Helen Wainwright - Full Transcript

Halen WainwrightDepartment of Pathology, University of Cape Town, South Africa

Interview location: UCT Medical School, Cape Town
Interview date
: 15th January 2008, and 25th March 2009

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Section 1

SA: Helen, tell me a bit about your early life.

HW: My father was an anatomical pathologist, and we grew up in Durban. He qualified in Sheffield. My mother was a French and Latin teacher. My parents were British; they had four children in the UK. They came out to South Africa and unfortunately found out they were having twins! So they ended up with six children – two of us born in South Africa.

SA: That’s you and your twin sister?

HW: That’s right. We both did medicine and she’s doing paediatrics at Baragwanath [the biggest hospital in the southern hemisphere, located in Soweto, Johannesburg] – specialising in children’s tumours.

SA: What made you decide on pathology?

HW: Well, I’d always wanted to do paediatrics, so I went to Red Cross Children’s Hospital [in Cape Town] to do my senior house job for six months and every two weeks I was ill. You see, every time you examine a baby they cough in your face, so you have respiratory tract infections. Then you have gastro troubles. I got German measles, and came out in spots and then it went to my chest, so I had pneumonia. By the end of the six months I thought, “Well, I’ve never actually been so sick – this is not for me!”

My father used to say, “Well, wear a mask.” But you can’t approach a little frightened child with a mask on. Presumably you dip into the viral pool and eventually you’d become used to it. But it was a miserable six months! [We laugh]

You can’t approach a little frightened child with a mask onAnd then pathology is interesting, because you actually find out the answers to a lot of the diseases. As a clinician sometimes you’re feeling in the dark; you give patients this particular treatment and you hope for the best. But with pathology you find out actually what happened – in most cases, not in all.

I also did six months of respiratory medicine, so when I started in pathology I was very interested in lungs. Now I’ve retreated back to babies and lungs – those are the things I’m particularly interested in.

SA: Growing up, was it the sort of household where you talked a lot about medicine?

HW: Not at all. My father was a frustrated mathematician! He managed to persuade at least three of his children to do mathematics. The two of us always wanted to do medicine, but the thing was that you couldn’t do it in Durban at the time. My father worked in the medical school, but it was a non-white medical school, so white students couldn’t go there.

Growing up under apartheid

SA: That was the early days of the apartheid era – so how politicised did they become, your folks?

HW: Well you know, my father’s colleagues in the department were all white or African or Indian, and they would come for meals when he was entertaining. I suppose you could say that life [in South Africa] was much easier for my mother, having help in the house, help in the garden, which you would never have had [back home in England] with a house full of six children.

SA: You say your father’s colleagues came back to your house at times, but under apartheid it became more and more difficult, didn’t it, to socialise between the races?

HW: Yes, but he managed it. He was very academic and the people who were performing well in his department, those were the people he was very proud of. They were ones who subsequently went on to do wonderful things.

SA: You say you were not allowed to go to his medical school, to the non-white medical school, so where did you go?

HW: We went to Cape Town. But now of course anyone can go anywhere.

SA: But did you have coloured students at Cape Town as well?

HW: We did. We had, I think, 50 coloured students in our group. And d’you know we weren’t – at least I certainly wasn’t -- aware of all the problems they faced. We had a reunion a couple of years ago and you then heard about a lot of the problems they faced.

You see, you were divided into groups to dissect a body in second year of medical school and you tended to keep to those groups. The group we were in was all white, and quite a few females; we tended to band together.

SA: And so you just didn’t learn about the frustrations of the others?

I didn’t realise they weren’t allowed to see a white patientHW: I didn’t realise they weren’t allowed to see a white patient -- I only heard about this [at our reunion]. You’d be together for lectures, but then I was in a residence and my residence was only white females. So your contact with the non-white students... They were all people from Cape Town, so they were living at home and coming to the medical school.

SA: Did you make friends among them?

HW: Only on a superficial level.

SA: So did you ever become politicised?

HW: Definitely not. No, I guess I was too self-centred, enjoying the wonderful life, you know what I mean? Away from home; living in a residence, and a beautiful place. Walking and doing all sorts of things. So I’m afraid, no...

SA: And when you had this reunion, were you shocked by some of the stories they told you?

HW: Absolutely!

SA: Did they resent how you lot had behaved?

HW: Absolutely; absolutely.

SA: And how did you feel?

HW: Well, that one should have known, should have been aware of it. But you know, when I look at my children I realise we were much more naive. We didn’t have television; we didn’t have the internet; we didn’t have the exposure that my children have had. I went to a private girls’ school... You know, we were sheltered.

SA: But when you started practising medicine...

HW: I worked at Groote Schuur, and the hospital had a white side and a black side, and they would have different food. But your firm would have both white and black patients.

Then when I went to Red Cross, and again you had wards which were for the different races. In the middle of the night you got a sick baby... There are rows and rows of children you’ve got to see and the one thing you really couldn’t care less about is if the baby is white or black. If it’s a sick child it needs care; it needs a bed. And then in the morning the doctors would change the colour of the folder, whizz the child across to the right section – it was just hilarious! I mean, we had to sort them out: are they in the right wards or not? It was absolutely daft.

But care on both sides was absolutely equal at Red Cross. And the children had the same sweeties, the same little pictures...

SECTION 2

Balancing the books

SA: You’ve worked under both regimes – what have been the big changes you’ve seen?

HW: The sad thing is that Groote Schuur used to be a top place. It catered for people who had no money at all, but it was the top place for all the wealthy people in Cape Town. The best surgeons were sitting there, so whatever operation you needed, you wanted it there. The [rich patients] would pay a huge amount of money which funded all the other activities, so you had a lovely spectrum – you had people who didn’t have money with various diseases, and you had the other end of the spectrum.

SA: But how did people without any money get to be treated there?

The paying patients subsidised care for the very poorHW: Oh, because if you came in sick, you got in! You never had people turned away. But people who could afford paid handsomely, so your equipment was very good. Everybody wanted to work with the best people, so you had really good quality care, whether you were black, white, whatever you were. The paying patients subsidised care for the very poor. And the hospital was always spotless – both sides, black and white.

Then Nelson Mandela came in and said, “No charge for any child”. There were plenty of children whose parents could afford to pay, so that was a shame: he made the statement and all the people who could afford to, suddenly stopped paying, so that wasn’t such a clever thing to do. It’s very easy to break things down; we’re busy breaking things down, you see. It’s just a shame.

My sister in Johannesburg got very angry because you got more of the budget for a white patient than for a black patient in the old days. If you just shared it between the two, who was to know what you were up to? But at Baragwanath, you see, they were all black patients so they had to manage on much lower budgets because nobody was paying.

SA: So in the old days it was the doctors and nurses who were subversive and who were making sure that paying patients subsidised the poor as well, while thesystem was trying to divide things up?

