Kumarasen Cooper - Full Transcript

Kumarasen CooperDirector of Anatomic Pathology and Professor of Pathology, University of Vermont/Fletcher Allen Health Care, Burlington, Vermont, USA

Interview location: Hotel room in Boston, USA
Interview date: 21st November 2007


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SA:  Kum, let’s start with growing up in South Africa – where did you grow up and what was it like?

KC:  I was born in a city called Durban, which is on the east coast of South Africa.  What was it like?  Well I was born into the apartheid regime and you knew no better; you considered the government of the day as being the superior force.  In my primay school as well as high school, and partly during my university years, you were taught to think of yourself as an inferior being, and [you were] treated as such.  You went to separate schools, separate restaurants; [you had] separate buses.  You lived in separate areas.  And of course you didn’t have the opportunity to engage at government level -- you had no political representation basically.

SA:  So did you grow up in a political family -- a politicised family -- or did you just find your own way within a very repressive system?

You were taught to think of yourself as an inferior beingKC:  Well the family was not politicised, I would say, at the time of my birth -- or of my brothers’ (there were three of us).  My father was a farmer and my mother was a teacher.  And they decided that in order to give their children a proper education they should build a school in the area.  It was called The Cooper Government Aided Indian School.  It was partly funded by the government, but my mum and dad had initially to get the foundation going, and they got funds from the local community, as well as putting a lot of their own money and time into building it.  My dad literally oversaw the building of the school.

SA:  And did you follow your own curriculum or did you have to follow the restricted government curriculum?

KC:  We had to follow the restricted curriculum.  There were four different curricula prescribed for the different  groups – there was the African system, the Indian system, the so-called coloured system, and then the white system.

Education was of prime importanceBut just to come back to your earlier question about the family being politicised, I think that at the time there was an awareness that in order to survive and function in such a society you needed to be educated.  And my mother and father saw that education was of prime importance. 

SA:  How many generations of your family had been in South Africa?  And how educated where your dad and mum?

KC:  My mum actually has a bachelor degree in history and English.  My dad I don’t think went beyond standard five or six, but he was able to do his own accounts and run his own farm business -- as well as build a school. 

But the story I was getting to was that, although we were not politicised, my older brother, who is five years older than myself, as he went through high school became more aware of the system around him.  He was clearly far advanced in his thinking for the day, and in his first or second year at university he gave expression to these thoughts and ideas.  To cut his long story short, he was highly politicised.  He was an activist and he formed the group known as the Black People’s Convention, or BPC, along with Steve Biko.

SA:  He was one of Steve Biko’s colleagues?  My goodness!

KC:  That’s right.  He was one of the founders of BPC.

SA:  As you say, cutting a very long story short!  But where did you fit into that, growing up five years behind him?

KC:  I grew up in the shadow of his activities, literally -- being protected by my mother to ensure that I continued with my education, got into university, completed the bachelor’s degree in university, which was a bachelor of science, and then got into medical school.

Obstacles to getting a place in medical school

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Now in those days there were six or seven medical schools in the country, only one of which was for black and Indian and coloured students.  This was Natal Medical School, which is now called the Nelson Mandela Medical School.  In order to apply to the other medical schools you had to gain ministerial consent, and I was refused throughout my university days.  But after my fourth year in university I managed to get a place at the Natal Medical School.

SA:  Why were you refused?  On what grounds?  Because of your brother’s activities or what?

KC:  It’s difficult to say, Sue.  It’s difficult to know what were the reasons.  But I recall all the letters of refusal throughout my university days.

SA:  And how did it strike you, [constantly getting refused a place]?

KC:  It struck a difficult chord, because I went into medicine primarily because my mother believed that I could become a doctor.  I never imagined I would do medicine; I thought I was going to be a biology teacher.  But after I matriculated and went into university she made me believe that I could do medicine, and so I used to send in these applications really for her, and they came back as negative.  In the fourth year she said, “If you would just do me one favour – send in just this once for the Natal Medical School”.  And sure enough it came through. 

Both my brothers, were arrestedIn parallel, my brother’s activities had come to the clear attention of the powers of the day.  You will recall that Mozambique was under Portuguese rule and was then gaining independence and freedom.  Around 1974 the Black People’s Convention put together a rally in order to celebrate the freedom of the neighbouring country. A whole group of them, including both my brothers, were arrested, resulting in the SASO-BPC trial (SASO being the South African Students’ Organisation), which was known as “Saths Cooper and Others”.  Ultimately, I think, 12 of them were convicted and given sentences ranging from five to 10 years.  They served two to three years in confinement during the trial and then a further six years on Robben Island.  In fact my brother’s cell was right next to Nelson Mandela’s.

Visiting his brother on Robben Island

SA:  And in all those years did you go and visit him?

KC:  Yes I did, and those were emotionally exhausting experiences.  Just getting onto the plane, flying into Cape Town, getting an appointment, ensuring that the authorities approved your visit, then getting on to these boats across from Cape Town to Robben Island, and being humiliated -- treated in a way that you were clearly made to feel inferior.  You were put into these places below deck rather than on top…rusty and dirty and it was just horrible.  I did meet Winnie Mandela on one of those trips!   I was wearing a lovely shirt just to impress my brother – my mother had bought it for me – and Winnie commented, “I like your top.”  She knew my mother, they had met on previous visits, and she said, “Your mother would dearly love me to have that!”  Of course on the way back I took it off, put my cardigan on, and gave it to her. [We both laugh].  I wonder if she remembers that story…

But those were difficult days…Then I entered medical school.

SA:  But to go back a little -- you said you grew up thinking that you would be a teacher.  Did you feel that your own aspirations were suppressed by the system?  And did you have low self-esteem?

KC:  I had low self-esteem, oh yes!  I grew up believing that the white population was superior to me.  There was no doubt about that.


SA:  But your brother didn’t share those feelings?

Conscientisation made us all realise we’re no differentKC:  He didn’t share those feelings.  They were the architects of the word ‘conscientisation’. It may be in the Oxford Dictionary, I’m not sure, but it’s a word that literally made you recognise that you’re a human being and no different from any other human being.  It was conscientisation that made us all, the youth of the day, begin to realise, “We’re no different.’   And when I completed medical school, got into my training as a pathologist, and began to mix with my colleagues in the department, who were mostly white, I began to feel part of this human family, part of ‘humankind’, as it were.

SA:  So it was a gradual process?

KC:  It was a very gradual process.

SA:  And did you find that your feelings about yourself affected your studying?

KC:  Not in my education, I could still focus on that.  The educational task was clear: I knew that I had to grasp and gain all that I could whilst I was going through this -- but I was a late starter in medical school.  As you know, in the Commonwealth countries you can go into medical school directly from high school, after A levels.  [I had been to university already] so I was a late starter at medical school -- I was about two years older than the average age of my peers.  I was focused and wanted to do medicine, so that was not a problem. 

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But having said that, there were outside interferences, because this was a period of turmoil.  This was the 70s, and you may recall the Soweto Riots.  All of this affected our student population and all the black universities in the country so that whenever there was an uprising anywhere, there was a ripple effect throughout the country.  Our only means of demonstrating our disapproval [of the government] was to boycott our lectures, boycott going to the wards.  That severely restricted my education.

SA:  How much time did you find yourself having to demonstrate?

KC:  A lot!  Lots of boycotts.  From 1972, when I went to the University of Durban Westville, from that first year I think we spent about 25-30% of our time marching and demonstrating out on the fields, listening to discourses and all sorts of things.

SA:  And how did you feel inside?  I mean, with your passion to do your medicine and also seeing what was happening in the country – how did you manage that, and how did you feel?

An education peppered with protest

KC:  [Reflectively] It was difficult… It was difficult.  Nobody has ever asked me that question.  Nobody has ever tapped into the issue of how I felt.  It was an extremely difficult period.  My brother was a leader of this movement.  My quest, if you will, to educate myself, to realise my mother’s … I don’t want to say ‘ambition’, but her wishes and her vision, brought a lot of turmoil within me.  Because it was a difficult time, trying to concentrate on your work, but during the day you’d be sitting listening to protest songs, and not attending your lectures as you should.  Throughout my university and medical school training the boycotts peppered all of my education, right up until the final year, when we boycotted for more than 30% of the time.  We stood extremely close to losing the entire year, and it was just by a sheer act of will that we managed to write our exams and get through.  It was extremely difficult.

SA:  So you weren’t given extra time?  You still had to pass your exams with all those disruptions?

KC:  Correct.  We normally finished the exams in the final year by October/ November, but due to the boycott this went all the way through to the early part of December.  And if we did not return to work and take our exams, we stood to lose the entire year -- which meant hardships and loans.  My mother was earning, I don’t know, it was R35 or R40 a month -- probably a few thousand rand in today’s money, I’d say…

SA:  So not more than a few hundred pounds?

KC:  No, no.  So with all those anxieties…

SA:  And did you have to pay for university?

KC:  Oh yes you had to.  I took a loan from the bank.  Tertiary education wasn’t free.

SA:  And how did the stress manifest itself among the students?  Did you all manage to talk with each other about your own personal turmoil?

