Liverpool – Tropical Medicine

Liverpool – Tropical Medicine

We set sail from Cape Town in the "Athlone Castle", one of the older Union Castle mail liners, in the middle of December 1959.  It was a large and impressive ship and I had never really been to sea before. The family saw us off at the docks in Cape Town and the ship departed in a festive mood with streamers flying and accompanied by loud music.  We had simple accommodation, a two-bed inner cabin without a porthole.  The first part of the cruise took us through the South Atlantic, and the sea was glassy and smooth.  We basked in the sun, swam in the small swimming pool and enjoyed the food. But as we crossed the equator and entered the wintery northern Atlantic the weather changed. We docked at Madeira to refuel and spent the day touring this well-developed tropical island. As we departed and entered the real northern hemisphere, the windy, blustery climate turned into strong gales with rain and heavy choppy waves and later a turbulent, heaving sea.  We experienced the great climatic biodiversity of the Gulf Stream, the North Atlantic drift and the cold water discharged from the major French Rivers, The ship rocked to and fro and by the time we entered the Bay of Biscay it was impossible to walk on the open decks and the chairs in the lounge rocked and crockery danced on the tabletops.  Aileen developed severe seasickness and we were thankful to arrive and disembark in Southampton.

We collected our baggage and took the packed boat train to Waterloo Station in London.  It was pouring with rain as if the heavens had opened and the city was shrouded in a heavy fog. The placid South African summer was now replaced by the cold air masses of the European winter. The grey buildings, the heavy fog and the endless traffic had plunged us into a different world. We took a taxi to the Ford Motor Distributors and picked up our new yellow Ford Anglia with its cutback, back window.  It was an unusual new shape.  We returned to Waterloo Station to pick up our luggage and I'm not sure how we managed the navigation. I was totally overwhelmed. The heavy city traffic, the poor visibility and the sheets of rain created “butterflies in my stomach" as we fled northwards to leave this strange, gigantic congested and terrifying city. Fortunately, the Ford dealer had given me a handful of maps to steer us in the right direction, so we found a bed and breakfast at Hemel Hempstead and stayed the night to calm our nerves.  The next morning was cold and we continued along the A40 to Liverpool. 

We had arranged accommodation through the Tropical School and arrived at our new address, 48 Moscow Drive in the afternoon.  I was shocked by the brown brick working class neighborhood, with its street upon street of post-Victorian row houses which had been built to alleviate the run down areas of the city. Row houses lined the streets and introduced us to the new post war British Society.

A delightful little white-haired lady showed us our accommodation. It was on the 1^st floor: a small bedroom, kitchen and bathroom with gas heating which I had never seen before. 

We made ourselves comfortable.  The rent was reasonable, 2-1/2 pounds a week including a little garage.  The back lane was so narrow that I had to maneuver several times to take out the car.  Liverpool was in the middle of its customary winter fog and it took a few weeks until I was able to explore the neighborhood.  We lived in a workers' quarter which had been built in the early 1920s with brown brick houses and little shopping centers.  At my first visit to the local grocery, the language was so different that no one could understand my accent and that all I wanted was a loaf of bread.  The local dialect was totally different.

Liverpool was an old port city with many rundown poor working-class neighborhoods. It had large slum tenement areas but fortunately it all eventually came "tumbling down" and today these areas have disappeared and a more modern renovated city has developed. It is now likened to the New York of England and has many important architectural landmarks but we never really explored and studied the city. We were a little overawed by the foggy environment which I had never encountered in South Africa.

I had registered at the Liverpool School of Tropical Medicine and the university courses started in January.  It was housed in a very uninviting dull gray building. The School had developed in Liverpool because of the sailors and large maritime population who arrived in the important English port from different tropical areas and the school had grown into an international teaching and research centre. Opened in 1899, the school was designed to train expatriate doctors planning to work in the British Colonies in the fundamentals of this new budding branch of Medicine. The local weatherwas quite the opposite of tropical Rhodesia.

