ANDRE VAN AS Pulmonologist and Internal Medicine Physician Clinical Development leader for pharmaceutical companies
After matriculating from St. John’s College, Johannesburg, my post-matric year included German history in the 1930’s as well as some of the curriculum of first year medicine. It transpired that the Medical Faculty of Wits had many members who were graduates of St John’s College and were referred to as the “St John’s Mafia” by the rest of the Faculty. Tom Bothwell arranged for the photograph below to be taken.
In the picture of the ‘St John’s Mafia are
Back row: JSS Gear, P McPhail, J Thorburn, F Kalk, A Gear, R Morrison, A Perrat
Middle Row: RN Scott-Millar, RF Griffiths, JM Pettifor, G Mitchell, JH Bristow, P Herberden, A van As, JD Torrance, FJ Milne, WJ Kalk.
Front Row: D Mitchell, JB Barlow, TH Bothwell, RW Charlton, JHS Gear, LGR Van Dongen, M Suzman
Absent: P Cooke, SAR Cooke, R Edge, G Fotheringham, HH Lawson, AM Myers, I Webster, R White
After an intense first year of note taking, my briefcase with all my notes disappeared from my locker in late August. I realized all the information must have been in text books and this helped me through the final exam. I continued my interest in cricket and rugby and played in the Wits Under 19 Team, and in the subsequent year in the second and occasionally the first team. We had a very successful season winning the Under 19 League that year, beating the favored Diggers team on the way. The picture below shows Prof. Becker, who was the head of Pathology, in front of me. I had no idea that about 10 years later we would be treating his wife, who was seriously ill requiring assisted ventilation, in our ICU.
Rugby at Wits
Wits had a strong rugby team with current or future Springboks (Clive Ulyatt, flyhalf, Wilf Rosenberg and Joe Kaminer, both centers) on the team, as well as two Transvaal provincial players (Tommy Borquin, scrumhalf, and Louis Fine, wing). Once I was pulled out of a Zoology lab to play for the first team and was provided with the gear of the absent player. At center I was closely marked and ploughed into the ground each time I touched the ball. After the match I saw number 8 on the back of the loaner jersey and realized that the opposing team thought I was Joe Kaminer.
Going up to the level of the Wits first and second team the following year was very different. Everyone was bigger, stronger and faster. Our opponents often had Springboks or Provincial players in their teams. With talent like Ulyatt, Rosenberg, Kaminer the practices were tough and the matches were even harder. I graduated to playing at center or flyhalf and acted as a substitute in these positions for the 1st team. Marking Wilf Rosenberg during practices was daunting as he was extremely fast, and a master at eluding tackles.
During a practice, I was playing flyhalf for the second team, Foxy Bernstein, a 230lb lock forward, broke through the line out and ran straight at me. I tried to tackle him, but at 145 lbs. I hardly affected him. However, I grabbed his jersey and he ran away with my arm and dislocated my right shoulder. Doc Helfand, a GP who acted as one of our coaches, asked me a few minutes later why my arm was hanging by my side. “Dislocated my shoulder” I said. He replied “Nonsense, you would be rolling in pain. What do you know, you’re only a second year student. Play on”. So I did, catching and passing the ball with my left hand. It took the rest of the evening for me to reduce the dislocation.
In this picture of the under 19 Rugby team we see
Back row: M Blackwell, W Siebeles, N Barlow, W Clough, T Bourquin
insets: J van Rensburg, RE Cathrall
Middle row: R Petty. A van As, H Koch, I McCusker, R Gush, P Marshall
Front row: L Tanchum, Dr B Becker (President) H Snyder (Captain) G Kraft (Coach) L Marais (Secretary)
I dislocated my shoulder five more times while playing and eventually I spoke to Hymie Green, one of our table docs, about it. He immediately arranged for me to see Prof Edelstein who did a repair (Putty Platt). This involved pinning the cartilage back in the socket, repairing the torn capsule and shortening subscapularis to keep the humeral head in the joint. This last step restricted lateral rotation of my arm and limited the ability to make a throwing movement. Needless to say that was the end of both my rugby and cricket careers.
Inequalities and hardships Many hardships impacted some of our students adversely. An example was the difficulty one of our African students had, travelling in packed trains each day from Soweto to classes and home again. His day started before sunrise and he often got home after dark. Homework was done by candle-light in a house with no electricity or running water. We had empathy for the situation, but did not fully appreciate the extent of the hardships. We travelled in our own cars or municipal transport and had our lunch in Mr. Neuman’s café on Esselen street. Where did these students have their lunch, or did they even have one to eat? Despite the challenges they made their way through Medical School. Social consciousness is learned, takes time to develop, and is influenced by circumstances. Wits at that time had a Conscience Clause allowing students to be enrolled regardless of race, creed or ethnicity. This was revoked in 1959 by the Extension of University Education Act that closed Wits Medical School to non-white students. That year Tukkies refused to play the annual rugby Intervarsity against Wits because we had a Chinese scrumhalf.