KC:  We didn’t talk to each other.  We did not.

SA:  And did you share it with your mum or anyone at home?

KC:  No, at home you chose not to speak about what was going on at school because of the conflict, you know?  Mother wanted you to attend your classes, get on with your studies, finish up and graduate.  And you were on the verge of becoming a physician…You can imagine the anxiety for a parent, so you wouldn’t talk too much about that.  But you’d try to read at home in order to catch up and keep abreast of what you should have been doing.  Ultimately we did manage to get back to our studies and save the year.  The class of 1980, wherever they are, would know that story…  It was so close.

A visit from the security police

SA:  And are you a cool-headed sort of person?  Did you just think: I will study when I get the time to, or did you find that at the time the anxieties played havoc with your head?

I was able to keep focusedKC:  I was able to study, Sue, and I think that probably carried me through many of the turmoils of my life, externally or internally.  I was able to keep focused on that, thankfully.  I will tell you of another period of my life, my matric year…You’ll recall that my brother was five years ahead of me, so he was already at university when I was in standard 10, which was the final year of my high school.  Days before my final exam, my matric, my brother was arrested.  The security police came thumping on the door at three in the morning, searched the house, and we were all awakened. 

The security police came thumping on the doorBut I was able to overcome those hardships and similar experiences during my university career.  When my brother was being sentenced, and during his trial, I was also able to focus on my studies during the turmoil and trauma around that.  And fortunately I was able to get good grades.

SA:  When the security police came, were they as brutal as the stories one heard?

KC:  Oh yes, they were.  They were huge guys.  Some of these guys had literally to bend their heads to get through the door.  These were huge, monstrous guys.  I mean, they chose very appropriate people! They were rough…They treated my mother gently – or treated my brother gently in front of my mother, but in other rooms or outside they clearly roughed him up.  So those were brutal times. My brother has never shared with me all of his torture and the brutal times he spent in solitary confinement.

SA:  And did he come out of Robben Island okay?  Is he a ‘whole person’ now?

KC:  He’s a whole person now.  I’d say he’s balanced.  He did not continue in politics, for reasons that I’ve not been able to work out.  He’s a clinical psychologist now.

SA:  Not so surprising! [We laugh]

KC:  Not so surprising.  And he spends a lot of his time consulting and attending conferences here in the US and around the world.
SA:  So you didn’t have big political discussions at home within the family?

KC:  Not that you’d expect a family like ours would have, no we didn’t.  It was strange.  There was a lot of conflict because my mother would be having her say about his activities – “Why did you have to do that? Why did you have to aggravate that?  Why did you have to go around giving these pamphlets out?” You know, [feeling that we were] literally “inviting all of these problems”.  Those are the family moments that I recall – a lot of turmoil in that respect.  But the solid foundation of the family was my mother, [who made efforts to] keep a home for us that we could always fall back on.

SA:  So do you look back on that time and remember your parents as supportive?

KC:  Fondly.  Fondly, and with strong feelings as well.

SA:  And are they still alive?

KC:  My dad died in the mid 90s.  My mum and dad divorced, I would say in the mid-60s, and she’d moved to the city, to Durban. We went to live with my mum and attended a famous high school in Durban known as Sastri College.  Sastri, as you’ll recall, is an Indian philosopher and author and the college was named after him.  He was revered in the same league as Tagore.  It was a good school, excellent teachers to whom I owe a lot of my education.  I still remember them… the English master, the maths master.


The thrill of pathology

SA:  You say you thought you would become a biology teacher, when did you start to show aptitude for science, interest in science?

KC:  In high school.  I just loved the laboratories, loved the science and the experimentation.  I just loved it.  Those masters, they inspired us and took us to heights we didn’t believe we could achieve.  But I should add that the order of the day was that no Indian or black or coloured student could ever get beyond a C grade, so C was a merit grade – it was highly acclaimed. 

SA:  You weren’t allowed to get beyond a C?  Why? Who decreed that?

KC:  The government.  That was the order.  So a C student was a merit student, and they were regarded, you know, as extremely bright in our day.  I was no way a C student, I should say! [We both laugh]. My final matric was a D pass.  But D got me to university, and my grades eventually got me into medical school.

SA:  So you did a BSc in biology?

KC:  Correct.  Well, a BSc in physiology and microbiology. 

SA:  And then your mum said, “Go into medicine”?

KC:  Yes.  And I got into medicine, and I loved it.  Loved it.  Just the science of medicine – the knowledge and understanding of disease processes, and translating that into clinical signs and symptoms.  And seeing patients, learning about all the diseases we saw in patients -- it was just fantastic, just phenomenal.

SA:  So in the South African medical training how much pathology did you do?  Because in Britain now I understand there’s a bit of a crisis in that young medics are being taught to be empathetic and to communicate well and so on, but they are learning less science.

I just loved every minute of that – learning the anatomy of the bodyKC:  Oh yes. I learnt pathology over two years.  It was divided into general pathology for the first year, which was taught in the third year of medical school, and then continued into systematic pathology in the fourth year.  And we had the luxury of having true English professors.  Professor Braithwaite, my professor of anatomy, was a marvellous gentleman!  Smoked these cigars, taught us as he puffed on his cigar!  He was an artist, literally, drawing these anatomical structures on the board which were almost [as good as] photographs – that’s what you took in and kept in mind when you dissected a body.

SA:  And did you find that thrilling?

KC:  It was wonderful.  It was thrilling.   It was superb.  I just loved every minute of that – learning the anatomy of the body.  Which then led into the pathology of the anatomy that you’d see.

Inspirational teaching

Professor Wainwright, from Sheffield, was my first professor of pathology.  Bless him, but he died of a heart attack two years after he’d taught me.  He was shopping in the local Indian market with all its fresh food stalls, and he just collapsed and died.  He was really a marvellous soul.

SA:  And was pathology well taught as well?

Nowhere compares to the training I receivedKC:  It was extremely well taught.  We had didactic lectures in all of pathology.  We attended three autopsies a week -- full autopsies, from the moment of dissection to correlating with the clinical notes, to producing a clinical-pathological profile of the entire case.  It was superb.  And we had practicals where we looked at slides, we looked at bottled specimens.  I think we were spoilt.  When I think back now to the medical students in South Africa, [and look at] the training here in the US and other parts of the world that I’ve been to, I believe that nowhere compares to the training I or the people of my time received.

SA:  And Professor Wainwright, did he really enthuse you in what you were doing?

KC:  Oh yes, he did. Oh yes.  He lectured, he wrote on the board, he never looked at his notes -- he’d look at a few things, but he would speak directly to the students, and I just loved that.  Clearly, now that I think back, that’s why I love teaching. I just loved what this man was doing, teaching pathology!  This is what I wanted to do.  It was his enthusiasm that attracted me to pathology. 

SA:  So did you then decide that you wanted to go into the teaching side of things or what?

KC:  Correct; the academic side.  Research had not entered my thoughts.  As a high school student I’d had the idea of teaching biology, so the opportunity to marry both the love of teaching and the love of biology attracted me to pathology.  You saw patients as well, and then later on you realised that you’d had the opportunity to interact with all the physicians in a variety of disciplines, whether it be the dermatologists with a skin biopsy,  or an orthopedist who was repairing a bone in the joint.

SA:  So you were not just backroom boys, you were really involved with the whole team?

KC:  Yes, oh yes.  We had regular ClinicopathologicalPertaining to both the signs and symptoms of a disease (the clinical picture), and the nature, causes and consequences of the disease (the pathology). conferences -- the physicians would come up, we’d meet with them, show them the pathology, and discuss individual cases.  And we still do that.

SA:  And did you see the patients as well?

KC:  Oh yes. Often I’d go down to the ward with my pathology request form, speak to the registrar, speak to the interns or the consultant.  I interacted a lot with the clinicians, and that I think bolstered my training and my art form.

The classical surgical pathologist -- a dying breed?

SA:  And was this more or less unique to South Africa?

Pathology is practised behind ‘the paraffin curtain’KC:  It’s not encouraged in these parts of the world (meaning the USA).  In South Africa it was.  I mean, the hospital was just 20, 30, 40 yards away from the pathology department.  These days I think there’s more isolation of the department, and pathology is practised behind ‘the paraffin curtain’.

The ‘paraffin curtain’ is derived from our tissue being embedded in paraffin wax blocks, and we have this whole archive of tissue in paraffin wax blocks.  So there’s this paraffin curtain that you practise surgical pathology behind, with the clinicians on the other side.   Then there’s also the ‘paraffin bubble’ -- this archive of tissue that’s in our repository, where we keep all these ‘secrets’, that’s the ‘paraffin bubble’.  I hope it never bursts!

The classical surgical pathologist is a dying breedBut coming back to the training – pathology training was multidisciplinary.  We all did -- and still do in South Africa -- train surgical pathologists to practise the art form in all disciplines.  It’s not like in the United States where people would then specialise in gastro-intestinal pathology or brain pathology, or head and neck pathology, or soft tissue pathology.  You train a surgical pathologist for five years in all the disciplines.  This is another concern of mine – that the classical surgical pathologist is a dying breed or dying art form.  You don’t get many classical surgical pathologists any more.

