Léo RamosPhysiologist Thomas Maack’s first job was as an office boy in a São Paulo shop that sold dental products. Later he became a political activist, physician, researcher, and a reformer of medical school curricula. In recent years he has dedicated his efforts to traveling the world, speaking at medical schools in other countries about new educational concepts that could improve physician training. At age 79, however, he finds that the most talked-about topic in Brazil is 1964, the year marked by the military coup. “Fifty years later, it seems no one can forget about my former militancy,” he says, always in good-humored fashion, during yet another passage through São Paulo.
Thomas Maack was born in Insterburg, Germany in 1935 and came to Brazil as an infant in 1936 when his parents arrived in São Paulo, having fled Hitler’s regime. While a student at the University of São Paulo School of Medicine (FM-USP), he was an activist with the Trotskyite Revolutionary Worker’s Party for three years. Upon graduation in 1961, he became one of the disciples of Michel Rabinovitch, who was known for steering talented young people into scientific research. As a professor, Maack was a critic of the traditional professorial appointment system (cátedra), which was controlled by the traditional families of São Paulo physicians at FM-USP. He was not alone—professors just starting out like Luiz Hildebrando Pereira da Silva, Erney Plessmann de Camargo, as well as veterans like Isaias Raw, Antonio Barros de Ulhôa Cintra, Alberto Carvalho da Silva, Rabinovitch, and the couples Maria José and Leônidas Deane and Ruth and Victor Nussenzweig, shared the same desire for reform.
Maack says the violence with which the coup struck FM-USP, resulting in dismissals and imprisonments, was not provoked by just the hunt for leftists. “It was particularly encouraged by the old-line full professor class whose members were afraid of losing power under the reforms that lay ahead,” he says. Of those arrested in 1964, Maack was the one who spent the longest time in prison—seven months—before obtaining a writ of habeas corpus and leaving for the United States.
First at the State University of New York’s College of Medicine in Syracuse, and later at Weill Cornell Medical College, Maack had a long scientific career. Prominent among his discoveries are the revelation of the mechanisms by which kidneys metabolize the proteins and hormones that circulate in the bloodstream, and the identification of the chemical structure and functions of atrial natriuretic peptides. When he got tired of the laboratory, he focused his attention on education and became one of the leaders reforming the medical school curriculum at Cornell, which ranks among the top 10% of medical schools in the United States. He now lives with his wife Isa in New York City. A professor emeritus, his expertise enables him to do consulting work about methods for setting up a modern course of study in medicine. In October 2014, he found himself once again at the University of Campinas (Unicamp), talking about the subject. Earlier, he was interviewed by Pesquisa FAPESP.
|Physiology and biophysics|
|University of São Paulo School of Medicine (undergraduate), Federal University of São Paulo (doctorate)|
|The Weill Cornell Medical College|
|More than 100 scientific articles with about 7,000 citations|
Let’s start by talking about the 1964 coup, which, as we look back now, in 2014, occurred fifty years ago. Besides being a researcher, you were a political activist. What organization did you belong to?
My militancy was rather mixed up because my political consciousness arose from the fact that when I was in ginásio [middle school] I had to take classes at night. During the day I was working as an office boy. I had been a very poor student in elementary school and got good grades only because studying came easy to me. My father, a German, thought I had to learn what life was like. He found a job for me with a friend who sold dental instruments. I went to middle school classes at night and got along very well with my classmates. Everyone was working and some of them, including my best friend, were very poor and lived in favelas. The teachers were fantastic. The diversity of the environment in which I studied had a profound influence on the formation of my political and social conscience. Still, I had to put political participation and activism on hold until I was admitted to FM-USP.
Why did your parents leave Germany?
They were refugees from Hitler. My mother was Jewish; my father was not. They realized early on that they would have to leave the country and did so at the beginning of 1936, when I was a baby. They couldn’t take any cash out of Germany, but could take their piano. They brought in a grand piano and the first thing they did when they disembarked at the port of Santos was to sell it so they could survive. My father had an incredible talent for languages. During the voyage he learned Portuguese in just two weeks. His first job in Brazil was as a German to Portuguese translator. Later he worked in advertising at a pharmaceutical company. He gradually rose to higher positions and ended up as the firm’s scientific director. It was not for financial reasons that they sent me to a public night school and arranged a job for me during the day. They wanted to teach me a life lesson, and I’m very grateful for that.
