Medical visionary at Penn

Ezekiel J. Emanuel values intelligence, but don't accuse him of Harvard-itis. He'll tell you an Ivy League degree doesn't prove anyone's worth.

"That's exactly what used to drive me crazy at Harvard," he snaps, a place where many students believed, "I got into Harvard. I've arrived!"

"You have been given the privilege of the best education in the world!" he'd say. "Your obligation is to take that and do something good for the world! You've only got a limited time on this earth. You have to use it the best way you can!"

Zeke Emanuel is in your face.

One of the principal architects of President Obama's health care reform act, he is an oncologist/bioethicist/philosopher/author/columnist and, now, vice provost for global initiatives at the University of Pennsylvania. He blogs about food for the Atlantic, opines about public policy in the New York Times, has authored or edited nine books, and published hundreds of research papers and articles in medical journals.

Although he doesn't own a TV, he appears regularly on Hardball, Squawk Box, and Morning Joe. (In his 20s, studying biochemistry at Oxford, he even starred in a British reality TV series, a precursor to Survivor.) In 2008, he spent an hour with his kid brothers talking to Charlie Rose about how they all came to be what Tom Wolfe might describe as Masters of the Universe.

Those brothers? Oh, you know them.

Rahm is the former White House chief of staff and current mayor of Chicago. Ari is a Hollywood uber-agent, representing celebrities such as Charlize Theron and Martin Scorsese. He also is the template for the character Ari Gold on TV's Entourage.

And Zeke?

Before reimagining national health care, he was the forward thinker who helped design an improved living will. And the scientific investigator who calculated how to fairly allocate scarce resources, such as H1N1 vaccines or vital organs for transplants. The same calculation that conservatives like Michele Bachman and Sarah Palin misconstrued as support for "death panels."

Yet somehow Zeke remains the least famous of the Brothers Emanuel.

So you probably won't recognize him when he passes you crossing the South Street Bridge or on West River Drive. Which he probably will at some point, because he doesn't own a car, goes everywhere in the city on foot, and moves at nearly cartoonish speed, a blur of limbs and buzzed steel-gray hair, propelling himself to wherever he's going with powerful purpose.

At 55, narrow and charged as an electrical cable, Zeke Emanuel is just hitting his stride. He wants nothing less than to change the world, make it healthier and more humane.

"I want to make an impact and to make things better," he said on a recent Amtrak ride between Washington and Philadelphia, a commute he makes at least twice a week, shuttling between his multiple roles.

After serving on President Bill Clinton's Health Care Task Force, then on the faculty at Harvard Medical School, Emanuel spent 14 years at the National Institutes of Health.

In September, he arrived at Penn to light booster engines under the school's already not-so-shabby reputation and launch it into the international stratosphere.

As vice provost for global initiatives, he is charged with extending Penn's global reach in research and training. He's on the faculty at Wharton and chairs the department of medical ethics and health care policy at Penn's medical school, which he is expanding with a new master's degree program. He's also teaching courses on the future of American health policy and on health care rationing, to train a new generation of doctors, nurses, and business leaders to think and act ethically.

This is only part of his 72-page resumé.

He has a black belt in tae kwon do, too. And bakes a mean raspberry rhubarb croustade.

It is late May and Emanuel is meeting with the academic committee, planning which issues to include in Penn's new bioethics curriculum.

Who should receive expensive new cancer treatments? Can doctors post beneficial medical information on Facebook without violating patient privacy? And, Emanuel's favorite, "Who gets the liver?"

"I sort of begin with, there is one liver and three people who need it, and why we'll never solve the liver problem no matter what we do."

He speaks in his rounded-r Chicago accent, tending toward expressions like "hotsy totsy" and "fancy dancy."

The liver question occupied Emanuel for two years at NIH. His study of how to fairly distribute scarce resources, published in the Lancet, examined the criteria used to decide which patients receive highest priority for a new liver and how much weight each factor merits.

Should the liver go to the sickest patient? The one with the potential to do the greatest good for society? To the young who will live longest?

"The answer is none of the above," he says. Decisions should be based on a combination of all these considerations and others as well.

Even then, the solution won't be perfect, but the result will be fairer than the model used before he and his associates developed the "complete lives system" the Lancet piece outlined.

From a public policy perspective, he argues, the objective should not be simply to save the most lives, but to also consider the quality of those lives and avoid giving unfair advantage to the wealthy and powerful.

One of his two iPhones rings. It is Rahm. "Boychick!" Zeke says. "Really? So, is that good or bad?" Five minutes later, he returns to the meeting as though he'd never left.

