A celebrity of world medicine

Interview with Dr. Christiaan Barnard.

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.

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.

Dr. Barnard has received honorary doctorates, honorary professorships, medical diplomas of honour, awards, medals, plaques, freedom of cities, accolades and tributes from various countries and institutions round the world. He has published 15 books, some of them jointly authored. They include academic and popular books relating to the heart; One Life and The Second Life, both autobiographies; and four novels, three of them co-authored. In addition, he has contributed, singly or jointly, over 170 academic articles to professional journals, including his landmark "A human cardiac transplant: An Interim report of a successful operation performed at Groote Schuur Hospital, Cape Town" published in the South African Medical Journal in 1967.

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.

Dr. Barnard, who has in his time raised controversy through his adventurous surgical exploits, some of his views (including advocacy of the legal right to euthanasia) and also his colourful lifestyle, says that after retirement he has found several new things to do. Aside from keeping in close touch with professional developments and writing and lecturing, he has kept himself busy on his farm and taken an active interest in wildlife, viticulture and ornithology. Before his recent visit to India, he wrote a letter describing himself as "a keen collector of wild animals and on my farm I have a great collection of various kinds of antelope, zebra, rhinos etc." and enquiring whether it might be possible to "explore the possibility of importing animals from India (that is, through Indian zoos) such as the Water Buffalo and the Indian Black Buck."

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 Frontline 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 transplants. 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.

Dr. Barnard, your professional preparation and training showed you were innovative, ambitious, very strongly motivated, and perhaps adventurous, excessively so in the eyes of the then medical establishment. Now, looking at the run-up to the great event stage by stage, as a resident surgeon at the Groote Schuur Hospital, Cape Town (1953-56), you were the first to show that intestinal atresia, a congenital gap in the small intestine, is caused by an insufficient blood supply to the foetus during pregnancy.

That's right.

Could you explain, in laypeople's terms, the medical significance of that discovery?

The practical significance of that was, we showed that that condition is not a truly developmental problem, but is an intra-uterine accident in that, for some reasons, a small area of blood supply was cut off and then that piece of the bowel disappeared because of the fact that the bowel in the foetus is not full of bacteria. And we also then showed that the ends of this narrowed area had a deficiency of blood supply. Although it survived, it did not have enough blood supply to function properly. And before that, we would just cut off that area, which in the end was not very successful. We showed that you must cut further back also to take out the area that hadn't died but for which the blood supply wasn't sufficient. And this increased the survival rate of those children tremendously.

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. For example, in the 1970s I gave a lecture to the South African Chamber of Commerce and the title of my talk was, "Why we deserve to be called Nazis". I compared the laws that the Nazis made against Jews to the laws that apartheid made. For example, the Nazis had job reservation: Jews could not enter certain jobs, which was the case also with apartheid. The Nazis had certain areas where the Jews couldn't go and couldn't sit; they said, "Juden Verboten". We had "Whites Only". The Nazis had ghettoes; we had the townships.

So I compared apartheid laws with the laws that the Nazis brought in - I must say that this talk was not very popular!

Was it reported in the press?

Oh, yes. The man who spoke after me said, "This talk has generated enough heat to melt the ice-cream." The speech passed because South Africa had received such bad publicity and the Government in power was very, very pleased that here was some good news: "A South African doctor has got the first heart transplant. He's an Afrikaner." They treated me extremely well. They wined me and dined me and I was the blue-eyed boy then!

Then I gave a talk one night in which I said to the people there: "I want you to help me answer certain questions. When I go overeas, they ask me these questions and I am unable to answer them." I said: "How do I answer the question when they ask me, 'Dr. Barnard, you have people at home who work for you and they are usually black people. When your child is sick, they look after your child, they feed the child, they bathe the child. But when that child goes to hospital and that maid is a nurse, she cannot look after the child!' (Black nurses were not allowed to look after white patients)."

I asked these questions and they were immediately very upset by the fact that I started opposing them, because they considered me such an important asset. In fact, a few days after that - when I now read what happened to people who opposed the Government - I believe there may have been an attempt on my life.

A few days after I made that statement, my wife and I went to a restaurant. We came out of the restaurant and a car knocked us down. We were both nearly killed. They arrested a black man - according to them, it was him - but he was found not guilty in a court of law because the magistrate said that there was absolutely no evidence he was there. There were people who said that there was a car waiting on the side of the road and that they saw the car pull out and go straight for us. Now, when you hear what happened to people who opposed apartheid, it may have been an attempt on my life because I opposed apartheid.

When was this?Around 1972-73.

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.

With regard to the impact of sanctions on life and work in South Africa, you are particularly interested in cricket and we know what happened to South African cricket when it was at its peak.

Yes.

We know of their impact on gifted players like Graeme and Peter Pollock, Lindsay, Colin Bland, Barry Richards and particularly the younger lot, who never got a chance because racist apartheid put South African sport beyond the pale. This must have created for exceptionally gifted individuals a very tough and challenging environment, and people are known to rise to challenges.

But what happened is this: they were ambitious; as you say, they were very talented; they couldn't explore their talent entirely, so they left. Many professional people also left. A lot of my colleagues in medicine, excellent doctors, left because they couldn't tolerate living under the system of apartheid. It was very sad for those people. I always say that the greatest regret that I have in life is that I worked under the cloud of apartheid over my whole professional career. This hampered me a tremendous amount, more than people think.

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.

