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Faculty Focus

John Butterly, M.D.: Doer of the undoable

John Butterly is a man of many parts: a cardiologist, a health-care executive, a teacher of undergraduate courses, the author of a book on hunger, and more.

By Amos Esty

John Butterly enjoys a good challenge. For one thing, there's his clinical specialty, cardiology, which he chose specifically because of the difficulties it involves. "I love taking care of very sick people," he says. "So I always loved cardiology." Then there's Butterly's work as the executive vice president of medical affairs for Dartmouth-Hitchcock Health, which entails thinking about ways to maintain and improve the quality of health care not just at DHMC in Lebanon, N.H., but at all Dartmouth-Hitchcock sites throughout the region.

Finally, there is the daunting challenge that Butterly took on about two years ago: writing a book about hunger that explains everything from the biology of starvation to the political and economic causes of famines.

So perhaps it's more accurate to say that not only does Butterly like a challenge, but he likes to take on lots of challenges all at the same time.

This last endeavor—writing about hunger—was inspired by an interaction Butterly had about 20 years ago, when he was living and working in Boston. At the gym one day, he found himself watching a news story about a famine in the Darfur region of Africa. "It was just heart-breaking," he recalls. He commented to a man next to him, someone he knew, that it was a horrible situation, to which the man responded, "Well, if they don't want to starve, they shouldn't live there." Then he added, "These people always starve."

Butterly was left speechless, but the encounter got him thinking about why so many people are allowed to go hungry. In 2002, by which time Butterly had left Boston to come to Dartmouth, his interest in the topic led him to work with Lee Witters, M.D., a DMS professor of medicine and of biochemistry, and Jack Shepherd, Ph.D., a Dartmouth College professor of environmental studies, to develop an undergraduate course on hunger.

Amos Esty is the managing editor of Dartmouth Medicine magazine.

About two years ago, Butterly and Shepherd began collaborating on a book that would bring together all the different strands covered in the course. The result is the recently published Hunger: The Biology and Politics of Starvation. Butterly describes the book as an attempt to understand and explain hunger. "It's a precept of medicine that you can't fix something you don't understand," he says. "This is a very complex issue, and this is really meant to be a book for the lay public."

Examining chronic hunger

Read an excerpt from Butterly's new book.
Read more

Throughout the book, Butterly and Shepherd argue that the underlying cause of many famines is not that there is a lack of food, but that the people who need food simply don't have access to it. One example they cite is the Great Irish Famine of the 1840s. "The problem was that the Irish had lost ownership of their land," Butterly says. "When the potato crop failed, there was a ton of food in Ireland, but it belonged to the landlords, and it was exported."

Another problem, Butterly explains, was that those who did have food espoused misguided economic theories to justify their good fortune. If others were starving, the line of thought went, then it was because there were too many people on too little land, and there was nothing that could be done—a theory Butterly calls an "abdication of responsibility."

Butterly and Shepherd conclude that more recent famines share many of the same dynamics as the Great Irish Famine. As in Ireland, the underlying problem is not a lack of food. "There's plenty of food around, it's just that the people who need it can't afford it or have lost their entitlement to it," Butterly says. "Although it is a complex problem—I'm not saying the solution is an easy one—it is solvable if we decide we wish to solve it."

A few months ago, in October, Butterly saw firsthand some of the effects of this lack of entitlement. He traveled to Haiti with several other members of the Dartmouth community to explore a possible long-term involvement for Dartmouth in that country. Of the children he saw in hospitals, about 70% were there as a result of severe malnutrition. "That's an extraordinary number in a world in which we have enough food to feed everybody," he says.

Although this was Butterly's first trip to Haiti, he has been actively involved with the country since the 7.0-magnitude earthquake struck near Port-au-Prince in January 2010. Butterly oversaw Dartmouth-Hitchcock's response to the earthquake, which included sending physicians, nurses, and supplies. (See here and here in this issue for further insight into Dartmouth's involvement with Haiti.)

