Hamburg: I’ve worked with you over these many years and watched the development of your own work and what you’ve stimulated throughout the world. Now we are looking in this field of prevention of mass violence whether it be civil wars, or interstate wars or even Genocide. In the prevention of mass violence we are looking for ... I have drawn upon a public health model and a lot of people have found that stimulating and the transition from basic research like your discovery of Rapid Eye Movement Sleep to clinical and behavioral connections on to the creation in your case of a field of sleep medicine, but anyhow getting the health profession seriously engaged throughout the country and throughout the world and then to public health of which public education is a very important part so that our assumption is, and there is evidence in the medical public health field that by and large if people understand dangerous risk factors they will try to change their behavior and direction in health.
It takes a while and doctors themselves are slow to pick up this approach but there is an analogy we are trying in both cases to prevent unnecessary human suffering and premature deaths whether you are talking about intergroup conflict, genocide, or the prevention of heart attack and stroke, or the prevention of serious accidents under the conditions of sleep deprivation and there is a model there stimulating analogy for us. Maybe if you wouldn’t mind if you’d start off with how you got into this field, I think everything was transformed by the discovery of Rapid Eye Movement Sleeping, maybe you’d begin there, wherever you want and tell us how it evolved.
Dement: I think, as you were speaking I think in some ways the beginning for me was when you were in Michael Reese Hospital in Chicago I think I had given a talk or something about rapid eye movement sleep or the brain waves and you were interested and you were like this is kind of an interesting thing but you were the only one interested in that way and and that interest by someone who’s highly respected both by your position, and your insistence to write Greek was very eminent kind of kept me going, made a big difference. I think also at the time there was very little molecular biology, pharmacology and psychoanalysis was very very prominent and I thought the relationship between rapid eye movement to dreaming might be a very big thing and I was interested in trying to find a way to deal with schizophrenia which is still our goal in American psychiatry.
Anyway, I think I don’t know it may have been Roy Greek or it may have been you, Mel Samptian I think was another I’m proud to come up with that name, but that was in some way very important to have a group that was interested I had probably planned initially that I would do this because it was kind of fun I can get a PHD thesis and then go on to something else like I don’t know surgery or something and it was that intention that when I left the University of Chicago there was still an interest and I think you and I stayed in touch and I think you took the first chair of psychiatry down here and moved from san Francisco to the Stanford campus and that was very important and unique faculty to the department of psychiatry that was just almost unprecedented as a research oriented faculty and then you persuaded me to come out
Dement: Yeah January of 1963, but I think I came out January of ’62, is it? Because it was in the Winter my car was buried in the snow in New York and there was a place called ED’s ice cream in the shopping center we went over and got ice cream cones in the sunshine licking ice cream cones that made a difference.
Hamburg: Most of my recruiting was done in the middle of winter.
Dement: Yeah you said it was called the Stanford Raiders, but all along the way I always had kind of a vision of a sort of broader application and sometimes I would say jokingly I am responsible for the health of the human race at night.
Hamburg: One third of our living time.
Dement: I think as we began to explore, first of all I had become very interested in an illness called Narcolepsy and part of it was that some aspects of rapid eye movement sleep were emerged pathologically in this illness and that was extremely interesting so when I came to Stanford I think it was in 1964 started a Narcolepsy clinic and it was literally the only clinic in the world I suppose so we had hundreds of patients that finally came here and that was my first experience with bankruptcy because none of these patients could pay their bills I mean it was a fee for service clinic although we were doing research.
I realized no one was taking care of people who complained about their sleep and I don’t know what finally made the critical decision but I finally decided to open a sleep disorders clinic and I remember we called a press conference announcing the opening of this clinic and one reporter came, one, and I told him about the clinic but he got off track because he was asking “Should children sleep with their parents?” I remember that and I said “Well I don’t really think so I mean I think it’s okay as long as they aren’t making love and I said well they can go to the kitchen or something” and a few weeks later I’m just reminiscing; the telephone rang at 4:00 a.m. and a voice said “This is ABC News are you that professor that recommends having sex in the kitchen?” or something like that and I said “What?”. I remember Bob Lindy I believe you knew was at the Medical School, I realized this was going to be on the Radio and the Newspaper and with his help I got it off ABC and so on and that was my first experience with you have to be a little careful with what you say to reporters.
