Lab Soft News

LabCorp Embroiled in Lab Test Patent Litigation

The Supreme Court has announced that it will hear LabCorp’s appeal of a case relating to the scope of patentability in the U.S.  Specifically, the court will review the question of whether a patent can claim rights to a basic scientific relationship used in medical treatment if that claim is limited to correlating test results. Here is a link to a patent law blog that discusses the case in detail and from which I have extracted information about this case. Here is another link to a patent law web site on which I have also relied heavily for content. The points below are a little dense but worth wading through because of the importance of this case for lab medicine.

• It is well established in patent law that the laws of nature, including a patient's biological processes, cannot be claimed or owned.
• A patent infringement lawsuit involving LabCorp is asking if a laboratory can patent the correlation between the level of an amino acid measured in a patient with the levels of vitamins in that same patient.
• Researchers at University Patents Inc.(UPI) in the early 1980s discovered a relationship between elevated levels of the amino acid homocysteine and the deficiency of two B vitamins, folate and cobalamin.
• These vitamins help form homocysteine and the researchers noted that unusually high homocysteine levels often signaled very low levels of these vitamins.
• In 1986 UPI filed a patent on a method for testing homocysteine levels in body fluids. In claim 13 of that patent, UPI sought to license the correlation between homocysteine levels and vitamin deficiency, describing a two-step process of first testing for the amino acid and then correlating the level with the B vitamin levels in the body.
• LabCorp obtained a sub-license for the patent from Metabolite Laboratories. Beginning in 1992, LabCorp paid Metabolite a royalty every time it reported to a doctor the results of a homocysteine test. After LabCorp began using another company’s testing method in 1998, Metabolite sued LabCorp for patent infringement.
• The jury in a November 2001 trial awarded Metabolite almost $5 million in damages after finding LabCorp liable for breach of contract and patent infringement.
• LabCorp appealed to the Court of Appeals for the Federal Circuit, arguing the following: for the “correlation” step of the patent (claim 13) to have any meaning, a doctor must confirm the vitamin deficiency through additional diagnostic steps and other analytical methods -- simply thinking about the relationship should not violate the patent.
• A panel of the appeals court rejected this argument, holding that an infringement “only requires association of homocysteine levels with vitamin deficiencies.” The supreme court will hear LabCorp's appeal of this decision.

All of this boils down to whether a patent describing a non-enabling correlation step can validly claim a monopoly over a physiological relationship essential to medical diagnosis and treatment such that a physician infringes on the patent merely by thinking about that relationship after viewing a test result. I am not a lawyer but, to me, the notion of patenting a correlation between a test result and some pathological state such as a vitamin deficiency is very shaky, given that this step is the very essence of lab medicine and clinical diagnosis.

:: Update on 4/3/2006

You can listen to or download here a 17-minute podcast about "Patenting Ideas" that makes specific reference to the LabCorp patent litigation. The program aired originally on NPR's Science Friday.

Non-Profits and the Sale of Healthcare Information

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has informed hospital leaders that it has decided to get out of the data-selling business. Below is an excerpt from the story on the web and here is the link to the story.

The Joint Commission on Accreditation of Healthcare Organizations' recent forays into "commercialization of data" won't be continued, JCAHO President Dennis O'Leary said. Instead, O'Leary said, the JCAHO would treat its database of hospital performance information as a public utility, free to any organization or individual wanting access....The JCAHO dropped a plan to sell performance data to third-party payers in November 2005 after the hospital industry complained about possible privacy violations and other issues. The JCAHO also had planned to provide hospital-specific performance reports to the Blue Cross and Blue Shield Association -- another point of contention with the JCAHO's hospital clientele.

The JCAHO decision was prompted by a firestorm of criticism from various prestigious organizations about the plan as the following quote emphasizes (here is the link):

The Joint Commission had been blasted by the AHA, Federation of American Hospitals and Association of American Medical Colleges after they learned the JCAHO was selling data to third-party payers....They also felt the Joint Commission's plan to require hospitals to submit more patient-identifiable data behind the aggregated reports that hospitals were already filing with the JCAHO would violate HIPAA privacy regulations.

OK... JCAHO pushed the envelope too far. The non-profit JCAHO collects data from hospitals as part of its inspection and accreditation process for which the hospitals pay a fee. Some one at JCAHO had a bright idea -- "let's sell this information exhaust that we collect from hospitals to other organizations. We profit on both sides of the transaction. And to really make things interesting let's ask the hospitals for even more information than we normally acquire from them so that we can enhance our information sales business business even more." Unfortunately, the hospitals and their lobbying organizations turned up the heat and the new JCAHO business venture evaporated into thin air.

