charles Diggs (D-Mich); Congressman Charles Rangel (D-NY); Senator Birch Bayh (D-Ind); Senator Charles Matthias (R-Md); Tally Holmes, Co-Chairman of Precincts of the Republican Party of D.C.; Dr. Frank Lloyd of Indianapolis; Senator Glen Beall (R-Md); Washington Post medical reporter Victor Cohen; WTOP-TV news reporter Eldridge Spearman: Paul R. Hathaway and Patricia A. Spaulding, Director and Assistant for Publications, respectively, of the Howard University Department of University Relations and Publications; Daisy Fitts of the Howard University Hospital Office of Public Relations; The Washington Regional Medical Program under the leadership of Vaughan Choate and Dr. Martin Levy; the hospital administrations and medical staffs of Georgetown University, George Washington University, Washington Hospital Center, Walter Reed and Bethesda Naval Hospitals; the Medico-Chirurigical Association; the Women's Auxillary of Howard University Hospital; the Advisory Board of the Howard University Hospital; the Alpha Chapter of the Chi Eta Phi Nursing Sorority; and the National Medical Association. Because of the efforts of the supporters of the Hospital and the success of the transplant service, Senator Edward Brooke (R-Mass), a Howard alumnus who played a major role in the breakthrough, received a letter on November 14, 1975, from James B. Caldwell, commissioner of Social Security, which stated, "A review of the latest available statistical data clearly establishes that Howard University Hospital is making a much needed contribution to the Metropolitan Washington transplant service." This final approval made Howard University eligible for reimbursement of over one-half million dollars in retroactive payments. Certification was made effective on July 1, 1973, when federal reimbursement for kidney services was started.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 8, 1977
Certification meant that the hospital would receive in the range of $20-30,000 for every transplant if the patient's course was uncomplicated and as much as $100,000 if there were complications. The stigma that had been associated with the uncertified status was thus removed. With certification of the Transplant Center and public acceptance of its legitimate program, referrals from all states in the United States and from other countries were expected to be forthcoming. Transplants were expected to increase to 20-3 0 per year. In addition, the favorable publicity for the Howard University Health Sciences Center and the resulting positive statements were certain to improve the hospital's image in the community at large. The Center's major effort in the future will be to reach communities in the District of Columbia so that the 30 patients who are awaiting transplants, an ever increasing list, will receive kidneys. Unfortunately, most kidney transplants (60 percent) are performed with the use of cadaver kidneys. This is because most living persons have problems with accepting the concept of donating a kidney to save someone else's life. It is not unusual for one to feel that giving a kidney would cause him to die from kidney failure. Because Washington, D. C. has an unusually high incidence of kidney disease, it is felt that Howard University Hospital might play a major role in kidney transplantation in the future. It is planned that Howard will become one of the leading Transplant Centers in the United States.
Acknowledgement Burke Syphax, MD, is acknowledged for his tireless efforts in the completion of this work.
567
It took almost two years for Howard University Hospital to receive certification as a kidney transplant hospital under the federal government's end-stage renal disease program, although Howard had a transplant program that was comparable to many in the country. By the time the Department of Health, Education, and Welfare approved Howard's program, many successful transplants had already been carried out there, largely on indigent patients who probably could not have received transplants elsewhere or on patients whose chances of survival, because of other complications, were so risky that other hospitals had turned them down. At first the high cost of these operations had to be absorbed by the University since the government reimbursed only those hospitals which had an approved transplant program. Howard has now received reimbursement (payments of more than $500,000) for its transplants because its certification was granted retroactive to July 1, 1973, when the federal program was started. So the Transplant Center is now enabled, and committed, to provide the best possible transplant care to the Washington, D.C. community which, incidentally, has one of the highest incidences of kidney failure in the country. Howard University Hospital has been approved by the Department of Health, Education, and Welfare (HEW) as a Kidney Transplant Center under the federal government's end-stage renal disease program. The HEW certification, coming almost two years after Howard first applied for it, is the
From the Departments of Surgery and University Relations and Publications, Howard University Medical Center, Washington, D.C. Requests for reprints should be addressed to Dr. Clive 0. Callender, Department of Surgery, Howard University Medical Center, 2041 Georgia Avenue, NW, Washington, D.C. 20060.
