Chapter 02: Medical Training in South Africa
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Description
Dr. Levin explains that medical training takes six years in South Africa. He describes the curriculum that was geared to building clinical competence. He also talks about his brother, Nathan Levin, who was a pioneer of dialysis. Dr. Levin’s brother took him to witness dialysis procedures and also brought him to his laboratory, where he was measuring renal function and manganese metabolism. Dr. Levin explains that he was frustrated, at the time, because he was drawn to thinking along linear and precise scientific lines, but clinical medicine was very imprecise. Under the tutelage of some mentors, he began to refine his clinical skills, using his senses and intuition to discover patient conditions and then putting that information into a coherent and logical frame of reference that could be used to make therapeutic decisions. During his medical training and residency, Dr. Levin worked in county hospitals and saw African patients with “textbook illnesses.”
Dr. Levin describes how, as a medical student, he founded a free clinic in Johannesburg that catered to served mulatto patients underserved by the medical community under South Africa’s apartheid system. He also sought out other experiences with the underserved, working at an Anglican Mission in Zululand and at the Charles Johnson Memorial Hospital, where he has additional exposure to African patients who had never had any medical care.
Dr. Levin speaks more about the apartheid system and its inhumanity; the South African practice of moving entire villages but not providing any services; the conditions of Africans who had never received any medical care; the struggle of clinics that had no blood products trying to treat stab wounds.
Identifier
LevinB_01_20130207_C02
Publication Date
2-7-2013
City
Houston, Texas
Interview Session
Bernard Levin, MD, Oral History Interview, February 07, 2013
Topics Covered
The Interview Subject's Story - Educational Path Personal Background Professional Path Inspirations to Practice Science/Medicine Influences from People and Life Experiences The Researcher Character, Values, Beliefs The Administrator Institutional Mission and Values Professional Practice The Professional at Work On Care Leadership
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
Could you tell me a bit about your medical training and how that desire to build research into your career evolved?
Bernard Levin, MD:
Medical school was a six-year medical school. I didn’t really have a broad college education. Of course, to this day, I wish I had. But we had a six-year medical school that was aimed at producing clinically competent physicians. The emphasis was on clinical competence and the ability to take a good history and do a physical examination that was excellent. The basic sciences were taught in the first two years, including chemistry, physics, biology, zoology, anatomy, and physiology. Then in the third year, clinical exposure on a very limited scale but with the addition of pathology as a very formal and extensive discipline, pharmacology, and a little bit of clinical psychology, and some minor clinical exposure thrown in. Then the fourth, fifth, and sixth years were heavily clinical but with the addition of subjects such as forensic medicine and public health and medicine on surgery, obstetrics and gynecology. Those were the six years. Then an additional year was mandatory of two out of three topics, either obstetrics and gynecology or surgery or medicine as six-month internships. Then it was expected that if one was going to be a practitioner, one would then go into general practice of some sort. If one was going to become more specialized, one would either do what was called a senior housemanship for a year or actually go onto a more formal academic track as a registrar, which was equivalent to a residency in the United States. That would be three or four additional years of training to become a specialist in whatever field one wished, followed then by a specialist examination. Some people chose to do that either in South Africa or to go abroad, mostly to the United Kingdom. Very few people in those days would go to the United States for additional training for a variety of visa-related issues.
Tacey Ann Rosolowski, PhD:
So how did your interests evolve through that experience?
Bernard Levin, MD:
My brother was a strong influence. I, at an early stage, and he being a pioneer in dialysis in South Africa, would go with him to watch dialysis being performed with huge drum-like machines that circulated blood and exchanged with surrounding fluids. And then when I got a little older, he would allow me to go with him to his laboratory that he worked in part-time.
Tacey Ann Rosolowski, PhD:
Now how old were you when you were going with him to see dialysis and then to the lab?
Bernard Levin, MD:
Probably about nineteen.
Tacey Ann Rosolowski, PhD:
Okay, so very early on.
Bernard Levin, MD:
And then at age twenty or so, I would go and work in a laboratory at night measuring renal function, which is what he was involved in. Then I was very interested in rocketry and had a chance to visit a satellite tracking station through a friend of my brother’s whose brother worked as a filmmaker who had access to this NASA satellite tracking station, which was near Johannesburg. And that was a fascinating experience. It further cemented my interest in research. About that time my brother and some colleagues became very interested in manganese and its metabolism in the body and were doing a series of experiments on manganese and its excretion by rats. So I would learn to obtain samples from the rats and then mount them in an appropriate buffer and take them to a scintillation counter for measuring the radioactivity. One of my brother’s colleagues—friends actually—who has become very famous, his name is Dr. Arthur Rubenstein, subsequently in his most recent career was Dean of the University of Pennsylvania Medical School, then a young researcher. And my brother and I were also involved in the study of a very fascinating man with an abnormality of his parathyroid gland. And I spent time at a psychiatric hospital where he was housed collecting his urine and measuring it and doing various tests on it. I also became interested in calcium metabolism and in my spare time worked on bone mineralization in the anatomy labs. I also experimented, or did some work, in the biochemistry department on uricase, an enzyme which is found in some mammals in the kidneys. And I would go to the abbatoirs and collect these kidneys and then extract uricase—without good supervision. And I used gallons of solvent, not knowing how much to use. I remember just needing vast amounts of solvents, I think it was butanol, because I really hadn’t a clue.