HW: Absolutely, yah. I think Baragwanath now is getting more of the budget, but they still [struggle]. If a patient comes in sick to Baragwanath they admit them whether or not they’ve got a bed. Initially in the paediatric wings it was one person in a bed, then two in a bed, then one under the bed, then...

SA: But what about here at Groote Schuur?

HW: They’ve just cut the beds, so now you die in the street.

SA: So you don’t admit people here if you don’t have a bed?

HW: That’s right. It’s terrible, absolutely terrible.

“Inspiring teachers”

SA: Going back to your own story, have you had mentors or really good teachers along the way?

HW: Oh absolutely. Inspiring teachers. One of the professors in the genetics department was absolutely wonderful and students would flock to his lectures. Then at Groote Schuur there were people like Professors Stuart Saunders and Jannie Louw -- one was a physician and one a surgeon. And then I worked for someone called Helen Brown... Just wonderful people to work for.

SA: And what about in your pathology training – has there been anybody who’s been particularly inspiring to you?

HW: Well somebody like Sebastian Lucas (London-based expert on HIV and AIDS) – you know, these are the people you meet at conferences. Sebastian Lucas does wonderful presentations, and reading his books... everything about him is just very impressive. One of our professors was a friend of his and invited him to come and visit and he was here for a few days. Sebastian said he wanted to climb the mountain, so I got him up at five in the morning, in the dark we started climbing up Devil’s Peak – that’s one of my good memories of him! He had to get to the airport by 11 in the morning, you see.

SECTION 3

A day in the life

SA: So tell me, what is your day to day work like? What do you find when you come in in the morning?

The only sad thing is that a lot of them tend to push off overseasHW: I come in just after 6 am because that’s a good time to get work done. I go for a swim first, at five, but once the day starts at eight the telephone rings, you get distracted and you can’t do things easily.

One of our jobs is to train a new batch of anatomical pathologists. The only sad thing is that a lot of them tend to push off overseas, so we train them for other countries. But that’s their choice. You can’t say: ‘I’m only going to train you if you stay in South Africa’, that’s not reasonable.

SA: But why do they leave? Are the conditions for pathologists here not good?

HW: The salaries in the private sector are very high, and I don’t think the salaries in the state sector are bad, but if you’re a young person and you want to have a family, then buying a house is difficult...

SA: And what about the pathology you’re doing besides the teaching?

HW: I’m in charge of the fetal and neonatal service, and placentas and all sorts of interesting things crop up. Then we also have a surgical roster. So it’s certainly busy, but...

SA: How many babies do you have to do per day, do you reckon?

HW: Oh smallish numbers... A couple of years ago I was doing 300 autopsies a year, something like that. And then we were taken over by the NHLS [National Health Laboratory Service] instead of the Province, and the NHLS charge a lot for [autopsies on] the babies so the hospitals have cut back a bit. So now I’ve cheated: I call the little babies ‘placentas’. You see, if you have an ordinary baby there’s a dissection fee of 1,500 rand (approximately £120), but if you have a placenta there is no dissection fee. So I have my sneaky ways of handling things!

SA: What percentage of babies that should be autopsied are actually autopsied today?

We have so many babies born deadHW: We have so many babies born dead that we try and look at the placenta of every single one in our area, which is all the maternal obstetric units in the Cape Town area.

SA: Why do you have so many stillbirths? What’s happening?

HW: Well, we have huge problems with alcohol. And we have huge problems with young women who don’t book, so they don’t even appear for antenatal clinic. Now, you don’t know whether it’s that the antenatal clinic is busy when they try to get time off to go. These clinics tend to take a set number of people and if you’re not there in time they won’t look at you, you know? There are all sorts of problems, so a lot of pregnant women don’t take any care at all.

And then we have a lot of pre-eclamptic toxaemia – a much higher incidence than elsewhere. No idea why. There is superficial implantation of the placenta, they have high blood pressure, they don’t present [at clinic]. We have a high mortality from it, mothers and babies. Haemorrhage in the brain. Very high blood pressure can suddenly appear, and if you aren’t monitoring a person, they don’t noticed that their feet are swollen, and they only wait till they start fitting.

SA: That’s one of the big things is it?

HW: That’s one of the big issues, yes. And obviously HIV and infections. Neonatal deaths are a big problem throughout the country. There’s this huge incidence of babies who don’t grow adequately in utero -- very high here, higher than elsewhere. It’s a huge problem.

SA: And what d’you think is the cause?

Those babies are all growth-retardedHW: Multiple things. Poor nutrition... And you know we have this huge fetal alcohol thing, where the mother drinks, all her friends drink, the relatives drink, so she drinks, and it just continues like that. Those babies are all growth-retarded. They don’t catch up, and it’s a major problem. A certain number die in utero or are miscarried early on, but the main issue is the poor children who have mental retardation for the rest of their lives.

SA: What does happen in utero? What do you find with fetal alcohol syndrome?

HW: The bad ones you can recognise just by looking at their faces. They have a long smooth upper lip, a thin lip. They tend to have an upturned nose, often have a squint, eyes are quite far apart. You can take one look, even when it’s a little fetus, and have a very strong suspicion that it’s fetal alcohol.

That’s the tip of the iceberg, the ones you can see just by looking. Then there’s a huge number who don’t have the facial features but they have the brain damage; they don’t grow; they have multiple organ damage and that sort of thing. They’re the ones at school, the teacher doesn’t know what to do with them, short attention span, they’re untrainable. [The statistics show that among] children six years old, the percentages are extremely high.

SA: And is the damage you see dependent on how bad the abuse has been at different points of development?

HW: That’s right. So with binge drinkers you’re suddenly providing a huge amount of alcohol. But you’ve also got to take into account how the liver metabolise the alcohol. Some people are very wonderful metabolisers, break it down quickly and get rid of it, and other people are slow, so the breakdown products hang around for more time and cause a lot of damage. That’s why you might find people with similar drinking habits and one having severe effects [on the developing baby] and one having less severe effects.

SA: What are the roots of the alcohol problem here?

This is the commonest cause of mental retardation, and it’s preventableHW: Paying people in alcohol, that’s the root. [In former times] when people worked on the wine farms, part of their wages were alcohol. And it’s an addiction: once you’ve had it, you want it and you’ll do anything to get hold of it. Whole communities are caught up in this. And then, if you think of South Africa and Australia, we’re very keen on sport, we drink a lot. I say it would be very nice if, when the wife’s pregnant, the husband also abstains for the nine months to make it easier for her.

SA: How did you feel, when you first started to see all this, was it quite shocking?

HW: Dreadful. It was shocking. And there’s nothing you can do if the brain’s damaged. This is the commonest cause of mental retardation, and it’s preventable.

This wasn’t mentioned in our medical curriculum, but paediatricians are extremely aware of it. You know, there are people who feel it’s OK to have the odd glass of wine when they’re pregnant. But animal studies show that it’s a poison, and the brain cells get killed off. You might say “Well we’ve got masses [of brain cells]”, but do you want to give your child a decent chance or is it OK if a few brain cells are knocked off?