May I take you back to your professional career before the first heart transplant? After completing your doctoral studies in surgery at the University of Minnesota in 1958, you returned to the Groote Schuur Hospital in Cape Town as senior cardiothoracic surgeon. You are credited with the introduction of open heart surgery to South Africa. Can you tell us something about this experience?

I was very fortunate. I was actually doing general surgery at that stage and just by accident, I got a position at the University of Minnesota in Minneapolis. It just so happened that that was the area, one of the few areas in those days, where they explored the possibility of using a heart-lung machine and doing open heart surgery. I got interested in it and started doing research. When I finished my studies there and wanted to leave in 1958, the head of the department managed to give me enough money to buy a heart-lung machine. I then picked this up and packed it off to South Africa.

There was no customs duty?

(Laughs) No, can't remember having any problems with that. And then I started training people in that particular field and eventually they were trained enough. Nobody knew anything about it except me! When they were trained, I did the open heart operation using my heart-lung machine. I remember that the patient I operated on was a girl called Joan Pick. She came to see me about a year ago: she's a grown-up woman now with children. We just went on and on doing more complicated operations - introducing heart valves and intensive care.

In fact, 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.

After December 3, 1967, there was an upsurge in heart transplantation. I believe that over the next twelve months 101 heart transplants were done.

Yes.

But then for a complexity of reasons it seemed to be on the wane. We read of problems surfacing, such as problems with the immune rejection of the transplanted heart, poor patient survival rates, concern about the allocation of enormous resources to something of such limited application. It seemed the surgeons were in retreat.

In fact, I deal with that problem in my talk. There was a tremendous increase and then, round about 1971, they just stopped all transplants. I think the main reason is that many centres were not adequately prepared to do the operation. They thought that you do a transplant and you send the patient back, you release the patient. We knew that it needs much more intense medical care after surgery than you have with ordinary heart surgery. They just got despondent and said, "No it's not just worth it," using all those arguments you cited.

We said, "We do know that we can help patients and give patients a better life" and, as I told you, we had patients who went on to live for twelve and a half years and twenty-three years. Those were the early patients. We continued with the work.

Very few of you. You, Dr. Norman Shumway...

Only three of us. Myself, Shumway, and a doctor in France (I don't remember his name).

And you and Dr. Shumway developed methods that significantly improved patient survival rates, to the point that 50 per cent of all patients lived at least five years.

In those days, 50 per cent of patients lived about one year. It went down for five years - for five years it was 35-40 per cent.

You never had any doubts about this?

No. I never had any doubt about it. I heard all those arguments even at medical meetings. People insulted me and so on, but the funny thing is that they had eventually to take back their words and they all started to work again with transplant patients.

In a sense, it must have been like climbing Everest. It was very difficult in those days and today hundreds do it.

That's right. You know, it's like children standing at the pool and they're worried that the water's very cold. Then one jumps in and says, "it's not so bad, you know." And everybody begins to jump in and start swimming.

I read a figure, in a newspaper report about you, that approximately 32,000 heart transplants have been done in some 270 centres round the world over the past three decades.

I don't know the total. I haven't kept track of it all but the number must be in that region now.

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.

You continued in your profession as the head of the cardiac unit at the same hospital where you trained as resident surgeon, until 1983. I believe you retired from active surgical practice at the age of 61. Is that a good age to retire for a heart surgeon?

I should have retired earlier (laughs). I believe that to be good at your profession, when you get up in the morning you must be hungry for the profession; you must want to go there and want to work. I remember the days when, if I had to choose between putting on a pair of surgical gloves and a woman, I would have chosen the pair of surgical gloves because that gave me such a thrill. Then I came to the stage when it was not so thrilling to put surgical gloves on. When I got up in the morning, I was thinking of excuses not to go and operate. And I realised: "Now is the time to quit because you're not hungry for your work anymore."

So I actually retired four years before I was due to retire. I still feel I should have retired maybe a year or two earlier, because at the end I didn't have the appetite. My Registrar would phone me and say, "We have a donor for transplant", and I would tell him to go ahead. I wouldn't even get up and go to the hospital. I'm sorry I continued a little bit too long.

There must be some cricket analogies as well.Yes (laughs).Too long, too late.

And the fortunate part of it is that when I retired I didn't sit there with nothing to do. I had lots of other things I could do.

On the price of celebrity: you must have been pursued by the paparazzi, among others, in your time.

Yes.Did that bother you?

Well, it did interfere. You see, I'm not against people writing about me as long as they write the truth. But in those countries they absolutely distort stories! When this involves women, then your wife who is at home sees the pictures and the stories and, of course, gets upset about them.

Let me give you an example. I once went to a place in South Africa. My wife couldn't go with me. It was a sort of a dinner dance and halfway through the function they asked me to pose with the staff of the hotel - it was held in a hotel - so we stood there with the staff of the hotel and it happened that a very nice little girl - one of the waitresses - stood next to me. And they took a picture of the group there and then...

Cropped the picture?

Yeah (laughs). And then I asked the little girl whether she would like to dance with me. She had one dance with me and that was the end of the story. A weekend later, it was headlines on the front-page of one of our major weekend newspapers: "Barnard Whoops It Up With Waitress!" And, as you said, they cut the picture so that there was only me and this girl standing there.

I knew the Editor of that newspaper and I phoned him: "I say, how could you do something like this?" You know what his reply was? "I thought it was funny." My wife didn't think it was funny and my family didn't think it was funny. Such things really upset me very much.

Also, when they lie about the work that I do. I can give you many examples of how they distorted what really happened, so far as the donor was concerned, so far as the patient was concerned.

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.