Contested Legacy: Marking the 50th Anniversary of Professor Christiaan Barnard’s Pioneering Heart Transplant (Part 1)

This is an excerpt of a paper on Barnard’s legacy in South Africa and my own implication in that legacy. (Part 1/4)

In this paper, I tell the stories of Barnard, Hamilton Naki, Basil Brown, three South Africans whose stories can tell us much about legacy, celebrated legacy, disputed legacy, fraught legacy, enduring legacy.

Introduction

There is an almost inherent tendency for human beings to revise our history, to make it more memorable, even more palatable, than the actual events, processes and personalities that constituted that history. Most of us do it, to a greater or lesser extent, sometimes unwittingly, often consciously. Hey, I’m guilty of it too. It’s not necessarily a bad thing. Except when we try to score an advantage by removing or distorting established facts, glossing over inconvenient truths, or outright denying them.

The same was true of Prof Chris Barnard, who performed the first human-to-human heart transplant on December 3, 1967, in Cape Town’s Groote Schuur Hospital, in his telling and re-telling the stories of his life. I fear, the same will be true as we mark the 50^th anniversary of Barnard’s heart transplant achievement on December 3 this year.

The writer Christopher Hitchens – while noting the propensity of funeral orators not to speak ill of the dead – railed against the sycophantic obituaries – which followed Barnard’s death in 2001. Hitchens wrote in The Guardian that nowhere had he seen the “once-notorious remark” of Balthazar John Vorster, head of the apartheid regime in the 1960s and 70s, who described the good doctor as the best ambassador South Africa ever had. As a radical student in 1970 opposed to the tour of England by the all-white South African cricket team, Hitchens had quoted John Vorster’s words back at Barnard during a televised BBC.

The First Transplant

As the sun rose on a Sunday in early December in 1967, a large team of doctors, nurses and technologists, led by Professor Christiaan (Chris) Barnard of the University of Cape Town and Groote Schuur Hospital, completed the world’s first ever human-to-human heart transplant.

The recipient was Louis Washkansky, a middle-aged businessman suffering from coronary artery disease and a fighter in every sense of the word. By all accounts also a much-loved family man, a philanthropist, a marvellous raconteur who sneaked forbidden snacks into his hospital ward despite the dire state of his health, a challenging patient who threatened his carers every day that – although bed-ridden – he would walk out and go home if they didn’t make a plan to heal him.

The donor was Denise Darvall, a 25-year-old bank clerk who had been knocked down in a hit-and-run accident barely 12 hours previously. Denise and her family had stopped in her new car en route to visit friends near Observatory, to buy cake for tea. As Denise and her mother Myrtle were crossing Main road, Observatory, to the car where her father and brother were waiting, they were run over by a drunk driver, policeman Friedrich Prins. Myrtle was killed instantly and Denise suffered extensive serious injuries, including skull fractures and head injuries.

Admitted on life support to Groote Schuur Hospital a few kilometres away, breathing through a pipe connected to a ventilator, Denise was declared brain dead by a neurosurgeon at 9pm. Her heartbroken father, Edward, was immediately faced with a difficult question as surgeons asked him to consider donating Denise’s heart to save the life of Louis Washkansky. It took the grief-stricken husband and father four minutes to agree to the transplant – Edward Darvall is recorded as saying to the doctors: “if you can’t save my daughter, try and save this man.” He also agreed to the removal of Denise’s kidneys to save the life of a young boy, Jonathan van Wyk, 10, who had been admitted to Tygerberg Hospital with kidney failure. Given the political context at the time, it is worth recording that Louis and Denise were white, Jonathan was classified as coloured.

Chris Barnard’s team of surgeons, anaesthetists, perfusionists, technicians and nurses had been on standby for weeks already, anticipating that a heart transplant was imminent. Barnard’s group of up to 30 worked through the night in side-by-side theatres. One part of the team- that included Chris Barnard’s brother Marius and Terry O’Donovan – harvested the heart from Denise’s body, on principal holding back from any incision until the respirator was switched off and her heart stopped beating.

Sadly, Louis Washkansky died 18 days after receiving Denise Darvall’s heart, from infection, rather than the organ rejection for which he was being treated after the operation.

