Public health has lost one of its true giants. On 9 November 2000, Avedis Donabedian, MD, MPH, passed away in a peaceful transition that ended a prolonged illness. Born on 7 January 1919 in Beirut, Lebanon, he had accompanied most of the 20th century both its achievements and its horrors. His family was a victim of the holocaust of the Armenian people, and his early life in a small town near Jerusalem made him a witness of social turmoil. It was perhaps this early exposure to traumatic external events that provided his inner lifewith both spiritual and intellectual depth. When he received the 1999 Sedgwick Medal for Distinguished Service in Public Health, the highest recognition awarded by the American Public Health Association, Professor Donabedian said: I belong to a people by a cruel enemy oppressed, persecuted, almost annihilated, its remnants dispersed without hope of return. Is it a wonder that thoughts of friendship, of welcome, of home, are so dear? (1).
After receiving his medical degree from the American University of Beirut, Avedis Donabedian practised family medicine in Jerusalem. His expanding horizons took him to Harvard University, where he earned a master of public health degree in 1955. After a brief period teaching at New York Medical College, he was recruited by the School of Public Health of the University of Michigan, where he became one of its most renowned faculty members. At the time of his death he was the Nathan Sinai Distinguished Professor Emeritus of Public Health. He was also a member of the Institute of Medicine of the National Academy of Sciences of the United States and an honorary fellow of the Royal College of General Practitioners of the United Kingdom and of the National Academy of Medicine of Mexico.
Through a corpus of eight books, over 50 peer-reviewed articles and countless lectures, Avedis Donabedian transformed thinking about health systems. He eloquently explicated how the social response to health problems is not a collection of unrelated events, but rather a complex process that follows general principles. In most of his writings Donabedian was ahead of his contemporaries, revealing insightful intellectual landscapes and charting the direction of future thinking and research, even of future language.
As a result of Donabedians work, the field of health systems research has become a robust space for inquiry and an exciting arena for action, within which Donabedian focused his attention on the quality of health care. The June 2000 issue of the Bulletin was able to bring to light one of Donabedians very few unpublished manuscripts (2), the introduction to which summarized the impact of his work (3): His seminal paper of 1966 (4) introduced the concepts of structure, process and outcome, which remain to our day as the dominant paradigm for the evaluation of the quality of health care. An indicator of the importance of this paper is the fact that it is one of the very fewCitation Classics in the field of health systems research (5). A culminating point in this remarkable body of work is Donabedians series of three volumes on Explorations in quality assessment and monitoring, which are the definitive systematization of concepts, methods and evidence (6).
Professor Donabedian sought to build bridges between scholarship and action. In his acceptance speech of the 1986 Health Services Research Prize, he declared: In all my work I have tried to embody the passionate conviction that the world of ideas and the world of action are not separate, as some would have us think, but inseparable parts of each other. Ideas, in particular, are the truly potent forces that shape the tangible world. (7).
Apart from personifying the traditions of rigorous scholarship, Donabedian had a masterful command of language, which added an aesthetic dimension to even his most technical texts. In the same speech he expressed this dual nature of his work: a love for ideas, a love for words, and a joy in the happy conjunction of the two. In fact, Avedis Donabedian was an accomplished poet, especially during the last years of his life. His legacy is, therefore, both scientific and artistic.
Avedis Donabedian is survived by his wife Dorothy, three sons and four grandchildren. He also leaves a circle of students and followers from all corners of the world. His global influence has been facilitated by the translation of many of his books and articles into several languages, including Armenian, French, Italian and Spanish. A testimony to this influence is the existence of the Avedis Donabedian Foundation for the Improvement of Health Care in Barcelona, Spain, and of several awards bearing his name.
All who had the privilege of learning from this outstanding teacher were the recipients of his inexhaustible generosity. The care he took in lecturing and advising students was proverbial. But our debt is not only intellectual. In the spirit of the true mentor an academic species that runs the risk of extinction he became involved not only with the transmission of knowledge, but also with the total personal development of his students, both by active intervention and by providing a paradigmatic role model. In his own life, Professor Donabedian embodied the principles of quality that he so thoroughly studied, because his own human quality was exemplary. For the many dimensions of his generosity, everyone who knew Avedis Donabedian is indebted to him. But to owe something to this extraordinary man is a paradoxical debt, because it has forever enriched our lives.
Evidence and Information for Policy
1. Donabedian A. In search of home. Findings, 2000, 15 (2): 25.
2. Donabedian A. Evaluating physician competence. Bulletin of the World Health Organization, 2000, 78: 857860.
3. Frenk J. Perspectives. Bulletin of the World Health Organization, 2000, 78: 857.
4. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 1966, 44: 166206.
5. This weeks Citation Classic. Current Contents. Social and Behavioral Sciences, 1983, 15 (6): 18.
6. Donabedian A. Explorations in quality assessment and monitoring. Vol I. The definition of quality and approaches to its assessment, 1980; Vol II. The criteria and standards of quality, 1982; Vol III. The methods and findings of quality assessment and monitoring: an illustrated analysis. Ann Arbor, Health Administration Press, 1985.
7. Donabedian A. Response. Baxter American Foundation Health Services Research Prize, 1986 (unpublished).
Ref. No. 00-1076