Tacey Ann Rosolowski, PhD:
But I can see as you’re describing this that you’re immersing yourself in these really interesting experiences of trying to crack these compounds. So this is the genesis really of wanting to explore really at this level, this molecular chemical level.
Bernard Levin, MD:
I was floundering around. I found when I came to clinical medicine that it was very frustrating, because I was thinking along scientific lines, and I was working in a lab and measuring things precisely. And then I came to clinical medicine, and people were so imprecise and so vague. There was a lot of what I thought was belief in what worked and what didn’t work. Evidence-based medicine obviously wasn’t in existence. And I would go to an individual who I admired very much and who subsequently became a mentor in Chicago and complained to him about how I found clinical medicine. Because of financial concerns and my dad’s extreme eagerness to see me complete my medical training without any delay, I didn’t do what others did and take a year off to do an additional science degree that was available, called a Medical Bachelor’s of Science, and perhaps rightly so. My father viewed it as sort of an unnecessary diversion and one that would cost money, because I had spent some of my time supported by what were called bursaries—scholarships. I was very fortunate to obtain some of these. And I’m particularly grateful to the university for helping me at that time. He wasn’t eager to see any diversions, so I didn’t have time to really pursue the science. I went straight into the clinical years and despite these frustrations about imprecision nevertheless found them very exciting.
Tacey Ann Rosolowski, PhD:
Just for the record, I wanted to say that you were in your medical program from 1959 to 1964, and you’ll have to help me with the pronunciation, the University of Witwatersrand.
Bernard Levin, MD:
Of Witwatersrand.
Tacey Ann Rosolowski, PhD:
Witwatersrand Medical School. And that’s in Johannesburg.
Bernard Levin, MD:
Right.
Tacey Ann Rosolowski, PhD:
And you had the MB—
Bernard Levin, MD:
BCH.
Tacey Ann Rosolowski, PhD:
MBCH.
Bernard Levin, MD:
It’s called Bachelor of Medicine, Bachelor or Surgery. It’s equivalent to the MD. So it’s somewhat fraudulent for me to put MD, because an MD in my university was a higher degree. But I gave up that struggle a long time ago, because people wouldn’t know what to make of it mostly. Looking back there was a lot of ignorance about anything outside of the United States at that time, as you can imagine.
Tacey Ann Rosolowski, PhD:
So you described these limitations intellectually and practically of the program. What good training did you feel you did get at that medical school?
Bernard Levin, MD:
I don’t want to negate the very excellent people who were there---
Tacey Ann Rosolowski, PhD:
I didn’t mean to imply that.
Bernard Levin, MD:
Because, I mean, there were some phenomenal scientists there. I had a professor of anatomy, Phillip Tobias, who died recently, who was a world-class paleoanthropologist who made major discoveries in South Africa and Johannesburg, particularly around Johannesburg, because that’s a hotbed of anthropology with lots of major discoveries. And we were imbued with it, so he was a phenomenally gifted man, orator, lecturer—just a giant of a man. And there were other very strong scientific influences, if one wished to pursue them. This particular individual I mentioned as a mentor, Godfrey Getz, who subsequently became my supervisor of graduate studies at the University of Chicago, had recently returned there from Oxford where he was studying with Hans Krebs of the Krebs cycle. I spent many hours talking to him while he would do gas liquid chromatography of fatty acids, which was what he was studying at the time. He’s a very erudite, scholarly man to whom I owe a lot. And in retrospect, I feel I did not pay back all that I received. But that’s another story. Clinical medicine was emphasized, the ability to use one’s senses and intuition to discover what was wrong with sick individuals and to put that into a coherent and logical frame of reference and then to arrive at a series of therapeutic decisions. And we had phenomenal clinicians in those days in every field virtually, and we were very fortunate to have access to just a vast variety of people who had flagrant illnesses, because many of the hospitals that we trained at were Africans who didn’t have medical care. So they would present with textbook descriptions of illnesses that one would never have seen except at hospitals that catered to poor people. Now, in this country, an equivalent would have been a county hospital. But there were people in great number like that in Johannesburg. We went to the white hospital as well, where people had much more subtle diseases and much more diseases of whites, such as diabetes and myocardial infarction. Those weren’t prevalent in the black hospitals or Indian hospitals mostly, there they were infectious diseases—tuberculosis, or cardiac valvular heart disease, a variety of very gross surgical abnormalities. So if one rotated through those hospitals and one had good teachers—and the registrars were—one was exposed to an incredible variety of medical information just waiting to be learned. We would spend many hours in clinical medicine. And of course, it was supplemented by didactic teaching. But didactic teaching just couldn’t compare with the breadth and the richness of the clinical experience.
