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Dhiren Govender - Full Transcript

Dhiren GovenderProfessor of Anatomical Pathology, University of Cape Town 

Interview location: University of Cape Town, Faculty of Health Sciences
Interview date
:16th January, 2008

Profile   |   Transcript Summary   |   Full Transcript

 

SECTION 1

SA:  Let's start at the beginning – tell me a little bit about your family background.

I am a fourth-generation South African of Indian origin.   My father's family comes from Tamil Nadu, the Chennai (Madras) area; my mother's family comes from Andhra Pradesh, so they are both south Indians.  But we don't know exactly where from; there's been a total loss of contact with family in India.

SA:  Do you know what brought your families over?

DG:  I have been informed that my paternal grandfather came as a young boy from India.  But on my maternal side it's an additional generation, so it's my mother's grandfather that came.  And they all came to work in the sugar cane plantations.

Growing up under apartheid

SA:  And what was your own path into a medical career?  

My father wanted me to study medicineDG:  Well most people's experience would be that there's someone in the family, a role model.  With me, no way.  My father wanted me to study medicine.  My father had a difficult life – I remember him working very long hours.  He was a farmer in KwaZulu/Natal, and then he went into business.  His brothers had had a farm for many years, but they were asked to leave because of the Group Areas Act [which segregated the population according to race] and they had to move to a so-called Indian area.  My father then started a business – a small shop.

SA:  And they were pushed off their farm with no compensation?

DG:  Well they were given some compensation and my father used that to start a small business, a small shop really – what we called a general dealer.  The kind of corner shop where people would come to buy their bread and milk.

Most of the universities took very few black students I personally wanted to do something in the science area, and at the time that I did matric – we're talking now the late 1970s – there were very few science options for good students. You either became a doctor, a lawyer, or you did engineering or something in that field.  I had a keen interest to do some type of engineering, but for many reasons, including my father's wish, I applied to do medicine.  There was much competition at that time, because most of the universities took very few black students (and when I say 'black' I'm using the general term for Africans, Indians and Coloureds).  Very few.  The University of Natal, on the other hand, was the only university that took only black students and no whites.  And with me living in Natal, it was convenient.  I applied, I got in, and I graduated.

SA:  At what stage did science begin to interest you?   

DG:   In school my favourite subjects were the sciences -- biology, physical sciences, and mathematics.  During the final part of our high school education we were allowed to choose a course, and I chose the science course because I knew I wanted a career in science.  I excelled in that.  But the important thing to realise is that when I did matric, we didn't write a national matric exam -- matriculants didn't all write the same exam paper.  Indian students wrote the so-called 'Indian Affairs Department' exam paper.

SA:  So was your whole education proscribed?

DG:  It certainly was.  Indian education was run by the department of Indian Affairs, which had its own minister in the government at that time, Africans had what they called 'Bantu education', and Coloureds and whites had their own education systems.  So four different systems.

SA:  And where did Indian education come in the hierarchy?

DG:  Difficult to say, but we were not as badly off as African students.  That was also because we did a lot more outside of school – additional courses, going for night classes.  I didn't do much of that but many did, and if we excelled it was because of a lot of commitment and what we did outside of formal education.  In retrospect I don't think Indian education was that bad, though we had limitations.

SA:  Were there ceilings on what you could attain?  What were Indians 'allowed' to aspire to, and was it different from what was expected of the other races?

DG:  There were no written ceilings.  So no one would say, "You're an Indian, you are not allowed to do this or that".  But where the problem would arise would be if you applied for a place at university -- you might not get in because you were competing with students from a much stronger educational background who probably had better results. The other thing would be finances – many Indians and Africans didn't have the finances to support their children through tertiary education.  Most of the time it was quite an issue for parents to get money to send their kids to university.

SA:  Did you grow up in a politicised family?  I mean, if your dad had been pushed off his land, how angry was he…?

The '80s in South Africa was probably the most volatile timeDG:  My dad was not an activist, but he had strong feelings and opinions.  He was certainly not someone in the public light or who participated in demonstrations.  I did. I was in university in the 1980s, and the '80s in South Africa was probably the most volatile time.  I can remember going on protests and boycotts because of some political issue every year of my medical training.  In fact in 1980, my first year of medical school, we went on a boycott for three months, and the threat was, "We're going to shut it down, because there's no time to complete the syllabus. You guys in first year will have to reapply, and compete with the new matriculants coming in."  But it didn't happen.  I remember that in 1980 our exams finished a few days before Christmas because we'd had to cover all the material.  It was quite a stressful year, first year.

SA:  So were you an angry young man, or had you grown up more or less accepting the limits that apartheid put on you?  Had you got low self-esteem or had you been brought up to feel the same as anybody else, but this was just a bloody awful system?

DG:    Absolutely.  At no time while I was growing up did my parents say or do anything that made me feel that anyone – myself or anyone else – was anything but equal.  Race was not an issue at all.  I was brought up that way: everyone is the same.

I don't think I was angry at university, but I realised how wrong [apartheid] was.  I don't think I was ever angry.  In fact maybe I'm more… not angry, but disappointed now than I ever was angry at the time of apartheid.  Then we knew it was going to change.  Now it's changed, but we realise you can't change literally hundreds of years of discrimination in a very short time.  It's a process, and we're getting there…  

SA:  When you started your training, what was your vision of the future?  Did you think you were going to be a clinician, a front-line person, or what?

DG:  My little understanding of medicine before I went to medical school was what I saw in general practice -- the family practitioner.  I didn't know much about the different areas of specialisation, so when I started I thought, "Well, I'll come back to my community; I will have my little surgery out there and I will do my share of community work."   But very early on – in fact in third year of medical school -- when I did anatomical pathology, I knew what I wanted to do.  All my class mates were surprised at me because they hadn't made up their minds, but I knew I wanted to be a pathologist.

SECTION 2

Gripped by pathology

SA:  What gripped you when you started anatomical pathology?