Below is another excerpt from a recent story about the prestigious Partners Healthcare in Boston that is now contemplating the sale of their data (here is the link):

Partners Healthcare, the giant of the Boston medical world, is studying a plan with other big academic hospitals elsewhere to sell aggregated patient data to the government, pharmaceutical and biotech companies, insurers, and publishers. ''As the adage goes, 'Information is power, and power is money,' " notes a confidential Partners' document outlining the ''data commercialization project."...the most likely first customer would be government agencies such as the Food and Drug Administration....But the confidential outline makes clear Partners sees the market as much broader. ''This project offers the opportunity to understand how various enterprises (government, pharma/biotech, consulting/analysis firms, investment analysts, publishers, etc.) utilize healthcare data to achieve their goals," the memo states.

I am now beginning to understand how this works. Hospitals and health systems supply JCAHO with data that can't be sold because such a sale would constitute a a breach of confidentiality and misuse of information. JCAHO needs to be treated as a public utility.  By way of contrast, patients are admitted to hospitals and, in so doing, help generate information about the diagnosis and treatment of their diseases that is stored in the hospital computers. This provides a golden commercialization opportunity for a hospital consortium, lead by Partners Healthcare, to sell the information to big pharma and to other for-profit companies. Let's see if anyone turns up the heat on this idea.

Measuring the ROI of Middleware Solutions

I have written a number of previous notes on lab middleware. You can review some of the most relevant here and here and here. Middleware is lab software that is installed and integrated with the LIS to provide functionality not provided by the LIS. In essence, it provides new lab capabilities at a relatively modest incremental cost. The individual middleware modules are sometimes referred to as supplemental lab application modules (SLAMs).

Although rules (algorithms) can be deployed on LISs and have been used for decades in lab computing, there has been an accelerated interest in rules lately for the following reasons: (1) middleware products can provide access to a rules engine for the first time in some labs; (2) personnel shortages are causing lab managers to explore ways to increase the efficiency of lab operations through the use of rules; and (3) lab managers are seeking ways to trim the fat from lab budgets because of cost constraints and rules can help them achieve this end.

Because SLAMs provide very focused solutions and because C-level executives are scrutinizing capital requests from lab managers for new software purchases, there is also a renewed interest in quantifying the return on investment (ROI) after middleware products have been purchased and installed. I hasten to emphasize here the criticality of obtaining baseline measurements about the efficiency of various lab operations, and most specifically the "problem" that the SLAM is designed to correct, before the SLAM is installed.

Here are three examples of middleware solutions that lend themselves to relatively easy measurement: (1) automated specimen archival retrieval; (2) results autoverification; and (3) positive patient identification. Although a number of metrics could be used to assess each of these, the most obvious would be: (1) mean time to retrieve a specimen for test add-ons by lab; (2) decreased test turnaround time (TAT) by lab by shift; and (3) a reduction in specimen identification errors however defined by the lab.

This discussion brings to mind one of the features of my new car -- the ability to display current miles-per-gallon performance while en-route.  Middleware could similarly calculate lab management and quality measures on-the-fly, allowing for experimentation by lab managers to improve some specific performance measure. For example, one could change staffing on a particular lab shift and look for improvements in TAT. There is a very satisfying feel about using a software tool to measure its own value.

Patient Safety and the Surgical Pathology Laboratory

I have posted two notes recently about errors in surgical pathology. You can review them here and here. Dr. Jeffrey Myers, division head of anatomic pathology in the Department of Pathology, University of Michigan Medical School, recently delivered a lecture to the pathology faculty in Ann Arbor entitled Patient Safety and the Surgical Pathology Laboratory, which he has allowed me to make available in PDF format on Lab Soft News. You can review it here. His lecture provides a logical continuation in this ongoing discussion about errors in anatomic pathology and an approach to their reduction.

