A celebrity of world medicine

Dr Christiaan Neethling Barnard, 74, is one of the celebrities of world medicine, one of the most widely recognised, honoured and feted figures the medical world has known. The South African cardiac surgeon shot to international prominence when he, with his team of 20 surgeons, performed the first human heart transplant on Louis Washkansky at the Groote Schuur Hospital in Cape Town on December 3, 1967. Although the event happened in white racist South Africa, in the accolades it received the event was something akin to Tenzing Norgay and Edmund Hillary ascending to the summit of Mount Everest on May 29, 1953.

Since that extraordinary event in medical history, many thousands of human heart transplants have been performed around the world, including a few in India. Dr Barnard did a double first by performing the world’s first heterotopic, or double heart, transplant on November 25, 1974. He also contributed to other advances and medical and technical developments in the cardiac and, in one case, the general surgical field.

He says he would like to be remembered not as the man who pioneered and performed heart transplants, but as an all-round and accomplished cardiac surgeon who has treated children and adults for a variety of abnormal, especially congenital, heart diseases.

Christiaan Barnard studied medicine at the University of Cape Town, graduating in 1946, and took his M.S. and Doctor of Philosophy in Surgery (plus a degree in cardiovascular surgery) at the University of Minnesota, Minneapolis, in the United States. Thereafter, all his professional life was spent at the Groote Schuur Hospital and other teaching hospitals at the Cape Town University, where he worked on a modest fixed salary. He retired from active surgical practice in 1981.

Over the past three decades, Dr Barnard has lectured in academic, professional and lay forums round the world and is a noted off-the-cuff speaker. He says, “The greatest regret that I have in life is that my whole professional career, I worked under the cloud of apartheid. And this hampered me a tremendous amount, more than people think.” He points out that he and his family, starting with his missionary father, were always unhappy with, and opposed, apartheid—which the surgeon publicly likened, in the 1970s, to the legal system instituted by the Nazis in Germany.

In September 1997, Dr Barnard visited Mumbai, Pune and Coimbatore to deliver the BPL Mobile 1997 “Achievers of the World” Lecture on “Transplantation and health in general”. Making himself very accessible, he has given press conferences and interviews that have been widely covered. The distinguished surgeon was interviewed in depth in Coimbatore by N. Ram for <i>Frontline</i> on developments in the field of cardiac surgery, on advances and problems in heart transplantation and organ transplantation generally, on aspects of his life and work, and on some medical, social and ethical issues:

What difference do heart transplants make, looking at the large picture?

Well, if you judge its value on the number of patients operated on, it’s very small compared with other operations such as bypass surgery, triple angioplasty, and so on. But it makes this difference in that it’s the only treatment you can offer patients who have extensively destructed heart muscles, or children who are born with a very abnormal heart. And eventually as a result of the heart going to near heart failure and not responding to medical treatment, there is nothing else you can offer these patients except transplant. So it is of value in that it is still the only treatment you can offer such patients.

You and your 20-surgeon team did the first human heart transplant. How did you get interested in this field? Could you give us an idea of the run-up to this extraordinary event in medical history?

The point that people don’t realise is that we [at the Groote Schuur Hospital, Cape Town] at that stage had already been involved in nine years of open heart surgery. We started in 1958, using the heart-lung machine to do major operations inside the heart; the transplant was really just a progression of our ability to operate on the heart. At the beginning, in 1958, we only chose patients with very simple defects: hole in the heart, congenitally narrowed valves and so on. But as we went along we were able to tackle bigger and bigger operations until, round about the 1960s, we realised that there were certain patients whom we could help only by removing their hearts and putting in new hearts. There were no mechanical devices available... we still don’t have them.

To sum it up, it was the natural progression of open heart surgery.

You needed the introduction of what is called extra-corporeal circulation to be able to shunt the blood away from the heart and then artificially oxygenate it and pump it back. Since that technique was introduced, the milestones in cardiac surgery were the introduction of new surgical techniques. First, it was mainly congenital heart defects that we operated on. Then we started working on the valve; we introduced artificial valves. Then of course we started with bypass surgery. And so we were just going on and on and all that the transplant was was the introduction of a new surgical technique.

