The Future of Medicine

1

THE FUTURE OF MEDICINE

by

BONGANI M. MAYOSI

B.Med.Sci.; M.B., Ch.B. (Natal); F.C.P. (S.A.); D.Phil. (Oxon); F.E.S.C.; F.A.C.C.; F.R.C.P. (Lond.); M.A.S.S.Af.

Vice-Chancellor and Principal of the University of Cape Town, Professor Njabulo Ndebele; Deputy Vice-Chancellor and Vice-Principal, Professor Martin West; Deputy Vice-Chancellors, Professors Cheryl de la Rey and Thandabantu Nhlapo; Dean of the Faculty of Health Sciences, Professor Marian Jacobs; Dr Nosisa Matsiliza, ikhankathakazi lam;Friends, Family, Ladies and Gentlemen.

Thank you, Professor Jacobs, for your very kind and generous words of introduction. I am delighted that both my mother, Mrs. Nontle Mayosi, and the only surviving sibling of my father’s, Mrs. Nontuthuzelo Mbuli, are present to hear these words. I am sure that their impression of me will improve after this day. My late father, Dr. George TimketsonSikhumbuzo Mayosi, is sadly not here to witness this occasion. Ndithi kuye namhlanje, lala ngoxolo, Rhadebe, soyifeza iminqweno yakho.

My siblings and I owe a great debt to our parents for instilling in us a love of learning, and to our mother in particular who suspended her own career as a nurse for 14 years to raise and almost single-handedlyeducate her brood of five children. We received home schooling from my mother and other mothers in the village of Ngqamakhwein the Transkei;this home-basededucation was supplemented by the meager offerings of the Bantu education system of the 1970’s. My mother’s name is Nontle, which means ‘the mother of beauty’, and I stand in front of you as an example of the success of her labour of love. Mama, enkosi.

I would like to acknowledge, too, with gratitude, the love, support, and understanding of my wife, Nonhlanhla, and my children, Vuyi and Gugu, our pride and joy, for without them, my life would be incomplete.

And to everyone here tonight – my relatives, colleagues, and friends who have come from all over the country – a very sincere ‘Thank you’ for finding the time to honour me with your presence.

It is with humility that I stand before you this afternoon as the seventh Professor of Medicine and Head of the Department of Medicine in its 87 year history. I am also deeply conscious of the distinguished example of my predecessors, three of whom are in the audience today.

I indeed stand upon the shoulders of giants. The first Professor of Medicine, Professor A.W. ‘Oubaas’ Falconer, arrived from Aberdeen, Scotland, in February 1920 to establishwhat was then known as the Division of the Medicine at thenew University of Cape Town Medical School. He was a leading spirit who contributed greatly towards the establishment of clinical teaching which took place at Somerset Hospital at the time.1

In 1938, Groote Schuur Hospital opened, at which time Falconer retired as Professor of Medicine and went on to become the Vice-Chancellor and Principal of the University of Cape Town.

Professor Falconer was succeeded by Professors Jack Brock and Frank Forman who were the joint heads of the Department of Medicine from 1938 to 1954. The numbers of students in the medical school continued to increase in this period, and, naturally, the emphasis of the department was on clinical teaching. The legendary combination of Brock and Forman served the department well. While Frank Forman was inspiring generations of medical students in the finest traditions of clinical medicine, Brock, who was appointed Professor of Medicine at the tender age of 33 years, began to lay strong foundations for medical research in the department.2

In 1954, Professor Brock assumed the sole Headship of the Department. It was during his term from 1954 to 1970 that the department expanded through the establishment of specialist clinics and the escalation of the research effort. This period of expansion arguably represents the golden era of the Department of Medicinein which, for example,the publication count grew from two papers per year in the 1940s to an average of 100 peer-reviewed publications per year by the 1960s. The establishment of specialist clinics, likethe Cardiac Clinic in 1955, made it possible for great achievements such as the first human heart transplant to occur on this campus. Professor Solomon Benatar remarked in his Inaugural Address of 1981 that ‘the foresight and vision of the University of Cape Town and the Provincial Administration in designing the Joint Agreement…and the tenacity of all concerned in sustaining it through difficult periods must be acknowledged, for without this mutually beneficial arrangement between the Province and the University it is unlikely that research or clinical activities would have developed to the same extent’.2

Brock was succeeded by Professor Stuart Saunders in 1971 as the fourth Head of the Department of Medicine. Saunders steered the Department successfully through a period of changing fortunes. The harbinger to the changing times was the banning and eventual move to exile of Professor Bill Hoffenberg for his anti-apartheid activities in 1968. The political repression and unrest of the 1970’s had a significant impact on the life and work of the department, resulting in the firstmajor exodus of highly qualified staffin 1977 and 1978, following the 1976 uprisings of school children against Bantu education.

The chronic problem of healthcare budget cuts and the flight of staff into the private sector or overseas continued in the era of Professor Solomon Benatar from 1981 to 1999. Professor Benatar valiantly stabilized the department in the midst of an increasingly hostile environment, and handed over to Professor Ralph Kirsch in 1999 a department that was sound with respect to the quality of clinical teaching, medical service, and research output.