I started the day after the New Year, and found the courses very exciting: tropical medicine, public health, parasitology, helminthology, and many laboratory exercises.  Prof. Maegraith, the Dean and Head of Tropical Medicine, was very inspiring and the other teachers very interesting.  I immersed myself in malaria and schistosomiasis but there were many other new exotic diseases and there was time to study the pathological specimens and the microscopic histological specimens as well as charting the natural history of the disease vectors. The courses were close to my heart as they dealt with disease prevention as well as the sociology of poverty and malnutrition which were so common in Southern Africa. I had acquired extensive practical experience in Rhodesia so that the studies were fairly easy and I graduated as the top student with medals in different subjects. 

The students were varied and came from many countries in the British Empire.  There was a competitive spirit and the other two best students came from the Solomon Islands and Singapore. 

I had planned to return to Rhodesia; but Prof. Davies, who had gone through the Japanese occupation of Singapore and was subsequently the director of health in Malaysia, pointed out that I was white and Jewish and that the "winds of change" were blowing through Africa and that I should not return to Rhodesia and that I should choose another specialty in medicine. 

We spent a rough winter in Liverpool.  The weather was tough and the heavy fogs precluded any traveling.  I kept my nose in the books and we had the advantage of a large bay window in the bedroom facing south where I could sit and study when we had rare days of meager sunshine. 

Vincent Harrison, my ex-classmate from Cape Town, was a pediatric registrar at the relatively new Alder Hay Children's Hospital and we would spend two evenings a week revising internal medicine.  His wife, Denise, and Aileen got on well together.  We had no other contacts in Liverpool and rarely made contact with the Jewish community.  We were lost in our own private world.

Aileen worked at a geriatric hospital but became pregnant and found the physical work too heavy. One of our old patients from Gatooma lived in St Helens and he brought us his old 5 inch television. We had never watched "telly" and it fascinated us.

The old Liverpool Royal Infirmary broke my heart. It was a black, red brick building which had turned brown gray from exposure to the soot and weather. The beds in the wards were arranged around the perimeter with a nurses' station in the center. I was supposed to make rounds with Lord Cohen but he spent most of his time in London. In practice, the wards were run by David Price Evans who was developing the embryonic science of pharmacogenetics. The old hospital has since been gutted and replaced by a new modern building.

We never had the opportunity to explore Liverpool carefully as the fog dominated the winter.

Despite the weather, the period at the Tropical School was an invigorating experience; I worked and studied hard and consolidated my knowledge of tropical medicine.

I needed to continue my training in Internal Medicine and although I made rounds in Internal Medicine with Noble Chamberlain at the Southern General Hospital there was the need for more systematic study. At the end of March 1960 we were ready to move ahead.

Rhodesia – Zimbabwe – Into the Wilds

Rhodesia – Zimbabwe – Into the Wilds

I finished my internship at the end of 1958 but was now left with a profound financial problem. How to support myself, and help my mother, and sister Gloria and brother, Arnold?

Frankie Forman suggested that I move northwards to Rhodesia and join Ray Mossop, an excellent general practitioner in Gatooma in Southern Rhodesia.

Southern Rhodesia is a land locked state located between the Zambezi and the Limpopo Rivers. It was developed by Cecil Rhodes who directed  the British South African company.  It was an important English colony, directed from London by the British civil service.  The country is rich, the land is fertile, it has adequate water supplies, fertile farming land and unlimited mineral resources including gold, copper, platinum, nickel, tin,  asbestos and lithium. 

It had a large, black population made up of the Mashona and Matabele tribes, and a smaller European population of colonial settlers and groups of traders who had migrated in the wake of the farming and mining boom. It was simple to start a trading store or a small factory and earn a good living.  It had a small Jewish population some of whom had migrated from South Africa; others had come from the island of Rhodes where life was difficult for the Sephardic population.

Gatooma (Kadoma) was located in the middle of a rich gold outcrop with deep hardrock mines and rich seams of gold. Experienced miners migrated northwards from the South African fields and local workers were recruited from Nyasaland. The surrounding land was fertile with rich grazing veld for cattle and sheep and extensive flat expanses suitable for maize and cotton farming.

