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'Republic of Suffering' Author Drew Gilpin Faust

Historian Drew Gilpin Faust writes that Civil War deaths — both their number and their manner — transformed America. Her new book is This Republic of Suffering: Death and the American Civil War.


Other segments from the episode on January 9, 2008

Fresh Air with Terry Gross, January 9, 2008: Interview with Drew Gilpin; Interview with Richard Shannon.


TIME 12:00 Noon-1:00 PM AUDIENCE N/A

Interview: Drew Gilpin Faust discusses her new book, "This
Republic of Suffering: Death and the American Civil War

This is FRESH AIR. I'm Terry Gross.

The United States embarked on a new relationship with death during the Civil
War, writes my guest Drew Gilpin Faust. Her new book, "This Republic of
Suffering," is about how the carnage of the Civil War, the bloodiest conflict
in American history, assaulting conceptions of how life should end and
challenge fundamental assumptions about life's value and meaning. Faust has
written several other books about the Civil War, including "Mothers of
Invention." She was inaugurated as president of Harvard University in October
and is the first woman to hold that position. She's also a professor of
history at Harvard.

Drew Gilpin Faust, welcome to FRESH AIR. Let's start with just a description
of the magnitude of death during the Civil War.

Ms. DREW GILPIN FAUST: The magnitude of death included 620,000 estimated
military dead and uncounted numbers of civilian dead. And to understand what
that means, I think we have to consider it in terms of the size of the
population as a whole and think about the rate of death in order to be able to
understand what such numbers might mean in the context of our own time. And
620,000 military dead was the equivalent of about 2 percent of the American
population at that time. And in today's terms, that would mean six million
dead. So as we contemplate what kind of impact that might have on our own
society, I think we can get some sense of what this level of death might have
meant to Americans of the mid-19th century.

Another way to think about it is to consider that as many soldiers died in the
American Civil War as died in all American wars from the American Revolution
through the first years of Vietnam. So it was a war with a much higher cost
of lives than any war we had engaged in up through the mid-20th century, the
total of deaths.

GROSS: You write that the massive numbers of dead and the gruesome ways in
which the deaths occurred violated the prevailing assumptions about life's
proper end, about who should die, when and where and under what circumstances.
Could you elaborate on that a little bit?

Ms. FAUST: Well, I think part of this impact came from the fact that this
war occurred in the middle of a Victorian era in which notions about death
were very much centered around the home and having an individual die in the
midst of the bosom of family, often on a deathbed surrounded by individuals
who would hear last words and be able to assess the future state of the dying
person based on how the death occurred. And so many Americans, of course, in
war died away from home, away from family, in circumstances on battlefields
where such a death toll hadn't been anticipated and therefore there wasn't
adequate provision for burial, for identifying the dead, for taking care of
the remains of the dead.

GROSS: There was this idealized sense of what a good death would be.

Ms. FAUST: Mm-hmm.

GROSS: And that included some of the things you described, dying near family.
What else?

Ms. FAUST: Well, this was an overwhelmingly Christian and, in fact,
Protestant nation, and notions of the good death, art of dying, had come down
through Christian tradition over a number of decades and centuries; and this
included the notion that the way one died had a predictive aspect to it, that
you could tell whether someone was likely to go to heaven, was likely to be in
a state in which he or she could be reunited with kin in the future life, in
which an individual could die easily or hard depending on whether or not they
were likely to be saved. And so scrutinizing a death and being present to
hear important last words that would end the life's narrative, all of that
came to take on great importance and to be expected as a way of ending a life.

The other part of this, of course, was the notion of decent burial: a grave
that could be identified, could be visited, could be marked, and a way in
which the dead person could be remembered and in some sense remain in the
bosom of the family even though that person had departed. And of course a
soldier who was lost out in battlefield, his grave unknown, could not be
recognized and remembered in that way as well.

GROSS: And a soldier whose body was mutilated in war couldn't be dying the
good death, either.

Ms. FAUST: Mm-hmm. Mm-hmm. I think that the fire power of the Civil War,
the numbers of bodies that were left to rot, the numbers of amputations in the
Civil War, all of this created threats to the understanding of the human being
as an integral soul, as a body and a soul that could be united.