And why did you leave public school?
When I finished middle school, my parents decided I needed to prepare for college, and so they enrolled me in Colégio Bandeirantes. That, indeed, was a financial sacrifice; it was expensive. I’ve told you all this because of the politics, but there is a good reason. While I was attending the scientific course [equivalent to the present-day high school] there was a Communist Youth group, a very active one, and it was the path chosen by many of my generation who later joined the Communist Party [PC]. But I had a biology teacher, Clemente Pereira, who was a geneticist at the Biological Institute and a strict follower of Mendel. At that time, the PC was promoting the views of Trofim Lysenko, Stalin’s right-hand man on matters of science in the Soviet Union. Lysenko said there are no such things as genes, that they were a bourgeois invention… My teacher participated in those debates between advocates of Mendelism and followers of Lysenkoism at the Paulista Professors’ Center. He took us there to hear the discussions and then explained what it all meant. It was that detail that kept me from joining the Communist Youth movement and later, the PC.
Mendel drove you away from the communists…
Completely. I couldn’t be a member of the same party as Lysenko. My first experiences in political action were in the student movement [the União Nacional dos Estudantes-UNE (National Student Union) and the União Estadual de Estudantes-UEE (State Student Union)], working on nationalist campaigns such as “The Oil is Ours.” Later I became very dissatisfied with the limitations of the nationalist movement and went looking for some association that was involved in a broader social movement. At that point, I was working with Nelson Fausto at Michel Rabinovitch’s laboratory. Fausto was a Trotskyite and ultimately recruited me into the Trotskyite Revolutionary Worker’s Party. He, too, moved to the United States and had a brilliant career.
How long did you stay with that organization?
From the third to fifth year of college I was a militant activist who gradually drifted away and broke with the organization prior to 1964. It was a small sect, with all the defects inherent in the cult of personality and a democratic centralism—that had a lot of centralism and was not at all democratic. But I don’t regret that period. Therefore, while a student at FM-USP, I was a very militant, and public, activist. Others were dismissed not for political activism but because they supported university reform.
Do you attribute the violence that FM-USP experienced to the effort to eliminate the reformists?
I am absolutely sure of it. All the people who were dismissed and indicted were professors of various stripes who wanted to bring about reforms at the university. Ulhôa Cintra [former director of USP and president of FAPESP’s first Board of Trustees] was not at all leftist. Professor Alberto Carvalho da Silva [a physiologist and a former scientific director and former CEO of FAPESP] was not a political activist either. Isaias Raw was a reformist who I actually believed, perhaps unfairly, had rightist tendencies. The hate that those old-line full professors had for people like these was tremendous. The reason is that they would have had more power than we leftists had to carry out reform both within FM-USP but even more so in the USP as a whole. One objective of the reformists was to end the family-based lifetime professorships. At FM-USP, more than at any other school, a full professorship was in many cases handed down from one family member to another. On the São Paulo campus of FM-USP, professors hung onto power much more tightly than at the other schools. Compare the position taken by Moura Gonçalves, director of the Ribeirão Preto campus of FM-USP, with that of João Alves Meira, of the same school in São Paulo. Army personnel wanted to conduct an IPM [military police inquiry] in Ribeirão Preto. Moura Gonçalves said he wouldn’t allow them onto that campus; if they wanted to do it, they’d have to stay outside, not inside. But João Meira gave up his private office space so Colonel Ênio Pinheiro could conduct an IPM on the São Paulo campus. That’s the kind of comparison we should make. It goes well beyond the military coup itself or the fact that someone was leftist or rightist. Initially the military did not want to get involved in the internal fights at FM-USP and USP but, at the same time, they took advantage of those disputes to obtain accusations against leftists and punish them. In 1964, the military were still boasting about being more moral than our university oppressors. For example, Colonel Sebastião Alvim, responsible for keeping me in prison for seven months, proudly told me that the Army would never impose the kind of cruel treatment I suffered when FM-USP expelled my 18-month-old daughter from the university daycare center after I was arrested.
The cátedra system ended during the dictatorship and the military government established more universities. And graduate education in Brazil became well-organized during that period. But you have criticized those advances.