For quite a while the sleep disorders clinic was very small and then it began to blossom and a major thing was when we discovered that sleep related breathing problems were very very important and we began to realize this is a huge issue and I began to first of all I think it was in 1975 there needed to be a professional society mainly so that everybody is doing the same thing you know the standardization. Prior to that someone would say “Oh I did this” but you weren’t quite sure what they were talking about because we didn’t have a standard language so I started the what is now the American Academy of Sleep Medicine in 1975 with 5 member centers. The late Elliot Weitzman who was chairman of neurology at Montefiore Medical Center was here on a sabbatical and he started one of the sleep centers. I would say as we began to kind of to educate society and we had site visits and the whole thing modeled on other professional societies by 1980 this field was starting to burgeon in American society and then a little bit in Canada then Europe sort of got on board
Hamburg: You had your French connection.
Dement: And the French connection yeah and a very strong Italian connection I think there’s still to penetrate the educational system is not easy in today’s world, we’ve sort of reached a society of limitations and curricular time is limited and so on, but I did not really intend to devote so much time to undergraduate education but it’s been very very successful at Stanford and I think for I guess the last phase of my career that I’m going to try to export what used to be human sexuality with Herant Katchatourian who you recruited here. I guess college students are more sophisticated now because “Sleep and Dreams” is by far the largest course at Stanford and I think that I can export it to other colleges and universities and that would be a good way to continue to make a major impact on the health or the public.
I think that the 3 main areas: One is the relation of sleep disorders to cardiovascular health then the whole issue of accidents and you know falling asleep at the wheel would be the typical accident, and then finally just performance I mean if you are wide awake and you don’t have a large sleep debt your performance is at its peak. Right now I think it was in the 1970s when I realized that lost sleep accumulates as a debt so what is the size of the debt that everybody is carrying around and we started studies by having people get extra sleep and lower their sleep debt we are seeing improvements in mood, performance, just about everything, even athletic performance.
Yesterday 2 members of the women’s basketball team were in the office starting this sleep debt reduction program and amazingly one of them is 6 feet 4 inches tall. Anyway.
Hamburg: Now am I right that the creation of sleep disorders clinic gradually became contagious, it spread through the country then it spread through the world so that today there are great many sleep disorders clinics where for some years this was the only one. Is that correct?
Dement: Well we were the only one for about 5 years after actually opening and then it was kind of hard because part of that was reimbursement for all night testing, but it did sort of catch on. First of all one of the major sleep disorders is called Obstructive Sleep Apnea, Apnea means no breathing so you stop breathing when you fall asleep and that of course is a serious problem. Fortunately you wake up to breathe, but this is a very prevalent illness and it’s realized that it’s 24% of adult males according to very excellent epidemiological studies and 9% of adult females and as you get older the prevalence may even be higher and it actually causes cardiovascular disease so as you look at risk factors for heart attacks and stroke this is a major risk factor, you know you have to deal with it.
Right now I’m sort of involved in trying to get this whole thing closer to the primary care level and even I don’t know home testing I suppose. One could say now that every single man, woman, and child should have their sleep examined and in some way even if it’s just an interview and make sure that things are okay.
Hamburg: So as the research went on in the field that you had largely started but stimulated and it got gradually more support from the National Institute of Health and so on it was disseminated pretty widely in various ways partly throug the application of sleep disorders clinics and the development of sleep medicine now as you say attention of primary care physicians and what they do about it but also you then organized a professional association so that the experts can share their information in this country and all over the world.
I remember meeting with you in Chicago where people from all over the world were there who were involved in either sleep research or sleep medicine, but there’s a major effort that you made that you didn’t expect to get, to get the research understood in its uses for clinical medicine and ultimately for public health. Is that a fair statement?
