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Miguel Reyes-Múgica

Chief of Pathology and Head of Laboratories, Children’s Hospital, Pittsburgh; Professor of Pathology and Marjory K. Harmer Chair in Pediatric Pathology, University of Pittsburgh

Miguel Reyes-Múgica grew up in relative privilege in a small town in Mexico, where both his parents were doctors. As a child he would accompany his father on visits to patients in rich and poor homes, and his experiences kindled in him a strong social conscience and a desire to follow in his parents’ footsteps. At medical school in Mexico City he fell under the spell of Dr Ruy Pérez-Tamayo, one of Latin America’s leading intellectuals. ‘He was professor of pathology, and when I took that course in my second year I immediately knew I was going to be a pathologist. I wanted to be just like him in many respects,’ he says.

Another big influence on his career was the earthquake of 1985 that levelled much of Mexico City and killed many of his colleagues. When the general hospital where he was about to start work was threatened with demolition, he went instead to the National Institute of Pediatrics, one of the largest and busiest paediatric hospitals in Latin America. It was a time when paediatric pathology was gaining recognition as a vital specialisation in its own right.

Reyes-Múgica went to the United States in 1990 for a year’s research, but for personal reasons never returned to work in Mexico. He went to Yale in 1994, where, as director of the programme in paediatric and developmental pathology, his personal focus was childhood tumours and melanocytic lesions (giant pigmented birthmarks with a potential to turn malignant) in children, the latter sparked by an extraordinary case he had seen in a baby in Mexico.

I was very close to my parents, and particularly to my father. He was more of a friend than a parent at times. He was a well-read man and, although not very religious, we would speak about life and death, and he helped me to discover my own path in medicine. At that time there were no structured programmes of specialisation in Mexico, so he was a generalist, but a very knowledgeable generalist who would take on any kind of case. My mother was more surgically oriented, so they complemented each other. Her hospital was at San Cristóbal de las Casas in Chiapas, where the Zapatista Revolution started in 1990. I grew up mostly in that small town, although I was born in Mexico City.

What sort of social environment was it?

There are many indigenous people there, and the relationship between the more Spanish-looking people and the indigenous natives has never been easy. But my mother and father would see patients from all strata, from the well-off to the very poor people – frequently, you know, payments were in the form of a chicken, a bag of eggs, fruits or things like that. My father labelled me a communist when I was about 11! I guess I developed a little social conscience when I saw the differences in the standards of living.

I was expelled from my high school for rebelling when I was 15, and my father put me to work with his parents, who ran some butcheries in the local market. I used to go with my grandfather to buy cattle, and we would slaughter them, and then we would do a complete post-mortem. So my first contact with cutting and looking at flesh really was there.

You say ‘post-mortem’, but, I mean, butchery is a lot different, surely?

Oh, a post-mortem in a human, an ‘autopsy’, is absolutely different from butchery. But it was an animal: it was muscle, it was viscera, it was handling a knife, it was knowing the different types of tissues from a macroscopic, naked eye, perspective, and recognising when something is not how you expect it to be. I recognise that experience as a very important influence on my personal development in pathology, and I can tell you that when I cut an organ, not only in autopsy but also in surgical pathology – which, by the way, is what we do most of the time; we are not ‘death doctors’ – the residents usually express surprise at the way I handle the knife.

And then you tell them, ‘Well, I learnt on cattle’!

Yes, exactly. Even though I am a paediatric pathologist and usually handle smaller organs, I use a longer knife, and I can cut very thin slices without injuring myself. I am a very neat pathologist.

So how did you not end up becoming a master butcher?!

Well, I had to go back to school. So my father and I made a deal and I went to a military school in Mexico City, where I spent a year fighting my way out of little troubles every day. After a year I left and went to a more normal high school, and then I entered medical school. But I learnt discipline in the military school, and it was a useful exercise. For a youngster from a relatively privileged family it was a good moment to realise that things can get really tough, and if you want to make it you really need self-discipline.

Because things happened very fast in my life. First I got married, aged 18, and the same day that my first daughter was born I was accepted at medical school – in the largest university on earth, which is the National Autonomous University of Mexico. The first day of class was interesting: I was the only one with family responsibilities. I was very fortunate because I had four or five wonderful classmates, all of them very intelligent, and I became part of this group that would get together to study. I had much less time than they did, because I had to earn a living as well. The first year of medical school I was assistant to a producer of a TV programme on cultural matters, so I had to read a lot in addition to reading my medical school books. It was fun, it was a lot of work, but when you are young you can afford not to sleep much!