In this PowerPoint lecture, he discusses the following topics:

• Error detection methods in our healthcare delivery system
• Factors associated with higher error rates in hospitals
• The critical relationship between quality and system design
• An analysis of process design in surgical pathology for error reduction
• Using information technology for error detection/avoidance in surgical pathology

The information contained in this lecture is extremely important and I urge you to review it. For me, lectures of this type represent a tectonic shift in the orientation of the younger cohort of leaders in anatomic pathology -- they are enthusiastically embracing systemics in anatomic pathology. Here is a definition of systemics from the Wikipedia:

Systems theory or systemics is an interdisciplinary field which studies systems as a whole. Systems theory was founded by Ludwig von Bertalanffy, William Ross Ashby and others between the 1940s and the 1970s on principles from physics, biology and engineering and later grew into numerous fields including philosophy, sociology, organizational theory, management, psychotherapy (within family systems therapy) and economics among others. Cybernetics is a closely related field.

This is not to say that earlier generations of surgical pathologists were uninterested in quality issues and error detection. The point is rather that this new cohort is approaching the problem in a more systematic way in terms of both error detection and elimination as well as the use of information technology to achieve quality goals. Most clinical pathologists can lecture for many hours on process control and quality systems -- and now surgical pathologists can do the same. In this way, another significant barrier is being broken down between CP and AP.

When Clinical Trials Go Awry

I published a previous note about Covance, which is a very large contract research organization (CRO) that specializes in the laboratory component of clinical trials around the world. Here is the link to that note. Recently in the news was a clinical trial in a London hospital that went badly awry under the supervision of another CRO, Parexel. Below is an extract from the story and here is the link to the original story.

Last week, six very healthy men suddenly wound up in a London hospital in critical condition.... All were human subjects in research paid for and conducted by private companies....The people in England were involved in a study of an experimental leukemia drug. It was paid for by a German pharmaceutical company, but run by a U.S. company, Parexel....Twenty years ago, most clinical research was conducted in academic medical centers. American companies did their research in the United States. Most research was paid for with government money. All that has changed. Private companies running studies for pharmaceutical and device companies are now a $14 billion industry in the United States alone. ...The problem with the intense commercialization of research is that it's not clear that contract organizations, which make their living meeting deadlines for drug company sponsors, always put subject welfare first.

Here is the home page for Parexel, the U.S.-based CRO that was managing the clinical trial in question in London. Although CROs maintain their own IRBs to protect the rights of subjects in the trials that they supervise, it is reasonable to ask whether the level of surveillance and dedication by such CROs is equivalent to that encountered in U.S. academic centers where the members of the IRBs are frequently quite removed from the incentives associated with the research projects reviewed by the boards.

In some ways, these issues pertaining to the protection of research subjects enrolled in clinical trials are going to be even more perplexing in the future. I think that it is inevitable that clinical trials will increasingly move to developing countries such as India and China. Here is a link to a balanced discussion of the issue as it relates to India. Here is another article on the web about the same topic.

There are three reasons why clinical trials for "big pharma" will move to a country such as India: (1) it is less expensive to run the trials there because of the lower costs to recruit donors and for professional support personnel; (2) normal subjects and subjects with specific diseases are easier to recruit there because of the large populations and the prevalence of various diseases; (3) it is easier to recruit "treatment naive" subjects there because the majority of people do not have access to basic healthcare services. If the pharmaceutical company engages a CRO to manage the project, they can always assign blame to that company if the project goes badly in some way.

The ethical problems associated with clinical trials in an undeveloped country are numerous. Can consent ever be truly informed when a clinical trial provides the only hope for a subject with a disease to have access to drug treatment, even with an unproven experimental drug? Paying a subject a small amount of money by U.S. standards to participate in a trial may be an overwhelming inducement in India where many survive on only meager earnings. If potential subjects are illiterate, what assurances does one have that they are truly informed about the risks and benefits of participation in a clinical trial before they are enrolled? Try explaining a randomized double-blind placebo-controlled clinical trial to a college graduate in the U.S. and see how far you get.

Transitioning to the Era of the EMR

Scott Silverstein writes a blog called InformaticsMD. In a recent note, he addresses the question of how the lack of attention to sociotechnologic issues can prevent clinical IT from achieving the quality, cost, and efficiency benefits of which it is capable. Here is the link to the article and below is a quote from the article (emphasis mine).

...applied IT is a field of a relatively small number of principles, a large number of arbitrary conventions and rules, and a narrow body of knowledge applied repetitively and programmatically, often without scientific rigor. This may be illustrated by the fact that most areas of applied IT can be done well, and often are, by those with little or no formal training....The belief that mastery of IT process and repetition for management information systems implementation entitles IT personnel to lead and control implementation and operationalization of essential tools in complex domains such as medicine (e.g., electronic medical records systems) is presumptuous and creates an environment strongly misaligned with the business of healthcare delivery. The belief often results in the exclusion or misutilization of medical informatics experts, appropriate clinicians, and other forms of mismanagement ....