The town was located on the main highway, 200 miles from Bulawayo and 100 miles from Salisbury. It was a typical small Southern African village with a population of about 5000 whites and a large African population.  The Cam and Motor and Golden Valley gold mines were run by the wealthy British Rio Tinto company and had a very profitable output.

The white and black populations formed a strong contrast. The whites were simple folk who owned the shops, owned and ran the farms, developed and expanded the small factories and controlled the infrastructure and civil service. The local indigenous population had a rudimentary education and undertook the manual tasks. The white-black polarization was complete although there were also “poor whites” who were unsuccessful in their occupations and who had become accustomed to alcohol. Some of the blacks were educated but the difference was much sharper than in South Africa. Apartheid existed with clear demarcations between the white and black areas. The schools were segregated.

The town boasted a small government hospital and another more modern hospital on the mine. It had five general practitioners and two government medical officers.

My mentor, Ray Mossop was a patient and experienced general practitioner who was looking for a new assistant to run his mining practice.

January 1959 was a major milestone in my life. My sister Gloria and I set out in my father’s grey Austin A55 on our 2000 miles trip to the North.  In the middle of the Karroo desert we ran out of coolant in the radiator and burnt the main bearing of the car. We found the nearest garage in a small town, Richmond, but there were no spare parts. We left the car and hitch hiked to Bloemfontein where we spent a week with my cousin Bubbles Gersovsky.  We parted with our last pennies to pay for the repairs and took a small loan to cover the expenses for the remaining drive northwards.

We were exhausted, when, a week later, we arrived in Gatooma, but found a pleasant furnished house on the mine compound with a large vegetable and flower garden. My predecessor, an older general practitioner, who had retired, had been a widower and had spent his spare time cultivating flowers. It had an unusual collection of dahlias and gladioli strains and the mine provided an expert gardener. Behind the house was a large vegetable garden and many banana, mango and avocado trees.

It was a simple house but was more than adequate for our needs.

The weather was quite different from Cape Town. It was tropical with hot summers and torrential rains that would erode the land and flood the shoulders of the roads and warm, dry winters where the land became parched and barren.   

I started work immediately. My main practice was in the mine hospital where I had a comfortable office run by an experienced nurse and my own pharmacy. This was attached to a small 40 bed black hospital run by Charles Marais, an experienced male nurse who dealt with the emergencies and cared for the administration. He was a great administrator and we had a well trained group of male orderlies and nurses.

The mine was located in Eiffel Flats about 6 kilometers from Gatooma. The town had its own 100 bed hospital to serve the local population and the surrounding district. We all had privileges in the hospital and helped the 2 full time Government Medical Officers with the overflow and emergency and night calls.

Dr Mossop had converted a house in the town into a clinic office and practice and there was also a small African practice which was under my care. I had a good interaction with the non-white population. I had an excellent male nurse who was the interpreter but soon I started to learn the local Mashona language. The missionaries had produced several excellent grammars and textbooks and had developed a new written language from its previous oral tradition.

I soon slipped into the daily routine. Morning rounds in the mine hospital, outpatient clinics for the mine workers and their families; a clinic in town in the late morning, ward rounds at the Government hospital at lunchtime and then back to the mine hospital for the afternoon clinics. On Wednesday we worked in the operating theatre where Ray did most of the surgery and I gave the anaesthetics. We had a good relationship and dialogue and often we would be assisted by one of the local doctors. Charles Hossey was very interested in surgery and later he left to continue further surgical training

The work was varied and interesting. The white mineworkers and their families needed good common sense general practice: viral infections, cuts, pregnancies and minor injuries.  

The black workers had more serious diseases.

The mine injuries were often serious due to major underground cave-ins and accidents: fractures, burns, asphyxia (gassing) and poisonings from the extraction processes. I soon became an expert in underground mine safety, explosions, and drilling related injuries. Mine collapse occurs when the structure of the underground mine became unstable and could not sustain itself. Workers were trapped under the rubble, leading to injury or even death for some or all of the crew.

I became an expert in orthopaedic surgery and learned how to treat and reduce major fractures.