The committee is discussing court cases. Terri Schiavo and the debate over prolonging life support. The Tuskegee case, in which the Public Health Service withheld treatment from hundreds of black men in order to study the progress of disease.

"I'm worried about too much legal emphasis," one committee member says.

Emanuel rests his chin on his fist, grasping a pen. He listens, knees oscillating beneath the table, inhales, then delivers his rebuttal.

Many bioethical questions have clear answers, he says. There are well-established rights and wrongs. Young doctors should not be asked to wrestle with problems that have already been settled.

"If they don't understand the concept of informed consent," Emanuel says testily, "what does it mean when they go on to the wards?"

His colleague presses, "We want students to have more than the facts. We want them to have reasoning. We want them to think, synthesize, integrate, apply."

Emanuel agrees, but says facts are the foundation of knowledge. Students need to know about settled cases before they can apply ideas to new situations. Then he backs off, allowing others to finish the debate.

All but the one side with him.

Although his critics put arrogance at the top of his list of flaws - and use unprintable epithets to describe its magnitude - when he lets down his guard, Zeke's conviction in the rightness of his beliefs seems less unassailable. It is flecked with traces of the high school nerd striving for approval. The straight-A student feeding on admiration for his sharp mind. The good son trying to live up to his parents' high standards of morality and achievement.

Zeke's personality was pickled in the Emanuel family brine of intense competitiveness, lofty goals, and unbridled passion.

"He's fiery and wonderful in that regard," said Christine Grady, who succeeded Emanuel as chief of the department of bioethics at NIH's clinical center. "But sometimes he forgets to be tactful."

Still, she says, he respects those who disagree with him, as long as their reasoning is sound. Like all Emanuel's friends, Grady accepts his rough edges because of the warmth and generosity he shows her, and the altruism that drives him.

It is early June and Emanuel is moderating a panel discussion about how to reduce health care costs, held at the Center for American Progress in D.C., a progressive think tank where he serves as a senior fellow.

An audience member asks, "What's wrong with administrative costs?" and begins rambling. "I like having my choice of toothpaste brands . . ..

"What's your question?" Emanuel interrupts.

The man says he believes the current system gives patients the most freedom.

"OK. OK. OK," Emanuel interrupts again. "Got it."

The man sits, affronted, but listens to Emanuel rat-a-tat a series of bullet points at him.

He rails against current policies that pay hospitals each time a patient is readmitted. Instead, Emanuel says, hospitals should be rewarded for ensuring patients are well before they leave and helping them maintain their health. Lowering readmission rates cuts costs and saves lives.

Electronic record-keeping could save millions. So will bundling health-care charges so that patients pay a single up-front sum for an illness. The system, already thriving in several medical centers, provides a "prix fixe" menu, comprising diagnostics, treatment, medicines, rehabilitation, and follow-up.

And, finally, he tells the man, patience is required. "We have not transformed the system. We are going to have to work very, very hard. A major overhaul like this is like raising teenagers. There will be rocky times, but we will get to a better place."

The real problem with the Affordable Care Act, he says, was the Democrats' failure to help people understand the benefits. "We didn't do a good job of explaining."

He understands public opposition. "People are fearful. You have to be in the weeds to see how it will work." But basic health care for all Americans, especially children, is a moral imperative.

Afterward, he bolts to his office, briefs an aide to Sen. Dianne Feinstein on his New York Times op-ed piece suggesting that wealthier Americans postpone receiving Social Security benefits until their late 60s.

That done, he taps out an e-mail to HUP's chief of infectious disease about the school's program in Botswana. Takes another call. It is a friend, just back from Israel, leveled by food poisoning.

"Rice and bananas, OK? . . . Feel better, buddy. If it's not better, call me tomorrow."

Then he dashes to Union Station for the 1 p.m. train back to Philadelphia.

He finds a seat, removes his jacket. The silver cuff links on his pale blue shirt read "I am the boss" on the right, "Trust me" on the left, a gift from one of his daughters.

He has three, in their 20s. One graduated from Dartmouth and one from Yale, where the youngest is still an undergrad. All have begun stellar trajectories. The oldest turned down a Fulbright to accept a $40,000 fellowship to develop her program assisting the families of AIDS victims in Uganda. The middle daughter is at Oxford on a Rhodes scholarship.

On the train, Emanuel gets a call from her in England. He tells her he's busy and asks if they can talk later, but then stops himself.

"You don't sound good," he says. "What happened? Oh, Honey. No. Tell me."

She talks for a few minutes.