But television started to take second place pretty fast. After the first year I realised I had to concentrate on medicine, so I looked for a position in the medical school as an assistant. They opened a competition for people that had finished some first-year courses to start teaching those courses to the following class. So I took the competition and I won two places. The competition was very tough because my class was tremendously big, about 5,000 students. They selected the best 100 students and, out of those, six won positions to teach – and that’s when I discovered histology.

The first histologist was a Frenchman, François Bichat, in the 1700s. He never used a microscope, but he described 20 different kinds of tissue just with his naked eye. He was the ‘father of histology’. When I started looking down the microscope, I discovered a different universe. Those years were very important in my life, because I had such a need to make money, to concentrate on my career, and I discovered that teaching something that was part of my own academic learning was the best combination possible. In the mornings I would teach histology, and in the afternoons learn my own subjects in medical school.

Then I discovered several mentors, but one of them, Dr Ruy Pérez-Tamayo, is the most important person in my academic life. He was professor of pathology, and when I took that course in my second year I immediately knew I was going to be a pathologist. I wanted to be just like him in many respects. He’s now in his eighties. He has shaped the discipline of pathology in Latin America, but he has also made tremendous contributions to pathology worldwide.

You say that when you first looked down a microscope it was a different universe – what was the thrill?

Well, the first time our lecturer told us, ‘Look at these cells on the screen’ – they used to project these slides – I couldn’t really understand it: what were cells, what were nuclei? So it was a challenge, and I like to be challenged: there were a whole lot of things I wanted to know. But then I discovered I had some ability to distinguish things under the microscope, and I liked that. It gives you immediate gratification to be able to diagnose something under the microscope, be it normal as in histology, or abnormal as in pathology. Pathology is just ordinary life in abnormal conditions, right? So when you know your ‘normal’, you are able to recognise when something is not normal, therefore pathological. And microscopy is magnificently beautiful! I still now can spend more time than I should just looking at something under the microscope because of the beauty of it.

So Dr Pérez-Tamayo was your mentor at that time? And did he take you under his wing?

Well, I took his course and he was aware of my presence relatively fast because I asked questions and things. Every year he would select one student to go and visit his lab, and that year he invited me. This was a completely different universe again. Here it was not a matter of looking down the microscope; it was doing all kinds of strange things that scientists do in labs. He was an expert on collagen, which is the most abundant protein in our bodies. I started working with his group on extracting collagen, and trying to identify an enzyme that would degrade the protein in order to explore the biology of certain diseases such as liver cirrhosis.

I spent about 18 months learning electrophoresis, protein extraction and things like that. And in the process I learnt many other little lessons in science – experimental design, and to be sceptical, never to believe the first time you see something.

So did you decide then that the academic side of things was more beguiling to you than actually seeing patients?

Well, yes, but I never gave up my intention of seeing patients, because when I started with my father I discovered I had some ability to relate to patients and their families, and I liked that experience. Even now I sometimes go to the wards and look at patients myself when I have specific questions to answer. Pathology is not only research; it’s not only looking at microscopes and glass slides. I never forget that behind everything we do there is a patient. So I am a doctor: I consider myself a physician with a particular subspeciality.

After working with Dr Pérez-Tamayo, how did your career develop?

I continued my medical school studies. I finished the four years of basic learning and then I did one year of practice, the internship, and then one year of social service. This is when you pay back society that has been generous enough to provide you with a free medical education. I worked at the National Institute of Pediatrics in Mexico City, and because it was one of the largest and busiest paediatric hospitals in the whole of Latin America, I rapidly began to develop some knowledge of pathology, in particular paediatric pathology. After my social service year I started my residence in pathology, and the director of the programme was again Dr Pérez-Tamayo, so I went back to him. I eventually went to the General Hospital of Mexico, the largest in my country, where I finished my specialist training.

Then there was another significant event in my life, in all our lives: the big earthquake in Mexico City in 1985. I lost seven of the residents in my department, including my room-mate, in that earthquake. Together with other people, I pulled him from the rubble of the collapsed building. Forty-nine residents just in my hospital were dead … Many people died.

Where were you when it happened?

It happened at 7.19 a.m. on 19 September 1985. I was kissing my small son, and we both fell to the ground with the first shake. Mexico is an area with high earthquake activity, and I have many memories of my father sitting on the bed looking at his watch and counting the seconds, and my mother praying. I’d had that experience many times, and I was never very scared. But I was a little surprised that this one was so strong.