There were also many other mining related diseases such as severe respiratory disease (chronic bronchitis and silicosis) and musculoskeletal strains from the heavy physical exertion. Fortunately the black manual workers were young and resilient. They came from Nyasaland on three year contracts and did not return if they had any disability.

Many of the workers were single or had left their families at home. Venereal disease was rife and there were several new case of gonorrhea or syphilis at every morning round. Stephen, my chief orderly would look at the smears and we always made a precise diagnosis. My favourite drug, Bicillin, had appeared on the market. It was long acting Penicillin: a single injection lasted for four weeks and eradicated the organisms. Later I spread my medical net into the African compound, invited all “the ladies”, treated their venereal infections and eliminated the epidemic.

Tropical diseases were endemic. Malaria, carried by the anopheles mosquito was rampant. The mosquitoes breed in any collection of water and transmitted the Plasmodium protozoal parasite. The mosquitoes bite an infected host, feed on their infected blood, the parasite multiplies and then when they bite and feed on a new host’s blood, transfer the plasmodium. These multiply in the new host; damage the new host’s cells with a predilection for red blood, liver and brain cells. It causes a fever every 3 or 4 days. The parasites settle in the deeper cells of the body where they cause later reactivation.  

We were fortunate to have available a group of new effective antiplasmodial drugs. Quinine was the well tried agent, but was now replaced by chloroquine, amodiaquine and primaquine. The drugs were expensive but the mine was interested in an effective, healthy work force. We also had regular daily spraying teams to eradicate the mosquitoes with DDT.

Before I left we had almost eradicated malaria from the mine precincts but new infections arrived from the migration of workers from outlying district.

The second major endemic disease was bilharziasis also known as Schistosomiasis. It is a parasitic disease caused by a trematode: flatworm (Schistosoma haematobium). Larval forms of the parasites are released by freshwater snails and penetrate the skin who swim or walk in the water. In the body, the larvae develop into adult schistosomes, which live in the blood vessels. The females release eggs, some of which are passed out of the body in the urine or faeces. Others are trapped in body tissues, causing an immune reaction.  The eggs released in the urine live in rivulets, penetrate into snails, their secondary host, cercaria are released into the water and enter through the skin to infect a new human host.

In urinary schistosomiasis, there is progressive deposition of the eggs and larvae in the bladder walls with damage to the bladder, ureters and kidneys. The disease eventually damages the bladder and the ureters and causes severe infections, obstruction and kidney failure. In intestinal schistosomiasis, there is progressive enlargement of the liver and spleen, intestinal damage, and hypertension of the abdominal blood vessels.

Control of schistosomiasis is based on drug treatment, (Prazaquantel), snail control, improved sanitation and health education. When I worked in Rhodesia, the available drugs were partially effective but today prazaquantal is really effective and the disease is disappearing.

There was a large cotton spinning factory in the town where we had Monday morning asthma from allergy to the cotton fibres or toxins from bacteria and also a chronic lung disease, Byssinosis, due to inhalation of the fibres.

I worked very hard physically and mentally with many night calls and frequent emergencies. There was a continuous psychological stress load from the variety, intensity and severity of the practice. I was a young man who lacked the extensive clinical experience of my older colleagues, but this improved as I gained more confidence.

I had a continuous learning program. Once a fortnight I went to the large government hospital, Harare, in Salisbury. Michael Gelfand was a pioneer in investigating the local diseases of the region. He was a good teacher and every Monday morning would send me the British Medical Journal, Lancet and The Practitioner of the previous week. I built a solid library of medical books and spent every free moment, learning and reading: internal medicine, surgery, obstetrics, tropical medicine and ear nose and throat diseases. How useful would it have been to have had the internet.

The medical material and experience was unbelievable. I became an experienced general practitioner. I learned how to give modern anesthetics. In Cape Town I had learned about good oxygenation, nitrous oxide and ether. In Gatooma my world changed. Pentothal, a short acting barbiturate for induction, suxamethonium for muscle relaxation and  intubation, flaxidal for longer muscular relaxation and then short acting anaesthetic agents like cyclopropane and the newly introduced drug halothane. It was a new world and I spent short periods at Harare Hospital in Salisbury to learn from the more experienced anaesthetists.