DG: You know, a lot of people ask me that, "What gripped you?"  I think that gripped me [he points to the microscope on his desk].  The histology, the morphology, the histopathology – looking at things and making diagnoses.  It was solving some kind of mystery: "Here's a problem, find a solution for it."  That's what really intrigued me; that's what I like doing still.  Although I'm not doing it now as much as I would like to.  And that's one of the problems about doing well.  You do well in research, you do well in teaching, you do well in service, and what do they make you?  A manager! [We both laugh].  Then you get away from those things you do well and you have to administer, to manage.  I've never been trained as a manager or administrator, I've been trained as a pathologist.

So anyway, in third year I knew what I wanted to do.  In the fifth year of medical school we used to have 'electives' – clinical electives, where you were allowed to go anywhere in the world and do something of your choice for about four weeks.  Usually you did it in your own time, not during the study year.  But it happened that when we came to fifth year they said, "We're not going to have electives any more."  I think it became a financial problem for most students – because remember, Natal University was mainly black students, and they didn't have money to go out and do electives.  So I chose to do an optional elective, in anatomical pathology.  

I did it for three weeks, at Natal, and incidentally Kum Cooper was a consultant there at the time.  He was about to leave for Oxford to start his PhD.  I worked in the department, they taught me how to do autopsies, and I looked at the surgical cases with them.  It was a really fascinating three weeks, and I knew then – "Can I put in my application now?"!

In an autopsy you tie everything upI enjoyed doing autopsies and I have my own views about them.  I feel we learn a lot of pathology, and a lot more clinical correlation -- applying pathology to the clinical scenario – when we do autopsies.  In surgical pathology we get a case; we report it; we go to multi-disciplinary team meetings; we present it.  There is some correlation with one diagnosis.  In an autopsy you tie everything up.  It's a pity that we don't do many autopsies any more.

SA:  Do you remember some of the cases you got involved in during your elective?

DG:  I remember the first case I did was an alcoholic, a chronic alcoholic.  Besides having cirrhosis and all the other features of alcoholism, he had a Klebsiella pneumonia and what stands out is when I cut the lung.  Klebsiella is an organism, a bacterium, that has a mucoid wall, so when you touch the cut surface it has a very sticky consistency, and I can remember them saying, "Take a knife and place it on that cut surface and lift it, see the consistency…"  That sticks in my mind!

SA:  So when you're doing autopsies, what senses do you use in your investigations?  

You use most of your senses – sight, smell, hearing, touchDG:  You use most of your senses – sight, smell, hearing, touch, you feel the consistency of things.  The only thing you don't use is taste.  But very often we teach using pictures and bottled specimens, and the one thing you don't get from those is the feel of it, whereas in autopsies you do.  Is it friable, is it hard, is it firm?  And you come across different ways to describe the consistency that you feel.  The consistency is extremely important.

SA:  Once you'd decided on pathology, did you have good teaching and inspiring teachers in your undergraduate training?

This is really the foundation of medicineIn our undergraduate training we did one year in anatomical pathology.  Our curriculum was, I think, based on the British curriculum -- we had chemical pathology, haematology, forensic medicine, anatomical pathology and medical microbiology as different pathology subjects.  Anatomical pathology would cover autopsies, histopathology, cytopathology.  But as a third year student, your exposure to histopathology -- diagnostic histopathology -- is limited, because you're not training a doctor to diagnose with a microscope.  But you learn about aetiology -- the causes of diseases -- and about how diseases come about, the pathogenesis, and about complications.  This is really the foundation of medicine: in my mind there's no doubt that if you don't have good knowledge of pathology, you don't understand the patient that well.

At that time pathology was taught by about four lecturers in anatomical pathology.   The head of the department was Professor Kallichurum -- very stern lady, so the work was done.  

SA:  Are registrars today less interested in the science of medicine, do you think?

DG:  I think they're more interested in the microscope – doing histo-diagnosis – and  less interested in the science.  Hence you'll find that pathologists nowadays don't want to do autopsies; they just want to do surgical histopathology.  But our curriculum hasn't changed, so anyone who does anatomical pathology must still be competent in doing autopsies -- there's no choice.  I think UK is reviewing that now – they want to offer histopathology without autopsies.

SA:  And what d'you think is lost in that?  

I think the bigger picture is lostDG:  I think the bigger picture is lost.  I think what we are tending to become is just diagnosticians – look down a microscope and not look at the whole disease.  And that's a problem, specially with trainees. You want them to get a big picture, because the pathogenesis, the way diseases are caused, is as important as looking down and saying OK, this is a cancer, or whatever.

Declining autopsies: a false economy?

I actually have a book where I recorded every single autopsy that I did, and in my registrar training I did about 200.  I remember in the first year I was a registrar (this was in Durban) there were times when we used to have five or six autopsies in one day in that department, and the total we did that year was about 1,000.  Now if we do 100 a year we're doing very well.  

There is a decline in autopsy numbers, and it's not unique to South Africa, it's universal.  I think there are many reasons for the decline here.  One important reason is that clinicians don't request as many autopsies as they used to.  If a patient dies, they're happy to say, "Natural causes," and put in some cause of death, rather than, "Let's see if we were right."  Secondly I think there's an issue here about management  -- administrators are looking at the cost of doing autopsies, and saying, "I don't think we need to do this autopsy because it's going to cost us money."  At Groote Schuur for example, a clinician has to motivate to the medical superintendent that there is a case for doing an autopsy. 

Autopsies are a form of quality assurance,for a hospitalI believe strongly that autopsies are a form of quality assurance, clinical audit, for a hospital.  This hospital doesn't have one, because they don't request the autopsies. I would say (and this is a thumb suck) that 10% of deaths should be autopsied, so that you would have an idea of quality assurance, and an audit of the deaths in your hospital.  We don't get 10% -- I think it would be between one and five percent.  So what I do now to train my registrars is I take forensic cases -- what would be the coroner's autopsies in UK.  The Forensic Pathology department gets a lot of natural deaths, and we get our registrars to do those autopsies to fulfil their minimum requirements for training, because if we depended on hospital autopsies we wouldn't get the numbers.

SA:  In the days when autopsies were done more or less routinely, how often did you have to modify the death certificate?