SA:  And do you in South Africa?

KC:  Yes, they’re still doing that; they’re still training that way.  But similar to Britain, there are difficulties in attracting people to the discipline, because of the problems that we all face, the world over, in pathology.

SA:  Are you finding here, and maybe in South Africa too, that it’s the concerns of patient groups about keeping materials and so on that are inhibiting you in teaching, research and things?

KC:  Not so much in South Africa.  Not yet in South Africa.  I don’t think the population has reached that level of, say, sophistication, in order to challenge the pathologist directly.  Whereas here in the United States, if there’s a problem of wrong breast biopsies -- with benign and malignant being mixed up, for example – it’s in the New York Times.  It hasn’t yet reached that level of sophistication in South Africa, because they still have primary problems to deal with.

“Fantastic pathology”

SA:  We’re getting ahead of ourselves a bit… Going back to South Africa, when you’d done your pathology training and you were working at the Edward VIII in Durban, what was your case load?  What sort of things you were seeing?

The wide array of fantastic pathologyKC:  We were busy, and we saw everything, Sue.  I mean, you can talk to pathologists in developing countries and listen to the wide array of fantastic pathology – not from a patient point of view, but from a learning/training point of view.  The range of it, the depth of it, was just surreal.  For example, I spent a week there in July this summer and I was able to get about 12 to 15 -- forgive the term -- ‘cases’ of pathology on slides, which are easy to transport; these would be slides that I could bring to Vermont to train or teach my residents.  Now those 12 to 15 cases (if I can use that word again) of fantastic pathology I would probably take about a year to see in Vermont, but I saw it in a week in Durban. That’s just to give you an idea of what we were seeing.  Yes, that does still exist, that range of pathology.

SA:  What were you seeing?

KC:  Unusual tumours, diseases that you rarely see in developed countries.  HIV/AIDS clearly is a huge problem that presently determines the type of pathology you see.  But over and above that, going back 25 years to when I was training, you were still seeing a wide spectrum of pathology, though not then the HIV/AIDS-related pathology.

“AIDS has changed the face of pathology”

SA:  To a pathologist, is there clearly a time "before AIDS" and a time "after AIDS"?  I mean has AIDS changed the pathological picture very specifically?

Between 30% and 50% of the pathology is HIV/AIDS-relatedKC:  Most definitely.  Again, we’re getting ahead of ourselves, but if I think back to Johannesburg, where I was the Chair of Pathology in the 1990s -- during my time there all HIV-positive patients received a bone marrow trephine biopsy on admission, and during the 90s we were seeing between five and 10 a day just in our department.  Things were clearly starting to change during that period.  And currently, speaking with my colleagues both in Johannesburg and Durban, I’d say between 30% and 50% of the pathology is HIV/AIDS-related.

SA:  And are you seeing different manifestations of disease, or entirely different diseases in HIV-positive patients?

AIDS has changed the face of pathologyKC:  Well, different diseases having a more common manifestation with HIV/AIDS.  For example, an unusual, esoteric tumour known as Kaposi’s sarcoma was clearly described many decades ago, and manifested in Middle Eastern countries and in elderly African males.  It became a common disease during the HIV/AIDS era, and now they see, I don’t know, about four, five, 10 a day of these being biopsied in Durban.  So yes, AIDS has changed the face of pathology.

SA:  The interesting thing is that South Africa, being at the southern tip of the sub-continent, was affected a long time after East Africa – HIV travelled down the continent.   I remember people saying that South Africa had the chance to avoid it, but of course that didn’t happen.  So did you watch AIDS absolutely explode?

KC:  Well yes I did.  Our first knowledge of it was in 1983, and in the early days, when I was a registrar and then a consultant in the late 80s, we encountered the odd cases morphologically, and then we were able to verify them with blood results in those days.  But in the early 90s, when I was in Johannesburg, we then had tests that we could do within the laboratory to determine whether or not patients were HIV-positive.  And yes, that did influence the way we practised and how we thought of the diseases we were seeing. 

With regard to the disease coming down from the north and seeing it grow in South Africa, yes I did.  But whether it could have been avoided, I have very personal thoughts and ideas about that. 

SA:  Like what?

KC:  I think it was inexorable, Sue.  I haven’t thought about it for a long time because I’m not in the mainstream of HIV/AIDS, being in pristine Vermont!   But I think it was inexorable.  You could probably draw parallels to other diseases that have plagued the world, you know?

SA:  Yes, that’s probably so.… Going back to your career story – how long did you spend in Durban, and then where did you go from there?


A fellowship in Oxford

KC:  Well I completed my five years’ training in pathology, and then I did another three years as a consultant.  And during that period I applied for, and received, a Nuffield Fellowship to study in Oxford.  Lord Nuffield, who started the Morris Minor car factory, bequeathed a large amount of money to the Nuffield Trust.  And part of the Trust was the Nuffield Fellowship, which gave a South African, a New Zealander and an Australian a chance to study in Oxford for three years.  Every year one was awarded to someone in each of these countries. The seven or eight medical schools in South Africa each put up a candidate and there was a group of Nuffield-appointed scholars who determined who was going to be the Nuffield Fellow for that year.  It was very competitive and prestigious and I was fortunate to receive the 1990 Fellowship.

SA:  What did you have to do?

KC:  Well I firstly had to get to Oxford, which I did in December of 1989.  My first travels to the UK were in 1987 to write the Royal College exams, which was a beautiful experience – I enjoyed that very much.  But getting there in December 1989, in the midst of the cold…. I then had to meet my professor, James McGee, a Scotsman who had taken the chair at Oxford at the age of 35! (I loved him; I still do.)  The Pathological Society had their winter meeting at Hammersmith that year and I met him there.  He said, “Kum, if you’re going to come into London, come to the Pathological Society meeting and then we’ll go off to Oxford together.”  So I did, and that was my first foray into UK pathology.  Then a wonderful three years in Oxford doing my PhD -- or DPhil as the Oxonian degree is known.

Researches the role of human papillomavirus

SA:  When you decided to try for the Nuffield Fellowship, had you got an idea in your head of something you wanted to study?

KC:  I had.  One of my second choices for a discipline apart from pathology was obstetrics and gynaecology.  I’d enjoyed my various stints of obs and gynae and I just loved the dynamics of obstetrics and the labour ward, as well as the gynaecological
oncology, which I was fascinated by. This was now during my training at medical school.  My internship was over two years, and I’d had a lot of patient exposure.

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There were five gynaecological wards, and every time I’d go into one I’d find 20 to 25 beds with patients with cervical cancer – these were patients who had just come in for staging and grading and then they’d go for radiation, or surgery, and this just fascinated me.  These patients ranged in age from their twenties all the way to their fifties and sixties.  It was during that time that the notion of the human papillomavirus as a causative agent for cervical cancer was being suggested and getting into the literature.

SA:  Up until then, what had been understood?

KC:  Well, it was known to be a sexually transmitted disease a long time ago.  There was the notion of the male factor -- the wife who stayed at home and remained faithful to her one partner but whose husband ventured to various brothels, if you will, and then she would get cervical cancer.  So it was known to be a sexually transmitted disease.  But ideas about the agent itself varied from cytomegalovirus to herpes and a variety of other organisms, until a scientist in Germany by the name of Harold Zur Hausen determined that it was human papillomavirus. 

This was around the early 80s, and I’d learnt about that in medical school.  Then as a pathologist I’d read more about it.  So with the Oxford Nuffield coming up, here we are with tons of material… Forgive me for using this term which seems in a way to be derogatory; it isn’t meant to be.  By ‘material’ I mean patients’ biopsies that I had in my archives and that I could take to Oxford and use to further research on the role of human papillomavirus in cervical cancers -- which is what I did.
  I suggested that subject to Professor McGee who accepted the idea.  Then I embarked on my DPhil and had a wonderful time working in his laboratory.

SA:  I noticed in the papers you sent me that you mentioned using In situ hybridisation A technique allowing scientists to identify particular DNA or RNA sequences while these sequences remain in their original location in the cell.  – was this a new technique?

KC:  It was brand new.

SA:  And it tells you what?

KC:  It tells you that the virus is present.  And the system I developed with Professor. McGee tells you whether the virus is integrated into the host Genome The complete package of genetic material for a living thing, organised in chromosomes. A copy of the genome is found in every cell. , or is episomal, lying within the nucleus.  This is a system that’s being used currently and marketed by commercial companies here in the USA.

SA:  So it tells you how deeply the virus has gone, what stage it’s at in its integration with the cell?

KC:  Correct.  And it’s believed now that that process, the integration into the host cell, is a stage that’s critical for the cell becoming a neoplastic cell, a tumour cell -- being autonomous in its growth characteristics, its ability to divide and then expand into a clone and occupy the resident human tissue, and metastasise and cause all sorts of destruction.  This system was one that was developed in Oxford by Professor McGee’s laboratory.   I’d come in with my material, used that system for the purposes of demonstrating human papillomavirus, published, wrote my DPhil thesis, and went back to South Africa.