I think one of the most striking aspects of the way Civil War death occurred
is that it really challenged individuals' understanding of what it meant to be
human, and what separated humans from animals. You find often in Civil War
Americans' writing about death that they talk about bodies being treated like
hogs or being treated like dead chickens and just thrown into pits. And so
this anxiety about whether a human being was, in fact, different from an
animal based on how these bodies were being treated was very troubling, very

GROSS: Well, you write that soldiers tried to construct a good death even in
the chaos of war. What were some of the ways that they did that?

Ms. FAUST: Well, I think many soldiers tried to create situations in which
the elements of the good death could be replicated. One of the striking
things that I found reading soldiers' letters and descriptions of battlefields
after battles was the numbers of soldiers who surrounded themselves with
photographs of their families as they were dying. So instead of having the
family around the deathbed, instead they would array photographs around
themselves, almost to replicate the notion that their family was present and
that they could look into the eyes of their family as they were dying.

They also often expressed last words or last wishes in ways that they asked to
have transmitted to their family members, and soldiers who survived were quite
assiduous in sending to family members information about the nature of the
death of a comrade. So family members might receive a letter of condolence
that included many of the elements of the good death that, you know,
indicating that their loved one had indeed had a good death, and express
belief, expressed a willingness to die, died easily, indicating that they were
going to make a quick transition into heaven. And so these letters were a
very important link between home and battlefield that was meant to overcome
that separation that war has introduced.

GROSS: Is there such a letter that you'd like to excerpt for us?

Ms. FAUST: Well, one of the most dramatic is one that a soldier wrote
himself, a man named James Montgomery, who was dying and was bleeding all over
the letter. And, in fact, when you hold the letter, you can see his blood,
and that is a very arresting connection for a researcher with the history of
those that she is writing about. And James Montgomery wrote to his father and
said that he knew his father would be--and I find this word so
striking--"delighted" to hear from his son as he was dying. And, of course,
that makes someone in the 20th century or the 21 century just shake with
amazement. And then you realize that the reason that the father would be
delighted is that James Montgomery could assure his father that he had died
well and that he was ready to die, that he was anticipating a better life; and
he could also tell his father about his fate and his father didn't have to
worry what had happened to him, wouldn't have to deal with the uncertainty,
the terrible uncertainty that accompanied unidentified deaths and unreclaimed

GROSS: You know, as you mentioned, during the time of the Civil War, the
ideal of the good death included that the way you died was going to influence
how you entered the next world. And you quote a pamphlet that was distributed
by the Presbyterian church to soldiers during the Civil War that warned,
quote, "Death is not to be regarded as a mere event in our history. Death
fixes our state. Here on Earth, everything is changing and unsettled. Beyond
the grave, our condition is unchangeable. What you are when you die, the same
will you reappear in the great day of eternity. The features of character
with which you leave the world will be seen in you when you rise from the
dead." So in this period where people are dying of mutilations and gangrene
and disease and dysentery and just, you know, pure battle wounds, how does the
idea of death start to change? Because it's hard to believe that the way you
exit the world will forever fix who you are in the afterlife if you're bound
to die this gruesome death. It's out of your control.

Ms. FAUST: I think that that description of how you are was meant to be one
about your psychological state and your spiritual state more than it was about
the condition of your body. But the issue of the condition of your body was a
very troubling one for mid-19th century Americans as well because the
traditional belief was that your body would be whole and be reunited, and also
be resurrected along with your spirit. And this was troubling because if
you'd had your arm amputated, then it was buried off somewhere far away. How
was that going to get reunited with the rest of your body? And so there's a
lot of writing about this issue of bodies and what happens to them and whether
resurrection includes bodies and how, in fact, this can be possible given the
kind of mutilation that you describe. So I think that the bodily assaults of
the war challenged many traditional beliefs as well as the spiritual assaults
of this terrible harvest of death.

GROSS: My guest is Drew Gilpin Faust, the president of Harvard University and
the author of the new book "This Republic of Suffering: Death and the
American Civil War." More after a break. This is FRESH AIR.


GROSS: If you're just joining us, my guest is Drew Gilpin Faust. She's the
president of Harvard University and author of the new book "This Republic of
Suffering: Death and the American Civil War."