DG:  Very often.  Remember, they wouldn't sign the death certificate until we'd done the autopsy.  So if a clinician requested an autopsy he wouldn't fill in the death certificate, though often he'd say what he thought the person had died of.  We used to have what we called the clinical-pathological meetings where we'd pick up some of the errors.  The clinicians would present the clinical findings and explain how they came to their conclusions, and we would present the autopsy findings and tell them exactly what happened.  But we don't have those any more.

Budgetary matters

SA:  And was the decline in autopsies something that happened very abruptly when the government started reorientating health resources towards primary care, or has it just sort of gradually happened?

DG:  You know, different people will have different views on why this happened.  The National Health Laboratory Service, the NHLS, is a public entity owned by government. What it did was to take all the previous pathology laboratories, which were run by the respective provincial health departments, and put them into one national organisation.  In a way it tried to address equity nationally, because before that, if you were in the Western Cape you might have earned a different salary, or had different conditions of service, from somebody who worked in Natal, for example. So addressing those inequities was one of the reasons why they created the NHLS.  But in creating that they put in a new funding model.  

In the past, each province got a health budget from the national budget, and the province took its health budget and allocated a portion towards laboratory pathology services.  But the NHLS is a fee-for-service organisation, so what we do now is we charge the hospital – in other words the health department -- for our services.  In the past the cost of autopsies was not seen.  No one could stand up and say, "An autopsy costs R2,000", because it was just part of the budget.  But now you have to pay for it, so you can actually see what it costs.  And people say, "Well, I don't want to pay R2,000 for an autopsy," or whatever it might be.  I think that's the issue: now it's fee-for-service.

We've become an expenseIn fact, from a hospital administration perspective, pathology has now become an expense.  Pathology in the past was an integral part of medicine; now we've become an expense.  So when they think about pathology they don't think, "Oh here's a medically qualified person who can add value to clinical services."  They look at us and they think, "Oh, that's going to cost us". 

“The scapegoat is always pathology”

SA:  But that's terrible!  Have you got an association or anything that can stand up and say, "This is going to be the effect on the foundation of clinical practice"?  

DG:  We’ve tried.  But they're driven by budgets…There are heavy constraints placed on administrators to make the books tally.  And it seems that the scapegoat is always pathology, and autopsy is one area that certainly has suffered.

SA:  And how do you feel about that?

DG:  I think that it's short-sighted.  I would say quite confidently that 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.

SA:  And do you think it's the beginning of the demise of pathology, or will it come back?

DG:  I don't think that it will result in the demise of pathology but what it might do is reduce the relevance of pathologists in terms of clinical services.  Now they look at us only for diagnostic services.  They don't look at us with regard to the audit, with regard to autopsies.  They don't look at us in terms of surveillance, "In our ICU, our deaths, are we seeing the same organisms causing pneumonia?" etc -- because there isn't a programme to look at that, at least from an anatomical pathology perspective.  They may have been doing it from blood cultures and other things, but not with autopsies -- there isn't a clear attempt at doing audit.

SA:  So epidemiology is also being affected by you not being able to give the data and so on?

DG:  Absolutely, yes.  Because we are not doing autopsies on an adequate number of deaths at Groote Schuur, there's no doubt about it.

The Red Cross Children's Hospital is slightly different. In paediatrics, they're doing a fair number of autopsies.  Again it's management -- I think the demands on the administrators are different.

You must remember that Red Cross hospital is unique, not only in South Africa, but probably unique in Africa.  If you go to any other centre in South Africa you won't get a separate children's hospital. The Groote Schuur and Red Cross situation is unique, and because you've got Red Cross you have paediatric pathology that's recognised.  If you didn't have Red Cross then it would be diluted with all adult pathology.

SECTION 3

South Africa can’t afford specialists

SA:  So they are trained specialists up there at Red Cross Children's Hospital, are they?

DG:  They're generalists who have gone into paediatric pathology.  Among pathologists at the moment we don't have sub-specialities like you would have in the UK.  We don't have a special course or a special examination for neuropathology (the Royal College does have one), for example.  Here everyone trains as a generalist.

SA:  So what's the thinking behind that, and how do you feel about it?

DG:  The thinking behind it is that if we were to go the sub-specialty route, if I may use that expression -- neuropathologists, paediatric pathologists etc – at this stage in the country we would need a lot more pathologists.  At the moment in South Africa there's a shortage of anatomical pathologists – and I'm talking about generalists.  If we had to go to the sub-speciality stage, the numbers required would double or even treble.  

At the moment in this department we have eight pathologists, including myself, and we just barely fulfil all the commitments – teaching, undergraduate, postgraduate, service work and research.  But if I were to say, "Well, let's do it the sub-speciality way – I need one person for gynaepathology, one for gastro intestinal pathology, one for neuropathology and so on," I'd probably need 15 pathologists.  I can't justify that in terms of my department, because I'm fee-for-service, so it's the money that we make that is used to pay the salaries.  Now, if we don't make enough money, we can't employ.

SA:  And if you employ sub-specialists, they have to have a critical mass of work?

DG:  Correct.  But there are some areas where there is critical mass.  I mean, in gynaepathology, in gastrointestinal pathology, there's certainly critical mass.  Even in skin, dermatopathology.  What happens here is that people have an interest and they pursue that interest.  So they haven't done a special exam or fellowship, they've done general pathology and then found a niche or interest area and pursued that.

SA:  And do you dissuade them from getting sub-specialist qualifications?

DG:  No, certainly not.  But it doesn't exist in this country.

SA:  Okay, so your own training – when you started did you have something that you were particularly interested in?  

DG:  When I did my South African fellowship, in 1993, I wrote the [UK] RCPath theory paper at the same time, and then six months later I did the RCPath practical exam – that brings back very fond memories.  I did my South African fellowship exam in Pretoria and at that time there was no consultant post for me in Natal.  The professor told me, "You're going to qualify and there isn't a vacancy."  I said, "That's fine, all I would like is for you to give me another six months as a registrar so I can complete my masters degree." And she agreed to give me another six months and she said, "Then you must look for a consultant post."  (I must also say up front that I always wanted to be an academic pathologist – I always wanted to work in an academic centre because I was interested in research.  I never thought of being head of a department, or chairman of pathology – that never ever crossed my mind.  If you want a story about chance, that was it!  

