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Christiaan Barnard—The Great Communicator?

2018; Elsevier BV; Volume: 121; Issue: 12 Linguagem: Inglês

10.1016/j.amjcard.2018.02.062

1879-1913

David K. C. Cooper,

Ethics and Legal Issues in Pediatric Healthcare

Christiaan (Chris) Barnard (Figure 1) is remembered because he performed the world's first human heart transplant on December 3, 1967, the 50th anniversary of which we celebrate this year. However, he had other talents that are not generally appreciated. These included public speaking and writing for the layperson. Christiaan (Chris) Barnard (Figure 1) is remembered because he performed the world's first human heart transplant on December 3, 1967, the 50th anniversary of which we celebrate this year. However, he had other talents that are not generally appreciated. These included public speaking and writing for the layperson. As a speaker at both professional and public meetings (Figure 2), Chris proved himself to be most articulate and entertaining and could always pitch the lecture at exactly the level that was ideal for the audience, whether learned physicians or school children. He was stimulating, serious, and yet humorous, a speaker who could immediately capture his audience's attention and hold it seemingly effortlessly for the next hour. I never saw him using notes to remind him of what he wanted to say, although to medical audiences he would illustrate his talk with slides (which we all use as a “prompt”).Figure 1Christiaan Barnard at the height of his fame as a surgeon.View Large Image Figure ViewerDownload Hi-res image Download (PPT) I provide just 2 examples of the stories he would tell to make a serious point or to entertain his audience. The first related to how 2 youngsters—patients in his hospital—had commandeered a breakfast trolley in the hospital ward. It became their grand prix racer, and the corridor became their track. “The trolley had two sections,” explained Chris to his audience. “At the bottom sat the driver, steering the trolley with his legs, and behind ran the mechanic, head down, propelling the cart down the hall. Unfortunately, the driver didn't maneuver the trolley well enough, and they ended up going into the wall, and of course the cups and saucers ended on the floor and broke. That was not very popular with the attending nurse; she put them both to bed and scolded them. “I walked into their room and looked at the mechanic and the driver. The driver had only one arm; I knew him quite well, as I had operated on him (for a congenital heart disease). Sometime later we saw him again, and he had sarcoma of the humerus, which is a very malignant disease. Surgeons had to remove the entire arm, including the shoulder girdle. “He was the driver. He was laughing and telling me it was not his fault that they had the crash; it was the fault of the mechanic, who didn't put on the brakes when he told him to. The mechanic was a little boy I did not know, but at that time he was really a picture of horror. He grew up in a very poor home; his mother and father came home drunk one night and had an argument. The mother threw a paraffin lantern at the father, but it ended on the boy's head and burst. “The boy developed third-degree burns of the whole head, and both his eyes were burned out—he was blind. At that stage, he had a big tube grafted to his nose to try to reconstruct the nose. He was squinting, like somebody who is blind, but he argued that it had been totally unnecessary to stop the race, because a few cups didn't matter very much—and he did believe they had won the race. “I realized all of a sudden that life is the joy of living; that is what it is. It is really a celebration of being alive. You see, what they taught me was that it's not what you've lost that's important, it's what you have left that's important. But I qualify this. There must be a joy in living. There must be still enough left so that there can be a celebration. You can't celebrate nothing; there must be something to celebrate. “So I think one must realize that, as a doctor, if you value life, your goal must not be to prolong life; your goal must be always to provide something for that patient that he can celebrate—provide something so that life can be the joy of living.” The second story I remember so well was his famous apocryphal “chauffeur story,” which I heard him tell many times, but I always laughed at the punch line. It gives a glimpse into his excellent sense of humor. Apart from his lectures abroad, Chris also accepted speaking engagements in South Africa. For this purpose, the South African government provided him with a limousine and a chauffeur. According to Chris, “The chauffeur was a tall fair-haired young man (not unlike Chris himself) who took great pride in his new and prestigious appointment. He bought himself a smart grey jacket and a peaked cap so that he looked the part (personal chauffeur to the famous Dr. Barnard).” Together, the professor and his chauffeur visited various cities and towns within South Africa, Chris giving a rather standard, well-organized, and reproducible, 20-slide “canned” lecture. He would explain that “the young driver, clearly intelligent and interested in the topic, always sat at the back of the lecture hall and listened intently.” On the way home from these lectures, the chauffeur frequently asked Chris for more details regarding heart transplantation. “After a few weeks, he became quite knowledgeable about the subject—at least for a chauffeur.” On one of these occasions, as the limousine was approaching a small town where Chris was booked to give a lecture, he said to the chauffeur, “Driver, I am very tired this evening. Since you have heard this talk of mine many times, I wonder if you would like to give the talk yourself today.” The driver looked somewhat perplexed, but Chris added, “Look, the talk is rather standard, and you have seen all the slides many times. There will be no doctors in the audience tonight. I think it would be quite alright for you to give the talk while