"Got it," he says. "Next. What's the second problem? . . . So I think what we've learned . . . I know, it's frustrating. I'm completely sympathetic. These guys are dolts."

He spends the next half-hour juggling calls, then reaches into his black leather backpack and retrieves a reusable lunch sack containing roasted quail blanketed in quinoa, leftovers from the dinner he and his girlfriend prepared for Supreme Court Justice Antonin Scalia and his wife, Maureen.

Emanuel says he tried to persuade the conservative judge that the health care act was constitutional. To no avail.

"But I took him to the cleaners on a bet," a wager that Congress would pass Obama's health care bill. "We went to Minibar," one of D.C.'s most exclusive restaurants, he gloats. "It has a 27-course tasting menu."

Despite their differences, Emanuel is fond of Scalia. "The guy is a very nice, warm person. . . . There are plenty of liberals I wouldn't want to spend time with. Politics is not the only metric."

In the 1940s, Emanuel's father, Benjamin, now 85, was a member of the Irgun, the underground nationalist group that committed acts of terrorism against the British in Palestine. Zeke was born in Israel. He and his brothers spent summers there after the family moved to Wilmette, a wealthy Chicago suburb.

Their mother, Marsha, 79, was a psychiatric social worker active in civil rights. She exposed them to the arts. (They all took ballet lessons.)

Family dinner conversations were tantamount to an intellectual fight club. The boys were expected to be well-informed, prepared to defend opinions they dared to offer.

At New Trier West High School, he excelled in science and math, graduating third in his class. On the debate team, he jousted with opponents, sometimes mercilessly.

"I made a girl cry," he recalls. "I think her name was Christine. It was the state quarterfinals during cross-examination." The topic eludes him, but the result never will. "We lost because of that. I blew it. I blew it. I blew it. It was an important lesson," he said. "Being right may not be the best way to get things accomplished.

The standard line about the Brothers Emanuel is that Ari is the richest, Rahm the most powerful, and Zeke the smartest. Asked whether he agrees, Zeke harrumphs, "I'm the one who came up with that!"

He then recounts how once, on TV, he said people think he's intelligent because he's good at math and can divide fractions in his head.

Ari called instantly to protest, "I'm good at math!"

The sibling rivalry that persists unabated "keeps us on our toes," Zeke says. The brothers talk to one another nearly every day.

They have an adopted sister, Shoshana. Benjamin had given her a checkup while making rounds in the hospital when she was born. Afterward, when he met her birth mother and advised her to take the baby to a pediatrician in a few weeks, he learned that the infant was going to be put up for adoption. She was one week old when the Emanuels brought her home. Later, they discovered that Shoshana had cerebral palsy.

Shoshana has had a much rockier ride through life than her brothers, who have tried to help her and the two children she had as a teenager.

"Go delicately there," Zeke Emanuel warns when asked about her. "She has a right to her privacy."

Emanuel's sense of right and wrong has always been fierce, says Greg Keating, who has known him since Amherst College in the 1970s.

"He was once driving back from Chicago with a black friend," Keating recalls. Racial tensions were sizzling and Emanuel, who had gone on civil rights marches with his mother, had nothing but contempt for bigots.

Somewhere in Ohio, a police officer pulled Emanuel and his friend over.

"Zeke lit into the police officer," Keating says. "The officer, luckily, backed down. But it could have turned out very, very badly."

As long as he's known Emanuel, Keating says, his brash self-assurance has been evident.

Once, first to finish a chemistry exam, Emanuel slapped his paper on the professor's desk, proclaiming the test terrible. The professor shot back, "Why don't you write your own?"

Before the other students had finished, Emanuel returned with his improved version. He claims not to remember his grade, but acknowledges there were few exams he didn't ace.

He didn't really want to be a doctor, he says, but his parents gave him little choice. He hated the hierarchical pedagogy of medical school and although his years as a breast cancer specialist were rewarding, he was frustrated by the country's broken health care system.

So many avoidable problems were beyond a clinician's domain, he said. "I decided I'd rather work on changing the system."

He was married for 25 years to Linda Emanuel, who, like Zeke, holds an M.D. and Ph.D. from Harvard. She created the ethics department for the American Medical Association and holds multiple positions at Northwestern University, including director of the Center on Aging.

They divorced in 2008 and Emanuel asked that she not be contacted for this article, but said that for many years, professionally and intellectually, they had been an ideal match. They collaborated on research and publications - one of the most notable of which was the revision of the living will.

It was at Harvard that he met Amy Gutmann, who later as president of Penn hired him for his current job.