The conflict within

SA:  But how thrilling was it doing the research?

Science at its bestKC:  How shall I summarise it?  I wish that every South African colleague of mine could have had the opportunity to spend three years in Oxford.  This was me coming from a developing country into a first world country, into a first world laboratory, which really was science at its best.  Here you are, having trained in a developing country  -- where you did hundreds and hundreds of autopsies, and saw thousands and thousands of fascinating tumours and disease processes --  now at the cutting edge of science in this first world country.  It was surreal… But again, there was the trauma that I referred to earlier, this conflict within me of pulling myself away from the country of my birth and trying to ensure that I got the best out of Oxford.

SA:  You found that difficult, did you?  It was a personal struggle?

KC:  Well, going back to that question you asked about my brother’s, or my family’s politicisation and my ability to continue with my education – they were the same anxieties, the same sort of conflicts that I had to battle through there.  As well as the cold!  Vermont is very cold, but in those days England was cold. [We laugh]

SA:  It’s very interesting -- what I’m hearing from you is that you got an education second to none in practical pathology back home, and saw an abundance of different cases, but the tools and the laboratory facilities you found in the UK were particularly fantastic – is that right?

The technology was just phenomenally superiorKC:  Correct.  The technology was just phenomenally superior; way ahead of anything I’d known back in South Africa. You had to read and learn a lot more.  And it was intimidating.  I mean, getting into London itself, and going to the Hammersmith meeting with the Nuffield Professor of Pathology -- that was intimidating!  Here was I, just an ordinary surgical pathologist from South Africa.

As I said, the Path Soc meeting that year was at the Hammersmith Hospital, and they were running this quiz on slides.  Of course I was this rookie from South Africa, but I thought: I’ll try this out and see what it’s like.  So I entered the quiz.  There was a case of champagne [for the winner].  My dear friend Thomas Krausz, who’s now in Chicago, was at the Hammersmith then and he was the adjudicator.  Years later when we’d become friends, he told me I’d almost won that prize.  It’s a lovely story.  I didn’t know I was that close, but Professor McGee knew.  Somebody had told him.  And he, being the lovely soul that he is, was singing my praises throughout Oxford.  You know, he would tell people, “Oh, he almost won this competition”, and that sort of thing.

SA:  But were you never aware of how good you were?

I was this rookie from South AfricaKC:  I never bothered about that, Sue.  It just never entered my head.  I just enjoyed getting on with things.  I still do.  The thing that brings me most joy, apart from my immediate family, is sitting with residents (or registrars) and a multi-headed scope and looking at slides!  And asking them questions and showing them things, and having them ask me questions.  That gives me the most pleasure, even to this day: I still spend an hour a week with my residents on the multi-headed scope going through all sorts of pathologies.

SA:  When you first arrived in London, and then went up to Oxford, did you have to fight through your shyness and diffidence?

I was getting used to the idea of having whites as colleaguesKC:  Yes, yes.  Remember, this was coming after a period back home when I was getting used to the idea of having whites as colleagues.  In South Africa there was still a sense of animosity between the whites and non-whites, but you’d want to break away from that, because these are now colleagues and you’re working in the same environment.  You lived in different areas of the suburbs or different doctor’s quarters, ate lunches in different places, but you still worked together, and there was a level of acceptance and understanding. 

And the United Kingdom was now a totally different environment, because they were predominantly Caucasian people.  I had to understand: these people are different, these are not the oppressors; these are not the people who voted in the apartheid system; these are now good, loving people and you need to work with them.  And of course they spoke differently.  But the cultural, social, geographical change was an enormously stimulating, exhilarating experience.

No bitterness

SA:  Tell me, when you first started to work with whites in South Africa, how did you cope with the fact that apartheid regulations about where you could live etc were still in force?

KC:  You worked with white colleagues, but of course [in the early days in Durban] you never socialised with them.  But towards the end of the 80s – around 88/89 – a social scene was beginning to build up, so you would have your colleagues home for a meal, or eat together at a restaurant. The apartheid system was starting to break down; we could go to the same restaurants.  And so during that period you were able to get to know your colleagues better – which was important.

SA:  So did you make friends?

I like not to dwell on the past or hold bitter memoriesKC:  Oh yes, most definitely.  And I have more friends in Johannesburg (we haven’t come to that part of my story yet). But yes, I have some dear, dear friends.  Some of my best friends are white.

SA:  And did you find that you yourself harboured prejudices too?  “Okay, these are the people who voted in apartheid.”  Did you have complicated thoughts in yourself about white people?

KC:  Let me answer it this way.  After the dismantling of apartheid, there was no white man who had voted for the apartheid regime! [We both laugh]  There still isn’t.  I’m not being judgmental or critical, but there never was anyone who’d voted for the regime, and it was a joke amongst us.  But I have some dear friends and I still spend time with them when I go back to South Africa.

SA:  So are you by nature not a very judgmental or bitter person?

KC:  No, I’m not.  I like to get on with whatever is the order of the day, engage with what’s at hand and give my best.  I like not to dwell on the past or hold bitter memories.

Mandela’s release: a bittersweet moment

SA:  You asked me to remind you of February 1990…

Here was Nelson Mandela being released, history was being made back homeKC:  Yes February 1990.  Here I was in Oxford, in the bitterness of mid-winter, sitting in a room similar to this [sparsely furnished and a little austere] and watching television. The date was February 11th, and here was Nelson Mandela being released…  In my country, and I’m sitting in Oxford with this warm cider, watching this little box.  What was I doing in England?  My wife and son of three months had not joined me at that time so I was all alone in England, getting this surreal experience in cervical cancers and human papillomavirus etc.  But the fact was that history was being made back home, and I wasn’t there.  Can you believe the atmosphere that must have prevailed in the country? This was the fruition of my family’s contribution to the struggle and I wasn’t part of it.
SA:  Did you weep?

KC:  Yes I did.  I did.

SA:  And did you share it with anybody in Oxford.

KC:  No.  I couldn’t.  Who could I have shared it with?  I didn’t even think about sharing.  It was the same as when I was a student -- you touched upon us sharing our conflicts as students and trainees:  no, you just absorbed it.  Maybe it’s just the stiff upper lip that the British taught us!  [We laugh]

SA:  Absolutely -- you’ve learnt it better than anybody!  That was undoubtedly a thrilling moment when Mandela was released, but after that, things got very, very difficult in South Africa.  So did you go on feeling sad to be out of the country, or were your feelings watching him being released sort of the ‘crystallisation’ of a moment?

KC:  It was the crystallisation of a moment which you carried in your heart through that time.  As you say, in the four years leading up to 1994 [and the first all-race elections], there was much turmoil, which, admittedly, made us question whether we wanted to return to South Africa or not.

SA:  Your wife had joined you in Oxford?

My tears just poured down on to his faceKC:  My wife had joined me and I should tell you, just briefly, this poignant little story, because I hadn’t seen my son in over six weeks when they came over.  I’d taken the Oxford coach to Heathrow, picked them up at the airport with warm jackets, and we’d stopped, just before emerging to the coach terminal, at the escalators.  Between the escalator that goes up and the one that comes down there’s a broad ‘counter’, if you will.  I placed my son there in order to put his jumper on.  He was asleep.  As I was putting it on him he woke up -- he was barely five months, and he hadn’t seen me for a long time, but he recognised me and he reached out and touched my face.  My tears just poured down on to his face.
So I put his warm clothes on, tears in my eyes, and we bundled ourselves back to Oxford.  We lived there for three years, welcomed guests and friends and family, and enjoyed the pubs and the Iffley River.

SA:  And what was going on at home?  Were you very conscious of that?

KC:  We were very conscious of things going on at home.  There was a lot of turmoil as conflicts began to emerge between the various factions in the country.  The apartheid government -- and the police particularly -- were still very much in control.  The turmoil resulted, in mid-1992, in the Boipatong Massacre, where several people were shot and killed.  My wife and I thought, “Oh my God, what’s changed?  What’s going on?”  And we seriously thought about staying on in the UK at that point.  But in the meantime Johannesburg, the University of Witwatersrand, had approached me. 

Whilst I was a student at Natal Medical School -- this is 1987-89 before coming to Oxford -- I was in charge of coordinating the third year medical curriculum, and I had to deal with the various heads of department.  The professor of microbiology was Jan van den Ende, a dear man – I’d got to know him and work with him.  I was just a young consultant, an underling, and I had not realised that a year later, after I’d gone to Oxford, he’d taken the job in Johannesburg as the director of the South African Institute of Medical Research (SAIMR).  His head of department was stepping down, and he called me to interview for the position. 

I was 36 and I said to him, “Professor Van den Ende, why me?” And he said, “Well, why not?  I worked with you in Durban and I know what you’re capable of.  I want you to come and interview for this position.”  I said, “There are several other people who have been groomed for this position.” And he said, “I don’t care; you’ll come for an interview.”  And so, late 1991, I went down to Johannesburg, at the age of 36, to interview for that position.  I was still in Oxford, they paid for me to go to Johannesburg to interview.  It was several months before they contacted me and said, “You’ve got the job.”

