AVROY FANAROFF

Neonatal physician and educator
Avroy Fanaroff is internationally recognised as a master neonatal physician and an exceptional educator. He is a pioneer and leader in the field of neonatology. He has helped to transform this new subspeciality from a primitive anecdotal based field, characterised by benign neglect and disastrous interventions, into a scientific, sound, evidence-based branch of paediatrics and obstetrics. During his career through the application of newer therapies and improved specially designed equipment, neonatal mortality has declined substantially and the borders of viablity shifted from 28 weeks gestation to 23 to 24 weeks. He is currently an Emeritus Professor of Pediatrics at Case Western Reserve University School of Medicine in Cleveland, Ohio.

Avroy writes: ‘No one can know what it is like to have a critically ill new-born in an intensive care unit, without experiencing it directly. In an ironic twist of fate for me, being a Neonatologist, our son Jonathan and his own son Mason were patients in the Neonatal Intensive Care Unit (NICU). Jonathan had meconium aspiration syndrome and Mason respiratory distress syndrome. We had been in Cleveland just over a month when Jonathan was born, had no friends or support system, and he was critically ill. Fortunately, he recovered fully, has a JD (Dr of Law) and MD. He is a Neonatologist, Professor of Pediatrics and has been head of Bioethics at the hospital. I believe that having had a child in the Neonatal Intensive Care Unit, has made both of us better doctors.’ 
 
Early life and training

Avroy Arnold Fanaroff (seen in this portrait aged 11) was born in Bloemfontein in May 1938 and educated at Yeoville Boys Primary School, and then King Edward VII High School in Johannesburg, where he matriculated in 1954.

Avroy says, ‘Like Len Kahn, I played soccer in primary school. Yeoville Boys won the Under 11 Championship after an undefeated season. I played and very much enjoyed Rugby in High School where Tennis was not offered.
‘I started playing bridge at Medical School with the likes of Arthur Vinik and David Klugman, who were provincial and national players. Theo Kretzmar and Mike Plit were my bridge partners. Then I did not play for forty years until my wife Ros took up the game. I now very much enjoy social and duplicate bridge.’


After graduation in 1960, Avroy did house jobs at the Johannesburg General Hospital and then commenced his paediatric training at Addington Hospital in Durban followed by the Transvaal Memorial Hospital for Children (TMH) in Johannesburg and Baragwanath Hospital in Soweto.(see  Newsletter #2 – Baragwanath for Avroy’s and Jeff Maisels’ memories of their Bara experience). He chose paediatrics believing that if a child was cured, their whole life was ahead of them, and neonatology because as so little was known about it and the mortality for premature babies was so high, he felt he could make a difference.

After training in South Africa, he went to London and studied further at St Mary’s Hospital Paddington, and the Middlesex Hospital, in London. He became a Member of Royal College of Physicians (Edinburgh) in 1964 and subsequently a Fellow of the Royal College of Paediatrics and Child Health (London) in 1998.

Avroy who had married Roslyn Drusinsky in 1968, then moved to Cleveland, Ohio in 1969, to take up a Fellowship in Neonatal Perinatal Medicine under the mentorship of the late Dr Marshall Klaus.

Mentorship of Marshall Klaus
He says: ‘Ros and I thought we were coming to Cleveland for a one-year fellowship. Fifty-two years later we are still happy to be here. My mentor, Marshall Klaus can take a lot of credit for that. He was not afraid to think outside the box. Initially a respiratory physiologist, who described the lipid structure of surfactant, he pioneered the studies in maternal-infant interactions and family centered care. He opened the delivery suites and intensive care units to fathers and families and made “bonding” a household word. He instilled in me the concepts of evidence-based medicine, as opposed to anecdotal medicine, before that term had become popular, and how to be a more caring physician. He also changed my mindset and behavior to trainees, from the British master-servant to one of collegiality. He made me more inquisitive and prompted me to ask the right questions.’



Above: John Kennell, Avroy Fanaroff, Marshall Klaus

After a two-year fellowship, including a Ford Foundation Fellowship, Avroy joined the Faculty at Rainbow Babies and Children’s Hospital (RB&CH) and Case Western Reserve University and subsequently became a tenured Professor of Pediatrics and Reproductive Biology.

Avroy served for over 20 years as Director of Neonatology at RB&CH, commencing in 1975. He built the unit into a nationally recognised centre of excellence, constantly ranked in the top five nationally in US News and World Report. He was appointed to the Eliza Henry Barnes Chair of Neonatology and as Department Chair from 2003 to 2008 (the Gertrude Lee Chandler Chair of Pediatrics).

Avroy says: ‘Tennis was the key to us integrating into the Cleveland community. It was how we met people outside the hospital. I also played league squash. Golf was an adventure we undertook for our 25th anniversary and we have been struggling with it ever since. I had the distinction of losing my flight in the finals four years in a row, twice needing extra-holes’. 