Last year, after deciding to leave NIH, he considered several offers before picking Penn. Insiders, however, none of whom would speak on the record, said his arrogance limited his choices.

"I'm hard-driving and want to get things done," Emanuel admits. "And at times, I can be brusque."

His college friend Keating believes Emanuel's problem is that his moral code strikes a single, emphatic chord.

"He's not as good as he should be at recognizing when he should live and let live," says Keating, a law professor at the University of Southern California. He was in law school at Harvard in the early 1980s when Emanuel was in med school and earning a Ph.D. in political philosophy from Harvard.

"It drove him crazy when people walked around with Walkmen because he thought it destroyed the public space. He would walk up to total strangers and chastise them, telling them they were supposed to be interacting."

And yet, Keating says, Emanuel can be extremely tender and caring. "He has a very sweet side. I don't know how many see it. He doesn't have a malevolent bone in his body."

It is a Friday night in June, and Emanuel has invited friends for dinner, one of his favorite pastimes. As with everything else, he strives for perfection.

His townhouse near Fitler Square is clean and modern. He is barefoot, wearing blue pinwale corduroys and a gray T-shirt. The table is set with handmade plates embossed with Queen Anne's lace, commissioned from the same company that supplies the famed Blue Hill restaurants.

"It was mid-recession. I negotiated a good deal," he says, slicing zucchini for the grill. The chicken marinates in Turkish herbs. The salad, a rainbow of lettuces, is garnished with nasturtium.

Over the meal with his guests, David Weinberg, chairman of the department of medicine at Fox Chase Cancer Center, and his wife, Christine Laine, editor of the Annals of Internal Medicine, Emanuel answers a question about why he keeps kosher even though he's an atheist.

"Atheism and Judaism are completely compatible," he says. "Orthodoxy and orthopraxy are not the same." (Translation: Correct belief and correct behavior.) Pressed to elaborate - is he honoring tradition? culture? habit? - he refuses.

Why?

"Because it annoys people," Weinberg jokes. "That could be Zeke's defining feature."

Emanuel laughs and changes the subject to chocolates.

In 1998, John Gallin wanted to expand the bioethics work at the NIH's clinical center, the world's largest hospital dedicated solely to medical research.

"Clinical research was becoming a business, a risky business, making big money for drug companies," says Gallin, the center's director. "I was acutely sensitive to the conflict of profit-making vs. doing the right thing and caring for people participating in studies."

With the advent of genomics, new ethical questions were pressing, such as "What does it mean if you're 50 percent black? Are you black or white? What are the disease implications?"

During a national search for a bioethicist, Gallin came across Emanuel and was immediately impressed. "He asked me, what's your goal? And I told him, it's simple: Build the best bioethics program in the country."

Emanuel did just that, Gallin says.

One of his projects at NIH that has had a particularly important impact was his analysis, and ultimate rejection, of the long-held belief that it is wrong to pay participants in clinical studies because it leads them to accept unreasonable risks.

With his team, Emanuel tackled questions such as whether it is right to compensate subjects for time away from work. Yes. And whether professionals whose time is ostensibly more valuable should be paid more than those who earn minimum wage or are unemployed. No.

The study's findings and recommendations have changed policy.

When Emanuel arrived at NIH, Gallin warned him there was not much money or space available. Undeterred, Emanuel hired his own architect and - within budget - oversaw the design: exposed brick, a communal area for weekly teas, Oriental-style carpets, large windows, natural light.

"You don't see space like that at NIH," Gallin says. "It was attractive to people."

Emanuel told Gallin he wanted to bring in lawyers and philosophers, not just NIH scientists. He used the atmosphere to foster camaraderie, mentor young academics, and ply them with home-baked scones, Gallin said. "Within three years, he leveraged the three positions I gave him to nearly 30. He recruited the best minds."

Gallin reaches into his bookcase for the Oxford Textbook of Clinical Research Ethics that Emanuel wrote during his tenure at NIH and dedicated to Gallin. Zeke, he says, always chafed at the institution's restrictions. Those trying to get him to play by the rules found him exasperating.

Gallin says he was asked, "How can you keep him? He doesn't know his place!"

"That's what you want!" Gallin replied. "He's not a B.S. person. That's worth a zillion dollars."

After his divorce, Emanuel seemed lost, friends say. Then, two years ago at an exclusive dinner in D.C., he met human rights lawyer Annie Sovcik. They've been a couple ever since, although they maintain separate homes.

Together, they run half-marathons - with Emanuel finishing first, averaging 7.28-minute miles. They travel to a cottage along the fjords in Norway. Last summer, during a business trip to Brazil, they went camping in the Amazon.