I was living with my three children at the time – I had separated from my wife, and I kept my children; I raised them. So I asked the nanny to take my son to kindergarten, and I took my two daughters to school. I could see people running along the streets, but I didn’t see collapsed buildings – until I got to my hospital. Then I began to realise the magnitude of the problem. Two buildings within my hospital collapsed – one was the building where residents lived, the other was the gynaecology/obstetrics building where the nursery was. There were 302 people killed in my hospital alone. The official death toll varied tremendously, but probably about 20,000 people died in that earthquake.

The army took over the hospital and the city in general, and we organised groups to identify people pulled from the rubble, and tried to help the injured. We would spend hours trying to remove rocks and material. There would be 50 or 60 people working in an area, and someone would suddenly yell, ‘Hey, silence!’ and you would hear someone asking for help. There were people, including newborn babies, pulled out several days later still alive. It was a terrifying experience.

What effect did the earthquake have on you?

It changed my life in many ways. First of all I am terrified of earthquakes now; I learnt my lesson. Secondly I switched my decisions. I was going to be chief resident in the General Hospital of Mexico that year. But after the earthquake there was talk about closing the hospital because of the damage. I switched and took a job in the National Institute of Pediatrics [NIP], where I’d done my social service. And instead of being a chief resident for a year, I began, in 1986, as a fully fledged junior staff pathologist in a very big hospital.

What sort of cases were you seeing?

NIP was a tertiary level centre with the ability to perform renal transplants and cardiac surgery and stuff. But also we had a very large caseload of run-of-the-mill infections, and the pathology of poverty – malnutrition, tremendously advanced cancers, all kinds of things. It’s a hospital that covers the full spectrum of human pathology, from zero to 18 years of age, so I was exposed to a massive amount of paediatric human pathology in the four years that I spent there.

How did you manage the two things – your career and bringing up a family?

Well, my ex-wife had some psychological problems. We decided to split and I kept my three children. I was in the second year of my residency training when the divorce happened, so it was tough. Usually I would take the children to school in the morning, and I would take an hour off to eat with them around 2 p.m. At 3.15 p.m. I would run back to the hospital and continue my activities, and then in the evening I would go back to the university to teach. So it was crazy: I didn’t have much time to be with my children, so I had to spend what is now called ‘quality time’ with them. And eating is an opportunity to exchange a lot of things; it’s a very important time of the day, and an educational experience for children.

And did you remain close to them?

Oh yes; they lived with me until they all left home. They are married now, and I have one granddaughter.

When I divorced I met my second wife, who was a medical student. It was tough, because she came from a very conservative family that wanted her to marry someone without a lot of baggage, and I had three children, but she finally married me. After four years together in Mexico we decided to try to come for one year to the United States.

I went to speak with Dr Pérez-Tamayo and he mentioned González-Crussí, who was a huge figure for me. He was a fantastic paediatric pathologist, a famous Mexican, and he had written Notes of an Anatomist. So it couldn’t get better. Dr Pérez-Tamayo wrote a letter and a week later I got a phone call from Dr González-Crussí inviting me to visit Chicago. He said, ‘If Dr Pérez-Tamayo recommends you, you’re accepted’!

Your intention was to come and do some learning here and then go back home?

Absolutely. I never even took the United States Medical Licensing Examinations [USMLE], so I wasn’t officially allowed to take part in any medical procedure because I had no credentials. I was a research associate doing projects, and I was just learning pathology on the side with Dr González-Crussí and his team. But then things got complicated with my ex-wife and it was very difficult. I sent my children on vacation to Mexico and they were kept there against their will. Finally I recovered my children in a complicated transaction that took all my little savings. My wife was pregnant at that time, and we decided to stay in the United States and cut our ties with Mexico at that moment.

Dr González-Crussí told me, ‘If you can take the USMLE, get your credentials in time to be appointed fellow, I will keep the position for you.’ I got my licence just a week before the deadline and I stayed on in Chicago as his fellow in paediatric pathology.

This was already my fourth year in Chicago, and then I saw that Yale University was looking for a paediatric pathologist. That was in 1994, and I was there for fourteen years.

Tell me about your time with González-Crussí. You had started reading his essays before you met him, had you?

