Dhiren Govender - Transcript Summary

Dhiren GovenderProfessor of Anatomical Pathology, University of Cape Town

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

Key Themes: Autopsy, New Technologies 

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Section 1

  • Talks about his family’s origins in southern India – they moved to South Africa several generations back.  Father was a farmer who lost his land under the Group Areas Act and used his compensation to start a small shop.  Apartheid dictated which curriculum he followed at school, set by the Department of Indian Affairs, and where he could attend university. “I was in university in the 1980s, and the '80s in South Africa was probably the most volatile time.”
  • Originally aimed to become a GP, but in his third year of training he did anatomical pathology and “I knew I wanted to be a pathologist.”
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Section 2

  • What attracted him was “the histology, the morphology, the histopathology – looking at things and making diagnoses.  It was solving some kind of mystery.”
  • He found anatomical pathology fascinating:  “In an autopsy you tie everything up.”   In recalling his early experiences he says that in autopsy “you use all your senses – sight, smell, touch, you feel the consistency of things.”
  • Expresses concern about the declining emphasis on the value of autopsies:  “I think the bigger picture is lost. We are tending to become just diagnosticians... [but]  the pathogenesis, the way diseases are caused, is as important as looking down and saying OK, this is a cancer.”
  • Recalls that in his first year as a registrar his department performed about 1,000 autopsies; now this would be no more than 100.  Suggests that reluctance of clinicians to request and hospital management to sanction autopsies is a false economy. “Autopsies are a form of quality assurance [and] clinical audit, for a hospital.” Low rates of autopsy also have an impact on training new pathologists: they make up the numbers required to qualify by assisting the forensic pathology department with their autopsy work.
  • Explains that the reorganisation of South Africa’s pathology services has tried to address inequalities between provinces by creating the National Health Laboratory Service, and the new funding model is ‘fee-for-service’:  “We've become an expense.” 
  • He recognises the budgetary constraints on administrators but says,“Groote Schuur is the premier hospital in South Africa, and not to have a clinical audit or some sort of quality assurance system with regards to deaths is really short-sighted.” Epidemiology also suffers from lack of data traditionally provided by post-mortems. 
  • Mentions that Red Cross Children’s Hospital is the only institution in this academic complex where autopsy rates are still reasonable.
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Section 3

  • Explains that in South Africa all pathologists in public service are ‘generalists’.  “If we had to go to the sub-speciality stage, the numbers required would ... double or even treble... I can't justify that in terms of my department, because I'm fee-for-service... If I don't make enough money, I can't employ.”
  • Talks about how his special interest in nephroblastomas started under the tutelage of Professor Runjan Chetty in Natal.  This tumour, rare in adults, remains an abiding academic interest.  “In terms of the histology, it is so diverse... No two nephroblastomas look alike.” 
  • They were seeing “relatively high” numbers, and were wanting to find out whether there was a significant difference between ‘third world’ and developed world scenarios.  “There were a lot of findings unique to the developing world, the African situation... But in terms of the biology there was very little difference.”  Reliance on traditional medicine and the cost of hospital treatment meant that“the majority of [rural] patients ... came with advanced disease.”  This largely explained the difference in survival rates.
  • Discusses aspects of their continuing research into the molecular basis of nephroblastoma, and makes the point that it can be difficult as a service pathologist to find the time to do research.
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Section 4

  • Talks about working in Durban with its broad range of tropical diseases.  “It’s a fantastic training ground.”
  • Acknowledges that in the Western Cape, alcohol abuse “is a big problem... because of some of the labour practices that we had.  The wine farmers...used to pay their staff in wine instead of salaries.”  As a result “the Western Cape has one of the highest prevalences of fetal alcohol syndrome.” 
  • Explains that because of the low autopsy rate, they cannot tell how prevalent alcohol-related disease is in the general adult population.
  • Talks briefly about his good experience in going to London to take the Royal College exam.
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Section 5

  • Qualifying in 1993, he found himself in the middle of the emerging HIV/AIDS epidemic.  “The spectrum of pathology began to change; we were seeing a lot more infections... [And] we were seeing totally different morphology with similar diagnoses -- so TB wasn't looking like the classic TB; fungal infections were looking a little bit different from usual.”  For example, “you normally see Cryptococcus in the lung, or as meningitis in the brain.  But we were seeing it in the skin or in the liver -- in a site where you wouldn't normally see it.”
  • AIDS is believed to be a leading cause of maternal mortality in South Africa, but explains that, again, the low rate of autopsy means that there are many unanswered questions.  “Are they getting opportunistic infections?  Are they developing malignancies?  Who knows? ” 
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Section 6

  • Explains how he came to his current position and found himself suddenly involved in “a ton of different committees”.
  • Talks a bit about his advisory role with the UK’s Royal College of Pathologists, where he represents central, west and southern Africa. They are exploring ways to assist countries such as Malawi, where there is currently only one pathologist.
  • Talks briefly about training.  Discusses affirmative action, maintaining standards, and different teaching models.  Regrets the lack of exposure to pathology practice in new curriculum.  “It's now considered not important for them to even look at a slide down a microscope... I know -- and I've predicted this -- that we will get less and less interest in pathology.”
  • Fears that recruitment into pathology may decline because “the new curriculum emphasises the clinical disciplines”, and moreover refers to pathology as “basic science”.  He takes issue with this:  “It's not true: pathology is as clinical as medicine or surgery, because we are engaged in patient care.”
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Section 7

  • Talks about how his identity is intricately tied to being a pathologist.
  • Discusses his experience of the transition from the apartheid era to a democratic South Africa. “The disease profile didn't change.  But conditions of service changed, because you started getting more attention to labour relations, to salaries.”  But it was daily life where he saw the biggest changes: “I could go to any movie theatre; I could take any bus; I could go into any coach on a train…And I really had not been able to before.”
  • Talks briefly about the rewards and frustrations of his work.  “I have high moments all the time when I make a fantastic diagnosis with the microscope... [But] now that I have so much administration I don't do as much diagnostic work as I'd like to.”
  • Talks about the role his mentors, Kum Cooper and Runjan Chetty, have played in his professional life.


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Section 8

  • Discusses one of his current research interests, a large collaborative study of hereditary nonpolyposis colorectal syndrome, focussed on a community near Cape Town.  “We can trace these families as they are spreading throughout South Africa, because you can trace the genetic mutation.”
  • Returns to the issue of changes in his profession.  “As we continue to train pathologists we probably will train more molecular pathologists... because besides looking down the microscope you'll also have to interpret molecular results.”
  • While he also acknowledges that “Improvements in radiological techniques have, to some extent, affected the practice of pathology”, he points out that “we are still basing our diagnoses on what you see down the microscope... I can't see that the radiologists can work in isolation.  They have to work in conjunction with us.” Multi-disciplinary teams are becoming the norm.


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