Louis Washkansky, after your landmark surgery of December 3, 1967, died within 18 days.

Yes.

For reasons that are well known: double pneumonia, “contracted after destruction of his body’s immunity mechanism by drugs administered to suppress rejection of the new heart as a foreign protein”.

Yes.

There must have been some cynical reactions to the effect, “Operation successful, patient collapsed” and so on. Did it have any effect on your morale?

No. Absolutely no. I mean, we were very sorry that the patient died, especially because initially he did so well. We didn’t have problems initially with him, he did extremely well. And we were very distressed that he died. But the thing that we realised, especially after the post-mortem on him, was that he did not die from his heart; his heart was in good condition when he died of pulmonary infection. We knew that this was a danger of any transplant programme, whether it was a kidney transplant or a heart transplant programme.

So there was nothing that happened in those 18 days that actually made us believe that this operation could not be done successfully. Therefore, as I said, I was very sorry but I was not put off by the fact that he did not survive. As you know, we did the next operation early in January 1968 on a patient who was in his 60s already and also suffered from severe heart failure. We were very fortunate in that particular instance to manage the progress to such an extent that the patient went home after about two months at hospital and he lived for one and a half years after the operation.

The second one?

Yes, the second one. And this of course showed the world that this operation could be done successfully to the extent that the patient could leave the hospital and live a normal life outside hospital. It may interest you to know that the fifth patient we operated on lived twelve and a half years. And the seventh patient we operated on lived twenty-three years—only died last year.

You were born and raised in apartheid South Africa. How did you feel about this as a young man, particularly after you became active as a surgeon?

At the beginning, as children, we were not so much aware of apartheid because we didn’t have laws in those days that actually forced you to discriminate. But we became more aware of it after 1948, after the election when the National Party came to power and made the laws that said: You had to sit on separate benches. You had to go into separate areas. You were not allowed to go out with a coloured girl or vice versa .

To me it was a totally unacceptable situation because my father was a missionary and I grew up amongst the non-white people of the country. To us it was quite usual to have non-white people in our house; they had tea with us and had dinner with us. My father, being a very religious man, thought that apartheid was against the teaching of God. He said to me many times after the National Party got into power: “You know, when they asked God what the most important commandment was, God said, ‘You must love God with your heart and soul.’ And the second one, equal to that, was ‘You must love your neighbour as yourself.’” My father said: “How can you love your neighbour as yourself when you practise these discriminations?”

So we as a family always opposed and fought against apartheid. People think that everybody who opposed apartheid was in jail. That was not quite correct.

The horrific effects of apartheid on black people are well-known. What about its impact on whites, especially white intellectuals and professionals like you?

I’m glad you have raised this question because, you see, a lot of people believe that only blacks suffered because of apartheid. That’s not true. The whites suffered severely. First, we paid high taxes to support apartheid, because we had to support the “Homelands” they had and maintain all the laws they had.

We were ostracised by the outside world even as doctors. I remember that one day I came to Dallas and was with a friend who was from Syria. We stopped at the hotel and we put our suitcases out and the man at the door took our suitcases. He heard us talking, we had foreign accents, and he asked my friend, “Where do you come from?” He said, “I come from Syria.” Then he said, “You, where do you come from?” I said, “I come from South Africa.” He put my suitcase down and said, “I don’t carry the suitcases of South Africans.”

There were many medical congresses where we were not welcome, for example, in the Scandinavian countries. Overseas bursaries for research were also not available to us. So there’s no doubt that the white man also suffered as a result of apartheid.

And yet you seem to have had an honourable record of opposing it.

But it caused great difficulty. It was very difficult to maintain a good unit under the circumstances. For example, as I said, we were not allowed to have a black nurse to look after our patients. We were not allowed to have a black patient and a white patient in the same ward.

What about blood transfusion?