I was to be the first medical professor of colourThis was the University of the Witwatersrand; I was to be the first medical professor of colour in the medical college.  Talk about the anxieties of going to Oxford, this was twice that anxiety!  This was the doyen of white tertiary education in South Africa.  ‘Wits’ was one of the two leading institutions in the country – the other was the university of Cape Town (of course Wits thought they were better than Cape Town, and Cape Town thought they were better than Wits! It’s the Oxford-Cambridge conflict).  And here I was, at the age of 36, a young Indian lad interviewing for the head of department in anatomical pathology.  All of my consultants in the department were white. 


Breaking down barriers

SA:  So you went back to this job in South Africa.  At that stage Wits was going through some turmoil too, wasn’t it?

KC:  Oh they were. They were going through their own turmoil with various attempts to manage the social changes in the country. 

SA:  But you decided to go back?

KC:  Well, I was being…what’s the word? Wooed.  I was flattered, and when I was offered the job I took it.  My interview panel was about 25 members of senate and the principal and vice-principal -- all the really big names at Wits.  And to cut a long story short, I got the job.

SA:  Were you nervous about taking it on?

Remember, this was a changing societyKC:   I was nervous about the idea, not the ability.  Not the pathology, not the administrative component, not the teaching component – I was comfortable with all of those, because that was no different to me from any other department in the world.  So those did not in any way make me anxious. The political component made me anxious.  Remember, this was a changing society. You do not just flick the switch and say, “Okay, yesterday was apartheid, today we have no prejudices.”  So you were going to have to be dealing with people who clearly had prejudices. 

A simple example: during my tenure at Wits I’d had people coming to my office, and my secretary, Molly Long -- bless her, she’s still alive, and I still communicate with her – if she had stepped out and somebody had come into her room to look for Professor Cooper, they’d say to me, “Good afternoon, we’re looking for Prof. Cooper”.  And initially that hurt, because here was I, the head of department, and people were asking me for Prof. Cooper.  (Okay, the name is a different story, we can go on to that.)  But eventually I developed this mechanism whereby I’d say to them, “Oh, he’s just stepped out.  D’you mind leaving your name and address and I’ll get it to him.” [Laughs]  I made it into a fun game; I did that several times and left it at that.  Of course they discovered later that I was that person, but I never encountered anybody who came back to me and acknowledged it.

SA:  But if you did say, “I’m Professor Cooper” did you ever see prejudice registered on their faces? 

KC:  I rarely introduced myself by title; that was not my style.  I just didn’t have it in me to say “I am so and so”, I just could not.  So, coming back to that question, yes, those were anxious days.  But I was accepted into circles, and the principal and I were close friends.

SA:  You were going to tell me how you got the surname Cooper…

KC:  Well my dad was an orderly in a white hospital, the Addington Hospital, in the early 1950s, and they could not pronounce his name, which was not an uncommon phenomenon in the old South Africa.  His name was Appasamy Perumal Govender, but they called him Cooper.  So when he left being an orderly at this hospital and went back to the farm, he took on the name of Cooper.  He changed his name to Cooper!  His first two sons were already born, and their two birth certificates had Govender struck out and Cooper written above it.  I was the only Cooper born Cooper from the three offspring of my parents!

SA:  Going back one step to Oxford when you were doing your DPhil -- that was an important bit of research, what became of it?  Has it changed the way cervical cancer is seen in South Africa and other places?

KC:  Well not in a broader sense, but studies that we conducted have contributed to understanding the mechanism of the disease.  And the system that we used – in situ hybridization – was, and presently is, one of the unique ways of determining the physical state of the virus.  It is presently being marketed as an assay for laboratories to use, particularly here in the United States, and I think other countries as well.  Like I said, the integrated virus clearly gives an indication of how that cell is going to behave, and so in that small sphere this has contributed to understanding. 

The South African Institute of Medical Research

SA:  Okay, so after Oxford you went back to South Africa – you were going to tell me something about the South African Institute of Medical Research…

KC:  The SAIMR is a pathology laboratory system that was created by the old government in the early part of the last century, really to provide a pathology service to the mines.  And as hospitals were built in the peripheral areas, the government then engaged the SAIMR to take over the pathology of these various hospitals too. It grew to doing literally 80% of the pathology of the country.  The SAIMR grew to be a huge laboratory and needed a director.  There are various groups within it – microbiology, anatomic pathology, etc.  They were academically linked to the University of the Witwatersrand and so these departments functioned as teachers to the university as well as service administrative components to the SAIMR.

SA:  And were you yourself doing both as well?

KC:  I was doing both as well.  So you had two bosses -- the dean of the medical school was your boss and so was the director of the SAIMR, who was your laboratory boss.  You answered to the dean about how you were teaching his students and doing research, and to the laboratory boss you took care of service and reporting of patient pathology.

SA:  Looking at the Wits side of things – you went back to Wits at a time of massive change, as you say, a time of transformation to become part of the New South Africa.  It must have recalled some of the things you had been through as a young student, seeing boycotts and turmoil within the university.  Did you see that among your students?

KC:  No. Wits was, I think, one of the earlier campuses to change the colour of its student population.  It did, it actively changed, and the group I taught at Wits was truly a mixed group of South Africans. 

But remember, this was the late 80s, just coming into the 90s.  Many of these children were coming through an education system that was already inferior.  Students who came from disadvantaged backgrounds clearly needed more help in terms of getting them through a first world curriculum at Wits.  And so there were systems in place, with English language and understanding and communication, which helped these students reach the required levels.

SA:  And what was it like for you?  You say you went to Oxford and were absolutely bedazzled by the facilities and resources you had – going back to South Africa, how did you take returning to a system which didn’t have those kinds of resources?

That brought a lot of joy to meKC:  It was good, and I’ll tell you why.  In Oxford I was able to meet people that I’d only read about.  There was Kevin Gatter down the corridor and David Mason -- these were big names, people that I’d only read about, and I could walk across and chat with them.  So you became accustomed to speaking to people who were academically of extremely high calibre; people who were published and at the cutting edge of their fields.  And so coming to Wits I brought all of that experience and used it to try to create a similar system.  I tried to create a microcosm of it within pathology, which meant allowing consultants and registrars to do research as well as their service work, and to engage in molecular research that I’d learnt in Oxford. 

That worked to great satisfaction. I was able to take technologists from the laboratory, train them, and put them into the research laboratory, and it was hugely successful.  We became one of the most successful pathology departments in the country.  The way to judge it was at the annual meetings -- we contributed by far the most presentations during the period that I was there, and that brought a lot of joy to me.

SA:  So what were you doing?  You were bashing down academic barriers?

KC:  Correct.  And creating new avenues.  And you had the ability to do this because, remember, this was a changing Wits, and you took advantage of that.  Here was this SAIMR director, Professor van den Ende, whom I knew from Durban, who had recruited me.  I said to him I wanted to create this laboratory and he said, “Go ahead, Kum.”  There were these two rooms packed with all sorts of things.  He said “Clear them out, put in the equipment.  You need money?…”  So he was able to make that happen.  “Bring in the techs…”  These were service technicians who were involved in the daily service loads.  He enabled us to bring them into a research laboratory, train them, and then he continued to provide a budget to ensure that we could fund research projects that pathologists and trainees could engage in.  So it was combining that.  And that was hugely successful.

SA:  And cross-fertilisation of ideas, with everyone throwing in their bit of expertise…?

KC:  Correct.  With collaboration with Haematology The branch of medical science concerned with the blood and blood-forming tissues;  haematopathology is concerned with diseases of. -- bringing in the haematology resident to perfect PCR techniques for determining clonality of LymphomaCancer originating in lymphoid tissue, a key component of the body’s immune system.  Cancers of lymphocytes (lymphomas) and other white cells in the blood (leukaemia) together account for about 6.5% of all cancers.s and determining the presence of other viruses like Epstein-Barr virus, and all sorts of projects.  Hugely, enormously satisfying and rewarding.  That was one of the reasons why my present boss got me across to Vermont; that was the component that attracted him to me.  But we’ll come to that.

SA:  So how did the research impact on the service provision?  Did you find that your skills and expertise in the service provision were enhanced as well?

KC:  Oh yes, most definitely. We were then optimising tests within the research laboratory that we would use for diagnostics for patient care. So yes, it was practical – it enabled us to translate a thought or a question based on observation of some morphological changes into an experiment that you could then perform in a research laboratory.  So it was enormously satisfying.  I had consultants and trainees who worked through that.  They derived a lot of benefit academically, career-wise, as well as finding it clinically satisfying.

SA:  You say SAIMR was set up originally to service the mine hospitals, how much pathology did you find stemming from the mining enterprise?

The Dream Team!KC:  Oh a lot.  We saw occupational diseases particularly – tuberculosis, fungal infections… These were diseases that were somehow related to the exposure of patients to the hazardous dusts that they breathed.  A lot of that pathology would come into our department for examination, and assays and testing and reporting on.  In fact there was a department of occupational pathology which was a sub-division of anatomic pathology.  The idea of the link between asbestos exposure and mesotheliomas emerged from the southern African experience, and I had the pleasure of working very temporarily with one of the original pathologists involved with that.  He died, but his grandson, by the name of Wagner, was one of the seminal workers in that area.