Our faculty kept social issues in the forefront and at a meeting Philip Tobias, Paul Levy and Sydney Brenner led a discussion drawing attention to the inequity of housemen’s pay. Black graduates received 3/5ths, and others 4/5ths of the pay of whites. Sometimes there were attendees, sitting apart in the auditorium, taking notes. They were undoubtably from the Special Branch of the SAP. It took discipline to concentrate on the main task of getting through Medical School without attracting the attention of the SAP which could turn one’s life into a train wreck.
Our fourth year ‘Firm’ - distractions In the 4th year our “Firm” mostly consisted of David Paton, Alf Mauff, Joan Feldman, AnthonHeyns, Abe Zeilinga and Tony Meyers. During our rotation at Bara, we lived in a student dormitory and played chess as a diversion. Anthon Heyns, reputed to have represented South Africa in international chess in his 1st year in medicine, played three of us simultaneously, blinded, while lying on a bed in the corner of the room. He won all three games in less than 10 moves. He had a photographic memory and we reckoned he had a very high IQ. He was seen preparing for the final surgery written exam by paging through the Bailly & Love’s textbook of surgery, and literally memorizing each page. Eric Cohen, who was also a high IQ student with a photographic memory, told me about an occasion that he played a game of mental chess with Anthon.
Some of our surgery rounds at Coronation Hospital were interrupted by a game of golf at CMR golf course which was conveniently on the way. This is how I came to be introduced to golf by Tony Meyers. Another popular diversion was to skip boring pharmacology lectures and play four-handed Klaberjass in Mr. Neuman’s café on Esselen street. Apart from the structured teaching rounds many Firms arranged additional tuition from the excellent faculty and registrar clinical teachers. The better known and legendary teachers were, Asher Dubb, Leo Schamroth and Harry Seftel. Lennie Taitz taught me about pediatrics and introduced me to cardiology by encouraging me to master Paul Wood’s text book “Diseases of the Heart and Circulation”. It is still in my library and there is a check mark on the title of each chapter, all committed to memory. Sixty years later it is still a magnificent account of diseases such as pulmonary hypertension, that have been recently “discovered” after the development of drugs to treat intractable conditions.
In third year, I heard about physicians at Edenvale Hospital willing to teach students and I wanted to get a head start on clinical training. There I met Dr Chaim Ipp. This led to a four-year student/teacher relationship which was very rewarding. He and his wife survived of the ravages of Nazi Germany in Lithuania and I was interested in getting a firsthand account about the Nazi Regime because of my interest in German history in the 1930s. He was reluctant to talk about it. I spent time with him whenever he was on call over the weekends. He taught me clinical medicine and would wake me to see patients admitted during the night. One that made a lasting impression on me was an African woman in diabetic coma. I learned how to manage hydration, blood sugar as well as the electrolyte abnormalities of diabetic coma. Over four years I benefited from his mentoring and came to know him well. He was clearly a superb physician trained in an era when Europe was a leader in science and medicine. It was a great loss and shock to hear about his tragic death in July 1960. I respectfully attended his funeral in Linksfield.
House jobs at Bara Graduation was a release from Medical School but left us unprepared for the intensity of internship work-load. We formed a group, and as was the custom then, and met with heads of the units in which we wanted to do our internships. We decided to apply at “Bara” and the Chiefs of the surgery and medicine units were very pleased to have a full complement of housemen who unburdened them from most of the clinical work that they had to do previously when poorly staffed. Bara served Soweto resulting in intake numbers up to 50 patients every fourth day which was overwhelming, and led to 36-hour shifts, with patients often two per bed (head to toe) and sometimes under the bed. The high intake numbers created a bed shortage crisis and the senior medical staff would do rounds and discharge patients who were judged to be well enough to cope with their illness at home. The decision to discharge patients with meningitis with a 10-day supply of oral antibiotics drew some criticism from the younger staff members. This was a no-win situation because space had to be created for the influx of new patients.
Overcrowding had a negative impact on the standard of care that could be delivered to the new patients and those already admitted. We had to draw blood and perform all the procedures as well as collect the blood results from the lab. There was constant competition between the 5 interns for the single Baumanometer and diagnostic set, which caused some strife. Despite these circumstances the educational experience was unmatched because of the wide variety of diseases that we saw. Two conditions were rare – asthma and myocardial infarction. Unfortunately, the full-time staff had no experience in the respectful treatment of house staff, which increased the stress of the job.
