#150-Senator Bill Frist, MD: A modern Renaissance man's journey through science, politics & business

KEYPOINTS

• 01

  Bill Frist's career has had three or four acts, all of them about health

  Frist trained at Princeton and Harvard Medical School, then learned transplant surgery at Stanford under Norman Shumway. He built the largest transplant programme east of the Mississippi at Vanderbilt, was elected to the US Senate in 1994 having never held office, and became the 18th Senate Majority Leader in 2002. Later he moved into private equity and education. He describes roughly ten-year cycles of learning and delivering, and sees them as 'all the same thing'.

• 02

  Heart transplantation succeeded through patience, not bravado

  Shumway spent about 10 years in the lab working out the science before operating on people. Christiaan Barnard, whom Frist calls more opportunistic, did the first transplant in South Africa in 1967. Around 1968–69, competing Texas surgeons did roughly 110 heart transplants 'Texas style', and nearly all the patients died. Most programmes shut down, while Shumway kept doing 10–15 a year and working out why patients died.

• 03

  Cyclosporine changed the odds

  When cyclosporine, a drug discovered by chance in a fungus, was added around 1982, mortality fell from perhaps 50% to 20%. Frist says about 80% of his heart recipients lived at least five years, and those who got past that often lived 10–30 years. Some of the people he transplanted 28 years earlier were still alive.

• 04

  Building a programme required an institution willing to cover early risk

  At Vanderbilt, with no heart transplant programme in Tennessee, the institution agreed to cover his first 10 transplants if insurance wouldn't. Donor hearts were the bottleneck: he had 50–60 people coming in but could transplant only one every four or five days.

• 05

  Physicians used to fill the Senate

  Frist says about 24 or 25 physicians served in the Senate in its early decades. The number roughly halved every 50 years until none had been elected since 1928. He argues physicians bring a habit of listening to 20 patients a day. Arriving in a chamber of 63 lawyers turned out to be an advantage.

• 06

  Frist opposes term limits

  Attia finds term limits appealing. Frist initially did too, but now calls them 'a huge mistake' for the Senate because the job is complicated and institutional memory matters. As the most junior senator (100th in seniority), he relied on colleagues who had served 18–24 years. His physician father told him to replace the 'Honorable' nameplate with 'Dr. Bill Frist': senators rent the office, they don't own it.

• 07

  PEPFAR was one of the largest health interventions in history

  George W. Bush, who had never been to Africa, announced the President's Emergency Plan for AIDS Relief in the 2003 State of the Union. Only Frist and perhaps five or six others knew in advance. US spending rose from about $200 million a year to $3 billion in the first year, and roughly $60 billion over time, in Attia's words. Frist credits Bill Clinton's later work on the issue.

• 08

  He changed his position on stem cells, guided by principles

  A 1996 amendment banned federal funding of embryonic stem-cell research (the cells were discovered in 1998). Frist, who is pro-life, backed Bush's 2001 limit on existing cell lines. He then laid out 10 principles in 2000 and again in 2005 to expand funding with ethical guardrails, such as stopping women from being paid to create embryos for destruction. His 2005 bill was vetoed, but he says those principles now govern the field.

• 09

  The Terri Schiavo case shows the clash between law, ethics and technology

  She collapsed in 1990 and was left in a persistent vegetative state. She had no living will, and her husband and parents disagreed. In 2003, five court-appointed doctors split 3–2 on whether she was vegetative or minimally conscious. Frist's bill guaranteed federal review, 'a process, not an outcome'. The courts declined the petition and the feeding tube was removed. Many call it his biggest mistake; he says he'd probably pass the same bill.

• 10

  The pandemic warnings went unheeded

  In 2005, citing the 1918 Spanish flu, Frist said a pandemic was a question of when, not if, in about 20 speeches. He notes that bioterror agents can be made in an 8-by-12-foot room. His biggest disappointment is that the brief non-partisan unity after 9/11 hasn't been matched since, and he blames misinformation on social media and cable TV for much of the polarisation.