I just totally loved the group that I worked with.  I have this black and white photograph in my room with my consultants, whom I called the Dream Team!  It’s a group of these core pathologists that still work there and I still spend time with them.

“If you can’t get in at the bottom, get in at the top!” 

SA:   We've jumped a bit ahead of ourselves.  Let's go back to when you first left Oxford…

KC:  We returned to South Africa late 1992 after three years in Oxford, solid years, and I began work at Wits in December of 1992.  I was now 38.  As a new professor there’s a compulsory lecture that you have to deliver to the entire faculty and staff and students.  It’s the inaugural lecture and it’s in open forum. Very formal, with regalia.  The principal, vice principal, dean, and a host of senate members attend this, and several months are spent arranging it all.  And there’s a dinner afterwards, where you’re invited to the principal’s private dining hall with some of your private guests.  I’d invited my family.  My mum was there, my in-laws and my wife and brothers.

SA:  And your father?

KC:  No he was not there.  I tried to get hold of him, but for some reason he couldn’t come up from Durban.  I don’t know why.  But my mum was there and I took the opportunity to pay tribute to her role in my doing what I was doing – being at the institution where I was.  And that was very poignant for me, because things had come full circle, if you will.  I’d achieved, in her eyes, the ultimate you could achieve in academic pathology in South Africa, as a chair of a department.  She was hugely proud!  Tears welled in her eyes and she couldn’t stop smiling. 

That’s a personal story, but there’s another story I wanted to tell you too. You recall my many attempts to get into one of these universities as a medical student, and requiring ministerial consent, and getting several letters of refusal (which I never kept, but I should have)?  Wits was one of those institutions that had turned me down -- not once but twice!  And I referred to that in the opening deliberations of my inaugural lecture.  After paying tribute to my mum, I recalled the difficulties I’d faced in getting to medical school and how I’d applied to Wits not once but twice and been refused.  And so the motto I created at the time was “If you can’t get in at the bottom, get in at the top!” 

That served two purposes – because, again, I was anxious.  I was addressing a topic that was close to my heart, on the research I’d done in South Africa -- watered down for a lay public, because I was delivering an inaugural lecture to the entire campus -- but I was still nervous.  I was nervous because it was an inaugural lecture, and I was nervous for all the reasons I’ve alluded to earlier.  This was a new faculty to me and I was anxious about whether I would be accepted or kicked out.  One of my senior mentors, on hearing about me taking on the job at Wits, said to me, “Kum, they will chew you up and spit you out.”  Those were the words he used, and they stuck with me. So here I was in 1993, delivering this lecture, thinking about those words: am I going to be chewed up and spat out?  What was going to be my fate? 

So, as I say, the delivery of that little story served two purposes: one, in somehow getting back at the system; but two, it also served to defuse some of the anxiety, because of the response of the audience to that.  There was hearty laughter, and that allowed me to relax, and I was able to deliver my lecture!  [We laugh]

SA:  So you’d finally said it, and it was received?

KC:  Correct.  I’d sought permission to say it.  I’d shared it with the dean of the day.  I’d said to him, “I have this story that I want to tell,” and he said, “Go ahead, Kum.”  And it brought some relief.  I wasn’t sure how it was going to be received.  There was the anxiety of that, as well as the greater anxiety of me being accepted as a member of faculty within this prestigious institution.  But it defused all that.

Apparently, unknown to me, that was the story around the campus a few days later.   I heard that that was the buzz going around the main campus – which brought some warmth.  This was the only medical professor of colour.  (There were PhD professors of colour on campus, but I was the first medical professor, from Natal University, who had been appointed.)  So there was this enormous responsibility, as well as the personal anxiety which I was trying to work through.

Another thing I should mention, and I don’t have any explanation for it, but it’s worth telling you…When I’d interviewed in December of 1991 there were 11 or 12 white consultants in Johannesburg at the University of Wits.  When I took the job a year later, in 1992, there were only four.  Now, whether they’d left because of the changes in the country, or whether they’d left because of changes within Wits, or whether they’d left because I was coming, I do not know.  But there were only four consultants left.  And we then began to build that department, which is where the research laboratory came in, the translational research laboratory.

SA:  So the politics of race in South Africa was always raising questions?

KC:  Always.  Always.


Voting for the first time

SA:  Okay, 1994? [The year of the first all-race elections]

I’d never voted in my lifeKC:  1994 was spent trying to get into the daily routine at Wits, but the highlight of 1994 was of course April, which was the vote.  I’d never voted in my life.  My wife and I talked and talked about this, and the day of the actual vote, we impulsively (like we did most things in our lives) got into our car, drove all the way from Johannesburg to Durban, to the suburb where we’d built our house before we’d left, and voted there.  And it was enormously emotional, hugely emotional – to cast that one ballot!  There were something like 27 different parties, but there was only one cross for the man you voted for, and it just had to be for Nelson Mandela.

We’d got there pretty late – four or five in the afternoon – it was windy, the sun was setting, we went into this huge hall which was the local cultural centre of this Indian suburb, and placed our vote.  We came out emotionally relieved, crying, and again not sharing -- I don’t know why, but there wasn’t this culture of sharing.  We cast our vote, and it changed the way we thought about our country, ‘the rainbow nation’, and the phenomenon of this almost non-violent change.  I say ‘almost’, because there was a lot of violence but it never went over the edge.

It changed the way we thought about our country, ‘the rainbow nation’Then five years later, in 1999, South Africa completes the five-year cycle.  We were moving in March 1999 to Vermont, and so I’d sort of missed the voting.  The heartache of moving house is difficult enough, but moving country?  It’s enormously difficult, and enormously challenging, so voting was not a priority in our minds.  We moved and literally missed that vote.  But then going forward to 2004, we learned that, as South Africans living overseas, we were not allowed to vote.  The ANC government had somehow changed the law so that certain citizens could not vote.  That hurt me, and still does.  Only those people who were travelling from South Africa during the voting period, and who had previously registered, could vote. We as South African citizens living in the United States could not vote.  Again, another trauma, more conflict.  It caused me so much heartache to realise that the country of my birth had literally rejected me, because I was not allowed to vote anymore.

Here I was, born in South Africa, been through an education system with enormous trauma because of the politicisation of my family.  Although I wasn’t directly involved, I was worse, I was a wimp!  I didn’t have the fibre to face up to those security police, nor could I take a beating.  But my brothers had done so, and I’d grown up with all of this.

My brothers and mother and family were still in the country, but here I was, 2004, in the United States, and not allowed to vote.  The previous apartheid system had not allowed me to vote.  I’d voted for Nelson Mandela out of emotion, not out of support for the ANC -- because, remember, I’d aligned myself with my brother’s group which was the Black People’s Convention – but out of pure emotion.  So I’m sitting here telling you that the only time I’ve voted legitimately in my entire life was that one vote in 1994.  For Nelson Mandela.  And I hold that dear to my heart. 

SA:  And then his party rejects you?

I’m a citizen of the worldKC:  Correct.  And so I’m a citizen of the world, and I refuse to vote again for the rest of my life – for anybody.

A sense of alienation

SA:  So yes, where do you feel you belong?

KC:  I don’t.  I just enjoy my pathology wherever it is.

SA:  And you don’t feel you should be back home, be part of the continuing struggle in South Africa?

That’s left me drained of feeling a sense of belongingKC:  Not any more; not any more.  When I left South Africa in 1999 I left the department  in the solid hands of Alan Paterson, and I was very happy that he was in that position. Two months ago – which is why I’m telling you now about the way I feel about not belonging anywhere – his family was watching television on a Saturday night, their house was broken into by six criminals, they were abused.  I won’t go into detail, but that has left me enormously eroded.  And I feel…what can I say?  When I think about it, it breaks my heart.  Here’s a person I had worked with, a family I loved.  I really won’t go into detail, but the reports in the paper did not do justice to it.  But that’s left me drained of feeling a sense of belonging.  It has.  Pathologically I still go back to South Africa and teach, and enjoy teaching and contribute as much as I can.  My family is still there, my friends are still there.  I love them all.  I love the people of South Africa.

My family is my home away from pathology, and pathology is my home away from my family.  How else can I put it?  Pathology has taken me all over the world, and I’ve visited lovely people. That’s it. I try to be the best that I can in whatever I do.  So where do I belong?  And what does it matter any more?


Settling down in the USA

SA:  Okay, so to your Vermont days...

KC:  That begs me to go back to 1990… In the 80s in South Africa as a young consultant I was impressionable, and I saw this name, Christopher Fletcher, publishing papers with dynamic new ideas.  I’d read these papers in Histopathology, which is a British journal.

SA:  Was it his stuff on soft tissue tumours?

KC:  Yes, soft tissue tumours.  These were just emerging, and as a registrar he was already making his mark in soft tissue pathology.  Anyway, I had this impression of Christopher Fletcher from reading the journals.  Now in 1990 I was in Oxford, and the next Path Soc meeting was in Belfast, Ireland.  Of course Belfast was a re-enactment of South Africa, with the guns and the army.  I thought to myself, “What are you guys worried about?  I’m used to it!”  Bars and fences and barbed wire and all that! “This is no problem.  Let’s go to the pub – it’s Guinness time!”