SA: OK, so when you get these babies, who are you working for? What’s the purpose of doing an autopsy?

HW: Well, when you get a miscarriage the clinicians want to know: why did she miscarry? And when you come back saying “This looks like fetal alcohol syndrome”, you might, hopefully, be able to get some help for this person so she decides to have no more children or she gets counselling.

SA: And do you feel you are having an impact?

HW: No. I’m sure I’m not; I’m just one person, I would doubt I’m having an impact. Pathology doesn’t have many lectures in the medical curriculum but today fetal alcohol is one of them, so hopefully the new bunch of people will start looking out for it.

SECTION 4

“Tuberculosis, and tuberculosis and tuberculosis”

SA: What other things are you seeing in the babies that you’re autopsying?

HW: Well, we’re still getting lots of syphilis, and that’s absolutely treatable. We shouldn’t be getting any syphilis. You go to antenatal clinic and the first test they do is for syphilis. If you’ve got it, they treat you straight away with penicillin and it can be cured. But if they don’t treat it you end up with bone deformities, all sorts of horrible things – diseased liver, diseased multiple organs...

I think the trouble is that we have large numbers of people moving into Cape Town, and there aren’t the facilities available. It’s not like in the UK where people will only move somewhere if there’s a job. Here people just appear and there aren’t enough medical facilities for them.

A lot of people come into hospital without ever having been to antenatal clinic, so what does that say? They don’t want to come? They’re unable to come? Or the clinic turns them away? I don’t know what it is. It’s just a shame.

And then with HIV we’re getting other infections in the placenta. I’m only talking about the patients who have a low CD4 count. In the [HIV positive] ones with a high CD4 count you see absolutely normal placentas.

SA: Talking about HIV, you've got the biggest AIDS epidemic in the world here, so I imagine you're seeing more stuff than was seen in Uganda, even.



HW: [We’re seeing] tuberculosis and tuberculosis and tuberculosis. In every conceivable form. And then sometimes two or three simultaneous infectious diseases -- so tuberculosis with various viral things. I mean, the cases we're interested in are the ones where they've eliminated the usual things and they are trying to find what it was. Cryptococcal meningitis is the commonest meningitis now in Cape Town, whereas it used to be very, very rare. [We’re seeing] all sorts of brain pathology. But unfortunately tuberculosis, ineverybody.

SA: With HIV, does the immune suppression really cloud the picture? Does it make it much more difficult to see these things, such as toxoplasmosis, for instance?

HW: Well, the patients don't react [to the infection]. In the old days, if you had toxoplasmosis there would be a lovely inflammatory reaction around it. The same with tuberculosis -- it used to have a nice typical pattern. We've got a pathologist who's joined us recently -- he's South African but he's been working in the UK -- and he was just fascinated by the change in tuberculosis. We do a special stain to look for these bacteria, and he was saying, "Well I wouldn't have done it on that one in the UK."

SA: So it's a whole different thing you're seeing down the microscope?

HW: Yes, which is fascinating.

SA: And does it become a typical pattern, once you've seen a lot of HIV-related disease?

We're assuming [this unnatural pattern of disease] is to do with the HIVHW: Absolutely. You become very suspicious, yes. And then we're also seeing cardiac disease, vascular disease, in young people who are HIV-positive, and we're assuming [this unnatural pattern of disease] is to do with the HIV.

SA: And is it a very different picture, as you say, from what they're seeing in the UK?

HW: Well if you go back ten years they saw all this in the UK. Sebastian Lucas was telling us all about it, he's telling us the future. I met him in Tanzania a few years ago and he was telling us what's happening with hepatitis C in the UK. We're just at the beginning of our hepatitis C [problem], it's not common here yet -- hepatitis B is our big one. But Sebastian was telling us how fast hepatitis C cases become cirrotic in the UK if they are HIV-positive, despite being on antiretrovirals. So we've got a lot to learn.

SECTION 5

The sidelining of pathology

SA: You’ve expressed some real concern about the state of pathology here and the curriculum...

HW:... and the medical students we’re turning out? Yes, it’s just very disappointing.

My undergraduate training in Cape Town, and then my pathology training at the University of the Witwatersrand, was very good -- equivalent, at that stage, to most other places in the world. Unfortunately it's no longer the same. The undergraduate training now has lost pathology -- it forms something like 2% of the marks in the year.

SA: Why has pathology been so sidelined?

HW: Because students used to find it rather difficult. It was a big stumbling block. Approximately a third of the class used to have to do a supplementary exam. We felt that, when students passed pathology, they then had a good understanding of the basis of medicine, in the old curriculum. But other people saw it differently. We pathologists were seen as the block to the progress of people in medicine.

All the science has gone out of [medical training]. It's all about being in contact with your feelings. So [the next generation of doctors] will be very nice and hold your hand as you die, but they won't be doing anything to help you because they won't know why you're dying!

SA: That's how you see it, is it?

Big black holes in their knowledgeHW: Unfortunately yes. There are still good clinicians who had that old background. In Cape Town we've only had one year of graduates with the new curriculum, but our intake of pathology registrars coming to train in this subject have come from other parts of the country, and so we've already experienced [the effects of the new curriculum], and there are just big black holes in their knowledge. And that's just the anatomical pathology side. Clearly, you know, the very clever students go back and they learn their pathology, but I'm talking about the average student – they just know nothing. So it's very distressing as a pathologist.

SA: And have you not been able to make your views heard?

HW: Not at all. Not in the slightest. But I think, say, in 10 years' time the wheel will turn, and we'll say, "Oh dear, our doctors aren't as good as they used to be …", because the GPs, who are the mainstay of medicine, are making a lot of mistakes.

But we’ve got some very nice [pathology] registrars [at the moment], and it’s very enjoyable watching them develop. That’s an absolute pleasure.

Our registrars have to do 50 autopsies each before they can sit their final exam, and there are very few being requested by the hospital. [An institution like] Groote Schuur [should have] an autopsy rate of about 20%. We must be about 0.05%.

SA: Of adults and children?

HW: Well, the babies are coming through but I’m just saying, the others aren’t. You have to get the family’s permission; then you have to get the superintendant’s. And there’s a second superintendant who tries to block every single autopsy. Somebody needs to do an audit there and point out that it’s not good enough.

Any case, we are trying to make up for [the low autopsy rate] by offering our services to forensic pathology. If anybody is stabbed, or has a motor vehicle accident, any unnatural deaths the forensic pathologists do. But they also get all the natural deaths of people who haven't seen a doctor -- anybody who just drops dead -- and they're very happy to open their doors to anatomical pathologists who want 'natural' deaths. So that's how we're trying to compensate.

“Pathology that no one has modified by medicine”

SA: So how does it work? The police department will get the body of someone who just drops dead, they'll go into the police mortuary?

