Angels with wet wings won’t fly’

Inaugural Lecture

May 2007

Vice-chancellors, The Dean, Distinguished Guests, my Research Teams, Members of the Gynae Oncology Unit and the Department of Obstetrics & Gynaecology, Colleagues, Friends and my Family

I have belonged to the two great institutions of the University of Cape Town and Groote Schuur Hospital since I was 17 years old, when I came to Cape Town to study medicine in 1976. I remember in my first year, learning of an anonymous writer in the 16th century who described the role of the physician as ‘to cure sometimes, to relieve often and to comfort always’. These core values have guided me during my journey through the corridors of UCT and Groote Schuur Hospital. However, medicine and its practice have demanded that we do much more than just take care of our patients - it has also demanded that we teach and train the next generation, that we do research, that we ‘publish or perish’, that we influence and inform health policy, government ideology and so on. We are constantly asked to push the boundaries of our vision and our work, to provide sound and accurate evidence of the validity of our interventions, to be accountable to our patients and to society at large. These are not small challenges and rising to the occasion is a constant work in progress. I have had many great teachers throughout my journey, too many to name individually, but the greatest among them were my patients.

In the 1980s teams of researchers were interested in the high infant mortality found in the favelas or slums of North Eastern Brazil – children were dying, as they still do in Africa, from a range of preventable illnesses, chief among them being diarrhoea. It was observed by some that mothers showed very little emotion when their children died. This observation prompted various interpretations from social anthropologists. One of the interpretations was that the constant state of scarcity and deprivation in which impoverished women lived had ‘a pernicious effect on their ability to nurture’. Such mothers, it was claimed, expected some of their children to die, and as a result, were forced to chose between their off spring, nurturing those seen as more likely to survive and neglecting those more likely to die. Thus active, animated infants were more highly valued than those perceived to be quiet and listless and less likely to survive. This inevitability of death, it was believed, discouraged mothers from bonding with sick infants and therefore, attempting to save them when they fell ill and subsequently died. This theory was known as ‘selective or benign neglect’.

Another group of researchers however, approached this observation using a different methodology which included in-depth interviews and intensive fieldwork over a seven year period during which 535 infant and child deaths were identified from household surveys. In contrast to the ‘selective neglect’ theory, the latter group of researchers found that mothers in the favelas experienced deep anguish at their children’s illnesses and went to great lengths to find treatment for their sick children, involving a range of practitioners from religious faith healers to herbalists to shamans and to orthodox medical practitioners when available, either in sequence or in parallel. Health seeking behaviour was governed by a complex set of biomedical, socio-economic and psycho-cultural realities. One of these was the widespread belief that children who die in infancy, transform into angels and develop wings in order to fly to heaven. The instruction to mothers was not to cry when their children died, as their tears would wet the wings of their infants, and angels with wet wings won’t fly! Many mothers described their terrible struggle to hold back their tears for fear of keeping their infants in permanent limbo and preventing their flight to heaven. A very different interpretation of the mother’s apparent lack of emotion, brought about by a different approach to listening.

This work had a profound effect on my way of thinking and understanding my patients and their relationship to their health. I was born into and raised in the Apartheid era, a system that divided and separated us from fellow South Africans, particularly black South Africans. Although I was conscious of apartheid and its manifold injustices while at school, my first real encounter with the reality of the lives of black South Africans occurred as a young medical student. Suddenly we were taking histories and examining patients whose language we did not speak and whose culture and the harsh of realities of their lives we barely understood. The wards at Groote Schuur Hospital were segregated – the black side always full to overflowing, the white virtually empty. Black medical students, the few that there were, were not allowed to examine white patients.

Throughout my student years, our lives were permeated by the horrors and injustices of apartheid, and the knowledge that we medical students were deeply privileged. It was haunting to know that there were thousands of young women with the same abilities and aspirations as mine, who were denied an education and often destined to work in domestic service, while I had access to an outstanding, world class education.

I entered medicine with naive innocence and it came as a terrible shock to learn that our profession had a history of colluding, directly and indirectly, with violence and oppression. During the 80s after a series of senior house officer jobs I worked as a general practitioner in Athlone, during the time of the Trojan horse episode and the heroic battles against the oppression of Apartheid that were taking place across the country – a time when people injured by police brutality could not seek medical care for fear of being arrested and tortured. Thousands of South Africans were being tortured and detained without trial, while our profession was largely silent, save for the likes of the Wendy Orrs and Francis Ames’ of this world.

I was a young doctor when Steve Biko was murdered by the security police with the direct collaboration of the medical profession. I learned of the collusion of our profession in the Nazi holocaust and the terrifying experiments committed by doctors against inmates of the concentration camps during the Second World War. All these, and many other lessons and experiences were sobering and taught me that science can never be divorced from its context. Medicine is not value free.

My first encounter of death was as a young intern at Somerset Hospital in Obstetrics & Gynaecology, when a mother of 5 was admitted after undergoing a backstreet abortion that went horribly wrong. She died from overwhelming septicaemia. She was one of many women who underwent unsafe abortions in a desperate attempt to control their fertility. Later I encountered women who had been raped or savagely beaten by their intimate partners. It was disturbing and distressing to realise that our profession did not distinguish itself by caring even remotely adequately for these women, nor did it frame these women’s experiences as human rights abuses and major public health problems. I learned that suffering and ill-health were profoundly political – how people were seen was strongly influenced by prevailing attitudes and prejudices, that political ideology, class, race and gender determined how one was treated, what illnesses one developed, what access to care and the type of care one received.