Dement: Yes, kind of a continual expansion in the sense that realizing number one that sleep disorders are highly prevalent. Number 2 that the awareness about the nature of sleep in sleep requirements people were not aware of this that there’s kind of a high risk for sleep related performance impairment and severe accidents. The Department of Transportation and the National Transportation Safety Board began to investigate accidents and it was just incredible that the role of sleep deprivation, for example most people still remember the Exxon Valdez Grounding and the oil spill, America’s worst oil spill and for a long period of time they were blaming it on the Captain and it turned out he was in his cabin and they finally realized that the person who was responsible for steering the vessel was tremendously sleep deprived and we literally asleep at the wheel of the Exxon Valdez and get it back to the shipping lanes correctly.
Other major major accidents like the explosion of the space shuttles Challenger the NASA managers were so sleep deprived I believe this was in President Reagan’s term there was a lot of attention I believe a teacher was going to go into space and the O-rings, and I’m not quite sure what O-rings are but the O-rings were known not to function properly at low temperatures and the managers just gave the okay to launch the vessel and 50 Million American’s saw it explode and that was sleep deprivation.
Now the National Transportation Safety Board has a whole protocol for looking sleep disorders and sleep deprivation in accidents. Now there are a whole series of major accidents that are attributed to this. It has had some affect, I decided we ought to look at the trucking industry, this is about 1991 this Congress had legislated a national commission on sleep disorders research and I think and again you gave me entrée to senator Kennedy and it was his office. I’ll never forget he had a physician specialist in his office and I went there, by this time the American Academy of Sleep Medicine had a Washington representative dare I say a lobbyist and I went there and said there should be a National Institutes of Health, a National Institute of Sleep Research and she said “Oh, okay how many practitioners are there?” I said “there are at least 300”. She laughed and said “No we can’t do that, but we could give you a commission”. So they actually legislated a national commission on sleep disorders research, and we met and held hearings in a number of cities and I think we started in 1991, March 1991 and it had a major impact in raising awareness and also we managed to create a new agency in the National Institute of Health, the National Center of Sleep Disorders Research, it’s very small but it’s there.
Hamburg: You were a chairman at the commission weren’t you?
Dement: that’s correct yes.
Hamburg: But that is another way through the policy maker institutions of getting more public understanding and more research in the field.
Dement: Correct, it was a very important experience because I learned number one how to use testimony of witnesses and how to select witnesses to testify to the commission and we had to report to the congress to sort of do that the right way. I think there’s a process there; I think I’ve been successful in educating my colleagues in doing this so that more people are in fact working on public health issues. As a matter of fact and understanding the importance relating to your elected representatives which most American’s kind of don’t do that and there has recently been an appropriation by the congress that actually got finalized for education about sleep disorders and sleep deprivation, that it’s going to be a branch of the Centers of Disease Control and I have been very focused on that agency also.
Hamburg: That’s a very interesting point, you’ve actually worked to strengthen major institutions NIH, and the CDC which provide an underpinning for generating new knowledge in medicine and public health and disseminating that knowledge. In the field of preventing mass violence we’re pretty weak on that, we don’t have clear cut institutions that support research on those matters even though there’s a lot of good research going on in places like Stanford throughout the world, but they are all in a shaky position about where they can get support in the absence of an institutional base, so there’s an important lesson in that, but to some degree you inherited that NIH existed but you saw to it that it got strengthened for the purposes of paying attention to supporting sleep research more adequately and now the CDC the Centers of Disease Control where the prevention Orientation is very strong.
Dement: I guess just sort of looking at society you know you’d see incidences of what triggers violence or look what isn’t there or in the law enforcement or whatever and I think until you look you’re not quite sure what the problem is, but in my case I would look at primary care medical practice and they’re doing nothing and that was a tremendous stimulation, my gosh we’ve got to do something here and in a sense point out what the issue is and what the problem is and try to at least suggest solutions and then try to implement the solutions. I studied Primary care medical practice I think we finished in about 1995 in Moscow, Idaho just because they were willing to let us go in and we discovered that at that level at least there were more then half the entire clinical population had a sleep disorder, diagnosable, flagrant symptoms and not a single one had been identified by the physician. Well that was an enormous trigger to start trying to do something at this level and I think that it all starts by just kind of looking at what’s going on, what’s really going on as opposed to mythology and what people assume and identifying the problem and I guess caring enough to do something about it.