Orthopaedic surgery was interesting. I saw all the fractures in the book. Treatment was conservative but I soon learnt to reduce the different fractures and fix them with plaster casts and treat larger bone lesions with effective pinning and traction.

There were several deliveries of newborn babies every day and the local midwives were very effective. Nevertheless some of the mothers needed a breech delivery or a forceps extraction and I soon became proficient in Caesarian Section. In retrospect the treatment was primitive, but our infant mortality rate was very low.

Surgery was more complex. The major procedures were sent to Salisbury, but I became expert at intestinal obstructions, volvuli and simple ear nose and throat surgery. My eye-finger-brain coordination had improved and found myself very comfortable in the operating room.

Severe, acute diseases of children were common: diphtheria, scarlet fever, measles and whooping cough with all their complications. Gastroenteritis caused severe fluid depletion and dehydration, particularly in the hot summers, and this was followed by severe protein malnutrition      Kwashiorkor (protein malnutrition) in the black children kept me busy but their image still exists in my mind: the thin emaciated and dehydrated child with no skin turgor, underdeveloped muscles, protruding ribs, and a skull-like head. The disease is still common in many parts of Africa and the peri-Saharan desert scrublands where the intertribal wars have caused extensive migration of innocent families, lack of food, recurrent gastroenteritis and severe malnutrition, Vitamin deficiencies were also common. Most of the children had worms and other parasites and soon I became expert in identifying them and their eggs. Gasteroentiritis, cholera and typhoid fever also affected the adults with severe fluid losses, dehydration and even death. Fortunately we had good antibiotics and an efficient intravenous fluid replacement programme.

We also had a small mobile clinic dispensary and once a week I would travel to the smaller surrounding mines where I also saw patients from the surrounding farms.

There was little time for social interaction. My sister Gloria left for Salisbury where she met Morris Fleischman who was a wholesale butcher, they were married and had two children. The town had a small Jewish population of Ashkenazi Jews who had come from Lithuania and settled first in South Africa, and a larger Sephardi population who had come from Rhodes and whom had settled either in Rhodesia or the neighbouring Belgian Congo. They were all traders or shopkeepers. Mr. Burke had been the mayor and also ran the local printing press. There was a small synagogue with a Friday night prayer meeting and the Rabbi from Que-que came once a week to teach the children. Medicine was more than a full time occupation and the occasional spare time was reserved for reading. I had little in common with the senior mine staff who would have their evening beer or drink and spend their free time on the golf course.

I met my wife Aileen in the local hospital and we were married.

The greatest event was a shattering motor car accident. I was called to the hospital to deal with an obstetric emergency. I rushed along the road from Eiffel Flats to Gatooma and a herdsman tried to cross the road with a small herd of cattle. As I came around a sharp bend the cows appeared and the car hit them from the side. There was a loud bump, I was thrown into the front windscreen and the bonnet of the car and two cows crumpled. The grey Austin was unrecognizable, and I was badly shaken. The car as replaced by a brand new Ford Zephyr.

Gatooma was an incubator for my medical development. I had become a mature independent doctor with a wide practical experience in many aspects of medicine, able to take major decisions and to practice human medicine with the patient at the centre of the process and able to interact with them at eyeball level. The metamorphosis had started and would continue in England.

After two years of hard work I had saved a small financial nest egg and we decided that my career needed advancement. I had made my small contribution to medicine in Gatooma and the time had come to move on.

There were no vacant positions in Internal medicine in Cape Town so I decided to continue my studies at The School of Tropical Medicine in Liverpool.

Rhodesian history has since undergone some interesting twists. Unilateral declaration of independence under Ian Smith with an international trade embargo made the country very self sufficient as small local industries flourished. Finally Black independence with poor government and corruption, eviction and murder of the whites led to total chaos and collapse of most of the government institutions.

The white colonial government was one-sided and did little to develop the deprived black population, white independence was unilateral, but black emancipation has almost destroyed a rich and fertile country.