Women’s health entered the global health agenda at the first International Conference on Population and Development held in Cairo in 1994 where it was recognised for the first time that population, gender and reproductive health issues needed to be urgently addressed in order to eradicate poverty and improve the quality of lives of the world’s poor. Six years later the Millennium Development Goals were formulated at the largest United Nations Assembly ever convened with 189 member states voting supportively. The goals are meant to be achieved by 2015.

These goals are listed here. It is noteworthy that gender equality, empowering women and reducing child and maternal mortality are specifically mentioned in the goals. What the world has finally woken up to is that women’s health, in the broadest sense of the concept of health, defined by the World Health Organisation as a ‘…state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity…’;unless women’s health is prioritised, eradicating extreme poverty, hunger and deaths from preventable diseases will not be possible.

Well how are we doing with regard to achieving these goals, particularly in our continent of Africa? I am now going to show you 7 slides of graphs highlighting some of the Millenium Development Goals

This slide shows the proportion of people living on less than a dollar a day, one of the benchmarks for measuring extreme poverty. On this axis are different regions of the world and on this, the proportion of the population living on less than a dollar a day. There have been some dramatic changes, particularly in East Asia, largely led by China, where the proportion of people living on less than a dollar a day has more than halved in the 10 years between 1990 and 2000. In Africa however, where just under half the people live on less than a dollar a day, there has been no change in the past 10 years.

What about achieving universal primary education for boys and girls? This slide shows that there has been some improvement in the world, even in Africa where the proportion of children accessing primary education has increased from around 50% in 1990 to 74% in 2001. Still a quarter of children do not have access to primary education and the proportion of girls accessing primary education is roughly half that of boys, so the gender gap remains in place.

Adolescent fertility rates have important health implications for women – women who bear children as teenagers are usually denied an education, have poor health profiles and often remain deeply socially and economically subjugated. This slide shows the adolescent fertility rates in different parts of the world. As you can see, we have the highest adolescent fertility rate in Africa at 135/1000 compared to 16/1000 in East Asia and 30/1000 in Europe.

The data on Maternal mortality, one of the more specific millennium development goals is even more devastating. As you can see from this slide, nearly 1000 women out of every 100 000 live births die from pregnancy related deaths. This is a tragedy of enormous proportions and the reason for this is very simple – inadequate access to health care.

Not only has the global HIV/AIDS epidemic caused widespread devastation, but it has also diverted resources, energy and political will away from the myriad of other important illnesses experienced by the world’s poor. These are the data from 2006. Just under 40 million people were known to be infected with HIV by the end of 2006, with over 4 million new infections recorded and nearly 3 million deaths. In South Africa, 5.5 million people were infected with HIV by the end of 2006 and that in a population of just 44 million which is a catastrophic proportion of infected people.

This map shows you the global distribution of HIV in the world and it is instructive to note that Southern and East Africa have the highest proportion of cases in the world.

This slide shows it even more graphically. 25 million of the world’s cases of HIV are found in sub-Saharan Africa, with the next highest prevalence in south east Asia at around 8 million people infected. And nearly 60% of people infected with HIV are women.

It was with this background that my research interest in cervical cancer developed over 10 years ago. Approximately half a million women develop cervical cancer every year, of whom a quarter of a million die. Over 80% of women who develop cervical cancer live in the developing world, particularly Africa, Asia, South East Asia, Latin America and the Caribbean, countries that have access to less than 5% of global cancer care resources. Yet we have known how to prevent cervical cancer since the early 1900s when George Papanicolaou developed the Pap smear. This Greek physician discovered that cervical cancer was preceded by a precursor phase, when the cells of the cervix were abnormal but not yet malignant - and that these abnormal cells could be detected by gently scraping a spatula against the skin of the cervix, placing the spatula on a slide, and after applying a special stain, known as the Papanicolaou stain, the cells could be visualised through the microscope. This apparently simple discovery would later have a major impact on women’s lives – in fact, many consider the Pap smear, as it became known, as one of the most successful public health interventions after vaccination.

It took about 30 years for Papanicoloau’s work to be widely adopted, but once mass organised screening programmes using the Pap smear were introduced, the incidence of and mortality from cervical cancer fell dramatically, to the point that today, cervical cancer is a rare disease in those countries that have made Pap smears widely available on a regular basis to women.

So if cervical cancer is preventable, why is the incidence of cervical cancer in developing countries in 2007 equivalent to what it was in Europe and the UK in the 1950s? These are our very own South African favelas – this is how people in our beautiful city of Cape Town with that beautiful mountain are living in 2007. Why is it that women who live in these circumstances, present to us with advanced, often untreatable and incurable cervical cancer when the means to prevent the disease have been known for nearly 100 years? Well the answer is not surprising – it all comes down to equity of access to health care. The infrastructure to maintain effective Pap smear screening programmes is complex and expensive – to give you an idea, it costs approximately £150 million per year to support the UK screening programmes – and $8 billion per year in the USA. These figures are beyond the gross domestic product of some poor countries.