direct consequence of the hard work of many Howard University employees and friends. Howard first applied for temporary certification in 1973 immediately after the passage of federal legislation HR-1. HR-1 authorized the Social Security Administration to develop a program which would provide kidney transplant and dialysis for any United States citizen in need of them, despite the patient's inability to pay the exorbitant costs involved. HR-1 provides for federal payment for such treatment, but only to certified transplant centers. According to HEW guidelines set up
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 8, 1977
by a Steering Committee comprised of the Regional Medical Program Services and the Joint Commission on Accreditation of Hospitals, the temporary certification was to be effective until HEW could identify the hospitals in an area capable of providing the most advanced diagnosis and treatment techniques and methods for end-stage kidney diseases. The Committee proposed that there be one kidney transplant center per every two million people in the United States. This meant that Washington could eventually have only two centers. The HEW guidelines, however, did not stipulate the number of centers which could receive temporary certification. Even though more transplants were done there in 1974 than in other civilian hospitals in the area, no on-site evaluation was ever done at Howard to determine whether or not its kidney program was one of the most advanced. Although Howard qualified for temporary certification according to the guidelines, which state that consideration for certification be given to those hopsitals that had made commitments to develop kidney transplant programs prior to the passage of HR-1, its request was turned down and no specific reason was given for not granting the certification. A "grandfather" clause in the guidelines provided for interim certification to those hospitals which had already performed at least one kidney transplant (Georgetown and George Washington). Georgetown, George Washington, and the Hospital Center all received certification in 1973, although federal 565
officials later declared that the Hospital Center's certification was granted in error because it had not performed kidney transplants prior to HR-1. It is hard to state precisely when the idea of transplant activity first began at Howard but, in 1964, Dr. William E. Matory of the Department of Surgery performed the first animal kidney transplant and also was first to use the artificial kidney in dogs in Howard's Surgical Research Laboratory. Following a period of preceptorship in the dialysis unit at the Washington Veterans Administration Hospital in 1966, Dr. Matory initiated the hemodialysis program at Howard University. He initiated the use of arteriovenous shunts in patients needing chronic dialysis in 1969. This pioneering work then served as the foundation for the kidney transplant activity which was to follow. The work begun by Dr. Matory was continued by Dr. Oswald Warner, a thoracic and cardiovascular surgeon, who returned to the Howard University faculty in July 1970. It was he who mastered the problems of vascular access which allows patients with kidney failure to be kept alive on the artificial kidney. No less important was the pioneering work of nephrologists, Dr. Edward Chappelle, Dr. Adrian Hoston, and Dr. Martin Dillard, all of whom were on the Howard University staff and who developed and sophisticated the hemodialysis program. These doctors fought to have Howard University participate in the planning of a regional transplant program even before the University had a transplant surgeon. Dr. Burke Syphax and Dr. LaSalle D. Leffall, Jr., former chairman and present chairman of the Department of Surgery, respectively; Dr. Charles S. Ireland, Dr. Vincent J. Roux, hospital director and medical director, respectively; and Dr. Carlton P. Alexis, vice president for health affairs, were key figures in the development of the kidney transplant program at Howard
University. In 1971, Dr. Clive 0. Callender, who was Howard's chief surgical resident in 1968-1969, was sent to the foremost kidney transplant center in the world at the University of Minnesota to train as a Clinical Transplant Fellow. In July 1973, he returned as transplant director at the Howard University Hospital which was then Freed566