Now you write that soldiers who survived battles had to then bury the dead,
and there were so many dead to be buried, there were new kinds of burial
practices that were developed because of the mass level of death in the Civil

Ms. FAUST: I think it's hard for us to imagine the lack of systematic
organization in the military in regard to death, and partly it was because the
level of death was so unanticipated. But there were no regular burial
details, there were no graves registration services. For much of the war,
they were not regular ambulance services in either army, though the Union Army
by about 1864 improved that situation somewhat. But this meant that usually
after battle there was just chaos, and there were so many bodies, and no
organized attempt or plan to take care of them, so after battles there was
also an act of improvisation to get the dead buried. It often took a
considerable period of time. There are letters from individuals, visiting
battlefields as long as 10 days after the actual battle, saying that the dead
still lay strewn about. There are many descriptions of overwhelming stench,
is the word that is often used, emanating from Gettysburg or Antietam, and
poisoning the air for miles around. So this horror of not simply the number
of deaths and the impact of those deaths, but simply the bodies and the
difficulty of figuring out what to do with them was very present in the minds
and lives of Civil War Americans.

So what do we mean by new ways of dealing with the dead? Some of these were
the kinds of dehumanizing practices that so threatened and scared Americans as
they found themselves forced to throw bodies into mass pits, without names,
without identity. Most soldiers who died on the battlefield were buried
without coffins. Probably half the cases of Civil War dead were not
identified and so there was no way to let loved ones know, and there were no
regularized processes in either Northern or Southern army for notifying next
of kin. This began to trouble soldiers and other--and families and officials
enormously. And so we can see in the course of the war the evolution of
efforts to try to overcome the dehumanization and the anonymity of these
burial practices.

GROSS: Well, you mentioned the dehumanization.

Ms. FAUST: Mm-hmm.

GROSS: And you described some of the burial practices, like roping dead
soldiers by the legs, tying the rope around their torso and then dragging them
to the pile of corpses.

Ms. FAUST: Mm-hmm.

GROSS: Sometimes using bayonets so that the soldiers wouldn't have to touch
the putrefying corpses.

Ms. FAUST: Mm-hmm.

GROSS: This is before there's, you know...

Ms. FAUST: Mm-hmm.

GROSS: ...rubber gloves or latex gloves.

Ms. FAUST: Mm-hmm. Mm-hmm. And then there's a horrible description that I
cite where a soldier talks about throwing the bodies into a pit and then
jumping on top of them in order to enable the pit to hold more soldiers, and
then sometimes causing the body to burst because it had been rotting for so
long. So very gruesome kinds of descriptions that soldiers wrote down, I
think, almost to exorcize the demons that this had introduced into their lives
and into their minds.

GROSS: And then there were fears that there were living soldiers hidden in
the piles of the dead.

Ms. FAUST: And there are examples of soldiers who, in fact, were discovered
to be in the midst of these piles. And one soldier wrote about being
discovered and eventually returning to fight again after he had recovered from
the wounds that had made him seem as if he were dead.

GROSS: Now I was really surprised to read in your book that during the Civil
War the military did not have the responsibility of informing the next of kin
of a soldier who had died. And they didn't have the responsibility of
recording the names of soldiers who died. That was changed as a result of a
few people who did a lot of work to change it, one of whom was Edmund B.

Ms. FAUST: Mm-hmm.

GROSS: ...the chief quartermaster of the military division of Tennessee.

Ms. FAUST: Mm-hmm. Edmund Whitman had been a quartermaster and the
quartermaster corps was the unit of the military that was assigned
responsibility for burial, and so he began to explore, at the behest of his
superiors, through the areas of the Western theater just looking for union
graves and soldiers who were buried in every byway and road and on former
battlefields in that area.

And he found two things. One was that there were graves everywhere. He
described the South as a great...(unintelligible) of the dead because
he found graves in copses of woods, by railroad tracks, under apple trees, in
people's farm yards, behind churches, behind settlements of freed slaves, just
all over the South he kept finding groups and even individual graves. So he
felt there was a substantial opportunity here to honor dead who would
otherwise be lost.

The second thing he found was that these graves were often being desecrated by
white Southerners who were angry about their defeat and felt that they could
express some of that rage and frustration about the loss of war by doing their
spring plowing as usual, even though the field was filled with union graves,
by harming the graves in other ways. And so Whitman made the point to his
superiors that, if action wasn't taken to protect these graves, that these
soldiers would not just be ignored, they would be dishonored and desecrated.