So I wrote, and I was successful.  And while I was writing the exam one of the consultants [in Durban] decided she was going to the United States.  So I was offered a post and I accepted.  

Professor Kallichurum  retired in '94 and from about September '95, Runjan Chetty became head.  (He's now in Toronto.)  And I think that many of my career achievements are due to having Runjan Chetty there.

A focus on nephroblastomas

SA:  What was special about him?
    
DG:  Research.  With his support and guidance and experience as an established researcher, my research really kicked off -- my interest is paediatric pathology, particularly paediatric oncology.  A lot of my work was done in that area, much of it in a specific tumour, Wilms tumour, a nephroblastoma.  We had seen many cases in our department.  In Durban for some reason, and no one knows why, there's a higher incidence of nephroblastoma compared with the rest of the country.  In terms of paediatric solid tumours, nephroblastoma was one of the most common we saw.  In terms of the histology, it is so diverse.  My masters degree was on nephroblastoma and I then did a PhD on nephroblastoma.  A fascinating tumour – different from most other paediatric neoplasms.  

The mean age for nephroblastoma is around three years, but we saw them from about age one to six years.  You very rarely get it in an adult.  We were seeing about 20-25 cases a year, which in terms of paediatric neoplasm is relatively high.  We had good management of them, good clinical information on them, and it was something that, if you had the material, you could easily explore.

SA:  What were the questions in your mind when you started?

If you go 10 kilometres outside the city you will see third worldDG:  We knew what the experience was in the US and Europe, in the UK.  Those were first world scenarios, and we wanted to see what was happening in the third world, and we are largely third world here.  If you are in Cape Town and Johannesburg you think it's the first world, but if you go 10 kilometres outside the city you will see third world, a developing country.  The majority of patients referred to King Edward Hospital in Durban, over 70%, were rural, and we wanted to see: is there anything different?

One of the things we found was not about the science, it was purely about socio-economics.  We found that we didn't have good follow-up on rural patients; they would be managed, and they would be discharged, and they would not return for follow-up.  So you could never say what happened to them, and that was a major problem.  We also found that there was a proportion of patients who refused to be managed according to western medicine; they chose to use their own traditional medicines, and we don't know what happened to those patients.

SA:  Had quite a number of them used traditional medicine before they even came to you?

So that's why the survival was not as goodDG:  A fair number did.  Often there would be some evidence, or there would be a history of, "Yes we tried the others before we came here", and those would stay.  Others would come to western medicine because of some emergency and then they would go and not come back.  So in that sense there were a lot of findings unique to the developing world, the African situation, that wouldn't have been seen in the first world.  But in terms of the biology, in terms of the tumour itself, there was very little difference.  We found the same kind of biology in the sense that the relapse rates were roughly the same.  The survival rate was different, and that was only for one reason – it was stage- dependent and the majority of patients that we saw came with advanced disease.  I'm only speculating here but: the child gets sick, we try all possibilities before we go for medical attention, and by the time we do seek medical attention we've got a stage four [tumour], it's metastasised.  So that's why the survival was not as good.

There are known good and bad prognostic factors, determined by studies in the US and Europe.  In the US we had the National Wilms Tumour Study Group, and in Europe the International Society of Paediatric Oncology -- they are really the leaders in nephroblastoma management and research.  But what we found was that some patients would have good histology, low stage, would have all good prognostic signs, but they would not do well.  That took us out of a clinical morphological study into a molecular study, and we started looking at other proteins and genes to see if they were of any prognostic significance.

SA:  And what did you find?

DG:  We studied [the gene] p53, for example, and that's published in the British Journal of Cancer.  We found that tumours that express high levels of p53 were associated with poor outcome – both that the patients were more likely to die (they were more likely to have high stage disease), and they were also more likely to have unfavourable histology.  That was also found by other researchers.  And we've done some other markers which didn't show too many exciting results.  But then we embarked on some molecular work that looked at micro-satellite analyses.  We were looking at polymorphic markers on different chromosomes, and we looked at chromosome 11, chromosome 16, and mismatch repair genes.  Those results I can't give you now because the work is still being analysed.

SA:  And did you do the molecular studies yourself?

DG:  Oh yes.  I took sabbatical leave and I did all the molecular studies myself.  

SA:  And was this just because the more questions you asked, the deeper you needed to go to find answers?

DG:  Exactly.  We started with morphology, the microscope.  Then we went into a protein study, but using immunohistochemistry, so we would stain it and also view it under the microscope.  Then we took it a step further and did the molecular studies.

SA:  And did you find things that were different from Europe and the US?

DG:  That's what's being analysed now.  But it does look exciting. Our results are similar to results from Europe and the US.

SA:  And how much time were you able to give to research, because you were also a service pathologist weren't you?

DG:  Yes, that's a major problem, not unique to any one department in this country, because service tends to take priority – obviously, since the patient's waiting for you to give a report.  And the shortage of pathologists has impacted on that.  If you're adequately staffed it's easy, on a rota system, to say to a pathologist, "Ok, you will all have one week off for research."  But you can't do that when you have the pressure of service work and you don't have sufficient pathologists.  So a lot of the molecular work that I did I took time off to go to the lab; I was on sabbatical, so I could be in the lab full time.

SECTION 4

First and third world pathology in one country

SA:  So in your service work, both here and in Durban, what are you seeing?  Because I'm sure it's incredibly different from the first world stuff.

DG:  Part of what we see in Cape Town is a lot like what you see in the first world, but in Durban, the spectrum of pathology is totally different -- you see a lot more infections, a lot more tropical-type infections, exotic infections, which we don't see here.  A lot of that is due to the climate: Durban is humid and sub-tropical, with a lot of summer rain; the Cape is colder, with winter rain.

SA:  And was the tropical pathology exciting?