HW: That's correct. The police bring them in and then the forensic team decide whether they're going to do an autopsy. Our forensic pathologists are in charge, and if they think it looks like a natural death then they’re very happy to have somebody else assist them, because the numbers of people dying unnatural deaths -- I don't know if you’re aware of their numbers? They’re are just massive. And you know, with bullet wounds they have to find every single bullet. You might have thirty bullets in one patient, and even though the patient is clearly dead you've got to track every single bullet. They have to spend a huge amount of time on their unnatural deaths, so they're quite happy for assistance from us.

SA: But I should imagine there are also a lot of natural deaths.

HW: Yes, a lot of natural deaths -- and the registrars are really 'enjoying' it, if you know what I mean, because you’re seeing pathology that no one has modified by medicine. You see, when we get a case from the Groote Schuur hospital, the patient might have been in ICU for a month, and by then their tissues are in a bad state. What happened initially is often masked by all the drugs and the ventilation and everything that's happened while they've been in hospital, whereas these other people are just wonderful pathology.

SA: So you literally start with a clean slate, you don't know what this person dropped dead from? Or you may talk to the families…

HW: That's right. Sometimes they're in their office, clutch their chest, or say, "I've got a headache" and they die. Or they're waiting at the bus stop and they collapse. You might have a little clue, but often you've got no clue at all. And you've got to realise that somebody who may look in wonderful shape on the outside may not be in such great shape on the inside! So it's very good experience for the registrars.

The other thing is that everyone who comes through our department here, we're aware of whether they are HIV-positive of negative. But they don't test the bodies for HIV at the police department, so you've got to be very careful doing pathology there. And the other problem is the conditions... You've got to be quite a tough registrar to work there, as you see very unpleasant sights. Even though you're working on a natural death, you're in a huge mortuary with large numbers of other deaths, many of which are very distressing to see.

SA: What are the conditions like there?

HW: Grim. The Dark Ages, I think you'd call it. They’ve just got so many bodies... But I think if you looked at our mortuary [at Groote Schuur] compared with any UK mortuary you might also find ours a bit of a shock. Compared to the UK, we're well behind.

Unnecessary deaths

We make the registrars present on a Friday morning – two of them each present one case every Friday. And we’ve had some terrible cases... A woman of 45 who’s a newly diagnosed diabetic; she comes along to hospital, they keep her in and treat her overnight, and then they discharge her and she dies a day later. Twenty years ago we would have kept her in until everything was sorted out. And she dies because they want the beds for HIV and TB cases. Those are the two things they’re good at treating – they’re no longer very good at treating these other conditions. So if you’ve got diabetes – and I’m sure this was a productive woman of 45 – you die, and that makes me very angry. Why should you have to have HIV or TB before you can get decent treatment?

SA: And what other sort of cases are you seeing that are dying unnecessarily?

HW: Well, we had one of these patients who abuses ‘tik’. This is crystal meth, and people can make it easily. They inhale it or they stick it up their noses or whatever, and you get very rapid addiction and very rapid ageing in these patients. There’s this one little hospital, Victoria Hospital, where a lot of them have been referred, and it’s been noticed that a good number of them come in with a huge heart.

This is somebody of 20 who ends up with a great big heart that’s failing. You can try and get them off their drug, and they’ve had some who’ve actually recovered. But this one died, and the clinician wanted to come and hear the results of the autopsy. He happened to stay for the next case, and one of our pathologists said to him, “You know, when I did my medicine we would not have discharged this patient.” And the clinician said, “Well, this is perfectly acceptable treatment; we need the beds for other patients.”

In other words, we don’t treat people as well as we used to... You’ve got to have the ‘right’ disease.

SA: So who’s accountable?

HW: Well that would be a lovely question! Presumably the person in charge.

We had another one was a 79-year-old man who had lots of diseases -- he was diabetic, he had atherosclerosis, he already had a pacemaker in, and he was having bowel symptoms. In the notes they said he’d had abdominal pain for two days, and then he died. He’d been given a note to come back to the clinic because they worried that he’d got cancer of the colon. Our registrar went down to do the autopsy and he found that the man had this huge hernia in his groin, and the bowel had become stuck in there and had perforated.

SA: And it hadn’t been noticed?

HW: I mean, how could you not notice it? A huge mass. Another one had a huge mass in his neck, seen at the hospital the day before he died. The person doing the autopsy said it was so large it would have been impossible to miss. So are they not seeing it? Or do they not know what to do?

SA: So your autopsies are showing up where there’s been negligence?

That’s the value of an autopsyHW: Well, that’s the value of an autopsy, and at a place like Groote Schuur if they’re stopping them then it means you’re not picking up any of the mistakes that are being made. That’s exactly the sort of place you’ve got to pick up the mistakes. It’s one thing to make mistakes when you’re working in a little hospital and you’ve got nobody you can ask advice of or whatever. But we’re not even checking at Groote Schuur to see that the standards are being maintained! That’s bad.

So this hernia, I asked the registrar to send a very polite letter back to the place where he was seen so that they know why he died. Because otherwise you’re not feeding back the information: we know about it, but nobody else knows about it.

SA: But what do families say when they hear about these things?

HW: I think we’ve got very forgiving families here, very forgiving.

SECTION 6

Organ retention

SA: So tell me, in your autopsies of children, what’s the custom in this country about removing organs and retaining organs?

HW: We’ve always kept the organs. They do in Europe and they do in South America, and I still do here. Every now and then we get a family who will say, “Please may we have the organs back?”

SA: So the issue of organ retention is not a crisis here?

HW: Not a crisis here. But we’ve had somebody who’s just left our department who was interested in neuropathology and he had huge numbers of brains which were unreported. Now to me that is a terrible thing. To me if you’re given an autopsy to do, you’ve got to start it, you’ve got to finish the autopsy. If families ask you to do X, Y, Z, you have to – you’re under a sort of contract to do that. So once he left, our professor just had all the brains incinerated.

I had a beautiful collection of baby hearts. I went off somewhere for two weeks and the professor disposed of them. I came back and they were all gone. He’s in charge of the department and I think he’s just very nervous. They were legally there, but he doesn’t like organs being kept.

SA: And what did you have that was special in your collection?

HW: All sorts of things... Ebstein’s Anomaly, for example. That’s a condition where the tricuspid valve, instead of being in the right place, is displaced low. And then we had things where, instead of having one spleen, you have a whole lot of spleens – polysplenia. Those babies have very strange return of blood to the heart. I had some beautiful ones like that. [We laugh] Not everybody would appreciate them!

SA: Do you see a lot of very strange things?

HW: Yes, because we’re seeing babies who die, we’re not seeing the babies who live and where everything’s fine. So we look at a lot of stillbirths. We do a placenta on every stillbirth, and if [the stillborn baby] looks peculiar, the clinicians then try and get permission for an autopsy.

I showed Richard Hewlett [a Cape Town-based neuropathologist] a brain the other day – it was a term baby, and it had a head about that size [holds up hands to show how tiny], a single eye, no nose, tiny little mouth – and then extraordinary things going on in the brain. Basically, virtually no brain at all.