My objection to that kind of rendering of accounts has nothing to do with what the military did or didn’t do. When I visited Germany, someone pointed to a highway built by Hitler and told me: “Hitler also did some good things.” My answer to that was: “It must have been the world’s most expensive highway, because it cost the lives of tens of millions of people.”
Was it after you graduated that you worked with Alberto Carvalho da Silva?
It was. He was incredibly honest and had tremendous moral courage. I was arrested in June 1964 at the offices of the university’s Department of Physiology, which he headed. This took place prior to the decree by Governor Adhemar de Barros that dismissed the first seven professors, including me, in October. When I was arrested Colonel Alvim went directly to Professor Carvalho da Silva and asked him to dismiss me. That would have been easy to do because I was only an instructor, I didn’t have tenure and my position ranked the lowest of all. Carvalho da Silva refused and told the colonel: “I will not do that unless you give me a good professional reason.” Professor Carvalho da Silva paid the price for this and other actions later when, on the basis of the AI-5 (Institutional Act No. 5), he was expelled from USP.
You spent seven months in prison, four of them on the prison ship Raul Soares. Were you afraid of being tortured or killed?
When I was imprisoned at the Quitaúna barracks in Osasco, being interrogated in the office of Colonel Sebastião Alvim, a rather excitable capital pointed a revolver at me and said: “Either you talk, or I’ll kill you.” I answered: “Then shoot.” That wasn’t an act of heroism on my part; I was just 100% sure that the captain would not want to soil the fancy carpet in the colonel’s office with my blood. The episode occurred in the very early phase of my imprisonment, before I was taken to the ship. My biggest fear was being sent to the DOPS [Department of Political and Social Order] where the most brutal physical tortures took place. The colonel kept saying: “The Army doesn’t torture.” But starting in 1968, it was the Army that was responsible for the worst kinds of torture. Being sent to the ship was somewhat of a relief, since the alternative was the DOPS. Most prisoners on the ship were stevedores and union members from Santos. One of the things I’m most proud of in my life is my relationship with the port workers, which I maintain to this day. I always say that the Left becomes united only in prison. The prisoners helped each other, they organized things so as to keep up morale, and they took risks for the common good. I was held in a separate cell that even had a bathroom, a luxury. The workers were housed in a filthy hold. I went there only when one of them got sick. There was no medical officer to take care of prisoners who became ill. That job fell to me because I was the only doctor. When things got complicated I would tell the captain that I wouldn’t be responsible: either he sent the patient to the Santa Casa de Misericórdia in Santos or the man would die.
Let’s talk a little more about your scientific life. Were your first papers written at FM-USP?
My career as a researcher began with Rabinovitch at FM-USP. Our group included about 10 medical students who were interested in pursuing an academic career. I published two articles while I was a student.
In one of the articles we described how kidney cells capture a circulating protein, lysozyme, and increased the levels of an enzyme known as alkaline ribonuclease. The article appeared in the journal Nature. The other article described an increase in that enzyme following the administration of teratogenic colorants. Those two studies taught us how to do research. Later, when I was an instructor, because I had always been interested in physiology I did a study on the reabsorption of low molecular weight proteins in kidneys. The paper, my first as an independent researcher and financed by the then-recently established FAPESP, was practically finished early in 1964. The article about that study came out much later, in the Journal of Cell Biology while I was in the United States. The military coup was the reason for the delay. All the annotations I had made were lost because the military had seized the notebooks I kept in the laboratory. They were looking for some secret code used by the resistance against the dictatorship. I told the story to William Kinter, my boss at the Department of Physiology of the College of Medicine in Syracuse, and he said: “Are you going to keep on moaning about it or are you going to repeat it all in order to finish the paper?” He gave me six months to do it, using funds from his own research. Kinter was generous: he let me work on something that wasn’t related to his own work. I re-did everything and published it.
And what was that article about?
It showed how a circulating protein, in that case lysozyme, is handled in an intact animal and what happens in the kidneys. It was the first article to demonstrate what occurs. No one believed that proteins filtered in the renal glomerulus were being reabsorbed, hydrolyzed in lysosomes, and that the resulting amino acids would go back into circulation.
Did your family accompany you into exile?
My wife Isa and daughter Marisa went with me. My second daughter, Márcia, was born there in October 1965. Isa took the opportunity to do graduate work in history at Syracuse University. She was given a grant and housing.
Why didn’t you do graduate work there?