I have read every book he has published to date. Dr González-Crussí is a vastly cultured man. He speaks many languages. But my first impression was that he was a fantastic pathologist. Pathology is a difficult trade; you need to be special in certain ways. It’s like, to do basketball you need to be tall. Well, to be a good pathologist there has to be something in your brain that allows you to orient yourself in the visual, spatial field, and he had a particular talent with that. But also massive medical information – he knew everything, and I was very impressed with that. Then I started reading his contributions to medical literature, and saw that he was able to jump from one topic to another in paediatric pathology, always as if he was an expert in that particular topic.

In his writings Dr González-Crussí has considered death a great deal. What are your own thoughts about death and dying?

I’m not a religious person, so I have tried to look at the process of death from the most scientific angle. But even so I recognise there are certain things completely beyond our scientific understanding. And I have had my own personal experiences – I don’t make too much of them, but others perhaps could.

I was called to do an autopsy on a baby who had a disease that required very rapid intervention in order to make the diagnosis, and to provide genetic counselling to the family. The only option was to go immediately after her death into her heart and take some parts for examination. The clinician called me before the baby died, asking, ‘Would you be available if she dies in the night?’ He called me later and said, ‘We’re going to interrupt artificial life support in half an hour, okay?’ So I drove over in the night, and they came with the baby a few minutes after she died.

When you die, cells are still viable in many organs, and when you stimulate certain tissues that are contractile they can develop mechanical activity. And what happened was that I was doing the autopsy with the head of the paediatric intensive care unit at my side, and when we got to the heart it started moving. The baby was dead, but the heart was sort of beating … Not really, but in a disorganised fashion there was a beat. I felt at that moment like an Aztec prince taking out the heart of a human sacrifice, if you will. And I wondered at that moment, ‘What am I doing here, opening the heart of this little baby?’ Of course, that was just for a flash second, and I understood that what I was doing was very important. The diagnosis was made, and the family now knows what type of disease they might carry, and understands what to do. It was a very valuable autopsy. But the experience was very chilling.

Is it something that has lived with you?

It has. It has. You wonder … In many autopsy rooms there is a statement in Latin that says something like, ‘This is a morgue, the place where death helps those that are still alive.’ And that’s exactly what came to my mind – the contribution this baby was making to her family and to humankind was huge. So I see autopsy as the most exhaustive, and final, medical exam that a doctor can provide for a patient. I don’t see autopsy as something horrendous and macabre.

But it was just too close to the event of death – was that what got through your professional defences?

It was too different. When you do an autopsy, usually the body has been in the refrigerator for several hours, it’s cold, it has changed colour and there are many familiar things. But with this little kid I saw something different. She was dressed as a baby. She was pink and warm. It is very difficult to open a body like that – and just very different.

People can lose track of what life is all about. Frequently I see a case where the clinicians have spent weeks, or sometimes months, treating a patient. They know all the parameters – respiratory, cardiac, etc. – and they follow those and watch the curve of progress up, or down. Then finally, when the patient dies, they come to me and say, ‘What happened? We don’t understand how this patient died.’ And my answer on several occasions has been, ‘Well, I can’t understand how this patient lived.’

Our practice of medicine nowadays is so fragmented into different specialities and little tasks that we as doctors lose track of the patient. So they come and say to me, ‘But this patient was doing fine. The blood pressure was this and that, the urine was so …’ But when I just show them the heart, the lungs, the whole thing … I mean, you can no longer recognise the human body. The baby weighs two or three times the normal weight because it has been inundated with fluids. It has seven or eight catheters in different places. It has been operated on three times… What I’m trying to say is that medicine is now a practice in which lots of specialists lose track of the big picture, and frequently it is only the pathologist that can try to bring all the loose ends together.

There are situations in which specialists put too much trust in their results. They are not sceptical enough, and they make mistakes. A memorable occasion was when a genetics counsellor stormed into my office very upset because I had issued a report saying, ‘Fetus without significant abnormalities’ after an autopsy was performed. She said, ‘What do you mean? We saw polydactyly in the ultrasound; that’s why we interrupted the pregnancy.’ Polydactyly is more fingers or toes than five. To interrupt a pregnancy on the basis of polydactyly may or may not be justified, but that’s not the issue. The issue is that I knew the specialist was going to challenge my findings, so when I performed the autopsy I put both hands on a glass slide – they were so small that they could fit into this little space – and you could see five fingers on each hand. So I didn’t open my mouth; I just took the slide and gave it to her in response to her question.