Anyway, in Belfast for the Path Soc meeting, in the bus to the accommodation, I see this Dr Fletcher sitting at the front in this black suit and red tie.  I knew it was him because he’d delivered a paper or made a comment and I’d linked the name with the face.  I was impressed by his charisma and the way he answered the questions.  I saw him sitting all alone in the bus, but of course this is Britain, no one approaches someone who is on a pedestal!  But I went up to him and introduced myself, and we’ve been friends ever since.  How many men have I said loved now?  I forget!  But he’s clearly one of them, and he’s dear to my heart.

I’ve never worked with him, but I was one of those people who used to send him specimens, from South Africa. We’d send him fantastic cases that he couldn’t work out!  They were always challenging and he’d say, “Aagh, it’s that Kum from South Africa sending me these difficult cases!”  And we just developed that relationship, and in 1993 I think it was, we invited him to South Africa on a visiting professorship.  He spent two weeks with us and that’s when we forged our friendship, as I would drive him all around the country visiting departments where he’d deliver his lectures.

SA:  And do you share his mindset – the fascination with the challenges down the microscope?

KC:  Oh absolutely.  I think that’s our ‘secret link’, if you will.  We share this passion. We never talk about it when the families are there – we’re not allowed to!  But yes, we could spend hours talking about pathology.  I love spending time with him in his department when he ‘signs out’, and seeing all these wonderful cases from all over the world.  He is the leading soft tissue pathologist presently in the world, there’s no question about it.  A lot of people see his English ways as being perhaps a little brash, but when you get to know him he’s ever so humble -- and ever so caring. 

People have talked about his legendary memory – he’s got this enormous capacity.  I was with him a couple of years ago and we were looking at this case that was very difficult.  We were going round and round, and then I said, “Chris, have you thought about this particular diagnosis -- a round cell liposarcoma?”  Forgive me for mentioning long scientific names, but it’s pertinent. Chris said, “Oh yes, Kum, that’s a good thought.”  I said, “Well you know Chris, this reminds me of a case that I saw in 1987 at St Thomas’ in my final Royal College exams.”  (This was one of 20 cases we were given and I gave him the history and told him about the Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms. .)  And he says, “Oh I know about that case -- I put it in there!” (He was at St Thomas’ at the time, but I had never met him there.)  And then of course he goes over to the filing cabinet of thousands and thousands of slides, opens the drawer and pulls out the case that I’d seen as a young consultant in 1987 at St Thomas’.

SA:  That’s a phenomenal story!

KC:  And it doesn’t end there.  Because, we then started talking about the case [I’d had in the exam] -- it was extremely difficult, but I’d found a few criteria that led to that diagnosis -- and he said, “Yes, but they never believed me then. They didn’t believe it was a round cell liposarcoma.”  I said, “Why? And why did they put it in the exam if they didn’t believe you?”  He was a young upstart, he was a young registrar and nobody would believe him that it was that diagnosis, but they’d still put the case in the final exam.  He told me that story!  The fact is he was always three streets ahead of the rest of us, always enormously ahead of the pack.  That’s just a little side story I thought I’d share with you.  He just has this uncanny ability.

So the friendship with Chris Fletcher began in 1990, and we’ve built on it over the years.  Obviously he knew about what I was doing in South Africa, and about our academic activities, and the cases that I was sending to him kept us in touch with each other in a diagnostic sense.  Vermont was looking for a director…It’s actually a similar situation, where you have the chair of anatomic pathology but you report to the chair of pathology, that’s the system in the United States.  There’s the chair of pathology and of course there’s a director of anatomic pathology and a director of clinical pathology.  And within these two disciplines you then have Haematology The branch of medical science concerned with the blood and blood-forming tissues;  haematopathology is concerned with diseases of. and microbiology and immunology and all the various clinical disciplines under clinical pathology; and under anatomic pathology you have surgical pathology, cytopathology and autopsy.

So they needed a director, and they had been looking, I learnt subsequently, for a couple of years.  They’d engaged a recruiting agency from Chicago, which had sent out notices to various people, and one of these had come to Chris Fletcher who said to them, “There’s this guy in South Africa you may want to contact.” 

They called me in April of 1998 and I said, “Thank you very much, but I do not have any United States qualifications, nor am I planning to write any of these exams.” (You had to do your medical exams and then your pathology board exams, so it was just a nightmare.)  This guy said to me, “Look, this is an issue for the chairman; let me have him call you in 24 hours.”  The next day the chairman called me up -- it was Ted Bovill, who’s my present chair -- and introduced the position to me. Of course, I then told him, “I do not have any qualifications, nor do I plan to get them.”  And he said, “There’s no problem.  There’s a law in Vermont known as the Groebler Law… ” which still exists – it’s still in the statutes.  This is named after an anaethesiologist, (or anaesthetist as we say in Commonwealth countries), whom Vermont had tried to recruit many decades ago, I think, and they’d introduced this law whereby they could appoint senior physicians who do not have the qualifying board exams of the United States.  They had to be senior and they had to work in an academic environment.  So there it was.

Ready for new challenges

SA:  So how keen were you?  How ready were you to be wrenched from what you were doing in South Africa?

It was tough living with a family in South AfricaKC:  I think I had done everything that I wanted to in Johannesburg.  I now realise that I was looking for other challenges.  I was looking to experience what it was like working in a first world country, seeing first world pathology, and working in such an environment. I was looking for a new challenge, so that’s how I came to Vermont.

It was tough living with a family in South Africa in the sense that there were social challenges, and crime was a problem – I should admit that to you.  We’d had cars stolen, and cars broken into, house broken into.  So there were the social challenges which were emotionally difficult to handle, because you’d been through so much change in the country, but you were still exposed to these issues where you felt that the government of the day should be protecting you.  My older son from my first marriage lives in Cape Town, but my younger son, who is now 18, would say to me, “Are the robbers going to come tonight?”  Those are just small memories of my feelings about what was going on.  You begin to revisit the entire situation of what you’d worked for, aspired to, and having your child say this to you…

But Vermont was hardly what I thought I was looking for.  Vermont’s beautiful, you see four seasons like in England, but it’s a country of its own.  We had to adapt to the American way of life, which is different from in South Africa and in England.  We could go to England in a flash, and adapt to England much more easily than we could to the United States.  The work environment was second to none; there were no problems in that respect.  You were able to function as you did in any department, except that the pathology was different – the type of cases you saw were different.  This was all first world pathology, pure first world pathology.  It was more diseases that pertain to lifestyle – the ‘cost of living’ as we call it – rather than diseases due to starvation and hunger and infection.   

Of course I was familiar with the pathology.  I mean, I’d seen some of it, because, remember, Johannesburg was unique in that you saw developing country pathology and first world pathology in the same place.  The white population was similar to the American population, so you’d see those diseases.  And of course the disadvantaged population was still exposed to all of the environmental pathology which you didn’t see here in the US. 

SA:  And did you find it as interesting, the actual cases you began to see here?

KC:  Oh yes, oh yes.  It was interesting; it was a new challenge immersing myself into that kind of pathology.  And of course the other challenge was the regulatory bodies that the United States has -- the accrediting bodies that have rules and policies on how you report things, the detail that you require.  These are enormously time-consuming.  There are aspects of it which are useful for prognosticating and allowing clinicians to determine how they will treat their patients, or how long they will be disease-free.  But there are things that are over-bureaucratic and we don’t know why we’re doing them -- is it just because they say so, or what?  That exists all over the world.

SA:  But are you finding pathology here still as challenging as it ever was?  Have you got new horizons to go to?  Or do you find yourself more in a “steady state”?

What we are leaving behind is classical pathologyKC:  Okay, that’s a question I’ve been throwing around in my mind for a quite a while now.  I think the answer is that the challenges lie in being in a national position and able to contribute to the way pathology is moving into the new century.  That’s serving on national bodies, like ADASP, which is the Association of Directors of Anatomical Pathology.  I served on that for five or six years.  And there’s another body known as the College of American Pathology that I’ve served on for the last eight or nine years, ever since I’ve been in the United States.  These national resource committees help educate pathologists and help pathologists define their role in their own laboratories. So I think that’s the role I see myself serving more and more – that’s where the challenges lie.

The steady march of over-regulation

SA:  You say “moving into the 21st century” – do you think pathology is changing?

KC:  Yes it is.

SA:  Into what, and from what?

KC:  I don’t know into what, but what we are leaving behind is classical pathology -- and in my own discipline that’s classical surgical pathology.  The teachers of my era, of the last century, that I referred to -- the English teachers in Natal Medical School who influenced me -- I think we’re leaving that era of classicism, if I can use that term.  Leaving it for what?  A renaissance?  Whether it’s for the good, or for the not-so-good,   Time will tell.

SA:  What do you think?  How do you feel about pathology at the moment?