I didn’t think it was necessary. My projects were so well advanced that I didn’t need a PhD. Kinter himself didn’t think it was necessary. As of 1980, the only degree I held was an undergraduate degree in medicine. In 1979, when I spent a year in São Paulo, my colleagues at the Paulista School of Medicine of the Federal University of São Paulo, Unifesp, convinced me to write a dissertation and they gave me a doctoral degree.
How long did you stay in Syracuse?
Four years. Two years as post-doc and two years as assistant professor. Soon after I arrived, Kinter became very ill. He had heart trouble. When his health deteriorated further, he asked me to substitute for him in certain activities. He was associate editor of the American Journal of Physiology with respect to articles about kidneys. So I started reading the articles that had been submitted for publication, selecting and distributing the texts for revision by specialists who understood the subject. This gave me key contacts in the renal physiology community all over the world. Kinter, by then very ill, left to work full-time at a marine biology laboratory in Maine. Before he left he found out that a position was available at the Medical College at Cornell, in New York City, and suggested I apply for it. In 1969 I was hired by Cornell. I kept working on the same subject, how the kidneys handle circulating proteins, until 1980. I then began to focus more on hormones: how the kidneys deal with insulin, the parathyroid hormone, the growth hormone, and small immunoproteins. I kept publishing and my work was well received. Some of those projects were conducted with Brazilian fellowship recipients who were working in my laboratory. With one of them, Daniel Siguelam, I succeeded in getting a kidney to function outside the body of a rat. The advantage of this technique is that the experiment can be well controlled. The project was very successful and helped me greatly with my future research and academic promotions. In the United States, researchers who are not promoted within five or six years often must leave and seek a position at another university. In other words, they can stay at the university only if their work becomes important and gains visibility. This means the turnover rate is very high, quite different from the situation in Brazil. At Cornell I was promoted to associate professor after two years.
So you received promotions much sooner…
Much sooner, yes. I became a full professor at the age of 40. Preparation of the isolated kidney also opened the door to the next stage, studying natriuretic peptides. I had run out of ideas about what to do with renal handling of proteins and hormones. During that period it was discovered that when the atrium–the upper chamber of the heart—is distended, excretion of sodium by the kidneys increases. Researcher Aldolfo de Bold, an Argentine who had settled in Canada, took an extract from the atrium and injected it into an intact animal. There was a question as to whether sodium excretion was a direct or indirect effect. Using the isolated kidney, that question was settled: I demonstrated that the atrial extract contained a substance that directly increased sodium excretion by the kidney. And because we had also prepared an isolated kidney, it was easy to segregate the substance that caused that effect.
And that changed the course of your research.
Exactly. I had read the abstract of De Bold’s paper, published in 1980, and thought: “That’s it!” I’m going to see whether the effect is direct or indirect. I worked with a Brazilian fellowship recipient, Maria José Camargo, from Unifesp. We used the isolated kidney to purify the substance from the extract. I needed to work together with a biotechnology company in order to determine the chemical structure of the substance. With that, we were the first group to obtain the synthetic peptide; we identified several functions of that new hormone. These included its effects on glomerular filtration, blood pressure, plasma volume, and the renin-angiotensin-aldosterone system. We discovered a new receptor of natriuretic peptides, the primary function of which is to remove peptides from circulation and thus regulate their plasma levels. The studies on natriuretic peptides and their receptors written up by my laboratory received more than 5,000 citations in scientific literature. In 1984, only five articles about natriuretic peptides had been published, including one of ours. Three laboratories were working on the subject. Today, I have in my database more than 25,000 published articles on that topic.
What are the clinical implications?
The discovery that blood pressure is regulated by a combination of hormones. Some of them increase pressure: renin, catecholamines, activation of the sympathetic system. Natriuretic peptides do the opposite. The immediate clinical implication is that, in order to maintain normal blood pressure and other cardiovascular and renal functions, there must be an equilibrium among those hormones. Any imbalance will raise or lower blood pressure and affect other cardiorenal functions. We have several medications in our therapeutic arsenal that can, for example, diminish the activity of the renin-angiotensin-aldosterone system. Unfortunately at present there is still no effective therapy based on the effects of natriuretic peptides, which are very difficult to use because they have to be injected. If taken by mouth, they are destroyed in the stomach and intestines.
When did you stop doing research?