The point is that with ultrasound – as much as it is very advanced and you can trust a lot of the results – you should never lose track of the fact that those are virtual images, and pathology has real images. This is where things stop: there is no more accurate and real exam than a pathological exam.

Do you feel people are relying too much on technology, almost in order to cheat death?

I recognise that if we do not apply our marvellous technology to these very sick patients, we would not be making the progress that we are making. There are voices that argue very strongly against the application of advanced technology to sustain life, to treat certain conditions in childhood or adulthood. I disagree with that because, as you know, our quality of life is much better now than it was just 20 years ago. And 50, 80 or 100 years ago, when there were no antibiotics and no anaesthesia and things like that, if the doctors of the time had not applied all their efforts to pursuing a particular question, we would never have got to this point. So I think that although the end does not justify the means, we should have the curiosity and the will to apply this marvellous knowledge. But we should do it in a respectful way.

Tell me a bit about your own research.

Well, I have been interested in a particular group of disorders that involves the development of the neural crest. The neural crests are transitory structures of the embryo that are the excess tips of the closing borders of the neural tube. The neural tube gives rise to the brain and to the spinal cord. But as the neural tube closes – because it first begins as a groove – the excess tissue remains there instead of disappearing, and it migrates to different parts of our bodies through a very complex process.

Neural crest disorders are of different types. There are neural crest diseases that are cancer-like, or cancer. And there are neural crest disorders that are the result of an abnormal migration or survival of the cells. The bowel, for example, has a brain of its own. The peristaltic movement of the bowel is coordinated essentially by this brain in the gut, and this nervous tissue, which has many millions of neurons inside, requires for its development the migration of the neural crest into the bowel, and the proper development and survival of the cells in a coordinated fashion. If you look at it under the microscope, it looks like a little piece of brain sandwiched between layers of other tissue in the bowel.

That’s amazing! And is there a lot of it?

Yes. It continues from the oesophagus all the way down to the exit. And the proper development of this gut brain is necessary for our bowels to move. There is a childhood condition called Hirschsprung’s disease, in which babies, usually, are unable to move their bowel, and become distended. And they can explode, literally, with a colon like an anaconda. Just imagine what it is like not to be able to move your bowel for five, six days. There is no peristalsis, because there is an area that is lacking these neurons in the bowel.

The disease was described in 1888. It was poorly understood for the first 50 years and then it began to be unravelled by a surgeon at Boston Children’s Hospital. For the first 50 years the surgery performed on these patients was wrong – they removed a normal piece of bowel and left the abnormal piece because it looks deceptively normal. But then we began to understand that, and the biology of this disease has been unpicked over the last 15 years. I have been more active in determining how to diagnose this disorder than in trying to understand the genetic basis, because for paediatric pathologists this is a serious daily problem. Frequently a biopsy comes to your table that says, ‘Please rule out Hirschsprung’s disease,’ and it is very difficult to make the diagnosis, because it is based on the absence of neurons, and absence of proof doesn’t mean proof of absence.

And is this a common condition?

It occurs in about one in 5,000. But the thing that I am more interested in is a little more uncommon. It’s called neurocutaneous melanocytosis. This is a disorder of neural crest cells that produce melanin – so-called melanocytes. All the pigment in our skin, melanin, is produced by these cells, which all come from the neural crest – with the exception of those that are in the eye. Every other melanocyte in our bodies – including those in the brain – comes from the neural crest. There are babies born with abnormalities in the population of melanocytes, and they develop this condition, neurocutaneous melanocytosis, where they have extensive areas of their bodies covered by moles, or ‘naevi’. These darkly pigmented areas can cover portions so extensive that they are sometimes called ‘bathing trunk naevi’. Or they look like Dalmatians – hundreds, thousands, of little satellite lesions here and there. And the problem with those situations is that not only is the skin abnormal, but the deeper tissues are also abnormal and can develop malignant tumours, melanomas, inside those naevi. Frequently they develop a naevus inside the brain, and that can interfere with the development of other structures. They have seizures, they have hydrocephalus – dilatation of the ventricles of the brain – and frequently they die. The condition is relatively rare, though I can’t give you an exact figure. One in 20,000 newborns will have a giant naevus, and some of those will be neurocutaneous melanocytosis.