So over a period of months, as he began his very systematic assessment of the
locations of graves, he kept making the case that all these graves should be
removed to national cemeteries. Over the course of the years between the fall
of 1865 and then through tours and the spring of 1866, up until 1871, Edmund
Whitman kept traveling through the western part of the South to identify
graves, and he at last was supported by the federal government in his
commitment to relocate as many as he could find into a system of national
cemeteries. He personally was involved in the relocation of over 100,000
Union bodies, and the program that evolved from his efforts in large part
ended up reburying over 300,000 Union soldiers in 74 national cemeteries. So
this was the real beginning of the national cemetery system. It also
represented a program of a magnitude that had not before really been imagined
as the responsibility of a federal government that had been quite weak before
the Civil War. This was not undertaken by the states. It was undertaken by
the central government, and I think we can see in that an example of the new
strength of the nation state that emerged from the war and the kinds of
responsibilities that it took on.

GROSS: So I imagine from everything that you're saying about how the
government and the military were unable to identify and name the dead during
the Civil War, that dog tags didn't exist yet.

Ms. FAUST: That's correct. There was no formal identification badge or
process. And soldiers invented ways of counteracting that. In the war they
would sometimes pin pieces of paper with their names on it on themselves when
they were going into a particularly difficult battle. Little tags, little
identity badges were also for sale and were advertised widely in the North and
South, and so some soldiers would buy those with their name and contact
information on them. And then other soldiers just improvised by making sure
there was always an envelope addressed to them somewhere on their person, or
writing their particulars about their address and next of kin in a diary or a
Bible that they carried with them.

GROSS: You know, in writing about burials and reburials during the Civil War
and its aftermath, you asked the question, `Why do living humans pay attention
to corpses?'

Ms. FAUST: Mm-hmm.

GROSS: And I thought that's such an interesting question to ask. We just
take it for granted that it's important to give corpses a proper burial. Why
did you even pose the question?

Ms. FAUST: Well, if you think about efficiency or affecting those who are
still alive to be affected, would you go around expending resources reburying
the dead? I mean, if you have a purely instrumental view of social obligation
or governmental obligation, would this be something you would think of? And
of course we do. And of course this matters enormously to us. And I think
Edmund Whitman explained it very well when he said that he was proud of the
government spending so much energy and so many resources on what might be
called, as he puts it, a "sentiment." In other words, this is a humanitarian
age. This is an age that goes beyond the instrumental or the material. It
recognizes the value of human life and the special nature of the body and the
soul and their intertwined character. And so he sees it as a real affirmation
of part of the humanity that many Americans feared the Civil War had

GROSS: Drew Gilpin Faust is the author of the new book "This Republic of
Suffering: Death and the American Civil War." She was inaugurated as the
president of Harvard University in October. She'll be back in the second half
of the show. I'm Terry Gross, and this is FRESH AIR.


GROSS: This is FRESH AIR. I'm Terry Gross back with Drew Gilpin Faust, the
new president of Harvard University and the author of the book "This Republic
of Suffering: Death and the American Civil War." It's about how the carnage
of the Civil War affected religion, culture and politics, and challenged
fundamental assumptions about life's values and ruins.

You write that it's not just death that was changed, the scale of death, how
people were buried, how people mourned the dead, but also ideas of the
afterlife were changed by the massive scale of death during the Civil War.
How were some of these ideas of the afterlife changed?

Ms. FAUST: Americans in the Civil War period were very interested in heaven
and what it might be like because they were having to face the fact that many
of their loved ones were gone and many of their loved ones they hoped were in
this other realm called heaven. So what was heaven actually like? Heaven
became a different sort of place in the course of the 19th century. And this
began really before the Civil War, with some writing about heaven in the 18th
century, that was beginning to make it less severe, less a God-centric place.
More a place that seemed welcoming to individuals in a way that was very like
their own homes in the world in which they lived. And so changing notions of
heaven made it seem a warmer place. It was a place where you would be
reunited with all your family. And in some writings about heaven, it was a
place that was even better than Earth in that not only did you have all your
books and your piano, but your hair didn't turn gray and all your incapacities
were overcome. And so it was very idealized.

And the consistency between your own life and the life in heaven, I think,
evolved from people's strong desire to feel that loss was not so overwhelming,
that the person who had departed had not given up everything that his
foreshortened life might imply. In fact, that person was simply around the
corner behind the veil, living a life very much like those of his brothers and
sisters and comrades and so forth back on Earth. I think it also sometimes
became a solace for soldiers who were suffering on the battlefields of
Virginia or Georgia or whatever part of the war, that heaven was a far better
place than the miseries of the battlefields that they were experiencing.