DG:  Very exciting.  The other thing about Durban is that the one academic pathology laboratory serves the entire province, and KwaZulu/Natal is the most populous of the provinces.  The 2001 census showed a population of around 9.4 million for KwaZulu/Natal, if I'm not mistaken.  Unofficially, I think it's probably more.  The Western Cape has about 4.5 million people, and we have two academic laboratories – Groote Schuur at UCT, and Tygerberg at Stellenbosch University.  So in Durban the spectrum of disease is broader and the volume of pathology is greater.  It's a great training ground, and I am certain that Kum Cooper will have echoed the same. 

“A legacy of the past”

SA:  Here in the Western Cape I understand you have massive problems of alcohol and drug abuse, and the pathology consequent upon that, particularly with children – what are you seeing?

Wine farmers, used to pay their staff by giving them wineDG: Helen Wainwright would be able to answer that much better than I because Helen is our local fetal and perinatal pathologist and she sees the fetal alcohol syndromes and related pathologies – the still births, the fetal abnormalities, the neonatal deaths.  It is a big problem, because of some of the labour practices that we had in the Western Cape.  In the past wine farmers, the vineyards, used to pay their staff by giving them wine instead of salaries.  We're talking about what I call 'the pre-democratic era', when people could do this and get away with it.  Now you can't get away with it, because we have a labour relations act which governs how employers treat their employees.  But [the 'tot system'] is one of the roots of the Has one of the highest prevalence of fetal alcohol syndrome,alcohol problem.  The Western Cape, where the vineyards are, has one of the highest prevalence of fetal alcohol syndrome, I believe, and the reason is socio-economic and a legacy of the past.

 

 

SA:  And is alcohol abuse a factor in what you're seeing in adult pathology too?

DG:  The problem is we see adult pathology only through our diagnostic work – biopsies of livers, for instance.  Let's say cirrhosis, one of the common problems of chronic alcoholism, we'd only see that if we receive a liver biopsy.  We're not doing hospital autopsy audits on patients that are dying in the hospital.  And how many patients with cirrhosis have liver biopsies?  So it's difficult for us, just by looking at biopsies, to extrapolate what the incidence of alcohol disease is in the community.

SA:  So are you finding that the lack of autopsies is meaning that you just see tiny snapshots of the spectrum of disease?

DG:  Yes.  I think so. Because we are not doing an adequate audit. And it's certainly not reflective of the entire admission and deaths in the hospital.

SA:  So how do you feel?  Do you feel frustrated?

DG: Yeah, in a certain way, I do feel frustrated, because there is so much more that we could offer than we're allowed to.

To London for the Royal College exam

SA:  Tell me about when you went to the UK.

DG:  Well, I am South African born and my visits around had been within this country, so when I wrote the [UK] RCPath exam that was the first time I went overseas.  It was 1993 and it was fantastic -- though horrible time of year; it was November and the weather wasn't good at all. I stayed in London, in Russell Square, and I wrote the exam at Northwick Park, Harrow.  The internal examiner was Professor Ashley Price, and the external examiner was Prof. Tony Freemont, from Manchester.  I enjoyed it from a holiday perspective and the experience was fantastic.  Everyday I had to be back in London to phone Prof. Price to see if there was an autopsy for me to do.  I spent three weeks in London.

I wanted to see if I was worth my salt With regard to the exam, when I wrote the South African exam, as I told you, I didn't write it in my own centre, Durban, I wrote it in Pretoria.  But you still know people from meeting them at conferences and seminars, so it's still kind of 'local'.  But having gone and done an exam in a centre where no one knows you, where you're absolutely new, and to be successful -- for me that was an achievement.  I really felt chuffed with myself that I went and did a British exam, and no one knew me, and I met the standard.  Now I always recommend to registrars to do the RCPath exam.
I didn't do the Royal College exam because I wanted to work there, I did it because I felt it to be prestigious, and also I wanted to see if I was worth my salt, whether I could do it -- that was the challenge.

SA:  And what was the body that you got for your autopsy?

DG:  It was an old gentleman about 65 years old who died at home, but he had gastric cancer.  But what I found was that he also had a renal cell carcinoma (cancer of the kidney), bowel pathology (diverticulosis of the colon), pneumonia, and systemic hypertension, his heart was enlarged.  I do remember the case vividly.

SECTION 5

HIV enters the picture

SA:  So back here in South Africa, you must have been in Durban when AIDS was really taking off…

DG:  Oh yes.  I became a consultant in 1993, and up to that time, throughout my registrar training, we were aware of HIV and AIDS.  We treated every autopsy as potentially hazardous, but then, as you know, the prevalence of HIV in KwaZulu/Natal is much higher than in the rest of the country.  Autopsies were [already] declining; we were not getting the HIV cases coming through; they were not being requested.  And there were problems with us doing them in conditions that were not ideal -- the mortuary wasn't a very good one to be able to handle HIV autopsies.

Patients' reactions to infections were not typicalBut the spectrum of pathology began to change; we were seeing a lot more infections.  As you know, with HIV there is a predisposition to 'opportunistic infections', but also to certain cancers related to AIDS – Kaposi's sarcoma, for example.  And we were seeing infections in places that we didn't see them before.  We were also seeing that the patients' reactions to infections were not the typical reactions that you'd see in immuno-competent patients.  So previously where we'd look at some morphological feature and say, "This is a fungal infection", now we were saying, "Well, this is more like an acute bacterial infection, but it's got a fungus sitting in it."

Totally different morphology with similar diagnosesSo things were changing because the immune systems of the individuals were mounting a different type of response, or a lack of response, compared with the immuno- competent ones.  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.  But having said that, the majority of the work was still not from HIV-positive patients.

SA:  You were saying that you would see infections in strange places – like what for instance?

DG:  Let's say you would see something like Cryptococcus, which is a fungal infection -- 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 sites where you wouldn't normally see it.  Or histoplasmosis, another fungus, we would see it in the bowel, or in the skin.  We were seeing things at sites that were not usual, because they were now becoming disseminated infections.
 
SA:  As a pathologist, seeing all these new weird ways that diseases could attack the body, did you find that teasing, or…?

