 Professor of Anatomical Pathology, University of Cape Town
Interview location: University of Cape Town, Faculty of Health Sciences
Interview date:16th January, 2008
Key Themes: Autopsy, New Technologies
Section 1
- Talks about his family’s origins in southern India – they moved to
South Africa several generations back. Father was a farmer who lost
his land under the Group Areas Act and used his compensation to start a
small shop. Apartheid dictated which curriculum he followed at school,
set by the Department of Indian Affairs, and where he could attend
university. “I was in university in the 1980s, and the '80s in South
Africa was probably the most volatile time.”
- Originally aimed to become a GP, but in his third year of training he
did anatomical pathology and “I knew I wanted to be a pathologist.”
Section 2 - What attracted him was “the histology, the morphology, the
histopathology – looking at things and making diagnoses. It was
solving some kind of mystery.”
- He found anatomical pathology fascinating: “In an autopsy you tie
everything up.” In recalling his early experiences he says that in
autopsy “you use all your senses – sight, smell, touch, you feel the
consistency of things.”
- Expresses concern about the declining emphasis on the value of
autopsies: “I think the bigger picture is lost. We are tending to
become just diagnosticians... [but] the pathogenesis, the way diseases
are caused, is as important as looking down and saying OK, this is a
cancer.”
- Recalls that in his first year as a registrar his department performed
about 1,000 autopsies; now this would be no more than 100. Suggests
that reluctance of clinicians to request and hospital management to
sanction autopsies is a false economy. “Autopsies are a form of quality
assurance [and] clinical audit, for a hospital.” Low rates of autopsy
also have an impact on training new pathologists: they make up the
numbers required to qualify by assisting the forensic pathology
department with their autopsy work.
- Explains that the reorganisation of South Africa’s pathology services
has tried to address inequalities between provinces by creating the
National Health Laboratory Service, and the new funding model is
‘fee-for-service’: “We've become an expense.”
- He recognises the budgetary constraints on administrators but
says,“Groote Schuur is the premier hospital in South Africa, and not to
have a clinical audit or some sort of quality assurance system with
regards to deaths is really short-sighted.” Epidemiology also suffers
from lack of data traditionally provided by post-mortems.
- Mentions that Red Cross Children’s Hospital is the only institution in
this academic complex where autopsy rates are still reasonable.
Section 3- Explains that in South Africa all pathologists in public service are
‘generalists’. “If we had to go to the sub-speciality stage, the
numbers required would ... double or even treble... I can't justify that in terms of my department, because I'm fee-for-service... If I don't make enough money, I can't employ.”
- Talks about how his special interest in nephroblastomas started under
the tutelage of Professor Runjan Chetty in Natal. This tumour, rare in
adults, remains an abiding academic interest. “In terms of the
histology, it is so diverse... No two nephroblastomas look alike.”
- They were seeing “relatively high” numbers, and were wanting to find
out whether there was a significant difference between ‘third world’
and developed world scenarios. “There were a lot of findings unique to
the developing world, the African situation... But in terms of the
biology there was very little difference.” Reliance on traditional
medicine and the cost of hospital treatment meant that“the majority of
[rural] patients ... came with advanced disease.” This largely
explained the difference in survival rates.
- Discusses aspects of their continuing research into the molecular basis
of nephroblastoma, and makes the point that it can be difficult as a
service pathologist to find the time to do research.
Section 4- Talks about working in Durban with its broad range of tropical diseases. “It’s a fantastic training ground.”
- Acknowledges that in the Western Cape, alcohol abuse “is a big
problem... because of some of the labour practices that we had. The
wine farmers...used to pay their staff in wine instead of salaries.”
As a result “the Western Cape has one of the highest prevalences of
fetal alcohol syndrome.”
- Explains that because of the low autopsy rate, they cannot tell how
prevalent alcohol-related disease is in the general adult population.
- Talks briefly about his good experience in going to London to take the Royal College exam.
Section 5- Qualifying in 1993, he found himself in the middle of the emerging
HIV/AIDS epidemic. “The spectrum of pathology began to change; we were
seeing a lot more infections... [And] we were seeing totally different
morphology with similar diagnoses -- so TB wasn't looking like the
classic TB; fungal infections were looking a little bit different from
usual.” For example, “you normally see Cryptococcus in the lung, or as
meningitis in the brain. But we were seeing it in the skin or in the
liver -- in a site where you wouldn't normally see it.”
- AIDS is believed to be a leading cause of maternal mortality in South
Africa, but explains that, again, the low rate of autopsy means that
there are many unanswered questions. “Are they getting opportunistic
infections? Are they developing malignancies? Who knows? ”
Section 6- Explains how he came to his current position and found himself suddenly involved in “a ton of different committees”.
- Talks a bit about his advisory role with the UK’s Royal College of
Pathologists, where he represents central, west and southern Africa.
They are exploring ways to assist countries such as Malawi, where there
is currently only one pathologist.
- Talks briefly about training. Discusses affirmative action,
maintaining standards, and different teaching models. Regrets the lack
of exposure to pathology practice in new curriculum. “It's now
considered not important for them to even look at a slide down a
microscope... I know -- and I've predicted this -- that we will get
less and less interest in pathology.”
- Fears that recruitment into pathology may decline because “the new
curriculum emphasises the clinical disciplines”, and moreover refers to
pathology as “basic science”. He takes issue with this: “It's not
true: pathology is as clinical as medicine or surgery, because we are
engaged in patient care.”
Section 7- Talks about how his identity is intricately tied to being a pathologist.
- Discusses his experience of the transition from the apartheid era to a
democratic South Africa. “The disease profile didn't change. But
conditions of service changed, because you started getting more
attention to labour relations, to salaries.” But it was daily life
where he saw the biggest changes: “I could go to any movie theatre; I
could take any bus; I could go into any coach on a train…And I really
had not been able to before.”
- Talks briefly about the rewards and frustrations of his work. “I have
high moments all the time when I make a fantastic diagnosis with the
microscope... [But] now that I have so much administration I don't do
as much diagnostic work as I'd like to.”
- Talks about the role his mentors, Kum Cooper and Runjan Chetty, have played in his professional life.
Section 8- Discusses one of his current research interests, a large collaborative
study of hereditary nonpolyposis colorectal syndrome, focussed on a
community near Cape Town. “We can trace these families as they are
spreading throughout South Africa, because you can trace the genetic
mutation.”
- Returns to the issue of changes in his profession. “As we continue to
train pathologists we probably will train more molecular
pathologists... because besides looking down the microscope you'll also
have to interpret molecular results.”
- While he also acknowledges that “Improvements in radiological
techniques have, to some extent, affected the practice of pathology”,
he points out that “we are still basing our diagnoses on what you see
down the microscope... I can't see that the radiologists can work in
isolation. They have to work in conjunction with us.”
Multi-disciplinary teams are becoming the norm.
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