I left the laboratory in 2010. I had decided I wanted more freedom and resolved to go out on my own. I left Cornell as a professor emeritus. I still have an office there and do a few things. For example, I’m going to teach at medical schools in Tanzania and Qatar. In the last 10 years, I have really concentrated on medical education. I saw that passive learning is not good. Giving classes is a very inefficient method of teaching. First, because the student studies the class material on a certain date but takes the exam months later. Knowledge is initially recorded, but soon evaporates. Second, because the volume of knowledge in biomedical sciences is so huge and advances so rapidly that no one knows what to teach. Every day some old concept is disproved by a new one. I offered to help reform basic sciences education at Cornell. The reform centers on self-teaching, based primarily on clinical cases. In studying the physiology of the heart, for example, students start with an actual case of a heart attack and try to figure out why it occurred, instead of going to a textbook in which an author explains how the heart works. Another concept we are attempting to introduce is the so-called “green time” i.e., time students are given for self-study so they can delve more deeply into topics of their choice. It is the part of the school schedule during which students have no required formal activities. This of course poses a bigger problem in Brazil, where medical students have classes and other scheduled activities from 8:00 a.m. to 6:00 p.m.
Does giving the students such free time work?
We conducted the project at Cornell in 1997 and it worked. The concept of “green time” means trusting students to make good use of this free time–first in order to make sure they have acquired the knowledge presented during the formal part of the course. Otherwise, nothing is gained. Second, they should begin exploring what interests them. For example, Brazilian students could start doing undergraduate research. Medical students in Brazil are much younger than their counterparts in the United States. Therefore, they need to have time—including time to date, to play soccer. “Green time” is criticized in Brazil because people say that’s all that the students will do. My answer is: test them. The system in Brazil for evaluating learning is absurd. Exams are given once or twice a semester, at most. Students study only during the week before the exam. I did that, I know how it is. It’s a system in which knowledge is forgotten very quickly.
How does it work in the United States?
American students must first finish college, a pre-professional university course involving four years of general sciences that lays the foundation for various careers. Then they embark on their chosen professional courses, such as medicine. In Brazil, no matter how good their high schools were, students are not well prepared for university. Professors of basic sciences in Brazil need to spend a lot of time explaining elementary notions that in the United States are taught in college. There, medical school takes four years. The first two years focus on basic sciences but even then are directed toward clinical medicine. Students see patients, visit doctors’ offices, and observe physicians dealing with patients. We begin with problem-based learning in which groups of 10 students meet with tutors for 90 minutes three times a week. Students evaluate a clinical case and find out what they still don’t know about basic science. And so they study, come back, make presentations to each other and, on Friday, the last day of the week, reach a conclusion. We have classes in general concepts: laboratory sessions on anatomy, dissection, etc. At 1:00 p.m. all formal activity comes to an end—except on Thursday afternoons, when students are required to visit physicians’ offices or health centers. And what do they do during “green time?” It depends on which year of medical school they are in. Someone who learns easily will find courses they want to take. Our only rule is that at the end of every two weeks students will be tested on the knowledge they acquired in the formal part of the course. So there’s no time for loafing. Some medical schools in Brazil are beginning to reform their curricula in this direction.
What do you think about the way physicians are trained in Brazil?
Most of them come from disastrous schools that would not be recognized in the developed world. There are more medical schools in Brazil—about 300—than in the United States, which has 120. With certain well-known exceptions, medical schools in this country are totally unequipped, they don’t have teaching hospitals. A quality medical school is a non-profit institution, but several in Brazil are operated for profit. I don’t know of any such thing in the United States. Physician training in Brazil would also improve greatly if a two-year pre-professional university course were given prior to medical school. Students would then have a stronger foundation in sciences and could evaluate whether they are suited for medicine, which is impossible to do today.
How has your life in New York City been during these 50 years in the United States?
It’s a good life. We go to a lot of concerts and plays. I read a lot and like to spend time with my wife, daughters, and grandchildren. My wife has also had a very satisfactory university career, as a full professor of history at Essex Community College in Newark, New Jersey. My daughter Marisa is chief of staff for a city councilwoman in New York. The youngest, Márcia, is an attorney in Washington, director of the public defender program at a law firm. Marisa, the one who was expelled from daycare when I was arrested, is the mother of my grandchildren.