The work in Haiti is but one example of Butterly's interest in improving health care locally, regionally, and globally. In 2001, two years after arriving at Dartmouth, he was named the executive medical director of DHMC, and in 2010, he became the executive vice president of medical affairs for Dartmouth-Hitchcock Health.

The new role, he says, is similar to his work as medical director, except that he now has to consider how to help improve care at all Dartmouth-Hitchcock sites. Part of that effort, he believes, will entail making all of those locations work better together. "Although we certainly share a vision of quality care and a mission to the population we serve, we are not as cohesive as we might be in regards to all using the same medical record, using the same policies and procedures of care," he says.

Grew up: Long Island, New York

Education: Cornell University '70 (A.B. in biology), University of California at Berkeley '73 (M.A. in biochemistry), University of California, San Francisco '77 (M.D.)

Training: Massachusetts General Hospital (resident and fellow in medicine and in cardiology), Harvard Medical School (research fellow in medicine)

Family: Wife, Lynn, a DH gastroenterologist; three children—Arielle, Daniel, and Joel; and three Labrador retrievers

Currently reading: A Short History of Nearly Everything by Bill Bryson

License plate: "BIG FISH"

Butterly thinks that Dartmouth-Hitchcock has a unique opportunity to develop better ways to provide health care, in part because of the presence of the Dartmouth Institute for Health Policy and Clinical Practice (TDI). "We have an opportunity here in building medical homes, in building an accountable care organization, to really improve the value of the care that we provide," he says. "We believe we can be a national and, frankly, world leader in being able to develop the processes that help us to improve the value of health care."

One example, he says, is DH's participation in a pay-for-performance demonstration project run by the Centers for Medicare and Medicaid Services. The project requires institutions to track certain quality measures for patients with chronic diseases. Those that are able to provide high-quality care for less money than is spent on similar patients elsewhere are eligible for bonus payments. Butterly notes that DH's success has earned the institution over $10 million in bonus payments so far. "That didn't just happen," he says. "This is hard work. This is not waving a magic wand and making it happen."

It probably helps that Butterly can be stubborn, something that was clear when he led the effort to make DHMC's Lebanon campus tobacco-free. "I was told, 'Well, you really won't be able to do that,' " he recalls. But the ban on tobacco has now been in place for more than two years, and the compliance rate is about 99%. "I'm very proud of having been allowed to lead the effort to make this campus tobacco-free," he says. Recently, he has talked to other local businesses and organizations about becoming tobacco-free.

Even as Butterly's administrative duties have increased, he has continued to see cardiology patients. "I love seeing patients," he says. "I never say no to a patient, whether I'm supposed to be in clinic or not."

He has continued to teach as well. Not only is he still involved with the course on hunger, but he also teaches an undergraduate course on global health with Lisa Adams, M.D., an assistant professor of medicine.

Butterly says he and Adams hope to write a book about global health that would cover topics such as why so many people worldwide still do not have access to safe water supplies, let alone to basic medical care. "We need to recognize that all human beings must have access to the basic necessities of life and have the right to develop their human capital under some degree of equal opportunity," he says.

Not only does Butterly like a challenge, but he likes taking on lots of challenges all at the same time.

Clearly, Butterly relishes tackling difficult projects. Even his favorite hobby—fly-fishing—is known to try many people's patience. Yet he heads to Maine to fish whenever he has a chance. Whenever Butterly talks about his professional accomplishments, he's quick to deflect credit onto colleagues. But he's less reticent regarding his achievements with a fishing pole. "I fish with this registered Maine guide . . . and I always catch these huge fish," he says. "So my nickname with this guide is 'Big Fish.' . . . When a registered Maine guide gives you the name 'Big Fish,' that's great." And it's no idle boast he's making—Butterly has the photos to prove his success on the rivers of Maine.

So with a health-care system to fix, patients to treat, classes to teach, a second book to write, and many more fish to catch, it might seem that Butterly has enough to do as it is. But there's an easy way to get him interested in taking on yet another challenge—just tell him how difficult it will be. "There's no better way to get me to do something than to tell me it's not possible," he says.


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