The first day in surgery in February I was scheduled to start at 6 pm and introduced myself to the Head Nurse to find out what needed to be done. She said everybody is busy in surgery and there are patients waiting to be seen, two with stabbed chests, both with a hemopneumothorax, one with a stabbed heart, and one disembowelment. I inserted 2 chest tube drains, drained the hemopericardium causing tamponade and wrapped up the disembowelment in sterile drapes and got him off to surgery, all in the first hour. My record single day intake in medicine was 22 patients, the last one at 4 am was a bled-out hematemesis requiring urgent blood transfusion.
All new patients had to have a complete H&P. The history was taken with the help of an expert African nurse interpreter who could speak all the dialects and knew exactly which questions to ask. After 6 pm two housemen took on the late shift and during one of these, my colleague, Essop Jassat warned me to be careful as bombs would be exploding in public places. A few weeks later the first bomb exploded in Park Station. The era of the ANC’s passive resistance had ended.
Pediatrics with Eric Kahn and Monty Schneir was a wonderful experience after Surgery and Medicine. I wanted to become a pediatrician but at the end of my six months no registrar position was available. Eighteen months of internships produced the burnout that trainees talk about today, and a position at the South African Blood Transfusion Service let me catch up on my sleep.
Intensive Care Units
Six months later my return to clinical medicine was as Medical Officer at “Fevers”. There I learned about ventilatory support of paralytic polio and viral encephalitis affecting brain stem function. One of the highlights was the weekly round on Thursdays that Dr James Gear attended. He imparted a trove of knowledge about infectious and tropical diseases in a very understated way. We ordered a new volume-cycled Engström ventilator to replace the old “iron lung” and the Radcliff ventilator that was built from bicycle parts. As blood gasses were not available then, minute ventilation was adjusted by measuring the apnea time.
A registrar position became available at the Johannesburg General Hospital in Prof. Elliot’s ward and for the next 3 years I worked at the “Gen.” The inception of a dedicated ICU in the making required a paradigm shift in medical management that was challenging. Prof. Elliott was able to get support to build out the ICU and together with my colleagues we published two papers in 1965 on our first years’ experience. The papers were amongst the first on an organized ICU. One was reviewed in the Year-Book of Medicine by Carl Muschenheim. For the next 26 years I ran ICUs in South Africa and subsequently the United States.
After completing internal medicine training, I wanted to join Saul Zwi who had been appointed head of Respiratory. There was no position available and a meeting with Dr Maureen Salmon, the Superintendent of the Gen, resulted in converting a part time position to Medical Officer, which served as my Pulmonary Fellowship training. After two years I became Physician to the Respiratory Unit.
A research grant from Boehringer Ingelheim took me to Bochum in the Ruhr District (West Germany) for eight months. A collaboration on mucociliary function with a brilliant Iranian, Joseph Iravani, resulted in the first publication describing the abscense of a mucous blanket in mammalian airways. This was a revision of basic principle. We knew that this concept would be controversial as it had been accepted dictum since the 1930’s, that the mucous blanket was responsible for removal of particulates.
On returning to RSA, to resume my position in the Respiratory Unit, Prof. Ian Webster at the NRIOD made a bench top laboratory and staff available to me to continue doing mucociliary work. This enabled me to complete a PhD thesis on airway clearance mechanisms.
As there was mounting criticism of the new concept I wrote an editorial in 1976 summarizing the concept and pointing out that four methods had been used to validate the observation. These included; first an ex vivo intact airway preparation to study several species of mammal; the second and third was scanning electron microscopy of the airway surface utilizing two different techniques to preserve airway mucus in four mammalian species; the fourth was a mathematical model showing that the concept of a blanket was untenable because the volume of mucus generated in the peripheral airways with a stream bed width of ~120 meters could not be accommodated in the trachea with a stream bed width of about 5.7 cm assuming a constant depth of the mucous blanket at 5µm.
The mathematical model was supported by experts in flow mechanics in the Chemical Engineering Department at Wits. For 42 years the proponents of the mucous blanket continued to ignore the hypothesis until in December 2018 I received two citation notifications that my paper from 1976 had been quoted. Two independent labs had verified the discontinuity of the mucous blanket. I contacted the authors of the papers, one in Sweden and the other in Iowa, and we are currently collaborating to publish a paper with all of the information, past and recent, that supports the discontinuity observation.