But you have always been my example in that regard I mean I can’t resist interjecting that.
Hamburg: I appreciate that. One important component of public education and sort of the development of an influential cadre of citizens who know about and care about the problem is what colleges and universities do. Now here you began what was certainly one of the first in depth sleep courses probably the first one and the interest in it has exceeded what I think anybody dared to expect. Am I right the student insisted when you became emeritus that you nevertheless continue the course?
Dement: Well, I didn’t actually retire but I did stop the course I said “ This is the last time I’ll give this course” and I guess word got around because of huge enrollment and I had well this isn’t really relevant to anything but there’s so many students registered that I had to give the course twice back to back and it was in an auditorium that held about 500 and I discovered that to do the exact same thing twice that way was boring, the second hour was horrendously boring so I moved to memorial auditorium which would hold the entire class which was about I don’t know 1200 or 1300 students and there was kind of a demand to bring it back and I actually had a couple letters from students who said the only reason hey came to Stanford was to take sleep and dreams and they discovered it wasn’t being given anymore and that kind of got me it’s like wow!
So I started it up again and it’s actually well first of all I think it’s very important to start at the most basic level you can in terms of educating people about important issues. I wish we could go to high schools, but we do have outreach programs from Stanford to local high schools and hopefully that will sort of catch on. I’m as I said committed now to exporting this sleep and dreams course to other colleges and universities and there may be 3 or 4 that have something like it but I have a textbook , all the lectures, all the images there may be a shift to internet and that way of teaching I don’t know but the classroom atmosphere is sort of important because you are interacting with students and there’s a humanity about it, but I do think that they learn that the mantra of the course is that drowsiness is red alert and if they remember nothing else they remember that once you have to make a conscious effort of will to stay attentive that’s red alert whether it’s in a car or operating a meat chopper or something and you back off and get out of harms way. I really think I’m striving to, they should remember this for the rest of their lives and then as much as possible spread the word and other components of their lives as they go through life.
I think that it’s happening and I think it can happen at a much broader level. I think the students respond to a commitment, a committed person.
Hamburg: It was a curious thing that many of the serious behavioral risk factors whether it be sleep and dreaming, whether it be in cardiovascular disease or other diseases are not much taught. They have been very slow to get it in the curriculum decades after the smoking evidence on lung cancer and heart disease and stroke was powerful only about 20% of the doctors asked their patients on first contact have you ever smoked, or do you smoke? And the teaching of it was very low for decades after we knew perfectly well that this was very damaging, people seem to be puzzled about how you could get people to change their behavior for health if you just plunge it into that a very straight forward rational way the more you understand the risk to yourself and others you care about the more your likely to do, so drowsiness is a red alert that’s a lifetime message.
Dement: Yeah, we have parents weekend every February so a student came to me, this is several years ago and said “My father preached about you in his church would you like to have a tape of his sermon?” I said “Yeah sure” He was talking about the early Christians and there was a parallel alternative community of early Christians living by the wisdom of their Savior and he said that at Stanford University there’s a parallel alternative community of students living by the higher wisdom of Dr. William Dement so that analogy is very hilarious it’s like okay I’ll accept that.
I think we really learn something about whether it be conflict resolution or feeling better it’s important to not lessen the living of your life you know when it takes, it takes and it can be permanent.
Hamburg: Now what do you think is the potential has there been some experience in the field of training for high risk individuals, lets say truck drivers. As I understand it correct me if I’m wrong there are very serious accidents that are often associated with a driver literally asleep at the wheel or almost asleep at the wheel.