They didn’t worry about that. They didn’t worry about donations of organs and transfusions. They didn’t mind you operating on a black man in an operating room where you had just operated on a white man and they didn’t care about that because I suppose they were unconscious. I wrote a book called The Unwanted , in which I had two characters, a white doctor and a black doctor. There I showed how unfairly the black medical student was treated. We would have a lecture room with students sitting in it and a place they brought the students to, with a patient in a bed and where lecturers held demonstrations. We had coloured students and black students in our class, not many but a few of them. If they brought out one white patient, these students had to get up and leave the next moment! They were not allowed to watch the demonstration. But even worse, they were not even allowed to watch post-mortems on white patients. It was unbelievable. The National Party government was really paranoid about white and black and coloured.

You developed a new design for artificial heart valves.

Yes, that’s right. We developed what is called a low-profile valve, a valve that’s thin. Our valve was the first low-profile valve; the valve they used then was quite big and I didn’t like the idea of putting such a big thing inside the heart. I developed a valve that was much flatter.

And you began experimenting with heart transplantation in dogs.

Yes. You see, I’ve often been criticised by the anti-vivisectionists for experimenting on animals but I don’t know any alternative. We had to use animals to determine the dangers of the heart-lung machine, in the improvement in the heart-lung machine and the various surgical techniques. I did a lot of transplants on dogs before I did a human heart transplant—to work out the technique. Then, eventually when we went on to the heterotopic transplant, we needed an animal whose chest was more like a human chest, because of the two hearts thing. So we switched and started working on baboons.

You were the first to implant a second heart into a human and link it to the existing diseased heart to provide blood circulation.

We thought of a parallel connection.

How did it happen?

I operated on a man who was a great friend of my eldest son, who at that stage was a medical student. My son was too emotionally involved to go into the operating room, but he was outside in the operating area.

This was the only patient I operated on for whom the heart didn’t want to take over—the transplanted heart didn’t want to take over once it was inserted. I struggled for hours to try and get it to go but it didn’t want to start. So I had eventually to turn off the heart-lung machine and let this man die on the operating table.

When I came out, my son paged me and said to me, “Dad, what happened?” I said, “He died.” And he asked, “Why did he die?” I said, “He died because the new heart was not able to pump enough blood to keep him alive.” And he said, “But why didn’t you put back his own heart; at least that kept him alive.”

That night I thought about that remark and I decided that the old heart may be sick and may not be able to give the man a good life. But there’s still enough function there to keep that individual alive. So, by connecting the second heart in such a way that it assists the old heart, why not leave the old heart in so that it can do what it is capable of doing?

And if that fails, can you do another transplant?

Sure. You can take out the other one. I have always explained it thus. When you have a horse pulling a load up the hill and the horse gets tired and starts stumbling, you have two ways of solving the problem. You can outstand the tired horse and instand a fresh horse in front of the cart: that’s the orthotopic transplant. Or you can leave the old horse there and instand a fresh horse next to it: that’s the heterotopic transplant. You can see the advantage if you have the two horses there. If anything happens to the new horse, the old horse is still there to stop the cart from running backwards.

There’s enough space in there?

The heart lies in the middle and towards the left. I put the second heart in the middle and towards the right. I can show you slides of the X-ray of the two hearts: you can see there’s more than enough space for two hearts.

What do you consider to be the really major medical and technical developments in the heart transplantation field since you retired?

Since the first one was done

Okay, since the first one was done.

I think there were three major advances. One was that we developed better methods of preserving the heart, of keeping the heart in good condition after it was removed from the donor. That’s done by injecting the heart muscle with a paralysing solution, which paralyses the muscle so it’s not active at all. And also cooling it down. The second one was that we developed much better ways of diagnosing rejection, which was very important because...

Anticipating rejection too?

Yes, anticipating rejection, diagnosing it, also monitoring the progress of our treatment. This is something we didn’t have in the early days. The strange thing is that, actually, the methods we used in the early days were, we now realise, totally unreliable. The third was the introduction in the beginning of the 1980s of a better immunosuppressant drug. That made a big difference. Transplants of all organs really took off after 1980, with the introduction of cyclosporine. More and more new drugs are being introduced.

Those, I believe, are the three major advances in heart transplantation. The surgical technique has not changed. It's exactly the same as what we did in the beginning.

[Dr Christiaan Barnard passed away on September 2, 2001, in Paphos, Cyprus.]