The Department I inherited in 2006 is probably the finest Department of Medicine in Africa, and a tribute to the fighting spirit of Ralph Kirsch and his predecessors in ensuring the survival of academic work in Cape Town under very difficult conditions. I am privileged to work with the fine men and women who make up the Department of Medicine of today, all of whom are committed to providing the best clinical care to their patients, to producingcompetent doctors and specialists, and to conducting research as perfect as any in the world.

Ourdepartmental staff of 169 people consists of 12 Full Professors, 18 Associate Professors, and 63 Senior Lecturers, who are supported by 40research staff and 36 administrative and clerical staff. We play a major role in teaching undergraduate medical students and in training specialists and subspecialists in medicine. We teach 1183students at any one time, who are made up of 1014 undergraduate medical students, 81masters students (of whom 50 are specializing in internal medicine and 15 are engaged in subspecialty training) and 35 doctoral students.

Today I have chosen to speak on the Future of Medicine. To address the question of the Future of Medicine, we need to start from the beginning. It has been said that our memory of the past, informs our present, and guides our future.Therefore, I will do three things in my talk: first, I will comment on the origins of Medicine, second, I will talk about the health status of Africa, and finally, I will venture into the future.

The African Origin of Medicine

According to Charles S Finch,3 an American scholar of ancient history and a medical doctor, ‘healing as a vocation may have begun at the time when a remote, nameless ancestor – taking cues from the habits of animals – brought leaves, grasses or roots to an ill relative in an attempt to relieve her distress’ and found a beneficial response.The origin and evolution of healing as a special skill probably antedates other important human inventions such as agriculture and animal domestication and might well deserve consideration as ‘the oldest profession’ in the world.3 The accumulated observations and trials of thousands of years have brought a wealth of healing knowledge to mankind, and medicine as a systematic discipline has emerged in different modes in all the cultures of the people of the world.

As with so many other human achievements, Finch argues that the art and science of medicineemerged first in the NileValley of Africa, reaching its highest level of development – until modern times – in Egypt, land of the pharaohs. When Egyptian dynastic history begins, medicine is already an established, fully-formed science. Theinformation to support this assertion is contained in the most important medical text-books of ancient Egypt, now known as the Ebers Papyrus and the Edwin Smith Papyrus, which are copies of medical papyri which date back to pre-pyramid times, to the very earliest historical dynasties of Africa.3

From the beginning of her history, Egypt possessed a mature, well-validated system of medicine containing systematic pathology, a completely-formulated pharmacopoeia, a formal knowledge of anatomy and physiology, a large medical literature, a well-defined medical curriculum, and a skill in surgery that was hardly matched outside Africa until the modern times. According to Finch, it is unthinkable that such knowledge, which is so sophisticated on a scientific level, could have emerged without a long period of anterior development. There is a 2400 year span from Hippocrates of Greece to modern medicine and the mature medical science that existed at the start of the dynastic period in Egypt would have had a pedigree at least as long.3

If the onset of the Egyptian dynastic period is dated around the first known calendar date of 4236 B.C., which is believed by some to be closer to the actual beginnings of Egyptian dynastic history rather than the conventional 3200 B.C., the best educated guess would push the origins of Egyptian medicine back, close to 7000 B.C.3

If Egyptian medicine was of a caliber beyond that of all later medicine up to the modern time, we have to presume that not only was the scientific spirit alive and well in ancient Egypt, but that scientific medicine actually originated in Africa. It is therefore a misnomer to characterize our practice of scientific medicine as ‘Western Medicine’, when in fact, like all human beings, it originated in Africa.

Imhotep, the African: Father of Medicine?

Indeed, no individual more fully embodies the highest and finest of Egyptian medicine than the figure of Imhotep( Sir William Osler called him ‘the first figure of a physician to stand out clearly from the mists of antiquity’.3 In truth, this African physician is the world’s first universal genius and polymath. As chief counsellor to the pharaoh Djoser, he was a statesman of the first rank; as designer of the world’s first great edifice in stone, the step-pyramid of Saqqara, he was an architect of genius; as the renowned purveyor of wise sayings and parables, he was the epitome of a sage; and finally, as a gifted priest-physician, he was accorded that rarest of honours in ancient Egypt, that is deification as the god of healing.3

Hippocrates, the Greek physician who is customarily accorded the title of ‘Father of Medicine’ was himself said to be descended from a long line of ‘Asclepiads’, that is a devotee of the Greek god of healing, Asclepios. In the famous oath ascribed to Hippocrates – which some believe was composed after his death – adherents of the Hippocratic school are made to swear by all the important healing gods of Greece, including Asclepios.3According to some scholars, by swearing by Asclepios in the Hippocratic Oath, the members of the Hippocratic school were in fact swearing by Imhotep since the two were synonymous in the Greek mind.