This passage is highly relevant for lab professionals, including informaticians, as we transition from one era to another. We are leaving an era when the LIS was relatively autonomous and customers (i.e., clinicians) directly signed onto the system. In this new era, the LIS replicates data to the electronic medical record (EMR) and the clinicians will rarely interact directly with the LIS. Moreover, I believe that the EMRs available in the market today are frequently poorly designed. This will prove to be a challenge when the EMR becomes the sole means for receiving lab test orders and reporting all lab test results.

In a recent post that you can read here, I made reference to "praise for lab computing" from Mr. HIStalk. The strength of lab computing has always been the fact that LISs have been designed by lab professionals for use by lab professionals. My recollection is that some the greatest challenges that I have encountered in lab computing have been with the MD interfaces -- reporting test results to clinicians in a manner that satisfies the requirements of both the lab professionals who generate the results and the physician clients who use them to diagnose and treat disease. My point here is we in the labs have usually been able to optimize lab processes but sometimes falter when interacting with clinicians.

In this era of the EMR, our LIS problems will be both solved and exacerbated. We no longer will be challenged by having to design a system to manage test orders from clinicians and reporting test results back to them, that task now being accomplished by the EMR and its own support personnel. On the other hand, we will now be totally dependent on a system external to the LIS that integrates all clinical data but is not optimized to manage lab processes. This is akin to former days when we frequently had to "dumb down" lab data in order to "wedge" it into hospital information systems (HISs) for reporting purposes.

I personally feel that we in the laboratories are rapidly approaching an impasse in that the our test results are rapidly becoming more complicated at the same time that our control over test ordering and reporting via the EMR is disappearing. For me, the following solution is inevitable: relatively simple test results will be replicated to the EMR and integrated with other clinical information. Complicated test results (e.g., genetics, molecular diagnostics) will only be made available to clinicians via specialized web-enabled laboratory servers to which clinicians will link from the EMR.

Client-Driven Healthcare Software Development

Mr. Histalk (here is the link) quotes the "Joel on Software" blog (here is that blog link) on the topic of whether vendors should develop code based on the basis of "specs" supplied by customers. Below is the relevant quote with my emphasis.

Should vendors just code to specs developed by customers? Yes, if you want a Frankenstein of special interest bells and whistles that pleases no one and is hard to support. You can't ignore customers, but they are your (and their own) worst enemy when it comes to software design. I quote the God of Software Design and Great Writing, Joel on Software: "Custom development is that murky world where a customer tells you what to build, and you say, 'are you sure?' and they say yes, and you make an absolutely beautiful spec, and say, 'is this what you want?' and they say yes, and you make them sign the spec in indelible ink, nay, blood, and they do, and then you build that thing they signed off on, promptly, precisely and exactly, and they see it and they are horrified and shocked, and you spend the rest of the week reading up on whether your E&O insurance is going to cover the legal fees for the lawsuit you've gotten yourself into or merely the settlement cost. Or, if you're really lucky, the customer will smile wanly and put your code in a drawer and never use it again and never call you back." And yet, in healthcare vendorland, most of the work that's done is meekly turning the marginally knowledgeable user's design ideas into a semi-working program, putting out customer fires by grafting unstrategic tweaks onto old code and hoping for a "great job" by unenthusiastic customers (well, at least the biggest ones they really care about keeping happy.)

This passage has stimulated me to think about the role of customers (i.e., lab professionals) in helping to develop and design LIS features and functionality in collaboration with software vendors. Below are my thoughts on this matter:

• LIS or middleware software must optimize information and specimen flows for each individual lab in which it is installed or it will be of no value or may actually harm lab operations.
• The only way to truly understand workflow is to design and test alpha software in a lab environment in collaboration with lab professionals.
• Lab professionals, physically removed from their work environment, may naively request up-front certain unworkable software features/functions; such problems can be corrected if the software design and development process is an iterative one. "You asked for this feature or transaction process Here it is! Is this what you really want?"
• It is often said: "If you have seen one lab, you have seen one lab." Lab professionals will often request LIS features/functions that reflect their personal vision of lab operations or [perhaps] a unique set of requirements for their own lab. It falls to the software developers to test their software in multiple lab environments to ensure that it will appeal to a broad market segment and function in multiple venues.
• Bottom line: LIS software development requires a team effort between the developers and sets of lab professionals from different labs. It is an iterative process and only complete when the product can be deployed in multiple settings and does not require elaborate customization to satisfy the needs of the various sets of users.
• If a well accepted and robust LIS product cannot deployed in a particular lab, it may not be the fault of the software; the processes of that lab may be so far out of the mainstream and so idiosyncratic that it is that lab (and its managers) that need to make changes