SA: Is this a genetic abnormality or what?

HW: Well it could be a trisomy 13. A 17-year-old mother; the baby died within a few gasps, tiny little lungs.

SA: Did the mother see it?

HW: I don’t know. Most people would look at that and get quite distressed. Usually, I can’t tell you what happens, but as far as I know they tend to show the mother. If the baby hasn’t got any brain they tend to wrap it in a towel or something – they don’t just take it naked and put it in front of her. I think they say it’s better to see it than to imagine what it looked like.

SA: Have you seen a Cyclops before?

HW: I’ve had about three Cyclops. You don’t get a lot of it. One of the causes is chromosomal. And I’m not sure if the mother had diabetes, because you get all sorts of things with diabetes.

With these new students this week we had an abnormality called a ‘mermaid’. It was a baby that looked fine at the head and the arms and then tapered into just a single fused leg with one foot on the end. No genitalia. Oesophagus had stopped up here [she touches her chest]. No stomach. Little bit of bowel. No kidneys.

SA: But it was normal from the chest upwards?

HW: Well, externally, but it wasn’t normal when you started dissecting it. You found all sorts of interesting things. And that one, definitely the mother was diabetic. We have a lot of overweight females, a lot of maternal diabetes, so you get very interesting things with that.

SA: Diabetes is becoming a big problem in Europe, but I don’t think people are aware of the fact it can be a serious problem in pregnancy.

HW: But you see [people in Europe], if they’re diabetics, they will go along to their obstetrician before they decide to fall pregnant. And the obstetrician will say that if you are beautifully controlled when you fall pregnant there won’t be a problem. Our people don’t plan pregnancies. You’re suddenly pregnant and your diabetes is all haywire, and then you get all these malformations. So that’s the trouble.

SA: Do you see a lot of these?

HW: Plenty, yah. A lot of them involve the brains and particularly the lower part of the spine. In the last year or so I’ve had four really severe things. So it’s very interesting.

With something like the Cyclops baby, we go and look at the organs that would be involved. We look at the pancreas. We can then do a stain to see the cells that produce the hormones, are there too many of them? There are various things we can do. And then I end up putting a little comment at the end of the report saying: recommend genetic counselling; recommend this; please investigate for this, or whatever.

SA: You’re obviously excited by the science of it. But as a mother yourself – as you say, some of these things are not a pretty sight – how do you psyche yourself up to see only the science and not to think of the implications for the mother?

HW: Well it’s interesting, when I see a Cyclops it’s not distressing to me at all, it’s fascinating. To think of the pathology that will be sitting in that eye... I mean, it didn’t have a lens, no lens there, and all sorts of extraordinary things happening.

I’ve only had one quick look at it, but I’ll be back looking at it again. You see, one of the lectures I’m giving to these people is on abnormalities to the brain, and this one is real, and it’s very, very severe. It’s the most severe end of the spectrum that I’ve ever seen.

SA: Which bit are you most interested in? Are you most interested in the malformation of the eye...

HW: And the brain, I’m tying them all together. Was it one ‘hit’? Did all the problems occur at the same time? You can ask, “At three weeks post-conception, are all these things developing at that time and being damaged? Or did something happen at three weeks... Something happen at six weeks... ?” See what I mean? While all those organs are forming it’s a very vulnerable time [in pregnancy].

The arms develop before the legs... There’s a sequence in which these things happen, so you can often time [the event that caused the disruption to development] by the pattern you get, the grouping. Very interesting.

SA: So did you specialise in paediatric and neonatal pathology?

HW: Well, the paediatric pathology society has a number of courses you can go on. The only trouble is they tend to be expensive, so when I started going, I went to one and then I had a gap, say, of two. I really should have gone to five consecutive ones straight away and done it all like that.

They don’t want you to go on a course in the first place until you’ve been doing some work in that field for a while, and then you go along and you take your best case. Everybody presents their cases and it’s great fun -- you talk paediatrics morning, noon and night, because everyone is equally fascinated by it. So they’re absolutely wonderful. You also meet the people who are organising it plus the people who are participating in it, so you then have this very nice network of people who you can confer with.

SECTION 7

The professional and the personal

SA: Tell me, do you ever see the reaction of parents to some of your reports? Because if they are as grotesque as you’re saying... If I delivered something like that, it would be very difficult to deal with.

HW: No, I don’t think it would. I think you’d go on the Internet, and you’d start reading about it.

SA: But if you had had a child like that...?

HW: My second child had a congenital heart defect, a squint, and club feet -- one of my three children.

SA: And how did you feel about that?

HW: Well, obviously one was distressed. I mean, you don’t know whether they are going to pull through or not, because some of these congenital things are lethal.

With my son I presume it was some sort of infection [during my pregnancy]. There wasn’t ultrasound in my day, so there was no question of detecting it early on or anything like that. But these things happen. You just accept it.

SA: Is your child OK?

HW: [Smiling]He’s 26 now. He’s playing cricket. Very awkward; very difficult. I’m having a big battle with him now, but...

SA: So has your own experience made you fatalistic, or do you think you always were fatalistic – or ‘philosophical’ -- about the hand life deals you?

HW: I think I always have been philosophical, yes.

SA: But how would you say that being a pathologist has affected your outlook?

HW: Well, my children think I’m rather peculiar! Because I often bring home my little pictures while I’m doing my reports, and all three of my children have said, “We don’t want to do medicine!” So I presume that says something. [We both laugh].

SA: Really? They haven’t been fascinated by it?

HW: No. The closest one of them has got is working with viruses. But non-medical viruses – plant viruses! [Laughing]

SA: So you brought a lot of it home?

HW: Definitely.

SA: And do you enjoy talking about it?

HW: Oh, I don’t talk about strange babies to them. But about medicine, yes, and students. And they’ve known a lot of the people I’m teaching. But I’d much rather talk to people who do the same work about strange babies and things, because they’re interested. The other people in my department may be interested but they’re not riveted. All these other pathologists, I can guarantee you they’ll be riveted!

SA: OK, so this week you’ve seen this ‘mermaid’ syndrome?

HW: Yah, and the other one was a skeletal dysplasia, a little dwarf that was referred from Johannesburg. They’re difficult. This was [sent to me by] someone who trained in our department and who is now working in private. He couriered it down to me in Cape Town.

People send me various things. There was one baby with a massive tumour so you could hardly see the eyes. The ultrasound person phoned to say, “I can’t see the eyes...”, and there was just this huge tumour that had taken over. The baby was about twenty weeks in utero.

The value of ultrasound

SA: So this was discovered before the baby was born?

HW: Oh, long before. You see, they’re doing detailed ultrasound. We’ve just had somebody giving us a lecture – a person I’ve done ultrasound with. She does the ultrasound and then she’ll send me the little babies and she and I put it all together for these students of ours. So it was very nice. You saw the little picture on ultrasound; she thinks it’s this, this and this, and then this is the pathology. So it’s the scanners who are picking these things up. In the early 90s they were doing scans at 22 weeks. They’re now doing them at 14 weeks, so the fetuses are getting smaller and smaller and smaller.