I sit and rest at the back of the room.” Still the chauffeur hesitated. “The people here do not know me,” continued Chris, “and you and I look very similar. I am sure they will not suspect a thing.” Outside the small town, the chauffeur and his passenger exchanged clothing; Chris took off his handmade Italian suit and put on the chauffeur's outfit, with the chauffeur putting on Barnard's suit. Chris took over the wheel of the limousine, and the chauffeur sat elegantly in the backseat. When they entered the town, there was, as always, a large crowd waiting to greet “Dr. Barnard.” The chauffeur, dressed as Chris, emerged from the limousine and was immediately ushered into the lecture hall where he was directed on to the podium. Dressed as the chauffeur in the smart gray jacket and peaked cap, Chris sat at the back of the room. The lecture proceeded uneventfully and Barnard was actually quite impressed with how well the chauffer had delivered it. Indeed, it made him feel slightly insecure to know that a chauffeur could give the lecture almost as well as he could. The driver had started rather hesitantly, but as his confidence increased, he had become quite articulate and informative. The young man clearly enjoyed being the center of attention, and when he had concluded his remarks, he gracefully acknowledged the applause. “The chairman then asked, ‘Dr. Barnard, would you mind answering a few questions?’ I began to feel a little nervous. It was one thing to give a lecture, parrot-like, but quite another to answer unrehearsed questions. But the young driver, now full of confidence, immediately said, ‘Of course.’ All went well for a while. The questions were simple and the chauffeur, from his many discussions with me in the car, was able to answer them without difficulty. “But then a distinguished gentleman stood up in the middle of the room and announced that his name was Dr. DeBakey and he was a visitor from Houston in the United States, and he would like to ask a question. I immediately recognized the famous American heart surgeon, and my nervousness turned into panic. What on earth was Michael DeBakey doing in this small town in South Africa?” Dr. DeBakey was the last person Chris had expected to see there. Now his chauffeur's lack of knowledge would be exposed—and it would appear as if he, Professor Christiaan Barnard, was unable to answer the question correctly. Dr. DeBakey would return to the States believing Barnard to be an ignorant fool. “Dr. DeBakey then proceeded to ask ‘Dr. Barnard’ an extremely complex and difficult immunologic question about heart rejection. There was no way the young chauffeur would know the answer—we had never discussed such a complex topic in the limousine. On the podium, the chauffeur, who also recognized the great Dr. DeBakey from the photograph he had seen in my office, was clearly at a loss for an answer. He looked very agitated and began to sweat profusely. At the back of the room, I became increasingly anxious. “But after a short pause, the chauffeur broke into a confident smile, and said, ‘I recognize you, Dr. DeBakey. You are certainly one of the most famous heart surgeons in the world. Your reputation is impeccable and your knowledge extensive. I therefore cannot understand how you can possibly ask me such a simple question. In fact, to show you how simple it is and how easy to answer, I am going to ask my chauffeur at the back of the room to answer it for me.” Needless to say, the answer from the chauffeur at the back of the room received tumultuous applause from the very impressed audience, and the crisis was over. As a writer, Barnard (Figure 3) wrote 3 medical research dissertations and was author or coauthor of more than 200 academic studies on his surgical work. It is less well-known that he wrote extensively for the layperson. For 8 years, he contributed a regular, syndicated newspaper column in South Africa, and his books included several advising the public on matters of health (in addition to 4 novels). In my opinion, Barnard's gifts as a writer have not been fully appreciated. His forte was to write on medical and health topics in a style that was understandable, interesting, and entertaining to the average man in the street. However, his interests extended well beyond the field of medicine, as illustrated by his books on euthanasia and the politics of South Africa. I do not know many, if any, other leading surgeons or physicians—or indeed leaders in other professional fields—who have demonstrated the range of interests that Barnard had, nor one who had the ability to capture the attention of the lay reader so successfully. Just as he could pitch a lecture at just the right level for his audience, so he could do so with the written word. As one would expect from a doctor, many of Barnard's articles provided opinions and guidance on health and lifestyle, but he also wrote on topics of national and even global importance. Here are some of his comments. He claimed that the population explosion was the single most important problem facing the world:“Every other problem the human race has ever had fades into insignificance besides that of overpopulation… yet nations the world over act as if they had more important things in mind… What is needed is a reversal of the tax burden from the childless single to the married or unmarried parent… The single adult without children should be rewarded by hand-outs from the receiver of revenue… Either we defuse the population bomb or we get wiped out in the population explosion.” Nevertheless, Barnard prophesied that obesity would become “the greatest health problem of the 21st century,” and to date, he has been proven right. He suggested people should (1) be wary of “crash” dieting programs (“most get-thin-quick diet programs only reduce the size of your wallet”), (2) use their common sense (“losing weight takes time [and] attaining a bikini figure in two weeks only works in magazines”), and (3) train themselves to restrict food intake (“a healthy diet is like jogging; practice a few times and it will come naturally… Diet without exercise if for the dustbin.”). He added that his “mother gave me the best dieting idea in the world: ‘Stop eating when you’re still hungry’.” Perhaps with tongue-in-cheek, Barnard advocated sexual activity as a form of exercise.