GROSS: You make it sound like the Civil War was a real boom for spiritualists
because so many people felt that through a spiritualist they can contact the

Ms. FAUST: Mm-hmm. I think this grew out of the rising prominence and
status of science in the mid 19th century, that it seemed to some Americans
that if heaven existed then we ought to prove it. There ought to be some
foundation to establish the reality of heaven. And spiritualism spoke to that
need because it showed that individuals who were dead were communicating with
live people and making tables rise and rapping on wood and in other ways
showing their reality. And spiritualism became a real comfort for many
Americans who felt that their dead were not lost but instead just around the
veil or around the corner, and were speaking to them.

There were spiritualist newspapers, seances. There were even seances in the
White House. Mary Todd Lincoln was very interested in spiritualism, and it
said that Lincoln himself attended some of these seances where Mary Todd
Lincoln was trying to communicate with her dead children. And there was a
spiritualist newspaper published in Boston that in every edition had lengthy
communications from dead soldiers often describing their own good deaths,
describing what heaven was like, describing their reunification with their
lost limbs and so forth. So it was a way of connecting death and life and
making that separation seem less frightening.

GROSS: Now you describe how a lot of people use their religion to help
comprehend the death and suffering that their loved ones experienced during
the Civil War and to help give meaning to death. But at the same time a lot
of people found that the Civil War shook their very belief in religion.

Ms. FAUST: Mm-hmm.

GROSS: Can you talk about the Civil War as an increasing time of doubt?

Ms. FAUST: For me, it's summed up very eloquently in a statement by the
southern poet Sydney Lanier, who said, "How could God allow this?" I think
many Americans felt that such horror was difficult to reconcile with the
notion of a benevolent God. And of course this is a long standing problem of
religious belief. How do we explain evil? And it always raises questions for
our understanding of a deity. How can a deity not stop such slaughter, such
suffering? And so I think many Americans found themselves asking those

At the end of the war, many Southerners said to themselves, `How could God
have allowed our defeat? We thought we were God's chosen. If there is no
victory for the South, if we're not God's chosen, how can I continue to
believe in God?' And so those questions of reconciling suffering with the
notion of a caring God was very difficult for many individuals.

One finds some of the most eminent writers of American history speculating on
these questions in the context of civil war. Herman Melville is one who
writes a series of poems about the war that raise the question of what is the
nature of belief? How can there be belief? And Emily Dickinson who, of
course, found death her subject throughout her career of writing, isolated in
her father's house in Amherst, used the context and imagery of war as a way of
exploring very fully the implications of death for the possibility of belief.

GROSS: The title of your book "This Republic of Suffering" is a great title.
Why don't you describe where it comes from.

Ms. FAUST: "This Republic of Suffering" is a phrase used by Frederick Law
Olmsted who was, during the Civil War, a sanitary commission leader, which
meant that he was involved with sponsoring hospitalships that came down the
East Coast from the North and parked more or less in the peninsula in Virginia
and served as medical resources for soldiers of the Union Army who were
wounded in the battles on the Virginia battlefields. And so he saw the real
horror of injury and suffering by those soldiers as they were brought back to
the ships after having fought valiantly in the Seven Days Battle or the other
conflicts in the Virginia theater. And he remarked once, looking at the
suffering of the men around him, that this republic of suffering did not give
much space for individuals because it was such a shared misery. And it struck
me that this was a good title for the book because the impact of death and
suffering had implications for how the nation regarded itself and that it
wasn't simply individuals who had to learn how to mourn and die and deal with
the tremendous loss that these deaths meant individually, but it was rather
the nation as a whole that also had to think about what it meant that so many
individuals had died in its service.

GROSS: I hope this isn't too personal to mention, but I know you've had
breast and thyroid cancer and apparently are in the clear for all of that now.

Ms. FAUST: Mm-hmm.

GROSS: But did dealing with that contribute to your interest in thinking
about death?