men's Hospital. His return occurred at the same time that the federal government had stepped into kidney transplant activity. The initial refusal of certification to Howard as a transplant center was viewed with some pessimism and many felt that there was little likelihood that Howard would ever receive approval. Fortunately, this was not the view of the administrators of the hospital who endorsed this embryonic transplant program without reservation. Upon Dr. Callender's return, the support given him by the hospital's administrators, the nursing administration, the chairman of the Department of Surgery, and the Department of Anesthesiology was invaluable. The initial planning and training of the transplant team were assisted in great measure by the procurement of a $500 grant from the Kidney Foundation, and a $20,000 grant from the Regional Medical Program. This money was used to assist in the training of the nursing and surgical transplant teams. Particularly important at this stage was the cooperation of Maude Jennings, associate director of Nursing, in charge of the operating room; Thomasina Wigfall, head nurse of the Annex Operating Room; Gwendolyn Webster, associate director of Nursing; and Alice Naughton, director of Nursing. The initial phases required the cooperative efforts of these nurses as well as the nursing teams on the wards. Here, Charlotte Reid and Geneva Greene, head nurses on the renal units, played vital roles in the development of the Transplant Service. Of equal importance were the services provided by the hospital security guards in the procurement of organs from other hospitals. These services were provided under the leadership of Captain Roy Williams. No less important was the role of the environmentalists in assuring that the rooms were appropriately cleaned and sterilized in the wards as well as in the operating rooms. This general cooperation was typical in every department that was called upon to assist the transplant team in its development. The role of the urological team, as provided by Dr. George Jones and Dr. Aaron Jackson, was overwhelming. With the foundation having been laid and the preparatory operations having been performed, the first transplant was performed on January 28,
1974. Scottie Leftwridge, age 38, who today works for Howard University Hospital, was the first transplant recipient. He is alive and well after more than three years. The first kidney obtained for renal allotransplantation at Howard was provided through a collaborative organ-sharing program from the Bethesda Naval Hospital. The cooperation of the Bethesda Naval Hospital Transplant Team, headed by Dr. Ron Filo, was vital to the success of this transplantation endeavor as the kidney had to be preserved for about 36 hours prior to the transplant. Bethesda Naval Hospital sent the kidney to Howard in a kidney-preserving machine. The first kidney transplant at the old Freedmen's Hospital was followed by many others. In April 1975, Freedman's Hospital was closed and its facilities were moved to the new 500-bed, ultramodern Howard University Hospital. Two unusual transplants for Howard University Hospital took place in February and September 1975. In February 1975, two brothers traveled from India to Howard where one brother gave a kidney to the other whose kidneys had ceased to function. The hospital donated its services as well as the services of the dialysis and transplant teams and used the operation as a teaching case for its medical students. Today, both brothers are alive and well. On September 30, 1975, Howard's first transplant on caucasians was performed on a brother and sister who had identical matches. Both were in their 50's. The brother, who was the recipient, had been refused by a Cleveland clinic on ground that he was too old and too sick to receive a kidney transplant since he suffered from extreme arteriosclerosis. He was brought to the Howard University Hospital and was felt to be a high-risk candidate, but nonetheless, one who should be given the opportunity for a renal transplant if he was willing to accept the risk. He was willing and stated that he would do anything to improve the quality of his life, even at the risk of death. Without guarantee and with informed consent, he and his sister underwent the transplant operations. Both are alive and well as of this writing (June 1977). Since Howard's first transplant in January 1974, 37 patients have rec eived 43 kidney transplants.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 8, 1977
Twenty-six of these patients are alive, 19 with functional kidneys. Our oneyear cadaver donor/recipient survival and function rates are 75 percent and 60 percent, respectively. These are above the national average for whites of 70 percent and 50 percent, in spite of recent reports indicating that the one-year survival of kidney transplants for blacks is 33 percent. Seventy-five percent of the kidneys donated are from cadavers. Much of the hospital's success with cadaver kidneys can be attributed to the use of antilymphocyte globulin, which helps fight rejection of the new organ by the transplanted patients. Howard was the first hospital in this area to use the drug and is now conducting research to further refine its use. The Department of Pharmacy, under the direction of Mr. James C. Burgess and Mr. Robert L. Malone, was helpful in obtaining and using this experimental drug. Howard also uses group therapy as a form of rehabilitation for its transplant patients. The Center employs a rehabilitation counselor and a social worker, both of whom work with the patients before and after surgery in an effort to assist them in adjusting