Advice

The Long Road Home

If you had a rewarding academic career in America for 20 years, would you upend it to move to Beirut?

Ray Knisella

November 14, 2016

T wenty months ago, I was named the 16th president of the American University of Beirut. Finally, after 33 years in my native United States, I was getting the opportunity to return and serve in a meaningful role in my ancestral Lebanon, the country where I had grown up.

The decision to accept this prestigious yet pressure-packed position did not come easily. After all, I was raised in Lebanon, but I was born in Boston and educated at U.S. universities. I had spent the entirety of my faculty career, 20 years, at two institutions — the University of Texas M.D. Anderson Cancer Center, and Emory University and its Winship Cancer Institute. Both had been fulfilling, rewarding, and highly supportive institutions where one could easily spend a lifetime. At Emory, in particular, I had helped lead the growth and development of a major cancer center that rose from being unrecognized in the cancer community to being consistently ranked among the top cancer hospitals in the country.

As an academic, if you are able to contribute lasting, resonant work — in which you can affect simultaneously both the best and the brightest, as well as the least fortunate — you are greatly privileged. At Emory, especially, I had found the peace and creative tranquillity that I had sought my entire career.

So why leave to go back to Lebanon?

After all, the campus in Beirut — where I had taken classes as an undergraduate, where I had later served as a trustee, and where I was now returning as president — had been plagued with strife in recent years. Student anger at rising tuition and educational costs in general was matched by faculty dissent at technical alterations in their contracts that seemed to put their vital benefits at risk. The nonacademic staff members seemed even more demoralized.

Think carefully about an opportunity to change gears. If it still excites you at the end of your deliberations, seize it. Grab it firmly with both hands and do not let go.
In January of 2015, when I visited the campus as a confidential presidential candidate, morale there was the lowest that I had seen since the end of the Lebanese Civil War. More troubling for me was the absence of an understanding of the relevance and the impact of the university. And Lebanon itself was in an alarming state, both economically and politically, with 27 percent of its citizens unemployed, and more than two million Syrian, Palestinian, and Iraqi refugees adding to a population of four million native Lebanese.

For many reasons — including the fact that the university had educated four generations of my family and three generations of my wife’s — saying no was never a realistic option.

But more important, I found myself positively thrilled by the prospect of making an impact at an institution that had the most powerful and permanent grasp on my loyalties, and one that had the potential to represent the very best natures of both America and Lebanon.

I was also determined to make a difference in the care of cancer patients, not only at the American University of Beirut but also in Lebanon and the Arab world. The university had continued to attract outstanding faculty members — superbly trained at the greatest universities in the Western world — to its mission, including to positions in the various fields of cancer care and cancer research. The university had roughly 850 faculty members across seven schools — small when you consider that the number is approximately a third of the faculty in the medical school alone at Emory — but the talent was impressive.

Circumstances, however, were daunting. The explosion in novel targeted therapies and immunotherapy had not bypassed Lebanon or the Arab world. But the challenges of providing such novel treatments at affordable costs were enormous in a Lebanon that was essentially undergoing an economic boycott by the Arab gulf nations.

Today, less than two years later, many of the challenges remain. But much has changed, and arguably for the better.

We have decelerated the increase in student tuitions that was threatening to make us unaffordable in Lebanon. We have also reached agreements with the faculty and the nonacademic staff on more sustainable — and frankly better — contracts, and a year of meaningful work, genuinely collegial but well coordinated, has seen the university rise in the prestigious QS rankings by 40 spots, to its highest ranking ever.

Morale on the campus is robust, and the sense of purpose is powerful. The students have developed and approved a system of proportional representation for their elections — a model for Lebanon and for the entire Middle East, where representative democracy is still a fragile entity. The university has been recognized in the last year for exceptional civic engagement, including the creation of a nascent civil-society movement and the sharing of scientific solutions to the country’s solid-waste crisis. Most important, in a historic vote of confidence in the faculty and in the future of AUB as a research university, our trustees voted to restore tenure after it had been frozen for more than 30 years.

Earlier this year, within a week of my inauguration, I resumed my clinical practice. It was the longest that I had gone without seeing patients in 27 years.

For the cancer physician, interactions with patients rapidly become a vital part of one’s life. In my last eight years at Emory, given the weight of my administrative and leadership roles, I had restricted my practice to seeing 80 to 100 new patients and consults a year — the vast majority of them afflicted with lung and aerodigestive cancers. I also followed my continuity patients with 500 to 600 additional patient encounters each year. While those figures were a significant drop-off from my peak in Texas, my clinic at Emory allowed me to remain up to date in my field and with my patients.

Even that lowered volume of patients is unrealistic for a university president. By the end of this year I will probably have seen between 60 and 70 new patients and consults. Under an agreement with the university’s trustees, all of my consultation fees are deposited in a fund for financially needy patients. But I have already learned a great deal about the differences and commonalities in cancer care between the developing world that is the Global South and the economically and industrially developed nations.

Among the patients whose treatment I have counseled or coordinated have been leading political and intellectual figures, as well as Lebanese laborers and farmers, and Syrian, Palestinian, and Iraqi refugees. The picture that has emerged is simultaneously enlightening and concerning. The use of genomic profiling in the pursuit of precision medicine — a practice that I have advocated for the entirety of my faculty career — is, to put it kindly, imprecise. Even among oncologists in the United States and Western Europe, the tendency to use these powerful tests uncritically is alarming.

With what I have learned so far, I have agreed to an additional task requested of me by Lebanon’s Ministry of Health: I will be working to update the cancer-treatment guidelines for the common malignancies that afflict the population. That project is timely, as recent data show that Lebanon has one of the highest rates of cancer incidence and mortality in the Middle East and North Africa. This will be considerable but important and impactful work, work that I am privileged to help lead.

So, one year into my long road home, I feel energized, focused, and enthused. The voyage back has allowed me to engage in genuinely meaningful work.

My situation is of course particular to me. But I would like to offer this advice to colleagues who are presented with an opportunity to undertake a radically different direction in their work and life: Don’t say no too quickly, yet consider carefully what you can accomplish.

Most cancer physicians and researchers — I would guess the overwhelming majority — engage in this field and this way of life because they believe that they can make a real difference. So think carefully about an opportunity to change gears. If it still excites you at the end of your deliberations, seize it. Grab it firmly with both hands and do not let go.

This is the third such time that I have taken my own advice. As to regrets, I have none.

Fadlo R. Khuri, formerly an executive associate dean of research at Emory University, is president of the American University of Beirut. He is a professor of medicine at the university and on long-term leave from Emory.