Ms. FAUST: I'm sure it did. I'm sure it did. I found that when you are
forced to think about death, life comes into a very sharp focus. So death
gives you a particular window on the world around you. Nineteenth century
Americans believed, and this was part of the good death, that you lived a
better life if you were always aware that it was going to have an end. It
sharpened your experience of the world in which you were located. Twentieth
and 21st century Americans try not to think about death. After I had my
experiences with illness, I think I recognized something of the significance
of the 19th century viewpoint, that thinking about death can enrich your life
not just detract from it. And so in some way I moved towards a more 19th
century view of death than perhaps the most common among my colleagues and
friends in the 20th and 21st centuries.

There's a poem by Donald Hall, the last line of which is, "it is fitting and
proper that we should lose everything." And I think about that poem sometimes
because the sense that things are not eternal, that you don't have them
forever enhances their value. I believe that's what he meant in that poem. I
think that's the perspective that the 19th century attitude about death can
offer to us, even in our own times

GROSS: Well, Drew Gilpin Faust, I want to thank you so much for talking with

Ms. FAUST: It's been a great pleasure.

GROSS: Drew Gilpin Faust is the author of the new book "This Republic of
Suffering: Death and the American Civil War." She was inaugurated as the
president of Harvard University in October. She declined to discuss the
controversy behind the resignation of Harvard's previous president, Lawrence


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Interview: Dr. Richard Shannon talks about national movement to
reduce hospital acquired infections

You go to the hospital with the hopes of getting treatment that will make you
better, but hospitals and nursing homes have become breeding grounds for drug
resistant bacteria that can infect patients. A study released in October
found that nearly 94,000 patients in the US in 2005 developed antibiotic
resistant bacterial infections known as MRSA, or MRSA, an acronym for
methicillin resistant staphylococcus auerus. Nearly 1 in 5 of these patients
died. When my guest, Dr. Richard Shannon, was the chairman of medicine at
Allegheny General, he led a study on the cause of hospital acquired infections
and initiated practices to try to limit their spread. Now, preventing
hospital acquired infections is one of his goals in his position as chairman
of the Department of Medicine at the University of Pennsylvania Health System.

Dr. Shannon, in that recent study that said that 85 percent of these
resistant infections are associated with health care treatments and 1 out of 5
people who get these MRSA infections die, I'm thinking, `Well, if I need
surgery, I'm afraid to go to the hospital because these infections are so
prevalent in the hospitals and one 1 of 5 people who get them die.' That's not
very encouraging. So what advice would you have for anyone who is facing a
surgical procedure?

Dr. RICHARD SHANNON: Well, first of all, the recent study really talks about
a total spectrum of these resistant strains called MRSA; and so hospital
infections, as you say, are about 85 percent of those. But in the overall
spectrum of all illnesses, this is still a relatively small issue. I think
what's striking about it is it's preventable. And the need to rededicated
ourselves to its prevention is really what's most important. That 1 out of 5
people die of a MRSA infection when they get one of these is truly remarkable;
but I think also has to be considered in the context that these are usually
patients that are sick with other illnesses. What they can't afford is to
then get an infection. So I think the mortality is high because these are
already sick patients with renal failure or heart failure or other organ
system failure, which when they get this final resistant infection is really
the straw that breaks the camel's back.

GROSS: So how do these bugs get into your system when you're in the hospital?
Or how can they--I don't want to make it seem like they always get in. But
how can they get in?

Dr. SHANNON: Well, first of all, in many cases, these bacteria are resident
within the patient even when they're not in the hospital. So about 3 percent
of the population in the United States carries MRSA or methicillin resistant
staph aureus usually in their nose, and it frequently causes no problem. But
when they get in the hospital and they're otherwise sick, that bacteria can
then enter their bloodstream or enter their lungs and cause a significant
pneumonia. Then you have all these procedures that occur, like intravenous
lines that get placed or surgical procedures, violation of the barriers that
usually protect you against these organisms. You come in contact with them in
open wounds, for example, or through urinary tract catheters; and all of a
sudden they have entry into the blood and can cause serious infection.

GROSS: And then, too, doctors and nurses can spread it to you? How do they
do that?

Dr. SHANNON: That's right. So the other interesting thing about these
bacteria is not only do they live normally within the human body, but they're
actually very hearty and can live outside the human body on surfaces that are
inert, like the tray that's used in the room to serve you lunch or on the
stethoscope of your doctor or nurse, potentially even on the curtain that
surrounds the bed. So these organisms can be passed from a human being to
these inert objects and reside there pretty heartily, and therefore constitute
a second reservoir or source, if you will, of spreaded bacteria.

