Richard Hewlett - Transcript Summary

hewlettAssociate Professor, Departments of Anatomical & Forensic Pathology, Faculty of Health Sciences, University of Stellenbosch, and National Health Laboratory Service, South Africa

Interview location: His home, Cape Town, South Africa
Interview date: 14th January 2008

Key Themes: History of Pathology, International Perspective, Mentors and InfluencesNew Technologies

 

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Section 1

  • Begins with a description of his struggles to become a neuropathologist in Cape Town in a professional environment where “they didn't want 'super-specialists'.”
  • Goes to Britain to train with the “outstanding” Betty Brownell.
  • Describes briefly the development of neuropathology from the 1880s.  Mentions the pioneering work of Alzheimer, Sherrington and Horsley, and later, Cushing in North America.  “The structure and the function of the brain gradually came to be perceived as integral to one another, and that led people to specialise in the nervous system in one way or another.”
  • By the 1950s neurosurgery was well established in Britain, but neuropathology was still just done by generalists. “[The first people to show interest in the brain] were usually pathologists who were attached to lunatic asylums, you know, and who had access to the brains of people who were neurologically abnormal.”
  • By the 1970s, when he was studying with Brownell, “there was a movement in Britain to establish neuropathology as its own discipline.” However, the only specialist exam then was in the USA, and with Brownell’s help, Hewlett went to America to qualify.
  • Talks a little more about Brownell’s leading role in establishing neuropathology, and about the major influence she had on his career.
  • His time in America made a deep impression. “Those East Coast neurologists... They were very careful about everything – the history and the slides, documenting everything. And the beautiful descriptive language [that they used to describe conditions]!”
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Section 2

  • Describes growing up in East Africa, to where both sides of his family had emigrated after the First World War.  His father was always involved in wildlife, initially as a ‘white hunter’, and subsequently as a conservationist.  He became the first warden of the newly declared Serengeti Park, and one of the founders of the Selous Reserve. 
  • Explains that his first wish was to follow his father into conservation, “but [my father] said, ‘There is no future in wildlife for whites.’  And there wasn't; and so I did medicine.”
  • Goes to Cape Town University, which he loved.  But the wider environment was a huge shock to his system: “Everything was fenced in; it was run by a very dour crowd of people.  I had to wear a tie, which I'd never done before… I was born and bred in the bushveld.  This was like being on the moon.”
  • Describes life under apartheid, and the contradictions he found.  The hospital service was “absolutely excellent”, but there was a quota system, and “the coloured medical students had to live elsewhere; they couldn't see white patients, they had to function in the 'brown' end of the hospital... it was like a bad dream.”
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Section 3

  • After UCT and his specialist training in Britain and the USA, he returned to South Africa, and a post at Stellenbosch University.
  • Describes how, as the US neuropathology qualification was not recognised in Africa, and Brownell had by now established a recognised neuropathology examination, he returned to the UK to take this.
  • However, he was still thwarted in his attempts to establish neuropathology in South Africa.  “Every attempt I made to have neuropathology recognised here was blocked at the top... They didn't want to employ someone in the department who wouldn't look at lungs and everything; someone who just looked at the brain.”
  • Discusses the implications of the lack of support for neuropathology in South Africa, and lack of a specialist service across the sub-continent.  The dementing illnesses are neglected, he says, and “even very basic reactions in the brain like stroke are not understood by the general pathologist.”
  • Describes getting involved with brain imaging. “That really was the sea change in my whole life.” Believes imaging and pathology are complementary skills.  “You can't separate the two.  You can't do without the imaging; it's essential.”  Unfortunately he has found that most people remain in one camp or the other: “the people that are interested in imaging don't understand the pathology,” and most pathologists “don't go and look at the pictures – and that's why they make terrible mistakes.”   For example, “they may identify a lesion as a particular tumour when it can't possibly be that, because the location is completely wrong.”
  • This unwillingness to cross professional boundaries, he explains, is one reason why there has been such a limited readership of the book he wrote on the subject of imaging and pathology with close colleague Stuart Rutherfoord.
  • His own particular research interest, TB of the brain, benefits enormously from imaging, because changes can be tracked over time.  “That's the big difference -- the pathologist gets the brain once [after the patient has died]. The imager can examine the brain repeatedly and see how a structural abnormalit is changing over time.”
  • Describes joining the radiology department at Tygerberg Hospital, Stellenbosch.  Today he runs a database of brain images accessed by neurosurgeons worldwide.  Gives an example of a puzzling paediatric case in which having the images and the history, rather than simply “a small brain in which some cells were missing”, made diagnosis possible.
  • Despite his championing of imaging as the way forward, he regrets a certain overshadowing of pathology, which he believes remains an essential element in diagnosis of certain conditions, such as brain cancers.  Gives more examples of how these combining the two practices enhances diagnosis.
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Section 4