Dement: Oh yeah, many many accidents. It’s a little hard after the fact to identify that, you know in the sense of someone goes off the road and is killed they say well we don’t know for sure, but what the National Transportation Safety Board now is incorporating is a specific protocol, where they look at a schedule that the driver has maintained for at least 3 days passed or whatever information they can actually have. If there’s any evidence that there was a sleep disorder and usually you can infer that drowsiness was a factor from this type of investigation and I think this is actually being incorporated, well first of all the National Transportation Board has a specific protocol dealing with sleep deprivation and sleep disorders and I think even the trucking companies are now beginning to investigate to look at their drivers with the point of view of do they snore, do they seem to have a sleep apnea or do they understand how to get enough sleep etc. and they look at the schedules also and there’s a kind of a tendency in the trucking industry at least, you’re paid by the mile to drive as much as you can but again as the risk goes up for a major accident you have to curtail that and that’s an issue of policy with the companies. I think a lot of times social change follows in the path of litigation you know a big law suit is probably the best way of getting everyone’s attention to an issue.
Hamburg: Now, so clearly public education has been a major component and a growing component and your public health approach to sleep disorders. I don’t want to keep you all day, but lets go back for a moment to the you began with basic research and then clinical research and then the question of continuing input of new research into medicine and then into public health, take example you mentioned the Narcolepsy you were the first physician to my knowledge to take an interest in Narcolepsy. Tell us that story about how it evolved through or up to finding the genetic mechanism that predisposes to it and what implications it might have for improving treatment and prevention, I don’t think that story is well known.
Dement: I often say I was at The Mount Sinai Hospital in New York, someone referred a patient, I had a sleep laboratory and the patient with the diagnosis of Narcolepsy was referred and I decided to do a sleep recording, and I always say within less then a minute I knew I had a major discovery because the patient did something that I mean how long had I been working 5 years at least and I’d never seen that which was to go from wakefulness immediately to REM sleep.
I had learned by that time that REM sleep was associated with motor paralysis, motoratonia except for the diaphragm and so I started beating the bushes for more patients with Narcolepsy and amazingly in the entire metropolitan New York, I had put an ad in the paper I think, talked to physicians, I finally got 9 patients I remember and I published a paper, but I was tremendously interested in so when you recruited me to Stanford University I immediately was looking for patients with Narcolepsy again there weren’t any. It was an amazing thing I put a little want ad in the San Francisco Chronicle describing the symptoms and I got about 100 phone calls, so we started studying these patients and confirmed that they had this REM sleep abnormality and that it could explain the weird what was then considered weird combination of symptoms of complete paralysis in response to strong emotion, a hypnologic hallucination where if you’d fall asleep you’d hallucinate and sleep paralysis which is where you’re in bed and you suddenly realize you’re paralyzed and then of course being sleepy all the time this could be explained.
We started a Narcolepsy Clinic and I was very energized by the fact that it was really helping people. I remember that it was 15 years for some of these patients from the onset of the illness to getting the diagnosis at Stanford. I mean 15 years of impairment and no treatment, then realizing their not just a very rare condition there were literally thousands. I think we feel now that there are at least 250,000 probably more in America.
Anyway, so I began to talk about this at every meeting I attended, The American Psychiatric Association, American Thoracic Society, American Academy of Family Practice. Anyway an amazing thing that happened I was at the American Academy of Neurology in Boston and I would show movies of these remarkable attacks of paralysis collectively called Cataplexy and someone came up to me and said “ You know I’m aware of a dog that sort of does this” and I said, “Oh that’s interesting” Anyway it turned out that the dog had been sacrificed because the veterinarian though it was epilepsy, they simply couldn’t control the attacks, so they had a movie so they sent me the movie and the dog would walk up to his food dish and become completely paralyzed. Now I would show this movie at every meeting I would go to and someone said they know someone in Saskatoon who has described a dog who does this. I got in touch with these people and asked is the dog could come to Stanford. It was a French poodle named Monique I tried to make arrangements to have this dog, this is amazing shipped to Stanford.
