 Professor of Clinical Histopathology at Guy’s, King’s and St Thomas' Hospital
Interview location: St Thomas' Hospital, London
Interview date: 26th July, 2007
Key Themes: Alder Hey, Autopsy, International Perspective, Legislation and Regulation, Mentors and Influences, Motivation, Relationship with clinicians
Section 1
- Talks about his path into medicine from a non-medical family. Studied
at Oxford, then moved to University College Hospital: “I've been in
London, apart from spells in Africa, ever since.”
- Discusses his decision to go into pathology, which he was finding
very interesting. He could not face the thought of “looking at
chronically ill people day after day” , and wondered: “is there a bit
of medicine which is problem-solving?” Pathology was the answer. “35
years later, that's what I still like about pathology: it's problem
solving.”
- Describes the various roles of a hospital pathologist, including
diagnostic histopathology, cytology, and autopsy work. He is very
involved with autopsies, and comments: “How much contact you have with
people depends what case-mix you're looking at and how interested you
are in feeding back the results.” He personally makes an effort to meet
relatives of the deceased: “I go to lots of inquests, and it's an
absolute golden rule -- and I make sure trainees know this -- that when
an inquest is over you go and shake hands with the relatives... It's
the only way pathologists are ever noticed.”
- Gives some examples of where the information he has to impart may not
be what the relatives want to hear. The other interested parties are
the coroner and the patients’ doctors. His own motivation is simply
“to work out what happened and why”.
- Acknowledges that he is unusual in having “carte blanche to do whatever
I think is required to get to the bottom of a case, without very many
inhibitions, financial or ethical. I don't mean ethical in the moral
sense, but in the sense that 'you can't do that because it's against
the Human Tissue Act'.”
- Talks in at some length about the different considerations in doing
an autopsy. “One has to factor in time versus depth of detail.”
Ultimately the aim is to “provide as much evidence as possible such
that an objective judgement can be made”.
- Goes on to discuss ‘consented’ autopsies requested by clinicians and
his particular interest in maternal deaths. These are extremely rare
in the developed world, he points out, so “the ones that happen are
going to be unusual.” He discusses briefly the art of speaking to
relatives in distressing circumstances.
Section 2 - Infectious diseases are another special interest, and he describes,
with some specific examples, his international consultancy work in this
field. “Every week will bring in one or two real gems. And you think,
‘Wow! I'm jolly lucky to be seeing all this’."
- He finds this work endlessly exciting: “It's the thrill of picking up
a slide and looking at...things which are either versions of a disease
I know about but I've never seen that version before; or genuinely
really rare things; or even things that no one else has ever seen
before.”
- Describes in detail solving the extraordinary case that “got me into
infectious diseases: this actually changed my life.” It was the death
in pregnancy of a young white woman “who'd never left North London” but
had contracted “amoebiasis, which is a tropical disease.”
- Talks briefly about his introduction to infectious diseases during his training with the “charismatic pathologist Michael Hutt”.
Section 3- Describes how AIDS entered the picture, and the arrival at St Thomas’
of Terrence Higgins, one of the first people known to die of the
disease in UK. “The penny dropped that this is what we were then
calling GRIDS – Gay Related Immune Deficiency Syndrome. AIDS hadn't
been officially labelled as such at that point.” He did not recognise
then that this disease would have such an impact on his professional
life. “I forgot about it. That's the relevant point. Terrence Higgins
was just another fascinating case.”
- Describes how in 1983 he took over the work of Michael Hutt who
performed pathology services for many African hospitals by post. “I saw
loads of things I had never seen before; things that don't happen in
Britain.”
- Comments that this work taught him some valuable lessons: “You learn
by having a prepared mind... [And] you have to face the fact that
usually the first time you see something really big and different
you'll get it wrong.”
- Describes a massive project on leprosy in Malawi. “There was a
population of about 150,000 [in the project site], and the project
literally examined them all, every square inch of them within the
bounds of modesty and ethics, every five years.”
- Explains that this is when his real involvement with AIDS began.
“Among the stuff coming from overseas was a whole set of intestinal
biopsies...[from Uganda’s] Makerere School of Medicine.” These were
from patients with Slim Disease: “the name given to a condition being
seen [in Africa] in the early 1980s, and which is now what we call
AIDS.”
Section 4- Describes the history of the growing understanding of the pandemic, its reach, and its various manifestations.
- In 1985 he attended the first international conference on AIDS in
Africa, and as a result was invited out to Uganda. He was shocked by
the scale of the problem: “I have never seen anything like it. These
are enormous wards, and every bed was occupied by a dying skeleton.”
- This encounter “flicked a switch: this is interesting, this is worth doing, this is a disaster.”