Tacey Ann Rosolowski, PhD:
You talked earlier about how you knew fairly early you had what you called a caring soul. How do you feel that emerged as well, in addition to absorbing the information? Here you are in these amazing Petri dishes—I don’t know—of individuals who have no healthcare. They’ve come with these dire conditions. How did that piece of you evolve?
Bernard Levin, MD:
It became obvious to me even as an adolescent, at fourteen there, that we were living in a very bad environment and bad society and that something had to be done about it. And there were various ways around it, and certainly medicine was one possibility of helping in a practical way what was not possible in a political way. I had a couple of experiences. I and some other students, social work students and medical students, helped found a free clinic called Riverlea in an area that catered largely to people who were mulatto, but there were other people there. And Riverlea, I’m pleased to say, if not still alive, lasted for many years as a free clinic. Students would go there, and sometimes supervised by older doctors, by qualified physicians, not always, but would render first aid and assess severe medical problems, if necessary sending people to a hospital or making arrangements for them to gain access to medical care. Riverlea was very important. And it was patented after a similar clinic, much bigger and much more successful in Cape Town called SHAWCO, which is still today alive, because I was just in Cape Town two weeks ago, and I saw the direction sign when I was there. So it’s been a very successful student-run clinic for now half a decade—I mean, half a century.
Tacey Ann Rosolowski, PhD:
I was just going to say that I’m struck as you’re describing this medical school experience. I mean, you have these themes emerging. There is the interest in experimental science and then exposure to social situations where there is dire need, there are public health issues, there is a need for prevention intervention, and also administrative skills coming through as you’re taking on roles as being the head of an organization, or the secretary, and now contributing to the initiative to develop this clinic. So it’s just interesting that I’m seeing the person that you are at MD Anderson emerging during medical school.
Bernard Levin, MD:
I suppose.
Tacey Ann Rosolowski, PhD:
I’m saying—is it true? What do you think?
Bernard Levin, MD:
I think so. I think I always was interested in some sort of leadership activities. And certainly I was given those opportunities by my colleagues or by my medical school. The other experiences I sought and had were for—I think it was two rounds. I went to work at an Anglican mission hospital in Nqutu in what was called Zululand then. Now it’s called KwaZulu. And the name of the little hospital was Charles Johnson Memorial Hospital. It was run by an English couple, both physicians, called Anthony and Maggie Barker, who were truly remarkable medical missionaries. And although I was not of their faith, they had no problem accommodating everyone. There were students there from the United States as well, and there were nursing and other students who came to work there. And that was a remarkable experience, because that was exposure to Africans who literally had no medical care, who were coming there particularly for obstetrical care at a very advanced stage without any prenatal care. So you can imagine the kind of dire problems they had. Then while I was there, I was exposed to an incredibly inhumane example of what the government would get up to. They moved a whole village of people from an area that was adjacent or a few miles away from this hospital to a somewhat distant site without providing any facilities whatsoever. They just transported this village, and the subsequent development of diarrheal diseases in particular was enormous. So this was part of the government resettlement program under apartheid. And that cemented itself in my mind. I also had an opportunity to do some obstetrical training at a—
Tacey Ann Rosolowski, PhD:
I’m sorry to interrupt you, but you said that cemented itself in your mind?
Bernard Levin, MD:
As a terrible iniquity. It was just—nothing one could do about it. If you want to get imprisoned or shot, I suppose one could have done something about it. But this was just a very complicated—it was a terrible thing to do to a group of families. I don’t remember how big a group or how many there were. There may have been fifty or 100 families. It wasn’t a huge city. But it was resettlement. So this hospital had some intake from that, because they had clinics that went out into the surrounding area. And also the experience of a formal rotation through our obstetrics training at a provincial hospital in KwaZulu, a place called Edendale, which was a wonderful training program for obstetrics and gynecology—primarily obstetrics in an African area. Again, this time with much more organized prenatal care, but still seeing people who hadn’t got adequate medical care coming for delivery. Then another formative experience was a three-week rotation in Johannesburg in a township, as it was called. That is a little city inhabited by blacks with their own social structure, but primarily a shanty town mostly without indoor plumbing and mostly with inadequate facilities. And on a Saturday night the men—young men—would consume large quantities of alcohol and get into fights—gang fights. This clinic, as it was called, was run by nuns who had no access to blood products. The closest we came to was something called dextran, which was a polymer of glucose, which could expand the blood volume temporarily because it had a high osmolality. But it wasn’t a suitable substitute for people who had lost a lot of blood really. It would just temporarily top off their blood volume. And that was the best we had, and even that was rationed. So there would be people coming in who had multiple stab wounds, and we’d triage them. Those who were obviously the most extreme, there was no point in doing anything. Certainly, you wouldn’t use the dextran, because that’s all we had. And then there were those who could be saved who would be rushed to a hospital in Johannesburg about twenty miles away by ambulance. But it was, in some ways, a frightening experience, because there was nothing there that you really could do except witness man’s inhumanity to each other.
Recommended Citation
Levin, Bernard MD and Rosolowski, Tacey A. PhD, "Chapter 02: Medical Training in South Africa" (2013). Interview Chapters. 1338.
https://openworks.mdanderson.org/mchv_interviewchapters/1338
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