KC:  There are several aspects to it, Sue, if I may say, at different levels.  If you look at the practice of pathology, one of the challenges I faced and enjoyed and have immersed myself in is the governing of the quality of pathology – the regulation of it – which is good.  I should mention that there is still a disparity between the way that we practise pathology in the United Kingdom and the United States and in the developing world – there still is a wide disparity.  And so one of the challenges here was becoming accustomed to those quality measures and those regulations, which were good, and I’ve immersed myself in them.  But I do believe there may be over-regulation, which could then destroy the classicism from which we came.

SA:  And are you managing to challenge some of this over-regulation?

KC:  I am.  I am, but in a small way, not any major way.

SA:  This is very interesting, because I get the sense from what you’ve told me that you have seen really fascinating pathology and you’ve been given your head – a bright person with good science can do wonders in the third world. And I also get the sense, from all the stories I’ve heard, that the over-regulation in the western world is really inhibiting to good pathology.  Is that what you’re seeing?

KC:  Oh yes.  Most definitely.

SA:   And what can be done about it?  I’ve met pathologists who are hopping around in frustration and yet somehow the world out there doesn’t understand…

KC:  I haven’t thought through solutions or answers to how we could avoid this. I may be fatalistic, but I see it somehow as being inexorable, the over-regulation, not only of pathology but of various aspects of practices that we do.

SA:  But is it inhibiting good clinical care of people?

KC:  No, I don’t think it’s inhibiting good clinical care.

SA:  Well I mean, if pathology is the foundation stone of clinical practice, how can pathology be badly affected without it affecting everything else in the clinic?

They become super-specialised and lose the big pictureKC:  Well that’s the key, that’s true… Maybe the way we train people, with too much regulation, could be a problem in that it deters people from coming into this discipline.  Maybe the over-specialisation…What do I mean by that?  The enormous advances in technology that have occurred now mean that people can only deal with this area or that area [of the body].  Instead of being general surgical pathologists, they become super-specialised in a particular field -- in GI pathology, or eye pathology or brain pathology – and lose the big picture.  That’s a fear of mine. 

Doing only bone pathology, or only eyes…I’m afraid of that.  Most of the classical people, including people like Chris Fletcher, have had their super-specialities but have been solid surgical pathologists as well.  And we’re not training like that today.  That’s a fear.  What will happen in 10 years?  What will happen if these kids get tired of looking at GI biopsies, or prostate biopsies?  “Oh I’m fed up with this…” but what else can they do?  I'm trying to express how I feel about what might happen in 10 to 15 years from now.

Restrictions and regulations are destroying the classical trainingAnd the restrictions that have been brought into the training itself, how many months medical students spend in various disciplines.  Those restrictions and regulations I think are destroying the classical training that I referred to.  They have reduced the number of months medical students can train in pathology.

SA:  But are you able to do anything about that in your university?

KC:  No.  Because these are national regulatory bodies.  And if you try, they ‘ding’ you! [Laughs].  Or they take away your license to train registrars.

SA:  So you saw some of the best times in South Africa -- in spite of the tough political scene around you, you had that window of opportunity when the old mould was being broken and you could influence the changes?

KC:  Yes, those were best times…For pathology and for me and for my life and my career; those were best times, no doubt about that.

Cervical cancer and public health education

SA:  Okay, well one thing I'm interested in is that, with your experience with human papillomavirus and cervical cancer, you have started a working group here in the USA and you’re trying to take the information into schools and things.  Tell me a little bit about that, because this is a controversial topic in the UK. We’ve now got the vaccine against HPV, but there’s big discussion about whether young girls should have it in case it encourages early sexual activity.

KC:  Well, having arrived in Vermont I realized that there were a number of young women -- 16, 17, 20 years old -- with HPV infection and these early dysplasias, and that concerned me.  Again I don’t have figures to quote, but I thought, “Well, perhaps we should get some form of education into the schools and the tertiary institutions” to inform these young people about their behaviour without being critical or judgmental – which is a difficult thing to do.  So I got together this group of diverse people – cyto-technologists and surgical pathologists like myself, obstetrician/gynaecologists and health people from the local government, some statisticians, and a few other interest groups -- and we put together a programme that for three or four years had people going out to schools and teaching children. 

We developed a video and a DVD and a handout, so that schools could use this material.  And the programme was successful.  We published something on it, and there was a follow-up study that looked at the effect of the programme, but it was never completed because the person I was working with went off to Seattle.  But we still see a lot of HPV-associated cervical disease in young women in Vermont.  And we’ve published on that as well – the numbers, types, and whether the vaccine will have an effect on Vermont.  Probably about 60% or 70% [will be protected], but there are still those people that you won’t reach.

SA:  Is it an acceptable thing, the vaccine for HPV?

KC:  I think in the United States it is, knowing the culture here.  Whenever there’s a new vaccine it’s, “Hey, this is going to prevent a cancer!  You’ve got to take this jab!  It’s only 300 bucks!” [We laugh].  You know, I don’t want to be critical, and I don’t know the answers about whether you then need to go into sex education and all that.  It’s difficult… But we keep to the biology of it.  We keep to the types of HPV that are prevalent in Vermont.  I work with an old colleague of mine that I met in Oxford, Mark Evans, who I recruited to Vermont, and he’s my director of the 'translational research' laboratory, like the one we created in Johannesburg and that I was asked to set up here too.


Spirituality and science

SA:  Okay Kum, a final question.  A minute or so ago you were saying that your family and your pathology are your world and they are your identity.  What has your close proximity all these years to disease and death done to your philosophy of life?  How has it affected you?
KC:  You mean emotionally or…?

SA:  Yes.  Lots of people go through life without ever seeing these things and trying to push the idea of disease and dying away, and then they think it’s an accident when they get seriously sick. “Why me?”  But you people are so familiar with these things, you must ask yourself questions about the reasons for living, and what death’s all about…?

That changed my spiritual pictureKC:  Oh, I think that’s part of what I refer to as my spiritual path – in Sanskrit known as sadhana – and that began in Oxford.  I was deeply religious, and my mother was deeply religious -- that was my background, being a Hindu.  And then coming to Oxford I discovered the School of Philosophy, which was started by Andrew MacLaren in the early 30s, during the economic depression.  He got this group of wise men together, and then they linked up with the Shankaracharya , this wise man in India.  They posed questions to him over the years and developed this philosophy course which was being offered in Oxford, and which I attended.  You just signed up and once a week attended these philosophy classes which ask: who am I?

It was beautiful, I mean it was what I’d been looking for – the link between  my daily practical existence and why I am here, where I have come from and where I am going.  So that evolved – I continued to attend the School of Philosophy in Johannesburg, continued being a devout Hindu. And coming to Vermont, not having a School of Philosophy, or a temple for practising and worship of Hinduism, that left me vacant, or blank if you will, without that spiritual foundation. Then I discovered a spiritual group known as the Sathya Sai organisation that had a centre in Vermont, and I joined them. 

I had known about Sathya Baba and visited him at his ashram in India in the mid-90s with my mother.  I was attending a pathology conference in Bangalore and was delivering some talks, and one evening I had the opportunity to drive away four hours to his ashram and spend the night and I saw him for the first time.  I had known a little about him, but that changed my spiritual picture.  He is special.  His teachings, his philosophy, his words, his wisdom are what I read and practise – try to practise as much as I can.

SA:  This is very interesting, because at the moment in Britain there’s this big battle between science and religion, which seems to have become horribly polarized.   But I find it interesting that a lot of scientists claim that science pushes out some of the early learning they had in religion.  Have you ever found that your science has challenged your religious sense?

KC:  No, not at all.  I find it all-inclusive, because the answers are there.  Looking at it in a global perspective doesn’t create any conflict.  Not at all.

SA:  So your faith has had more of an influence on how you see the issues of living and dying than your pathology?  Pathology hasn’t touched it particularly?

KC:  I still have questions as to why cells become cancerous.  And I’ve tried to explore those questions from a spiritual standpoint and I still don’t have answers. 

SA:  So it begs more questions does it?

KC:  Oh yes! So many questions out there, and we still don’t know the answers.

First-world, third-world disparities

SA:  Okay, truly a final question!  How optimistic are you about pathology at the moment?

It’s difficult to predict where we’re going - this is a global villageKC:  It’s an ambivalent feeling.  Ambivalent in the sense that there's satisfaction in being able to continue contributing at a national and international levels in what I do.  But there's gloom about where we are going and what will come of it.  Of course there’s always this idea, “Oh I won’t be here when it happens”, or “I’m retired, I don’t care, let them deal with that.”  [Laughs]  But that’s not really what you want to feel when you leave.  You want to leave it a better place, and I think that’s where some of the gloom sets in – the question of what we are going to leave behind -- and I really don’t know the answer. 

My immediate focus is to take it a day at a time, and help and contribute where I can.  But it’s difficult to predict where we’re going, it really is, bearing in mind the global perspective, and the disparities between countries in how we practise pathology.  In Africa they’re having difficulty getting basic stains; in the United States it’s whether you should do the super-stain or not.  You cannot say that these disparities don’t affect all of us – this is a global village.  So where do we go from here?  I really don’t know.


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