The reputed primacy of the Hippocratic school as the originators of clinical medicine was finally laid to rest in 1930 when Breasted translated the Edwin Smith Papyrus, a document whose original antedates Hippocrates by over 2500 years. The diagnostic, prognostic, and therapeutic methods revealed in this document demonstrate that even in our own day, our physicians have not surpassed the clinical acumen of the priest-physicians of the Nile Valley of Africa, of whom Imhotep was the epitome.3

I submit, ladies and gentleman, that Hippocrates in no way merits the title ‘Father of Medicine’, either by virtue of his antiquity or the level of his scientific thought. If such a title belongs to anyone, it belongs to Imhotep the African.3

A study of other African systems of medicine is more problematical, however, because of the absence of surviving written records. Thus, most of what we know comes from the testimony of European missionaries whose contemptuous view of traditional African culture was most pointed when writing about traditional medical practices.3According to Finch, it can be shown that the best of the traditional healers in various parts of Africa acquired a startling level of proficiency and, contrary to contemporary opinion, were not without medical science.3 We will leave the exploration of the evidence on this statement for another day…but I cannot resist the temptation to tell ananecdote concerning the Khoi remedy for rheumatic fever that my mentor and good friend, Professor Jimmy Volmink (Deputy Dean for Research, University of Stellenbosch Medical School), brought to my attention recently.4

In 1876, there was a lively exchange of correspondence in the Lancet, the British medical journal, between by Thomas Maclagan, a doctor from Dundee, Scotland, who reported on his use of salicin to treat the symptoms of rheumatic fever, and Dr. Frederick Ensor, a surgeon at the ProvincialHospitalinPort Elizabeth. On 14 April 1876, Dr. Ensor wrote to the editor of the Lancet as follows:

“DEAR SIR - I have seen with much interest your papers in the Lancet on the Treatment of Rheumatism by Salicin, and thought that the following story might be welcome.

“In 1861, I was district medical officer in Hope Town… the town is… occupied by a race of nomadic Dutch Boers, who live in wagons or tents, traveling about from place to place...

“On one occasion, I was sent for to visit the wife of a Dutch Boer, who was said to be veryill. I found my patient…lying on a camp bed in a littletent, where the heat was something terrific; a naked bush child trying to fan away the cloud of flies,which was tormenting my poor patient, bound hand and foot, I may say every joint, in the cruelbonds of as fierce an attack of rheumatic fever as I ever saw. She was perspiring profusely…

Iprescribed the usual alkaline mixture, with calomel and Dover’s power at bedtime, and rode away.

“Some two months after, my former patient entered my surgery, looking remarkably well, and I verynaturally congratulated myself and her that she had recovered so completely. I was quite takenaback when she bluntly told me that my physic hadn’t helped her a bit. On enquiring what had helpedher, she said that the old Hottentot shepherd had made her a decoction of the shoots of the willowswhich grow on the banks of the river, and that after taking this for a few days she began to get better.

“Your papers in the Lancet brought the picture of the stout Dutch woman back to my memory. Iafterwards learned that a decoction of willow-tops is a favourite remedy for fever, and what the Boersand native Hottentots call ‘sinkings koors’ or rheumatic fever.

“Trusting that this remedy which you have scientifically thought out may prove as beneficial as the‘willow-tea’ selected by these children of nature.”

Commenting on the information he had received from South Africa, Maclagan wrote:

“(it is)…a curious commentary on our civilisation…that one of the most common and painful diseases of the civilised world should have remained one ofthe opprobria of medicine for many years after a remedy for it was known to the rude Hottentots ofSouth Africa….the untutored Hottentot shepherd used the proper means, while the accomplished Europeanphysician was trying this, that, and the other remedy, with results so unsatisfactory that he hadalmost given up the idea of ever being able to do more than watch the natural progress of the malady…”4

The Khoi people made the extract of willow tea by boiling the leaves of the willow plant (Salix alba) and used this for pain relief and to treat fever. We now know that the effect of the willow leaf is largely due to the activity of a glycoside, salicin, which is changed following ingestion to salicylic acid, a compound that is related to acetylsalicylic acid, the active ingredient of aspirin.5

The State ofColonial and Post-colonial Medicine in Africa

The Khoi people, who were the original inhabitants of the Cape peninsula and called TableMountainhoerikwaggo, of course did not survive the relentless advance of colonialism in Africa. My colleague and friend, Del Kahn, the Professor and Head of the Department of Surgery at the University of Cape Town, reminded me of a statement that set scene for medicine and politics in South Africa for almost 100 years following the assimilation of the Khoi people. The statement is contained in the book compiled by Professor Jannie Louw, the second Professor of Surgery at the University of Cape Town, on the history of the first 50 years of the University of Cape Town Medical School. The statement reads as follows:

‘At the turn of the century, the health of the public was receiving a good deal of attention, thanks to Dr Barnard Fuller, who was then part-time Medical Officer of Health. In the 1900 annual report he referred to the outbreak of bubonic plague in the city. The first step decided upon was to remove all Bantu (people) from the city precincts and to house them in a Bantu location in Uitvlugt (or Ndabeni). At that time Dr Fuller was convinced that this racial group played an important part in the spread of plague and aggravated the slum conditions which then existed in District Six and the Malay Quarter. This is illustrated by his reference to the influx of ‘uncontrolled hordes of aborigines into the city confines’.1