New York City Monitors Diabetics: An Update

In a previous post that you can read here, I discussed a program whereby public health authorities in New York City will monitor diabetic patients. A recently published front-page article in Clinical Laboratory News (March 2006; Volume 32, Number 3), the monthly tabloid publication of the AACC, sheds more light on this matter. This particular article is not available on-line so that I will quote from the relevant portions of it. Here is the link to a one-sentence summary of it on the AACC web site.

Note: As an aside, I cannot think of a good reason why material such as this should not be made available in its entirely on-line at the AACC web site. If you are a member of the AACC and you agree with me, you might communicate with them and let them know how you feel about this issue. The CAP makes the total CAP Today content available electronically and the material attracts a large number of visitors to the CAP web site.

• Last December, the New York City Board of Health and Mental Hygiene amended the city's health code to require local clinical labs to report hemoglobin A1c results to the public health authorities.
• These results will be organized into a registry , referred to informally as the New York City A1c Registry (NYCAR).
• This is said to be the first time that a governmental entity has created a registry to track test results relating to a chronic non-infectious disease.
• The new registry will receive the test results via files uploaded from the 39 clinical labs that process HbA1c tests for NYC residents -- 29 are hospital-based and 10 are commercial labs. Quest currently processes 25% of HbA1c testing in the area.
• It has been estimated that the registry will receive 100,000 test results per month when up to speed.
• Health Commissioner Thomas R. Frieden is apparently quite keen on registries, having spent five years in India where he set up a TB registry.
• The Board currently maintains hepatitis B/C registries, HPV registries, a city-wide immunization registry, a lead registry, and a World Trade Center registry.

The Clinical Laboratory News article is well written and I can't do justice to all of the points that it makes. I will comment on only some of the key issues that are raised in it:

• The reporting requirement places a heavy burden on the clinical labs by requiring them to report information that they might not have easy access to such as patient addresses and date of birth.
• The development of the registry raises security, confidentiality, and privacy issues in that the test results could potentially be accessed by unauthorized individuals; will be uploaded by the performing labs without any prior consent from the patients.
• Physicians treating the patients included in the registry may be vulnerable to charges of malpractice even if they are not at fault for the abnormal HbA1c levels due to non-compliant patients or those who frequently change doctors.
• While effective in evaluating glycemic control, HbA1c is not recommended as a diabetes screening tool by any of the major medical organizations including the American Diabetes Association. To diagnose the disease, a fasting glucose or a two-hour oral glucose tolerance test is recommended.
• It is not clear to me from the various stories to date about the registry as to whether it is being established to monitor glycemic control of previously diagnosed cases or for new case-finding or for both purposes.

It occurred to me that this registry may have the counterproductive effect of convincing physicians in NYC not to order HbA1c a a tool for managing the glycemic control of their diabetic patients in order to keep the results out of the registry and thus avoid surveillance for both themselves and their patients.

To summarize, public health officials in New York City are creating a registry of perhaps the wrong test results on unconsented patients to monitor a chronic disease as a consequence of which some physicians may be inappropriately stigmatized and others may be persuaded not to appropriately monitor those patients with the disease.

Some BRCA1 and BRCA2 Genes Missed by Myriad

An article published yesterday in the New York Times (here is the link) disclosed that Myriad Genetics' test for mutations in the BRCA1 and BRCA2 genes missed them in about 12 percent of breast cancer patients from families with multiple cases of breast or ovarian cancer,.... Experts cautioned that the chances of such false negative results were much smaller for women who were not from such high-risk families, so that most women who tested negative had little cause for concern."

The new study, being published in The Journal of the American Medical Association, is likely to increase the pressure on Myriad Genetics, which offers the test. The company, based in Salt Lake City, has long been the focus of controversy because its patents give it a monopoly on the test, for which it charges as much as $3,000. Some geneticists say the monopoly has slowed development of better testing. "A fuller testing process would include more than one technology, and competition would enable that to develop," Mary-Claire King, a professor of medicine and genome sciences at the University of Washington and senior author of the paper, said in an interview....Dr. Gregory C. Critchfield, president of the genetic testing division of Myriad Genetics, denied that the company's monopoly had impeded progress. The company hoped to have a more thorough test available by the end of the year, Dr. Critchfield said.