to the psychological effect of having someone else's kidney - often a problem with such patients. In the group therapy sessions, patients help each other in their adjustments after surgery as well as during the preoperative waiting period. The transplant expertise is provided by a team consisting of three nephrologists, three transplant surgeons, a pediatric surgeon, three general surgeons, a transplant social worker, vocational and rehabilitation counselors, dietitians, and dialysis and nephrology nurses. This breadth of expertise gives the capability of transplanting other organs such as the pancreas and liver. In spite of its initial success, the transplant program continued to function unsanctioned until Dr. George Jones, Chief of the Division of Urology and Dr. Jesse Barber,, Chief of the Division of Neurosurgery became involved in its fight for certification. They petitioned supporters of Howard University, at all levels, to make them aware of the transplant activity at the University and of the injustices that Howard was suffering in not being certified. The persons who were involved in consulting and communica-
ting with the Department of Health, Education, and Welfare and the local press regarding the unfair treatment of the hospital were: Senator Edward Brooke (R-Mass); Congresswoman Shirley Chisholm (D-NY); Congressman Carl D. Perkins (D-Ky); Congressman Walter Fauntroy (D-DC); Congressman Louis Stokes (D-Ohio); Senator Edward M. Kennedy (D-Mass); Congressman Charles Diggs (D-Mich); Congressman Charles Rangel (D-NY); Senator Birch Bayh (D-Ind); Senator Charles Matthias (R-Md); Tally Holmes, Co-Chairman of Precincts of the Republican Party of D.C.; Dr. Frank Lloyd of Indianapolis; Senator Glen Beall (R-Md); Washington Post medical reporter Victor Cohen; WTOP-TV news reporter Eldridge Spearman: Paul R. Hathaway and Patricia A. Spaulding, Director and Assistant for Publications, respectively, of the Howard University Department of University Relations and Publications; Daisy Fitts of the Howard University Hospital Office of Public Relations; The Washington Regional Medical Program under the leadership of Vaughan Choate and Dr. Martin Levy; the hospital administrations and medical staffs of Georgetown University, George Washington University, Washington Hospital Center, Walter Reed and Bethesda Naval Hospitals; the Medico-Chirurigical Association; the Women's Auxillary of Howard University Hospital; the Advisory Board of the Howard University Hospital; the Alpha Chapter of the Chi Eta Phi Nursing Sorority; and the National Medical Association. Because of the efforts of the supporters of the Hospital and the success of the transplant service, Senator Edward Brooke (R-Mass), a Howard alumnus who played a major role in the breakthrough, received a letter on November 14, 1975, from James B. Caldwell, commissioner of Social Security, which stated, "A review of the latest available statistical data clearly establishes that Howard University Hospital is making a much needed contribution to the Metropolitan Washington transplant service." This final approval made Howard University eligible for reimbursement of over one-half million dollars in retroactive payments. Certification was made effective on July 1, 1973, when federal reimbursement for kidney services was started.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 8, 1977
Certification meant that the hospital would receive in the range of $20-30,000 for every transplant if the patient's course was uncomplicated and as much as $100,000 if there were complications. The stigma that had been associated with the uncertified status was thus removed. With certification of the Transplant Center and public acceptance of its legitimate program, referrals from all states in the United States and from other countries were expected to be forthcoming. Transplants were expected to increase to 20-3 0 per year. In addition, the favorable publicity for the Howard University Health Sciences Center and the resulting positive statements were certain to improve the hospital's image in the community at large. The Center's major effort in the future will be to reach communities in the District of Columbia so that the 30 patients who are awaiting transplants, an ever increasing list, will receive kidneys. Unfortunately, most kidney transplants (60 percent) are performed with the use of cadaver kidneys. This is because most living persons have problems with accepting the concept of donating a kidney to save someone else's life. It is not unusual for one to feel that giving a kidney would cause him to die from kidney failure. Because Washington, D. C. has an unusually high incidence of kidney disease, it is felt that Howard University Hospital might play a major role in kidney transplantation in the future. It is planned that Howard will become one of the leading Transplant Centers in the United States.
Acknowledgement Burke Syphax, MD, is acknowledged for his tireless efforts in the completion of this work.
567