It was Western Airlines which I think is no longer with us and I remember they said no sick dogs on the airplanes I said the dog’s not really sick it has a neurological condition, but no sick dogs on the plane so I was stuck. I’m thinking what can I do it was during Nixon administration there was a gas shortage, I couldn’t drive to Canada and a light bulb went off that changed my life, I thought call your congressmen and it happened to be Pete McGlosky and I called his office and explained the situation and he said we’ll try to help you and I’d like to say that it was 15 minutes later the phone rang it could have been a day but the phone rang and it was the president of Western Airlines and said we’d like to help you. So they sent the dog down. That was the first time I realized that your elected representative really can make a difference and you should have a relationship and I’ve fostered that ever since with all the succeeding representatives here in this area and the Senators.
That was really what got me going in sort of lobbying the congress. I was absolutely certain that there was a neurological molecular abnormality even though at that time neuro-chemistry was at its infancy so we wanted to have a heritable form we were constantly inbreeding the dogs and finally developed a heritable form and found out that there’s a specific gene an autosomal-recessive gene and then I had to maintain this colony we couldn’t really do much. I was challenged over and over and over you are spending millions of dollars you know we were up to 80 dogs at one time and I kept saying I know this is going to be the answer so we began to be able to do some neuro-chemical studies and studied the spinal fluid and then finally as it began to be able to sequence the genome and I recruited a young scientist in 1986 to come here and sort of be in charge of whatever we could do with the dog colony and as molecular genetics began to flourish we began to sequence the genome and in these dogs isolated the Narcolepsy Gene.
It turned out to be a new peptide, this is amazing it was a new peptide that had been discovered I’m pretty sure in 1998 or 1997 called Hypocreatin the gene, the K-9 Narcolepsy gene expressed an abnormal Hypocreatin receptor this new neuro-peptide and that was it and all the animals had this abnormality so we began to look for it in humans and it was found very quickly that humans with Narcolepsy did not have Hypocreatin in their spinal fluid turns out the cell bodies are absent in brain bank materials then that is the cause of Narcolepsy; the failure for Hypocreatin cells to develop. Now why that happens is still not clear it’s still a frontier but interestingly enough now we have these dog colonies that we don’t need them anymore. I think I even went to the University Board of Trustees to be able to adopt out the dogs and give them to people to take care of them as opposed to sacrifice them, we now have one dog that we exhibit to students, it kind of comes out and when it gets excited it becomes paralyzed.
Hamburg: Well it’s intrinsically fascinating but it does show something that is an implication for our field and I should stop now but the ongoing interplay between your concern with some human suffering the disease, the disorder and underlying mechanisms it goes back and forth, each stimulates the other new discoveries that at basic levels stimulate inquiry into the clinical problem observations in clinical problems stimulate new basic research and the analogy is that as we go along and try to prevent mass violence that we really do need that kind of interplay of those who are on the firing line, diplomats, practitioners of various kinds working the problem. Epidemiologists who look at the risk factors of a population that has high casualties in it, but back and forth between the research on the underlying problem and the application of findings in that research to prevention, so I think it’s very interesting and it’s a dramatic and intrinsic story about what you’ve done with Narcolepsy, but it also is a stimulating direction for work in other fields that are related, but fundamentally you are trying to end human suffering and prevent premature deaths.
Dement: I have to add one more thing, I do think in the prevention of violence that you know everything should be considered at least from my point of view I think sleep loss is a factor you know if you are sleep deprived you are more irritable, you’re more likely to fly off the handle etc. and I think it might make a different.
This is completely off the point but I was thinking how could sleep disorders be important in global warming, well people would be using a quilt instead of turning the heater on. I think that I am not trying to extend this into society but in many of the issues that at least come to litigation you see that violence is frequently a product of some kind of sleep loss is involved, when people are sleep deprived they are more likely to fly off the handle and I certainly believe that now I don’t know if it’s actually a proven fact. Certainly when we study the impact of mood on laboratory subjects there’s no question that mood becomes negative with sleep loss, but how far that goes we really don’t know at this point. I always think that everyone should be aware of this factor.
Hamburg: I thank you very much indeed. It’s been a very stimulating interview and intrinsically valuable, but also full of implications for the field in which we are working on prevention of mass violence. I thank you very much.
Dement: You are very welcome.