DG:  Oh certainly, it was challenging.  Because, as I said, the morphology was a bit different.  We wrote, publications came out, and Durban still produces publications on infections in HIV-positive patients.  We can't do it [in Western Cape] because our numbers [of HIV-positive cases] are smaller.

SA:  One of the things I read the other day that I found very interesting is that AIDS is now the leading cause of maternal mortality, and the rates have gone up – are you seeing that here in the Western Cape, and is it an issue in this hospital, this area?

DG:  I'm kind of singing the same tune constantly: if we were doing adequate audits in the hospital we would be auditing maternal deaths.  We would be doing autopsies and we would be able not only to say that mothers were HIV-positive (remember, HIV-positivity doesn't mean that you have AIDS), we might also be able to say what exactly was the cause of death.  Are they getting opportunistic infections?  Are they developing malignancies?  Who knows?  We do a few autopsies, but it's not a representative sample, certainly not.  And it's not our fault, because we are offering the service. It's largely an administrative issue.

SECTION 6

Conflicting pressures as head of department

SA:  So what is your bread and butter service work at the moment?

DG:  I have to be careful when I answer that question because you are wanting to know about the microscope…But I have to be honest; I made reference to this earlier when I said that when you perform as a diagnostic surgical pathologist, when you perform in research, when you perform as a teacher, they make you a manager!  

I was in Durban for 14 years, and in fact I was on my way to UK.  As a pathologist you can't stay too long in the same department; I wanted to experience something different, so in 2003 I was on my way to the UK, looking for a job there and registering with the General Medical Council, (which I subsequently did).  [But then the chair of pathology at University of Cape Town came up] and a friend said, "What have you got to lose by applying? You can turn it down if you get it, or you might not get it, and then you can do what you want to do. You've got nothing to lose.  Apply!"  So I applied.  And I got it.  Then I agonised.  It was six weeks before I accepted the offer.  

It was 2003, August, that I started here and I got stuck in administration, because they wanted me to focus on the undergraduate curriculum and the postgraduate programme.  When I came in I was appointed to various committees and bodies.  For example, I was a director on the board of the NHLS -- my three-year term just ended. That took up a lot of time, because one of our tasks was to create an agreement between universities and the NHLS.

Then I had to act as the head of the school of pathology for one year.  Then I was elected onto the senate of the Colleges of Medicine of South Africa.  And now I've been appointed as an international advisor for the Royal College of Pathologists [in the UK].  What the Royal College is doing is attempting to reach out to the world in terms of pathology – how can it offer assistance to any area that needs it?  So they've appointed advisors for the Americas, Africa, Europe, Asia and the Indian-Pakistan area, as well as the Middle East.  I'm representing Africa -- central, west and south.

SA:  And what sort of assistance are you asking for?

DG:  Okay, one of the examples would be – and this we're looking at now – how can British pathologists provide assistance to countries in Africa where there aren't any pathologists?  Like in Malawi at the moment there's only one pathologist, and there's a project being looked into whereby British pathologists will come to Malawi on secondment for short periods to work there -- and not only to provide the service but to build the capacity, so that eventually there'll be sufficient resources and skills for the Malawians to do it themselves.  

There are other things we could look into as well.  For example, we have a College of Medicine in South Africa which has 27 medical and dental disciplines, one of which is a College of Pathologists, and we could look at some kind of relationship with the [UK’s] Royal College of Pathologists.  We wouldn't mind if someone from the Royal College of Pathologists reviews or moderates our examinations.  We would also like to learn from them.

A new medical curriculum...

SA:  This brings us to a very important issue:  how much pressure have you had on standards?  Pressure to get people through who have probably come from disadvantaged backgrounds?  I've seen this in other circumstances, that the sheer pressure of expectations can be a threat to standards.  

DG:  I examine and I convene exams for the local college, and there has never been any pressure to push people through.  If people don't make the grade they fail.  An unwritten rule would be that a postgraduate doesn't get the benefit of the doubt.  An undergraduate you might consider giving the benefit of the doubt, but a postgraduate not.  Our College of Pathologists is of course for postgraduates.

SA:  So at the medical training level do you feel that standards may be at risk?

DG:  There's potential for standards to be at risk, and that's why I think that teachers, conveners and course coordinators have to be vigilant.  Because if you're not, you could very easily, not realising it, drop your standards.  I think most faculties have processes and mechanisms in place to monitor the standards so that they don't drop.

You know, like UK, we have gone through a major change in the approach to medical undergraduate teaching.  We had a didactic curriculum but we've gone to the problem-based learning model.  In fact South Africa has very often taken the lead from the UK in terms of what it did in medical education.  We've done things the same way; the way our medical schools are structured.  And I guess the new methods of teaching have taken their lead from the UK and other countries.

There's been a lot of resistance to problem-based learning, because basically what you are doing is telling people who have been teaching for all their careers – which could be anything from one year to 25 years – "Hey, what you did wasn't good enough.  You have to now change and do it this way."  But what we've adopted here in the University of Cape Town is a hybrid model – we've taken a middle path. So we do have some lectures, but not as many as in the old curriculum, and we do have problem-based facilitation sessions as well.

...implications for pathology

SA:  And are you getting young medics wanting to go into pathology?

Less interest in anatomical pathology as a field for specialisationDG:  That is a problem.  That is actually a consequence of the new curriculum.  When I did medicine – remember I told you that when I did pathology as an undergraduate I knew I was going to be a pathologist?  Now these students don't know what pathology is, because they don’t get the same exposure. They don't look at microscopes -- it's now considered not important for them; they look at pictures on a computer.  I know, and I've predicted this, that as this new curriculum progresses, we will get less interest in anatomical pathology as a field for specialisation.

SA:  Do they do dissection?

DG:  In anatomy?  Yes.  They have a cadaver to dissect.  Not all universities in South Africa do, but Cape Town does.  There are cadavers; they do dissection; but they do limited dissection.  In our days you did everything.  Now they would be selective and dissect what they consider appropriate and relevant.