- He became involved in the early investigations, having suspected in
1986 that “an awful lot of what we think is HIV-related disease may
well be tuberculosis -- made worse by HIV. Which subsequently turned
out to be entirely true.” From hypothesis to proof took five years.
- Recounts in colourful detail gathering samples from Ugandan villagers
for investigation at the UK’s specialist labs at Porton Down. “I left
Kampala after two extraordinary weeks that changed my life.”
- Explains that since there was no treatment for HIV infection,
establishing exactly what the opportunistic infections were was crucial
to caring for patients.
Section 5- His next big overseas project was in Côte d’Ivoire in 1991. Recounts
working with friend and fellow AIDS physician Kevin de Cock on a
project initiated by the US Centers for Disease Control in Abidjan.
- He overcame his initial misgivings about working in Côte d’Ivoire – “I
was appalled by the climate” – when he realised the amazing opportunity
it presented. De Cock told him: "Ivorian Law, Napoleonic Code, it's
French. Anyone who dies in a teaching hospital in Côte d’Ivoire can be
autopsied without consent." Nearly 500 people were autopsied in a
year; this was seminal work.
- Touches on the whole debate about where public health considerations
might or might not legitimately outweigh the concerns of the
individual. In situations, such as that in Côte d’Ivoire, he believes
“the public health benefits are so colossal that...they override to
some extent personal objections.”
- Describes the pathology they found, and how this is where the TB
hypothesis was clinched. “All the patients I was looking at [in the
UK] were gay white middle-class men. That's what AIDS was in London
then.” But “Africa was completely different. The first thing that hit
us in the face in Côte d’Ivoire was: actually, it's all TB.”
Section 6- Returned to England and spent the next two to three years analysing the material from Côte d’Ivoire.
- Points out that he was lucky not to get the post in Liverpool that he
applied for. “I'd have had Alder Hey to deal with, and I'd have been completely incapable of dealing with
that... I'm not very good at managing people. [And] there's no AIDS
there!”
- Moved to St Thomas’. Returns to the story of Michael Hutt, who was so
important in his own life. Describes Hutt’s role in tropical pathology
and in making Uganda’s Makerere “a jewel” of a medical school. It was
on his return from Uganda that Hutt received Wellcome Trust funding to
set up his postal pathology service for Africa.
- Describes how Hutt was instrumental in getting Lucas sent to Nairobi in 1980.
Section 7- Relates his own experience of the Alder Hey controversy. Gives credit
to the chief executive of St Thomas’, Jonathan Michael. “He realised
that organ retention was a big issue, we were vulnerable (he didn't
know how vulnerable, but he found out pretty quickly!) and it had to be
addressed head on, openly. And we had to have an absolute protocol
about what to do.”
- Makes the point that “one thing that didn't happen here, and that did
happen in Bristol, Alder Hey and other places, was that we didn't have
a whole lot of anguished mums and relatives on our doorstep. You might
have thought we should have had, given the numbers, because we had
masses of stuff. But...patients coming to this hospital come from an
enormous catchment area, so big that they never get together.”
- Goes into some detail about the complexities of the controversy, and
the role played by Dick Van Velzen. Has misgivings about the new
legislation that came in as a result, saying that things have “got more
bureaucratic, but there's still a huge grey area in tissue retention...
and it's not very clear. Or it's very clear what to do if you want to
stay absolutely within the letter of the law... You do nothing! That's
easy. But the point is, to be good and to be useful for public health
you need to do a bit more than that, and that's where the grey areas
come in.”
- Discusses the value of archives, not least as a teaching tool. “We
have a fantastic series of pots of malformed fetuses...Now this is not
prurient stuff... You can be lectured like mad about the importance of
antenatal screening; 10 minutes in the Gordon museum and you can see
why you do it.”
- Discusses the status of pathology today. Comments that there has been
a “huge renaissance” in surgical diagnostic pathology; that reporting
procedures are much improved; and that pathologists are a central part
of clinical management. “No longer are we invisible.”
- Nevertheless, he muses, “We don't have the full-hearted support of our
clinical colleagues as absolute equals.” Explores briefly the
changeable relationship between clinicians and surgical pathologists
over the past half century.
- Concludes with a brief discussion about the reasons for and
implications of the decline in consented autopsy rates. “One a
fortnight... We used to do three a day!”
- Emphasises what he believes are serious shortcomings in the coronial
autopsies system. These have been “of very variable quality and too
many clinicians have seen very bad reports which are not ‘the truth’
and don't represent what the patient had, and they have therefore been
put off, thinking that all autopsies are like this... [This] is a huge
problem.”
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