Emanuel found the service overly pampered. "He complained day after day that we weren't getting enough authentic local food," Annie says.

Finally, he barged into the kitchen one night, and in his limited Spanish, yelled, "Mas tipica! Mas tipica!"

Eventually, he got what he wanted. They ventured deeper into the jungle, where he fished for piranha, helped chop down a palm tree and harvest the hearts, then assisted preparing the dinner.

As he and Annie stooped by a river, cleaning pots and pans, he turned to her.

"Bet you never imagined doing this when you met me at that fancy dancy dinner!"

Emanuel's vision and persistence saved the health care act from political neutering, says Neera Tanden, who worked with him on the bill when she was Obama's chief domestic policy director.

"He understood the issues. I understood the politics," recalls Tanden, now president of the Center for American Progress. "People would say he was too aggressive. But he was right. If Zeke wasn't there as a bulwark, ensuring that the bill produced actual reductions in health care costs, those provisions wouldn't have survived."

Though he won a few bets when the Supreme Court upheld the Affordable Care Act, Emanuel has watched the political aftermath with concern. The Republicans' plan to repeal and replace the law will be "harder than the rhetoric suggests," he says. The comprehensive reforms derided as "Obamacare" will significantly reduce the deficit, control future growth in health care costs, and, finally, after 100 years of failed attempts, ensure that all Americans have access to basic medical care, Emanuel insists.

The opposition, he says, has never proposed a coherent alternative. To the extent they succeed in hobbling the current law, he says, "the country is the real loser."

He can't tolerate insincerity and says he doesn't mind when he's attacked for what he believes.

"I don't care what idiot people say . . .. Unlike many people, I don't mind a fight."

In his 2008 book, Health Care Guaranteed, he proposed radically changing American health care with a voucher system. Even the book's admirers said the plan, which would have phased out Medicare, Medicaid, and employer-based insurance, had little chance of ever becoming reality.

"If you want to improve the world, you have to do something that's feasible," Emanuel says. "But you don't know what's feasible until you go out and try to do something."

Then he adds, "But I tell you what. In 10 years, our health care system is going to look a lot more like my voucher system than the fee-for-service model we have now."

After the curriculum meeting, Emanuel dashes back to his office in College Hall. On the bulletin board, he has tacked up his "nine commandments" for brewing tea. Atop the bookcase is a butcher's knife encased in plastic, a parting gift when he left NIH, in honor of the professional style he calls "Combative Collegiality."

"Part of my challenge at Penn," he says, "is to re-create that here."

One of his ambitions is to build stronger ties with international alumni and foster cross-faculty cooperation.

"We need to make Penn better at being an agenda-setter in the world," he said during a recent faculty presentation.

It is not as though Penn didn't already have an international presence. Or, for that matter, a bioethics program and distinguished bioethicists on the faculty, such as Jonathan Moreno and Art Caplan.

In March, Caplan, 62, announced he was leaving. Everyone assumed it was because of Emanuel, that there wasn't enough room for their two egos on one campus.

Without dignifying the dig or denying their ample sense of self-worth, both men say the assumption is wrong.

Emanuel says he was looking forward to co-teaching with Caplan. And Caplan?

"I had already stepped aside a year before," he says. "No one should have a lifetime sinecure in any department." Based on the theory that he wanted out, though, he was deluged with unsolicited job offers. NYU's was impossible to refuse.

As a member of the committee that hired Emanuel, Caplan was well aware of his successor's abrasive reputation, he says. "It's just a style. Zeke is very smart. Maybe not as smart as he thinks he is, but pretty close. And maybe not about everything he opines about.

"But he arrives as the national expert on bioethics and health policy . . .. He wants excellence, expects performance, and doesn't have a lot of time for work he doesn't consider outstanding."

There is already speculation that Emanuel may leave Penn to join a second Obama administration or, down the road, to run a university.

But he is loyal as well as ambitious, his friends say. "I was phenomenally disappointed when he left," Gallin says. "He left NIH because people were telling him he couldn't do things. He couldn't write without approvals. He lost the freedom to express himself."

For however long Penn gets to keep him, Gallin says, the university will benefit greatly. And the work Emanuel accomplishes there will undoubtedly lead to a more ethical and fairer practice of medicine, both in the United States and internationally.

"If there were more people like Zeke," Gallin says, "the world would be better off."

See a video about Zeke Emanuel, Penn bioethicist and health-care overhaul architect, at www.philly.com/zeke

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