And we have autopsy demonstrations. The problem is that because we have such limited numbers, we can't guarantee the students that, "Tomorrow, when you're scheduled to see an autopsy demonstration, we'll actually have one."  So there are scheduled sessions where we use museum specimens, wet specimens from the museum, or we may bring them up to a classroom and show them an autopsy presentation on slides – that's how we're teaching pathology.  Because we can't guarantee there's an autopsy.

There are some students who are excited by pathology.  But I'm sure a lot more would get excited if they were given more exposure. The one way that the curriculum has tried to give students exposure is through an elective called a study module.  In their third year they have a four-week period where they do some kind of elective – it could be in any medical specialty.  But the problem is that in a class of 200, pathology would probably only get six to eight students, and that is not sufficient.  It may be that among the other 192 or so, there are some really good students who may miss out because of limited places.  But I think that interest in pathology may drop, because the new curriculum emphasises the clinical disciplines.  

Pathology is as clinical as medicine or surgeryI sometimes get a bit annoyed that in the new curriculum they refer to pathology as 'basic science'.  Somehow when you get a tag of basic science you are looked at as a non-medical discipline.  And it's not true: pathology is as clinical as medicine or surgery, because we are engaged in patient care.

SECTION 7

SA:  So what does being a pathologist mean to you?

DG:  I think the best way to answer that would be to ask someone, "Who is Dhiren Govender?"  If they tell you, "Well, he's a guy from Durban…" then they don't recognise me as a pathologist.  But I think that my identity is being a pathologist.  In my professional life that's how I'm viewed: as a pathologist.

SA:  And are you proud of that profession?

DG:  Absolutely.

SA:  And how do your family feel?

DG:  My wife is a medical technologist, so she's in the field.  My mum was a nursing sister, so she understands pathology too.  My dad, unfortunately, died before I finished medicine, even though he wanted me to do it.  He died when I was a fifth year medical student, so he never saw me as a doctor – but he knew I wanted to do pathology.

Transition from apartheid

SA:  It's interesting, you qualified during the big transition.  I mean, 1990 Mandela was released, 1994 you had the elections – how different do you think your era was from somebody like Kum Cooper's?  Because Kum qualified before everything changed and he says he found it quite strange suddenly being among whites, having white colleagues and so on.  How did you find the transition into a democratic South Africa?

The disease profile didn't changeDG:  I think the transition was noticeable.  I was a consultant at the time, and  pathology never changed – that stays the same.  The disease profile didn't change.  But conditions of service changed, because you started getting more attention to labour relations, to salaries.  And patient referral patterns started to change, because provincial demarcations changed.  Pre 1994 we had four provinces; now we've got nine provinces.  This impacted to some extent on volumes of work.

Fortunately postgraduate training pre '94 was non-racial.  So I trained with whites.  I had had mixed exposure, so I had no problem there with the transition.   And the change didn't affect the job we did too much.  It might have affected our personal standing and status and socio-economic position – salaries certainly did go up.  

I could go to any movie theatreFrom the point of view of living your life, there were major changes – changes that were very noticeable.  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.  There were two bus stops:  'whites' and 'non whites'.  Different coloured buses in Durban – blue buses for whites, green buses for non-whites.  Public transport; two separate buses.  I lived in an Indian area – declared an "Indian group area".  You couldn't live anywhere else.

Latterly, towards the late 80s, things were changing, because of the sanctions South Africa was experiencing, but only in a very limited way.  There was a colleague of mine who came to work in Cape Town and when he wanted to stay in a certain area he had to get a permit, because it was declared a white area.  It was terrible.  And it's amazing that many people forget that now, that blacks (and I'm using the term generally) did live difficult lives.  

SA:  And do you still find that race is an issue?

DG:  Yes, I think that race is not totally removed from being an issue.  Some individuals still haven't transformed. 

The rewards of the job

SA:  Okay a couple of last questions.  What have been the highest and lowest points in your career as a pathologist?

I have high moments all the time, making diagnoses in pathology is so rewarding DG: You know if I had to do it all again, I'd still be a pathologist. I wouldn't choose anything else.  I don't think I ever regretted being a pathologist.  High moments?  I have high moments all the time when I make a fantastic diagnosis with the microscope.  You know, as I said, now that I have so much administration I don't do as much diagnostic work as I'd like to, but I get to see the problem cases from the department and I get an absolute thrill when I make a suggestion and it turns out to be correct.  Still, making diagnoses in pathology is so rewarding. Leave the research and the teaching and all the other issues, just looking down the microscope and saying, "Well, I think this is the diagnosis, please just go and do these stains," and it comes back, "You were right."  That's the thrill.

SA:  Who do you feel you are working for?  Is it the science, or is it for the patients?

DG:  Sue, to be honest with you, in the last three years, since I got all this administrative stuff, I feel differently from how I felt before that.  Before, I felt that I worked for the patient.  In the last three or four years while I've been doing all this admin stuff, I don't feel I'm working for the patient.  Although I know that ultimately it's to the betterment of patient care in some way or another, I feel I work for the university.

I don't feel that's a loss, and I'll tell you why – because I don't feel I'm going to do that all the time.  I know that I came in, I was given a specific task which meant I would have to deal with administration issues for at least three years.  In the next six months to a year I see myself coming out of that, and starting to focus more on what I enjoy: diagnostic work, research, and teaching. I have started to spend more time on diagnostic work and increasing my research time.

SA:  And who are you outside of pathology?  What do you like to do?

DG:  Many things!  I'm a bit of a movie buff - a James Bond fan.  I'm also Formula One fan. My wife and I live in Cape Town, but all of our family, the extended family, is back in Durban, and I guess we miss them.  We still follow the Indian culture and there is not much of Indian culture in Cape Town.  Visiting Indian singers and artists go to Durban, or Johannesburg, they don't come to Cape Town.  So we miss out.

Mentors

SA:  One last question:  who have been your mentors, your main inspirers?  Have you had people who have helped you shape your path?

DG:  Yes, I certainly did.  And one of them you know -- Kum Cooper.  You know you asked for high points and low points?  I think one of the high points would be getting my first publication, and it was with Kum Cooper.  It was on a lesion of the rete testis-- a testicular lesion that we found in testes that don't descend down into the scrotum.  And why that's a high point is because I did it while Kum was in Oxford.  He set me up before he went to Oxford, you know, he said, "Get all this stuff and put it together."  So I did a lot of the work myself without any previous experience, and we published in the Journal of Pathology.  So that was a high point.  