GROSS: Now you first became really deeply involved in this when you were
working at Allegheny Hospital in Pittsburgh and there was an outbreak of
hospital acquired infections. Was this in the cardiac unit where you were

Dr. SHANNON: The first time I got actively involved in this was an outbreak
of a contaminated bronchoscope. So this was a piece of equipment that
actually turned out to be contaminated with bacteria, and actually it was a
fairly widespread problem in the hospital that first got me engaged in this
notion of antibiotic resistant bacteria. But then I think the second part
came when I began to experience, even in my own practice, patients whose lives
were really altered by infections that they didn't come into the hospital

GROSS: So what were the first steps you took to try to change this and
prevent hospital acquired infections?

Dr. SHANNON: So I think the first step that any leader in a hospital has to
take today is ownership of this problem. One of the things that historically,
I think, has led to slow progress in this area is that frequently these
infections are reported in these very vague terms, such as, you know, 10
infections per 1,000 hospital days. And while that's an epidemiological
correct way to describe the frequency, doesn't tell you anything about the
human consequences. So I had a patient who came into the hospital that had a
central line. He was actually waiting for a heart transplant, and that
central line became infected. He had to be taken off the transplant list and
17 days later died. Here's a man who had waited two and a half years for a
heart, the hope for his future, only to have that taken away by something that
arguably was preventable.

GROSS: The central line is like an IV line.

Dr. SHANNON: It's like an IV line, exactly, so very commonly employed in
hospitals. So seeing that firsthand in someone that I cared for and
recognizing that this didn't have to happen, provide a compelling moral
imperative for me to learn more about how to make care more reliable and
prevent these unsafe conditions.

GROSS: Well, you're now chairman of the Department of Medicine at the
University of Pennsylvania Health Systems, that's like three hospitals. What
are your hospitals doing to try to prevent the spread of hospital acquired

Dr. SHANNON: So building upon the traditional experience that we've had at
Penn, there are really three new steps that we are taking specifically to
address this issue. The first is to put a human face to these infections so
that each individual health care provider owns this problem. I think one of
the barriers has been that when we report these infections in complex numbers,
no one feels responsible. It's as if they're--this is an anonymous
circumstance. So instead of saying we have 5.1 infections per 1,000 line
days, we're saying we had 15 people that had a central line infection. And
we're telling those 15 stories to all health care providers so that they
understand the human consequences of what to them may seem to be relatively
benign problems. So putting a face and decoding the data is the first step.

The second step is we're working with all our staffs, particularly in the ICU
and on the oncology units, where the consequences of these infections can be
very severe, to observe their work and actually figure out where there are
defects in the current delivery of care that may propagate into an error. Now
it's rare that any one little glitch will create a hospital acquired
infection. But if several processes go awry and are not recognized, it's
usually that set of circumstances that can lead to one of these infections.

So we're trying to have our staff, our nurses in particular, see with new and
different eyes these defects.

GROSS: What's the third prong of your approach?

Dr. SHANNON: So the third element is that when we encounter an infection we
solve to root cause why it happened that day. So historically infections are
reported months after they occur, losing the context for any learning about
what happened. Whenever there's a possible infection, I actually get an
e-mail message from the infection control people and I go to the bedside with
the care providers. And we don't ask who did it, we ask what happened so that
we have a rich context for learning. And in doing so two things happen. One
is you can fix what you learn went wrong and you can say to the patient and
their family, you know, `We're really sorry this happened, but we figured out
why and I want you to know it can never happen again because we fixed it now.'

GROSS: Give me an example of something that you discovered by doing that?

Dr. SHANNON: So one of the things we discovered was that in the middle of
the night that a catheter that patient--an intravenous line that a patient had
in got kinked, it bent and it wasn't working. And rather than removing it and
putting a new one in, one of the medical staff actually just tried to put some
alcohol at the site and push the catheter back into the skin. They did that
because they didn't feel comfortable putting in a new catheter. So what we
said was, `Anytime a catheter becomes defective, you call the pulmonary fellow
who can fix this problem expertly and don't try and fix it yourself.' And in
doing that, we've not ever again had another problem with an infection related
to a kinked catheter.