  • Mentions collaboration with Anne Osborn, a leading neuroradiologist in the USA, who has been supportive of his approach.
  • Goes on to explain how lack of resources has been a factor in slow uptake of his ideas and approach.  Describes the financial implications for pathology of the reorganisation of health services in post-apartheid South Africa.
  • Talks more about colleagues with whom he collaborates, including Kathy Taylor who refers all neuropathology cases received from the country’s leading epilepsy centre to him.
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Section 5

  • Explains his fascination with the brain.  “It's the key to everything – to what we are and how we think.”  Philosophically, he says, his work on the brain has “persuaded” him “that there isn't anything up there [pointing upwards]; that it's all a system that has evolved.  A very amazing system.  Electrical, and chemical, controlled by the genes.”
  • Expands upon his perspective on life and his profound sadness at the deterioration of the natural environment of his beloved Africa.
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Section 6

  • Talks about HIV, and the frustration of being unable to explore effects on the brain because of extremely low rates of autopsy.  Apart from the financial and ethical constraints, there is a real reluctance on the part of pathologists to accept the risks of contamination with HIV. 
  • Believes the situation in Africa is “desperate... autopsy pathology... has just absolutely plummeted .”
  • Describes how he first got intrigued by the brain and says, “neuropath and neurology have never ceased to fascinate me to this very day.”
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Section 7

  • Describes a series of memorable cases, including that of a woman with intravascular lymphoma.  “That's the sneakiest condition to diagnose.”
  • Acknowledges that mistakes do happen:  “I always own up.  If you're not going to admit to not getting things right it's hopeless.” Further important qualities for a neuropathologist, in his view, are intellectual curiosity, patience and attention to detail.
  • Outside his work, playing chamber music and being “a bibliophile” have given him huge pleasure.

 

 

Section 8

  • Talks about the setting up of a prion lab in South Africa and the role of Scottish CJD expert, James Ironside.
  • Returns to the story of TB and how his work with imaging has led to new insights into the disease in the brain, and especially in HIV-positive individuals.  Believes HIV has “muddied the waters... It has changed the immune system… They'll have to reinvent pathology...  It will be sorted out, of course it will.  But with molecular genetics, not by pathologists looking down the microscope.”
  • His view is that “this era of anatomical pathology is over.  It started with Virchow and those people, and it's gone on for nearly two hundred years and it's now over; that's the only way to see it.”  Discusses the fate of the archive he has built up over the years, which is gradually being dismantled through lack of interest. 
  • Expresses a certain philosophical acceptance of how things are.  Recalls how one of the lowest moments was his abrupt departure from UCT and one of his highest moments was taking the neuropath exam in Britain with colleague and friend Stuart Rutherfoord.
  • Pays tribute to Rutherfoord and their productive professional relationship.  “When Stuart died it was as if half my brain had died too.”
  • Ends by reiterating his love for the continent of his birth.  “Pathology has been a wonderful intellectual life, but the real me is somewhere up there in East Africa…”

 

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