SA: And are you finding good correlations between the scan images and your pathology?

HW: Very nice correlations. Sometimes it’s a confirmation of what she thinks; sometimes it’s something different that she can’t see. It’s a 50/50 thing. It’s very interesting.

SA: So do you think scanning is ever going to take over from what you do? Is it ever going to be sufficient in itself?

HW: Never. It’s wonderful: now she’s showing us pictures in 3D and 4D. Before it was a profile, now you see the whole little face. So it’s very good for all the external features, but what about the internal? It’s very good for kidneys; very good for hearts; good for bones. But not everything.

It’s very nice. You see she’s very professional. She sends you all the details of what they think they’ve got on the scans, and then you go from there: does what you find support that?

SA: It sounds as though you are very busy.

I only hear the bad news!HW: Yes, but I mean these things don’t happen every day. There are plenty of normal pregnancies: things go well. I don’t hear any of that. You see, I only hear the bad news! And there’s plenty of bad news.

We went off to Tygerberg (Hospital) today and we watched the students cut up twenty placentas there. They were all problems.

SA: And what were you finding?

HW: Oh, all sorts of things. There were some interesting green ones. If the baby becomes hypoxic, its bowels then start opening and it passes meconium into the fluid and that gets into the baby’s lungs and it stains the placenta. Now you’re trying to find out why; what made that baby hypoxic and caused its death?

And then there were a whole range of haemorrhages. One of them was another of these ‘tik’ (crystal meth) abusers and you get all sorts of strange things with drug addicts. You don’t know; they may be taking multiple things.

SA: Would you say that a lot of the pathology you’re seeing is the pathology of poverty?

HW: Poverty; ignorance. Why do people take drugs?

SA: After you’ve done the autopsy, how much work is there still to do? With the Cyclops, for instance, what will you do next?

HW: Well, I’ll check to see, is it a [chromosomal abnormality known as] trisomy 13? I’m going to count up how many features would support [that hypothesis]. They usually have an extra finger; this one didn’t have the extra finger. So it’s a matter of counting up how many things I’ve got for it [being a trisomy 13] and how many against.

SA: What else would you have looked for apart from the extra finger?

HW: Congenital heart abnormality. This one had an unusual abnormality of the vessels coming out of the heart, as opposed to inside the heart. So that is much less clear cut.

SA: What else, other than diabetes and alcohol, are you seeing a lot of in your department?

HW: Epileptics. And then we also see [the effects of] warfarin. We still have a lot of rheumatic fever in Cape Town, and if you don’t pick it up [in the clinic] they get valve damage. Then, they often need a valve prosthesis, so they have to go on blood thinners, and the easiest one in South Africa would be warfarin. If a woman has warfarin while she’s pregnant, then the baby is damaged. It can cause bleeding in the baby, or it can cause actual damage. The baby’s nose is absolutely flat and they have great difficulty breathing. So a tiny, squashed little nose is a typical appearance. Then on an X-ray they have lovely speckled calcification next to the spine and all the growth plates. The last conference I went to I took my experience with warfarin, and people said, “Look! We don’t see this sort of thing.”

SA: Is that because in the developed world they know the effect of warfarin and this would be picked up in antenatal care?

HW: Well, you see they’ve tried putting people on different things, and overall warfarin is best for the mother. You put her on other things that are better for the baby, but the mother dies! No, you want to get rid of rheumatic fever, which is caused by a streptococcal sore throat and if you don’t treat that with antibiotics then two weeks later there are antibodies that attack your heart, and attack your muscles, and your connective tissue throughout your body. If the patient’s got a streptococcal throat they must be treated with penicillin, and you can get rid of this whole thing. But you don’t want a doctor who gives antibiotics for every single sore throat , because if you give penicillin for a virus all you’re doing is building up antibiotic resistance in your community.

So you want a discerning doctor. Will our new ones be discerning? We hope! We’ve brought in a whole lot of general practitioners to teach in our curriculum, and guess what? They’re saying to the students, “We don’t see rheumatic fever.” That’s what they say!

SA: Why?

HW: Because they’re missing it. We’re seeing rheumatic fever – we’re seeing it when they die. So the GPs are saying, “You don’t need to know this because it doesn’t exist any longer.”

SA: So how big a problem is it as far as you’re concerned? How often do you see it?

It’s a sneaky sort of diseaseHW: Well you know, the cardiac people will see it when they get people with valvular disease. We see it from surgical specimens. The surgeons put in a valve; they take out the old valve and send it to us. And then we see it in autopsies. We see it at a late stage, but when somebody teaches that it no longer exists, then you get a little concerned.

If you let a child who’s got rheumatic fever play sport they drop down dead while they play. The other time [people who’ve had rheumatic fever] get caught is in pregnancy. In pregnancy your cardiac output has to double, so if you’ve got a narrow valve, suddenly your heart can’t cope with that extra circulation. We get a few coming in as maternal deaths.

I liaise with the medical students and I say, “Well, I’m afraid, you do need to know about it, because we see it.” You see, rheumatic fever is very sneaky. It’s pain in the joint, and then it can flip to another joint. So you might say, “Well this child is just being damn difficult.” It’s not as if they suddenly present with a fever. They start to get all these symptoms, but if you listen to their heart, you realise what’s going on. It’s a sneaky sort of disease, so if you’re not thinking of it you can miss it. And then it quiesces. If they survive that initial part, then you get all the secondary changes.

“A waste of human life”

SA: Tell me, when you decided to go into pathology, were you ever tempted to do forensics?

HW: No, never tempted to do forensics, though I have a lot of contact with forensic departments.

SA: Why were you never tempted by forensics?

[Forensic pathologists] have a really tough time seeing the worst of human natureHW: Well it’s violent death and I just found it incredibly distressing. [Forensic pathologists] have a really tough time seeing the worst of human nature all the time. That’s what I couldn’t take. You know there are some really unpleasant people around, but there are an awful lot of wonderful people. But they only see the dreadful things, all the time. You’ve got to be very strong. I don’t think I’d be able to handle it. Such a waste of human life.

SA: And the ‘natural’ deaths never affect you in that sort of way?

HW: Never! Well, it can be very sad. But it’s very easy to accept what’s natural -- and it’s really clever if you can beat the odds. With a lot of these children’s tumours now, they’re beating the odds. It’s just incredible.

SA: But what does disturb you, what have been sad moments? Irene Scheimberg says she can’t bear it if a baby is brought in for autopsy in its clothes. Some things just get through the armour.