GROSS: We're talking about how to stop the spread of hospital acquired
infections with Dr. Richard Shannon, chairman of the Department of Medicine
at the University of Pennsylvania Health System. Stopping these infections
became his special interest in his previous position at Allegheny General
Hospital in Pittsburgh.

There's some real basic things that doctors and nurses need to do, like
washing their hands. Are you confident that in most American hospitals
doctors and nurses wash their hands each time they see a new patient?

Dr. SHANNON: I think that doctors and nurses are engaging in regular hand
hygiene much more commonly. But are they doing it a hundred percent of the
time? No. And what my point would be is they must do it a hundred percent of
the time. In order to do that, we have to make that process simply a part of
their work. So let me give you an example. When a doctor walks into the OR,
he or she must put on scrubs. You couldn't get into an OR without scrubs.
One hundred percent of the time when someone goes into the OR they're wearing
scrubs. That same sort of highly reliable process must apply to hand hygiene.

GROSS: Now in the UK they just put in new rules to try to prevent hospital
acquired infections. And it's kind of like an elaborate--well, not that
elaborate--dress code. Doctors can't wear ties. They can't wear long
sleeves. They can't wear jewelry or watches. What's the logic behind that?

Dr. SHANNON: Well, I think the concept is that when you lean over a patient
to examine them, frequently your tie, as in my case, might brush against their
gown. And if you didn't know that their gown might carry the organism, you
could inadvertently then carry that to the next patient. I think the UK, much
like the United States, is suffering from a really serious epidemic of these
antibiotic resistant organisms. So I think what the UK is trying to do is to
make it such that any contact between a doctor and patient, whether or not the
patient has one of these organisms, is done in a way that maximally protects
the chance that the doctor could walk away with the bacteria and transmit it
to another patient.

GROSS: Now you were mentioning to me, before we started the interview, that
one of the things you did as a health care leader is to understudy--to
basically understudy Paul O'Neill, the former treasury secretary, back when he
was the head of Alcoa, which is based in Pittsburgh and you used to be at
Allegheny Hospital in Pittsburgh. So what did you learn from Paul O'Neill and
Alcoa about managing problems?

Dr. SHANNON: So what I saw at the start of this work was that we had lots of
evidence but no good practices. And so I went to industry, working with Paul
O'Neill at Alcoa to see how Alcoa makes aluminum reliable and does so without
anybody getting hurt. Alcoa is the safest place in the world to work. And
that's because Paul O'Neill is a leader and created conditions that made it
such that the precondition of any task was that no one would get hurt. I was
simply taken by the fact that industry is really committed to defect-free
processes. And I thought I could learn something from industries that create
reliable products and apply that to care delivery.

GROSS: What did you learn?

Dr. SHANNON: It was fascinating. I spent time at Alcoa, where I learned the
Alcoa business model as to how they went about identifying any unsafe
condition that might pose a risk to a worker. And then Paul O'Neill exposed
me to the Toyota production system model, where I went to Georgetown,
Kentucky, and I watched them make automobiles. And Toyota is the world's
greatest manufacturer of automobiles because their processes are defect free.
And I watched how they relentlessly pursued excellence by doing processes the
same way every time. And that said to me, if we went back to hospitals and we
took the same approach to maintaining catheters in a person, we might be able
to achieve similar sorts of very impressive results.

GROSS: So what have you changed, for instance, with catheters?

Dr. SHANNON: So what we've done is we learned early on that much of the
focus in infection prevention was on how you place the catheter. What we
learned through our observations and borrowing the processes from Toyota was
it was in maintaining the catheter. Once it was in, how do you take care of
it? And what we initially discovered was there weren't reliable processes in
place by which nurses and others took care of catheters. So now it's very
unambiguous, very clear to everybody where the catheter is in the person's
body, what the condition of the catheter is every day. There's a specific
person responsible each day for looking at that catheter site and making sure
it's intact. And any time there's a question, that's immediately kicked up to
a higher level person who can make a decision about whether the catheter needs
to come out or not. So identifying a highly reliable, unambiguous process in
which everyone's responsibility is made clear creates a much more likely
defect free process during the course of that catheter being in place.

GROSS: Dr. Shannon, thank you so much for talking with us.

Dr. SHANNON: Thank you, Terry.

GROSS: Dr. Richard Shannon is the chairman of the Department of Medicine at
the University of Pennsylvania Health System.

(Soundbite of music)

GROSS: You can download podcasts of our show on our Web site,
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

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