Work on extremely low weight infants
Fanaroff’s scholarly pursuits and research have been devoted primarily to the diagnosis, treatment, and outcomes of critically ill neonates. His research encompassed respiratory disorders and included the first randomised trial of Continuous Positive Airway Pressure (CPAP) and the development of the nasal prongs to administer CPAP and the prevention of oxygen toxicity. He was the first to report the large insensible water loss in very low birth weight infants unrelated to their metabolic rates and published on the vulnerability of hospitalised neonates if their parents did not visit frequently. He was one of the first investigators to define the epidemiology of necrotising entero-colitis, the major gastro-intestinal disorder in neonates and a leading cause of mortality. He also studied infectious diseases in the newborn and helped to define the importance of fungal infections in preterm infants as well as the clinical features of sepsis in low birth weight infants.

He has also participated in studies on the use of exhaled carbon monoxide to estimate bilirubin production and tine mesoporphyrin to inhibit heme oxygenase and prevent bilirubin production. Together with his colleague the late Maureen Hack, a neonatal specialist who graduated from the University of Pretoria in 1959, they systematically documented the changes in survival, and short and long term outcomes of very low birth weight infants, and followed many of these babies to adulthood.They reported increasing survival without an increase in long term morbidity. Indeed in 1970 the mortality for an infant weighing one kilogram (2 pounds four ounces) was ninety percent and today the survival is ninety five percent for these infants. The borders of viability have been extended so that babies born fifteen weeks early have a sixty percent survival of whom around forty percent will show some neuro-developmental impairment. The results continue to improve and the rates of cerebral palsy, blindness and deafness have all fallen for this vulnerable group.

Authored and Edited

Fanaroff has authored and edited three leading texts in neonatology: Klaus and Fanaroff’s Care of the High Risk Neonate now in the 7th edition and edited with his son Jonathan Fanaroff. The picture on the cover of this book (right) is Jonathan’s daughter Brooke.
Martin, Fanaroff and Walsh’s Neonatal Perinatal Medicine with Richard Martin MD, Avroy Fanaroff MD and Michelle Walsh MD, now in the 11th edition and Lissauer, Miall Avroy and Jonathan Fanaroff’s Neonatology at a Glance with Tom Lissauer MD, now in its 4th editions. These books have been translated into many languages including Spanish, French, German, Portuguese, and Japanese.



Here above we see son and father, Jonathan and Avroy working together – another example of a son following directly in his father’s footsteps (see Aubrey Milunsky and son Jeff).

Avroy has also written or co-written over 300 papers which have been published in peer reviewed journals. He also served as the senior editor of the Yearbook of Neonatal-Perinatal Medicine for 30 years, writing commentaries on 60 to 100 articles annually.

He was a founding member in 1987, of the Eunice Shriver National Institute of Child Health and Human Development, Neonatal Research Network. He has participated in all the major interventional trials in the Network and was the Principal Investigator of the first Network trial documenting that intravenous immunoglobulin was not effective in preventing nosocomial hospital acquired infection.

 
Executive positions
He served a six-year term on the Board of University Hospitals Health System and was on the Executive Committee of the American Board of Pediatrics as well as Chair of the sub-board of Neonatal Perinatal Medicine. He served as Of Counsel ( an advisory position to the chair of the executive) to the American Academy of Pediatrics Neonatal Perinatal Executive Committee from 2000 to 2012 and was Chair of the Organization of Neonatal Training Program Directors. He served on an international task force to expand screening for critical congenital cyanotic disease in Europe and is currently the Executive Director of the International Neonatal Association.



Pictured above we see Avroy (left) in 2007 when his friend and colleague Jeff Maisels (right) also won the Virginia Apgar award.

Avroy Fanaroff has received many awards throughout his career. He received the American Academy of Pediatrics (AAP) Professional Education Award in 1996 and the Perinatal Section Education Award in 1999 which was renamed the ‘Avroy Fanaroff Neonatal Education Award’. In 2002 he received the prestigious Virginia Apgar Award for lifetime achievements in Neonatology.

Avroy was inducted into the Cleveland Magazine ‘Medical Hall of Fame’ in 2003. In 2005 he received an Honorary Fellowship of the Royal College of Paediatricians and Child Health, in London and was named a Legend in Neonatology in 2006. He received the Founders Award from the Mid-West Society for Pediatric Research in 2009. He was named amongst the best doctors in his field annually from 1994 through to his retirement in 2012.

Avroy was recognised with two honorary MDs: one in 2004 from his old Alma Mater, Wits University, and the other, in 2006, from the University of Turku, Finland.