Principal Physician at JG Strijdom (later Helen Joseph) Hospital
A full-time position of Principal Physician was created in 1973 at the J.G. Strijdom Hospital (later the Helen Joseph Hospital), to which I was appointed. The hospital had been managed by part time physicians and needed an upgrade of patient services as well as student and resident teaching. During my 7-year tenure numerous improvements were made. I created three additional fulltime positions, filled by Vivian Fritz, Herbie Schneider and Tillman Gebhart. In addition, I founded a modern respiratory unit that provided a wide range of comprehensive services. One of the first online Pulmonary Function Laboratories was established to measure airway function, ventilation and gas exchange as well as to perform exercise testing. A physics graduate, Ian McDonald, was appointed to write additional programs in machine language to upgrade and improve the performance of the online system.
The exercise lab enabled us to assess the degree of risk and exercise capacity of post MI patients and offer them a cardiac rehabilitation program. We also had a state of the art twelve bed ICU built, and Jeff Lipman, who trained in our ICU at the Gen, managed the unit very capably.
Prior to joining the JGSH I visited a colleague, Prof. Henry Herzog in Basel Switzerland, to learn how to do rigid bronchoscopy and how to apply adequate topical anesthesia. A bronchoscopy service using flexible bronchoscopes, aided by fluoroscopic visualization to do transbronchial biopsies of peripheral lesions, was created. We took over bronchoscopic diagnostic work from the thoracic surgeons. The Medical Unit was staffed with six housemen, four registrars, and Fellow trainees (among them Les Berman, Rob Dowdeswell, MichaelGreenblatt, Les Stricker and Graham Cassel).
We were very active in pulmonary medicine and the unit became a tertiary referral center as a result of the Cardiothoracic unit being moved to our hospital. On Tuesday mornings, our pulmonary outpatient clinic was followed by an afternoon session where all the patients were discussed and PFTs, X-rays and patient management reviewed. In addition we had regular multidisciplinary meetings with a radiologist, oncologist and thoracic surgeon in attendance, to discuss the management of patients.
Teaching schedules, services and organisation
Once a week a teaching seminar topic was allocated to one of the registrars or fellows and presented to the staff for discussion. A Renal Dialysis Unit was set up by Ben Goldberg and run by Tony Meyers. Vivian Fitz, who at that time worked closely with John Barlow’s Cardiac Clinic, provided cardiac consultative services. On the fifth floor we were given a ward which served as a Medicine Department and also housed the PFT lab, bronchoscopy suite, exam, and procedure room to see consults and do allergy skin testing, as well as offices for the medical, nursing and technical staff.
Additional support came from 2 pulmonary function technicians and three full time nurses. Our team functioned smoothly and over time we were able to accommodate elective final year students who wanted to get involved in clinical research projects. It was troubling that all of the expansion outlined above came at a time that conditions at Bara were deteriorating because the Transvaal Provincial Administration was not prepared to invest the money needed to expand services there.
To New Mexico USA 1980
With the sanctioned South African economy deteriorating, and no end to the political regime in sight, it was time to move on. In 1980 I was appointed Chief of the Pulmonary Division at the University of New Mexico and the VA Medical Center in Albuquerque, NM, USA. Getting the job in the USA was not an easy task. It took 2 years to prove that I was not keeping a US citizen out of a job and all FMGs were required to pass the USMLE and the Visa Qualifying Examination (VQE) (established in 1977).
The VQE was a 3-day 6 session (each 3 hours) basic science exam that had a 90% failure rate world-wide. Quite a number of the candidates taking the exam in Johannesburg walked out by the second day muttering “this is ridiculous”. Apparently, the AMA was concerned about job competition from foreign MDs.
In Albuquerque my task was to rebuild the Pulmonary Division that had been without leadership for 4 years, upgrade the pulmonary diagnostic services, modernize the bronchoscopy lab and support Pulmonary Faculty and Fellows to apply for successful research grants.
After six years I started my own private practice, concentrating on consultative services as well as doing studies for the development of pulmonary drugs. Consulting with the Pharmaceutical Industry resulted in being recruited to head up Respiratory Development Sections of several companies. In these companies I worked closely with pharmacologists who had extensive pharmacological expertise. During this time, I learned about the importance of the molecular and chemical characteristics of compounds in determining the safety and efficacy of the molecule.
In 2010, 50 years after graduation (30 in Academia and 20 in the Pharmaceutical Industry), I retired from working full time and focused on teaching, writing and photography (www.andrevanas.com click on the link and go to Gallery/Floral).
All of this history was made possible by the unselfish support from my wife Sandra (née Erasmus) for the 54 years we have been married, and who always helped me to successfully apply the main lesson in life. Main lesson learned? – Turn adversity into advantage.
I have written this bio highlighting events that had a formative influence on my medical career but also events that were very memorable. I apologize to my colleagues who are featured in this bio if some of the events do not match their recollection. Sixty years is a long time and the mind embellishes the memory, but I have tried to be as accurate as possible.