But just over 10 years ago, I came in contact with a newly developing support group of parents. They had each had a child born with a giant naevus, and the doctors had freaked out and said, ‘I’ve never seen this. I don’t know what it is.’ Or, ‘It’s a melanoma; let’s treat it like this …’ There was very little knowledge. So parents created this family support group. All of the members are either parents of children with these lesions, or they are patients themselves, because many people have survived 20, 50, 60 years suffering with this situation, and they are ‘freaks’. Sometimes people can hide it. But other times, half your face may be black with a tremendously disfiguring lesion.

So that is where I concentrate most of my research efforts. I was doing that with my late wife – she passed away five years ago.

What are you discovering?

First of all that this is much more frequent than we used to think. People are now aware of this group and are coming forward and saying, ‘I have one of those. I was born with this naevus.’ We are also discovering that it’s a very complex disorder in terms of genetics. We know of no twins, for example, that have this problem, so there is not an inherited basis. It does not repeat in families. There is nothing the mother did during the pregnancy that would represent a particular risk.

So we are first eliminating a number of things. We are sure that these are real clonal lesions – by which I mean lesions that arise from a single cell that starts to reproduce and forms a clone. But we need to gather a lot more samples and make a very organised effort in our research. And when you don’t have such a massive number of patients, it’s very difficult to gather data and get researchers interested.

What made you particularly interested in this condition?

Well, when I was a pathologist in Mexico there was a baby that came to the department of oncology, and it immediately became the ‘patient of the month’ – everybody was talking about it. The baby was born with something in the genital area that was very striking – they couldn’t even tell if the baby was a boy or a girl. They thought it might be a tumour that would kill the baby rapidly, so they took a biopsy. What I saw was something very strange: it reminded me of what is described in congenital naevi, and at the same time it had features of nervous tissue.

Nervous tissue? From where?

From the neural crest. Melanocytes, in my opinion, are really modified neurons. They are cells that become specialists in synthesising pigment, but they have these dendrites, these prolongations – they are like an octopus, literally. They have cytoplasm that is the body of the octopus and they have all these ‘tentacles’ that carry the melanin and transfer it to surrounding cells.

I never stopped thinking about that case. When I moved to Chicago I told Dr González-Crussí about it and he said, in his classic reflective way, ‘Very interesting … I have never seen a case like that.’ Then a couple of months later he called me up for a frozen section analysis. They were operating on a patient with a melon-sized tumour in the perineal area that was surrounded by a patch of hyper-pigmentation, like a naevus, and I remember his voice on the phone: ‘Miguel, you remember the case you told me about from Mexico a few years ago? I think we have something very similar.’ Sure enough, it was identical under the microscope. So we decided to publish those two patient cases together, in the oldest pathology journal, Virchow’s Archive. From that point on I was hooked into the biology of melanocytic development.

Dr González-Crussí was telling me that paediatric pathology, as a specialism, is relatively new. Were you aware of that when you came into this field?

Yes, I was aware. I remember that when I went to Yale, some of my colleagues were wondering, ‘Why do we need this guy? We can do the paediatric cases.’ It was a fantastic department at the time, and people were very well trained and experienced in many fields – but paediatric pathology is completely different from adult pathology. Under a microscope, tissue from a child that is one day old is different from the tissue of a child that is one month old, and that’s different from tissue of a one-year-old, and that’s different from the tissue of an 18-year-old. In paediatrics the key is development. When you take a case to an adult pathologist, the questions he or she will ask when looking at a slide, of a tumour, for example, are essentially, ‘Where is the lesion? How fast did it grow? How big is it?’ The first question a paediatric pathologist will ask is, ‘How old is the patient?’

So yes, when I came to paediatric pathology, I think people had started to recognise the need. There had been paediatric pathologists, pioneers, but as a speciality it became more recognised around 25 years ago.

Tell me, how important is your profession to you on a personal level?

Well, pathology is a very important part of my life, but it’s not the only one – and it’s probably not the most important one. A friend of mine, another doctor who was with me in Chicago, said something that has remained with me. He said, ‘You know, before I see you as a doctor, as a pathologist, I see you as a parent.’ And I think that is what defines me: I am a father. Three of my four children live close by, my youngest lives with me, and we all get together every other week. We drink a bottle of wine; we cook and have fun. We speak about matters, we travel together.

That brings me to one final question: you didn’t go back to Mexico?

I couldn’t. The rupture with my ex-wife was so difficult that when my children were kept against the law for a few days in Mexico, I realised I had to keep a distance, for their health and for their education. So even though my original plan was to be a pathologist in Mexico after some speciality training here, I couldn’t. I remained here and tried to make the best of it, but I have tried to give something back to Mexico, and to Latin America.