HW: Right, right. I don’t like doing an autopsy when you find that somebody made a terrible mistake. I had a baby... The mother, I’m sure, wasn’t particularly wealthy but she was going private, and, you know, you expect people to put themselves out if somebody is paying privately for a pregnancy. This is what she said -- and it was subsequently reported in the newspaper -- she said she came to the hospital in labour, the doctor wasn’t there and she delivered on the bed with a sister who wasn’t particularly helpful. Then the sister took the baby away and didn’t tell them anything. I don’t know if that is true or not, but anyway the baby was taken off to ICU and the paediatrician wasn’t called. I think the paediatrician came four hours after the birth of that baby to find it in a very bad way, and it died.

So there wasn’t a doctor when the baby was born. They didn’t call a paediatrician. I just find it...

SA: Why did the baby die?

HW: Well, the obstetrician who asked me to do the autopsy said that the cord was around the neck. Now there was no evidence of that: if the cord’s around the neck you tend to see a constriction, and then the head a bit swollen. I didn’t see any of that. I just wondered if it didn’t get the right treatment. That’s what I don’t like – it was a beautiful looking baby, and it seemed like an unnecessary death. When it’s a little runt of a baby I don’t feel the same thing.

SA: How often do you get what seems like an unnecessary death?

HW: Very rarely from the private side. From the government side, yes, because you’re dealing there with junior people. But these are well qualified people who are getting big salaries. In [the public sector] it’s a different situation. They’re junior people who often haven’t got someone to call, and they’re doing the best they can. I don’t have any problem with anyone who’s doing the best they can, but when it’s just negligence I find it very upsetting.

SA: But how often do you find treatment-related death?

Accidents do happenHW: I do, occasionally. I had a baby, from the private side again, but they were feeding Intralipids. If the baby can’t take food by mouth, you’ve got to put food into a blood vessel, and this had slipped from its neck and gone into the heart sack. So this lipid was just going into the heart and that was that. But the paediatrician phoned us up and said, “I think the line had slipped.” This is something that can happen; that’s a different situation. She explained to the parents, “We put the thing in to try and do this, and there was [an accident].” Everyone has faced up to the problem, you know what I mean? These things happen, I can accept that. It’s when someone tries to cover up, pretend it hasn’t happened, gives you false information -- that sort of thing upsets me

You’ve got to accept that people do their best; sometimes it’s not the right thing and accidents do happen. Medicine is a tricky business, and these babies have very tiny delicate vessels -- it’s not like dealing with a big strong fellow with big vessels -- and access is difficult. I think parents can relate to this if you explain to them what’s happened. It’s this wall of silence: just take away the baby and don’t say anything... In a private hospital, I mean, that is just bizarre.

SECTION 8

Family life

SA: Are you a religious person?

HW: No, not at all.

SA: Do you think religious belief is compatible with what you have seen, or do you think the vagaries of Nature are too obvious to encourage belief in a god?

HW: Well I think for some people a spiritual belief is what they need. I don’t have any objection to that, not at all. I have one religious son, and to me that’s his choice. He’s the one with the cardiac problem – he had cardiac surgery when he was two for this defect.

SA: And how is his heart?

HW: Well, last year, around about April, he had this terrible condition. He suddenly started running high fevers, and then severe pain in all his joints, and eventually wasn’t able to move. We took him to lots of people. I think it was rheumatic fever; he had rheumatic fever when he was four. He went and saw everybody at Groote Schuur; everyone in private; everyone in infectious diseases. They did blood cultures, they did all sorts of things, and the one thing that was massively raised in his blood was the streptococcal AntigenAny foreign substance or organism that stimulates the body's immune system to produce antibodies and cells that react specifically with it. . He’s been doing a lot of work with children living in an orphanage, through the church, taking them on outings up the mountain and various things like that. He’s a cricket player, so he’s normally very, very fit. Eventually they put him on corticosteroids.

SA: And has it resolved?

HW: Well I don’t know if you could say that, but he’s managing to play first class cricket. So it’s resolved to a certain extent. But if his feet are sore, he’s not going to mention it to anybody. Just bizarre...

SA: Was this a consequence of his earlier rheumatic fever, or what?

HW: Well, we thought, “Is it the heart?” But they said “There’s nothing going on in the heart, the heart enzymes are normal.” The ECG has never been normal because he’s had this surgery. The cardiologist at Groote Schuur doesn’t think it was rheumatic fever. But he hasn’t got another diagnosis.

SA: But if the streptococcal AntigenAny foreign substance or organism that stimulates the body's immune system to produce antibodies and cells that react specifically with it. was very, very high, why isn’t that diagnostic?

HW: I don’t know. My sister went and consulted a cardiologist up in Joburg and he said, “Why not just give him ten years of penicillin.” So that’s what he’s on and I’m afraid that for the next nine years he’s taking penicillin every day. Anyhow he seems to have got over this now, thank goodness.

SA: So has he had illnesses all through?

HW: Oh yes. I’ve got three children and if anyone gets sick, he gets it too and he gets a double dose compared to everybody else, since he was little.

SA: So what heart surgery did he have at two?

He was in heart failure from about three weeks oldHW: He had a hole between his two ventricles, and the vessel going to the lungs was too narrow, so that had to be widened. He didn’t grow at all till he got to two, and then once he got the surgery... He was in heart failure from about three weeks old.

SA: Why did they leave it so long to do the surgery?

HW: Because the heart’s a walnut size at birth, so the surgeons won’t do it till it’s a reasonable size to operate on. And they did a wonderful job. Once they’d fixed it, he just shot up like a bean! People used to stop me and say, “Excuse me, why don’t you feed this child?” Because I had a daughter who was quite large, and this child who was like... You know, with chicken drumstick legs, these two skinny little things!

SA: When did you discover he had all these problems?

HW: As soon as he was born. My sister came to check him out, “Take him to a cardiologist,” she said.

It was very good, I used to live in Johannesburg so every time he got sick he was just whistled off to a paediatrician, and that was my sister! That’s what they need -- as soon as they get the slightest bit of illness they need rapid treatment.

SA: But those two years, before he had the surgery, what was life like?

HW: Well, he wasn’t allowed to cry. The moment he started crying he just became too tired to drink. He was having difficulty breathing, drinking, anything like that. So we had to cradle him a lot, or put him in the back of the kombi (van). We had some dirt roads nearby and they were absolutely wonderful – the car would go bounce, bounce, bounce, and he would drop off to sleep straight away. Or you’d put wrinkles in the carpet and put him in the pram -- he loved sort of rough things, and he’d drop off. But if you sang lullabies it didn’t work at all.

SA: So how did you cope? You carried on working...

It was very difficult going back to workHW: Oh no, I didn’t. No, no, I stopped for six years. It was very difficult going back to work after that, because there were a whole lot of changes in those six years. But I enjoyed having the children, and I intended giving up work just for an initial period. Those first two years are great fun.

SA: So what sort of changes did you find when you went back to pathology?

HW: Immunoperoxidase -- that’s a special sort of stain – didn’t exist when I went off, and it had already been going some time when I came back. That was a huge change. It was lovely, because if you’ve got a tumour... There used to be a few things we could do to try and determine what it was, or else we’d have to go and do electron microscopy. Then suddenly we had these magic things and you could see, “Ah, it’s heading towards a tumour of the skin, a melanoma; or it’s heading towards this, or whatever.” You’ve got this tumour sitting somewhere and now we can tell you it’s come from the lung, or the kidneys or whatever. So that came in and it’s been absolutely wonderful. It really revolutionised things.