“You expend about as much physical energy in an act of intercourse as in 20 press-ups, probably a good thing for many middle-aged couples who get no other form of exercise.” He addressed another sex-related topic, aphrodisiacs.“Any teenager knows that an expensive dinner is more erotic than a hamburger. As a peacock spreads his tail feathers to show the female what she's missing, so men flash their wealth… all the paraphernalia that says: ‘Baby, I've got it.' Not surprisingly, they do get it, at least often enough to make the whole exercise worthwhile.” Barnard appealed for the government to do more to prevent people developing bad habits that resulted in poor health, and pleaded particularly on behalf of children.“How nonsensical… to shape an educational system aimed at producing children sound in mind and body while ignoring advertising campaigns which tell them how to find great adventure and become he-men and sophisticated women through smoking the right cigarette or drinking the right liquor.” However, Barnard had an ambivalent attitude to stress. “Stress, which increases the heart rate and elevates the blood pressure, is considered bad, whereas exercise, which also increases the heart rate and elevates the blood pressure, is considered good. If someone was ill in my clinic, I could think of nothing else all day… In my job, stress was a kind of engine that drove me to do better and more.” “How could one avoid heart disease?” he asked, in another study.His “thumbnail sketch of the person least likely to have a heart attack… is briefly: an effeminate municipal worker… without ambition, drive or competitive spirit… subsisting on fruits and vegetables… detesting tobacco… scrawny and unathletic… low in income, blood pressure, blood sugar, uric acid and cholesterol… having had his precautionary castration.”“A heartless sketch?” he asked. “Not really. All that's missing are the guts. And if you have some guts to be different then you also have the discipline to avoid extremes in your life's activities. That, in fact, is all you need to know about heart attacks.” He sympathized with those whose appearance was affected by disease. “The worst diseases,” he wrote, “are those where people around you see you have got it.” As an example, he suggested “a faceful of acne.” Barnard was not impressed that all aspects of life were improving in the modern world.“No-one who lives in an urban environment, behind the locks, bars, and burglar-proofing of modern housing, need doubt that he is less free than his grandfather… No businessman threading his way through the maze of bureaucracy could fail to be aware of the chains on private enterprise… No traveler remains untouched by … security requirements.” As a doctor, he had strong views about the physician's approach to his calling.“There are important differences between the doctor's responsibility to scientific inquiry and his responsibilities to his patients… As doctors, we treat patients. We don't treat coronary arteries. It is the patient who is sacrosanct—not his heart… The principal aim of the doctor should be to help the patient achieve a physical and mental state of health that will enable him to indulge his own private concept of being alive.” He was touched by simple gestures of thanks from patients or their families.“I once found a gift on my desk that made my entire day. It was a box of fly-specked, bruised, second grade apples… windfalls. The giver was a husband of a patient. He was a farm labourer, and this was all he could find to show his gratitude. Those apples were the sweetest I have ever tasted—when I managed to get them past the lump in my throat.” (This last line is surely memorable.) He certainly did not believe that doctors should take all the credit for the health of the population.“The engineering and architectural departments … annually turn out more guarantors of the nation's health than any medical faculty.” He summed up his opinion in simple terms.“A single plumber probably achieves as much in the field of preventive medicine as most medics, while the ordinary health inspector, doing a boring routine check of take-away shops and corner cafés, saves more in terms of the nation's health budget than any topflight, nationally-known specialist, myself not excluded.” He was not too proud to put his own life's work in perspective:“In the almost 14 years of heart transplants … we have operated on 57 patients, of whom 17 are alive … A report by the WHO … said that in the previous 14-year period … some 400-million children worldwide had died of malnutrition. Looking at the world as a whole, our efforts vanished in the sea of misery in which mankind appears to spend most of its existence.” (Another memorable last line.) The above passages are, I suggest, examples of a writer with the gift for making old topics of renewed interest and of Barnard's ability to capture the attention of his readers. Whenever he wrote, however, he tried to entertain the reader by adding humor here and there. For example, when discussing sex and aging, he added this little anecdote. “I once sat next to an elderly gentleman in an airplane and, as we were about to land at London's airport, we were given the usual immigration forms to complete. In the space next to the word ‘Name’, he dutifully printed his name. On the next line, in the space marked ‘Sex’, he wrote wistfully ‘occasionally’.” Christiaan Barnard was not only a very good and innovative heart surgeon but also a gifted communicator of considerable skill. David Cooper was a surgical colleague of Barnard for several years in South Africa and subsequently in the United States. His biography of Barnard, Christiaan Barnard, the Surgeon Who Dared, was published by Fonthill Media in November 2017. The author has no conflicts of interest to disclose.