I don't know if Kum told you, but he's related to me.  He's my first cousin.  Kum's father and my dad were brothers.  Kum was instrumental in me doing the Royal College of Pathologists exam, because I remember that when I was writing the South African exam I was focusing on that, and I said, "I'll do the Royal College exam six months later." And Kum called me a day before the closing date of the Royal College application,   "Did you put your registration in?"  "No."  "You will do it now.  I am putting the phone down and you will call the Royal College and you will tell them that you're faxing it through. You will do it now!"  I did it, and for that I will always thank him.  Because if you defer things you never do them.

And there's Runjan Chetty. With regard to my development as an academic pathologist I think he must take most of the credit.  I was already a consultant in the department, eager to do research, and he taught me, guided me.  And I've learnt a lot from him.  I also learnt a lot of management from him.  He gave me the opportunity to act as the head of department when he went away. So I have got a lot that I owe to Runjan Chetty.

SECTION 8

Focus on familial colorectal cancer

SA:  Returning to your research interests, is there anything particular you’re working on at the moment?

DG:  Just outside of Cape Town, bordering the Northern Cape, there's an area called Kleinsee.  There are families who have a syndrome called hereditary nonpolyposis colorectal cancer syndrome.  We know they are carrying a specific gene mutation, and we have quite a large cohort which we are studying now.  

We have lots of projects going on – looking at that cohort, comparing them with sporadic colorectal cancer [which is caused by a random mutation, not an inherited one] in the general population, and comparing them with some of the other familial syndromes, other polyposis syndromes.  We've got funding for that, and it's a collaborative project between anatomical pathology, human genetics, and surgery, so we're working together and trying to get the full picture.

We can trace these families as they are spreading throughout South Africa, because you can trace the genetic mutation. As we get cases we chart every case on a map, so you can see how it's spread from this area throughout South Africa.

SA:  Who first noticed it?  Who said, "We’ve got something that looks like a cluster here," or whatever?

The answer came from geneticsDG:  What was found was that these patients were getting colorectal cancer, and then genetics was done.  So really the answer came from genetics.  The patients are harbouring a specific mutation, a DNA mutation in one of the mismatch repair genes.  They were seeing it in families, and at a young age compared to the sporadic cases.

SA:  And can anything be done?

DG:  Surveillance. What’s being done is that a team goes out annually to that area, does colonoscopic screening and biopsies.  At the moment that's all we can offer, surveillance.  And the people know the risks, so they are very cooperative.

SA:  Tell me, are you seeing more and more cancers these days?  In your fairly short history in pathology have you seen cancer increase?

DG:  Definitely.  And who knows all the reasons?  I mean, we know what are the factors that influence cancers – environmental, geographic, exposures, occupational risks, etc.  But to link with every cancer, it's a long process.  But the familial colorectal cancer, we know, because we've identified specifically what mutation it is that's affecting this particular group of patients. 

Pathology under threat?

You know, I was at a meeting and somebody said, "Hey pathologists, we'll do away with you guys very soon because we won't need you to look down a microscope, it'll be all molecular biology."  And I wonder if there's some truth in that, because almost every tumour now has a recognisable molecular abnormality, a genetic aberration.  So if you get a tumour you will just do a molecular test and say, "This is the translocation; it will be this tumour or that tumour".  I said, "Well, you can give your opinion, but I don't think it will happen in the near future."

Pathology hasn't reached the end.  But as we continue to train pathologists we probably will train more molecular pathologists, or include more molecular pathology into the training.  Because besides looking down the microscope you'll also have to interpret molecular results.

SA:  Of course various people have said that the other thing that will take over from pathology will be imaging.  What is the relationship between imaging and the work that you do?

DG:  If you ask a pathologist you will get a different response compared to a radiologist.  They will swear that they can make many diagnoses.  I do feel however that improvements in radiological techniques have, to some extent, affected the practice of pathology.  I do feel that radiology is able to make more diagnoses than they were able to in the past – especially with the MRIs and the new techniques that have now become available….

SA: Where they can do slices…

DG:  Yes, which has added a new dimension to radiological imaging.  They swear that with regard to diagnosis they can look at certain tumours and say it is that tumour.  But I don't think it's a 'hard' science -- I don't think radiologists get it right all the time.  I'm not saying that pathologists get it right all the time, either, but I think that they will continue to evolve and develop just as we are.  

SA:  But are you complementary?  What do you add to radiological imaging?



DG:  You can never look at a radiological image and see a squamous cell, or see a gland, but you can look at a microscope and see these things. So a lot of the radiologists' ability to make diagnoses is based on a correlation of what they've seen with what pathologists have been seeing as well.  And remember, the diagnoses are still morphological.  We still say "squamous cell carcinoma", or "adenocarcinoma" – we don't call it something else, like "carcinoma with this shadow on an X ray," or "carcinoma with irregular features on an MRI".  We are still basing our diagnoses on what you see down the microscope.  Until the time when the nomenclature of disease changes, I can't see that the radiologists can work in isolation.  They have to work in conjunction with us.

And we work well together – to the extent that there's tending to be overlap now.  This department has over 35 multi-disciplinary team meetings a month, and radiologists -- if necessary or if it's appropriate -- are there as well.  So we are seeing what the pathologists are seeing, what the clinicians are seeing and what the radiologists are seeing. 
There is that attempt at bringing everyone closer together.

The other thing is biopsies taken under radiological imaging – that's tending to bring us closer to them.   Not that we're doing all the biopsies, but very often we're asked to be there to see that the material they are obtaining is adequate for making a diagnosis – things like fine-needle aspiration may be done under imaging.  And we say, "Well, we've got adequate tissue to make a diagnosis."  So yeah, we're starting to work together more, but I don't think it's ideal, we have a long way to go.  But as a pathologist I still think pathology is the more superior discipline!  [We both laugh]

ENDS

 
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