SA: So how quickly did you pick up the new things?

HW: Well I did a stupid thing – I did my first exam and then stopped. So I was only half way through [when I took maternity leave]. It would have been much better to have completed my training and then taken the time off.

SA: How old was the little boy by the time you went back to work?

HW: He was four. And he’d had his surgery and all that. His surgery was absolutely phenomenal. They went in through the atrium, so through the thinned-walled chamber, worked through that and put a patch over the hole. It was incredible.

SA: And what did they do with the plumbing that wasn’t quite right?

HW: I think just sort of chiselled out a bit of the muscle to make it wider. It was just incredible. And the change, you know! It was done at a hospital called J G Strijdom, and we lived out at Morningside in Sandton. He had to go back three weeks after his surgery, and I put him in the car – he was only two and a half but he could see we were going towards the hospital -- and suddenly from his little seat in the back there was this horrible howling. A little thing this size, with his little cap on, and I almost had to drag him up the stairs because hedid not want to go!

He’d been tied down, you see. They put him on a ventilator, and they tie you down. He was in ICU, actually, for a relatively short time, but he obviously knew all about it. Then the chap said, “Oh it’s you Alistair, what are you doing here? I just need a little listen to your heart.” He listened to his heart and he said, “Alistair, I don’t want to see you.” [We’re both laughing] And this child just flew down the stairs, dashed to the car!

The surgeon was absolutely phenomenal. And then my sister was there to do the regular check-ups. We started saving for this operation from the moment this child was born. And then it was done at Strijdom, which was a government hospital, and it cost something like R1,500 (about £120 today). So we gave a big donation to research. We thought it was going to be R40,000 or whatever, long ago, and it was all on the state.

SA: But how traumatic for you was it?

HW: It was extremely traumatic, because this husband of mine [couldn’t visit Alistair in hospital] I met my husband at Varsity. He was from Zambia and he had a big spleen -- that’s tropical splenomegaly -- and every time he had an exam he’d have a release of malarial parasites. This was when he was studying.

When Alistair went into ICU, we made sure that he had somebody he could see every single minute. You weren’t allowed inside the ICU, but you could look through the window and he could see someone of his family there all the time. My husband had the most monstrous attack of malaria – black water fever and everything – while Alistair was sick. So it was a traumatic time.

But people came up with all sorts of lovely little things [to keep Alistair happy]... You didn’t need to do much. Then he came home and within four days he was on one of those little plastic scooters tearing around the house! One minute his whole chest had been opened -- he’d had open cardiac surgery -- and then he was tearing around the house.

When I was at home [before Alistair’s operation] I didn’t let my daughter go to nursery school, so I had various children coming to play with her at the house. But I had a rule: if anybody was sick they were not to come anywhere near. So he was kept away from risk. But once he’d had his surgery, she then went to nursery school.

SA: Going back to your return to work, did you, as a woman and mother, ever feel there was a glass ceiling? I mean, what was it like being a woman in pathology?

HW: There are lots of women in pathology. It’s good for women. You get the occasional call at night, but nothing like the other disciplines. It’s never been a problem for me.

Time off

SA: So what do you do to switch off?

HW: Swimming; exercise; hiking. There are so many choices [for hiking] round here. I’ve got my brother and sister-in-law arriving next week and they’re coming to stay with me for three weeks. My brother’s got this lovely detailed map of Table Mountain and last time he wanted to try every path. You didn’t have to get to the top of anything, just see how everything connects – he’s a mathematician! [We laugh]

My child with the heart problem, he goes rock climbing! I don’t want to watch. To me, that’s his choice, but to watch it is the worst thing.

A sabbatical in Australia

SA: Finally, Helen, tell me about your sabbatical.

There were pathologists at the two hospitals in Australia – one was a paediatric hospital and one was a maternity hospital, so there were placentas and lots of babies. They had organised things so that every baby who dies in the whole of Western Australia -- just think of the size and distances of it! – has an autopsy. They’d fly an Aborigine baby from a little island in the middle of nowhere; it would come along for its autopsy and then be flown I don’t know how many thousand miles back for its burial. The organisation was just exquisite.

SA: How did you get to go there?

HW: It’s always [a matter of] contacts. I knew the one pathologist because I’d met him on one of these baby courses. He was tired of working on his own, so he wanted locums. One chap from the Red Cross [Children’s Hospital in Cape Town] did three months, another did three months, and then I did two.

It was just wonderful doing only babies the whole time; it was absolute bliss. And then the bird life! It was just a wonderful place to go and visit. The hospital was lovely; the conditions were absolutely super. And the mortuary staff... They’re qualified technicians, often very senior people, so the mortuary was immaculate. You put a foot wrong and they told you! It was absolutely professional, beautiful quality work. It was a pleasure.

SA: And what did you see?

HW: Well a similar range of pathology to here, but then many more metabolic diseases, because they see every single baby. I saw some wonderful conditions, such as Hurler’s syndrome: this is one of those very rare metabolic things where the unfortunate child deposits these products that won’t break down in the brain, so it looks like a gargoyle. Very physically abnormal. They’ve got these deposits in the heart valves, in multiple tissues... At birth they look terrible; huge tongue.

So I saw extraordinary cases like that. It was a really good paediatric hospital, you see, so the clinicians have diagnosed these things at birth and then they follow them up until they die, and then they send them in for an autopsy.

SA: So it’s just sort of tradition that they want to find out what has happened afterwards?

Tiny little coffinHW: Yes. And then they have a very nice way of handling the remains of babies. Very particular. Even if it was a tiny little fetus, there would be a tiny little coffin. And they’d have a memorial service about once a month. You know, if you try and incinerate a baby like that there are no ashes, but if you put the placentas in too then you get some ashes. So they’d put ashes in a little box and they’d come and scatter their ashes on the rose garden, and that sort of thing. It was dealt with very well. The mortician did the grief counselling; everything was well thought out.

And then all the little old ladies in Perth would knit garments, so every baby that died -- when it went off for incineration or burial or whatever it was -- would be fully dressed in newly knitted little hats, bootees. Even if they were very macerated, they would be all dressed up. And then there would be a little blue box or a pink box. Little footprints, or mementoes for the parents. All so thoughtful.

SA: And what happens to the bodies here?

HW: Well here it’s exorbitantly expensive to have an incineration, so we have one in a Blue Moon. Mostly it’s just hospital disposal -- we do a huge number of hospital disposals, because we’re dealing with people who can’t afford things like that. And if it’s a big baby we have a pauper burial. So it’s just completely different.

SA: So are you as excited now by pathology as you ever were?

HW: Oh yes, yes. I look forward to coming in to work in the morning, yes.

ENDS

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