Here is the link to a PowerPoint presentation by William Rusconi, VP of Marketing for Myriad entitled: Patenting and Licensing of Breast Cancer Suspect Genes -- BRCA1 and BRCA2. Myriad will obviously assert for themselves the broadest possible rights to their BRCA patents and the lecture is worth reviewing for content despite its orientation to the company.

Below, for a Canadian site, is an extract with valuable information about the Myriad patents and here is the link to the original material.

Between October 2000 and April 2001, Myriad Genetics was awarded a series of patents by the Canadian Patent Office that gave the company extensive control over BRCA1 and 2 genes and a specific test that it has developed to identify their presence (BRCAnalysis). The patents awarded Myriad a monopoly for 20 years from the filing date of the patent application. Although it has been suggested that Myriad’s patents also provide exclusive right to any information relating to or derived from these genes, as well as any methods developed to diagnose and treat hereditary breast and ovarian cancer, experts do not believe the courts will uphold these “rights”. The American College of Medical Genetics has declared its concern that such monopolies limit the accessibility of competitively priced genetic testing services, hinder the development of quality assurance programs and limit the number of knowledgeable individuals to assist in patient care. In addition, monopolization of a gene may impede the scope and pace of research that might beneficially impact clinical application.

There is abundant controversy concerning patent protection of genes.  Here is an interesting explanation about why market forces (i.e., competition in the development of competing technologies) may not operate properly regarding patents with an extract below:

One reason why the market system does not always operate properly in the case of patents on genes is because genes and genetic sequences are different from classical chemical compounds. Genes and genetic sequences have an informational content. One cannot "invent around" the sequence if it is patented, because each gene and each gene sequence is unique in its kind. Hence, through patenting, a "double" monopoly arises.

I have no special expertise in neither genomics or patent law.  However, as I review this BRCA/Myriad, a few thoughts seem certain:

• Myriad now has a "tiger by the tail" in the sense that they will defend their patents but, in so doing, all of the burden about understanding all of the missense mutations at the BRCA locus, and the development of tests to detect them, will rest with the company.
• Both now and in the future, unless the courts allow others researchers to work with the BRCA genes, Myriad will be vulnerable to suits regarding the failure of the company to inform clients correctly about all of the implications of the test, even if the misinformed parties are small in number.
• Cases like the current ones may sway public opinion, and most particularly a larger body of healthcare professionals, against broad gene patents, although I understand that this is a sophisticated issue and the courts may not be influenced by a shift in public opinion.

Salvador Allende: Pathologist, Populist, and President

Below is a brief description of Salvador Allende's early education and here is the link to the reference:

Born on July 26, 1908, in Valparaiso, Salvador Allende came from an upper-class Chilean family with a long history of political activism....After graduating from secondary school at the age of 16, Allende enrolled in the Coraceros Cavalry Regiment and, after a tour of duty, entered medical school at the University of Chile. Medical school helped further radicalize him as he lived, in very humble circumstances, with a group of students attracted to the writings of Marx, Lenin, and Trotsky.... He graduated in 1932 but, because of his radical history, was turned away from the Valparaiso hospitals and had a difficult time finding work as a physician. Allende was forced to take work as a pathology assistant, performing autopsies on the cadavers of the poor. He found the work dull, but it reinforced his dedication to social justice.

Below is another extract from an article about Allende; here is the link to the article:

Adherents of Rudolf Virchow's vision about the social determinants of mortality and morbidity immigrated to Latin America near the turn of the 20th century. Virchow's followers helped establish departments of pathology in medical schools and initiated courses in social medicine.... Allende's experiences as a physician and pathologist shaped much of his later career in politics. Acknowledging debts to Virchow and others who studied the social roots of illness in Europe, Allende set forth an explanatory model of medical problems in the context of underdevelopment.

I can personally relate to the idea set forth in these articles about the radicalizing effects of performing multiple autopsies on the "cadavers of the poor" but my personal goals were less grand than being an advocate for social justice. My primary life's goal at that time was to elevate myself out of the basement and gain some proximity to windows that emitted natural light. More of a challenge for me intellectually is the idea that Virchow, and Allende as his intellectual heir, spawned many of the radical political and social justice movements in South America. I need to catch my breath! Should I trash all of my Che Guevara posters and replace them with Rudolph Virchow posters.  And where would I buy them -- at the closest CAP boutique?