Avroy writes: ‘One of the most remarkable aspects of my career was receiving an honorary MD from the University of Turku, Finland. There are three aspects to the degree, a custom-made Abe Lincoln Medical Hat with a Medical badge in the Front, the Diploma and an engraved sword, formally sharpened the night before graduation. The degree recipients all wear tuxedos with vests and white gloves and their accompanying persons have to be in formal dress. After the degree ceremony, all graduates march, swords sheathed, to the cathedral, where swords are checked, and the recital and blessings take place. All unique and inspiring. To call the banquet that night, lively, would be an understatement.’

Avroy has also been given the Physicians Recognition Award at University Hospitals, the Saltzman Award for civic leadership and the Maimonides award for outstanding leadership and devoted participation in medical service.

He has lectured in many parts of the globe where, through his writing and speaking he has influenced the quality of care. Many physicians, have reported that Avroy’s book, has served as a companion and guide to them when they are on call in the Intensive care unit.

Family
Avroy has been married to Roslyn nee Drusinsky since 1968. They have three children and seven grandchildren, ranging in age from 23 years to 20 months.

He writes: ‘It is difficult to paint a picture of your wife, soulmate and best friend in a paragraph but here is my attempt.  My wife Roslyn (Ros) is the rock of the family. She was educated at King David High School and then obtained a degree in teaching from Wits. We had two children within eleven months of emigrating to the United States, so that ended her teaching career. Once the children were at school she served as an art consultant helping people decorate their homes and offices. She has been actively involved with the Cleveland Museum of Art, the Contemporary Art Society and Women’s Council of Jewish Federation as well as the Children’s Hospital Art Council.



‘She loves to read, exercise, swim, play tennis and golf and is indefatigable. She is a wonderful friend to many, the life of a party and wherever she is, people will be laughing and having fun. She loves to travel, has a ‘PhD’ in shopping so her appearance is always immaculate. She has taken up bridge seriously now. Our eldest grandchild called her “Mena”’ and that has stuck for all the grandkids, who adore her, as do!’ 

Our family
‘Our son Jon is married to Kristy, a neonatal nurse practitioner, with incredible technical skills. She literally threads intra-venous catheters into vessels the size of a hair. Their children are Mason 7, Cole 4, and Brooke 20 months. Covid-19 has deprived us of hugging them.

‘Our daughter Jodi has a degree in Graphic Design from the University of Michigan and then a master’s in Art Therapy. Her husband, Peter, another Michigan undergraduate, has a law degree from American University and their daughter Morgan is a junior in the art school at ‘Michigan. Austin, their son has just graduated, virtually, from New York University, Stern College, with a business degree.
‘Amanda our youngest has a law degree from Northwestern University. Her husband, who is a corporate litigator went to Chicago Kent Law School. Amanda has always been adventurous, and an outdoor trail leader, but when I learned that she had been ice-climbing in Alaska, while living in a remote Native American village, building a school playground  there, I was inclined to check her genes, as I have a terrible fear of heights. They are blessed with a scholarly son, Jackson, and a smart athletic daughter, Raya, who was doing circus classes when the Pandemic hit.’


International Collegium and other hobbies
‘Since 1971, Ros and I have been part of an International Collegium which meets bi-annually, alternating between North America and Europe. The quality of the scientific program is very high, but the highlight of the meeting is the ability to exchange ideas and friendships with so many international colleagues and to visit the wonderful sites in so many countries. The Leonardo DaVinci museum in France and the Nobel museum in Stockholm come rapidly to mind, as do the Canadian Rockies and glaciers. Collaborative research and a journal comprising the best manuscripts are an additional feature.

‘Photography is another hobby. For a number of years we had a greenhouse, but with a lot of travel and a harsh climate, keeping the plants including orchids safe, became a burden so we gave up that hobby. Retired from the hospital and medical school, the days fly by, and I am never bored.’


A gratifying, productive career
‘All together, I have been blessed to have experienced a long, gratifying and productive career. Work was never a burden and I enjoyed all aspects, clinical, research, education and administration We have travelled the world, where I still enjoy clinical challenges and teaching. My legacy will not be the research manuscripts I have written, nor the books I have published, rather the people I have influenced and taught, my so-called ‘academic children’ and grandchildren. It is heart-warming to hear someone from a foreign country say, “your book was my companion as I struggled on call in the Neonatal Intensive Care Unit.  

‘I am deeply grateful to the University of the Witwatersrand School of Medicine, and my teachers for preparing and launching me on this journey.’


 
This biography and pictures were contributed by
Avroy Arnold Fanaroff, MB Bch
(Rand 1960) MRCP (Edinburgh 64) FRCPCH (London 96)
Cleveland, Ohio, August 2020

Edited by Geraldine Auerbach MBE, London

and enhanced by text by CG Brenner and Rochelle Keene, in preparation for a book on 100 important South African doctors who have made international contributions, to be published in 2020.
WitsUSA