But, almost 50 years later, heart transplantation remains the best viable treatment for end stage heart failure, although we are likely to see significantly increased use of the artificial heart pump, for example the LVAD ( or the left ventricular assist device) in the future.

The ABCs of being Chris Barnard

Born in Beaufort West in 1922, Chrisiaan Barnard had graduated in medicine from the University of Cape Town in 1946.  After internship at Groote Schuur Hospital and a general practitioner’s appointment in Ceres, he took a position at City Hospital in Cape Town, before re-joining GSH as a registrar. Barnard had qualified as both a physician and a surgeon, a significant merging of disciplines. He then continued his studies at the University of Minneapolis before returning to GSH and UCT, where he eventually retired as head of the department of cardiothoracic surgery in 1983.

Barnard has been variously described as ambitious … brilliant … charismatic … devil-may-care … driven … edgy … fussy … groovy … haughty … intolerant … jet-setting … ken … meticulous … narcissistic … opinionated … partial … having a prodigious memory … quixotic … a raconteur … skilled … temperamental … unconventional … vaunted … a wagerer … youthful … zealous.

John Terblanche, who was chair of the department of surgery at UCT and worked under Barnard in his younger days, described him as “the father of open heart surgery” in South Africa.

At City Hospital he did far-reaching research into tuberculosis meningitis, the form of TB which affects the lining of the brain and spinal cord. Later, at Groote Schuur again, he did extensive research into bowel obstruction in newly-born infants, a condition known as intestinal atresia.

The hospital’ head of surgery Jannie Louw reported that the research turned a 90% mortality rate into a 90% survival rate and was responsible for opening up the whole field of intrauterine surgery. Louw also reported Barnard’s results with congenital heart disease were as good as that reported from the best centres elsewhere in the world. He was singularly responsible for the installation of a heart-lung machine at Groote Schuur Hospital.

A big part of his medical legacy is patient care, especially after heart procedures. The intensive care approach, involving round-the-clock care of a patient, was perfected in South Africa as a result of the cardiac clinic programme at Groote Schuur.

Early biographer Peter Hawthorne remarked of Barnard that, he set “high standards of perfection and finds it intolerable if others fail to match his standards. He lives, eats, thinks and sleeps his work – and fully expects others to do the same. It makes him an extremely exacting man to work for”.

What contributed to Barnard becoming the first surgeon ever to do a human-to-human heart transplant?

Firstly, absolutely detailed preparation, training, research in cardiac surgery, renal transplantation and immunology. It is likely that, by the time he returned to Groote Schuur from Minneapolis, Barnard had already cast the vision of doing heart transplantations in Cape Town, and he set about it with a well-planned strategy. In the nine-year period leading to the heart transplant in 1967, the team at Groote Schuur Hospital under Barnard had performed a thousand open-heart operations and 48 heart transplants on dogs. In 1967, he conducted the second kidney transplant in the country (the only kidney transplant he ever conducted), with the recipient, Mrs Black, surviving for 21 years.

Secondly, the Groote Schuur hospital – Uniiversity of Cape Town research and teaching complex had a justifiable international reputation for a high standard of medicine, what Prof Bill Hoffenberg described as “advanced and sophisticated – an environment conducive to innovation”.

Thirdly, the heart transplant was also pursued within the context of dramatic moments of pioneering surgery since World War II, including skin, liver and kidney transplants. The first successful living donor kidney transplant involving a set of twins was performed by James Hardy in 1963, followed three years later by the first successful pancreas transplant by Richard Lillehei and the first successful liver transplant in 1967 by Thomas Starlz.

By then, several heart transplantation research teams were conducting extensive laboratory experiments on animals. The most significant cardiac surgeon in this mix was Norman Shumway, who had previously collaborated with Richard Lower and now was at Stanford. Prof Walt Lillehei, widely regarded as “the father of open-heart surgery” and credited by Barnard as having taught him all he knew about heart surgery, was mentor to both Barnard and Shumaway at Minneapolis. He said Barnard’s abilities both as an experimental researcher and clinician, and devotion to duty were unrivalled. “He was one of a group of surgical residents that subsequently became internationally successful – but Chris Barnard stood out in that group,” said Lillehei, who added that the stubbornness which Barnard’s Afrikaner upbringing had instilled in him made him a good researcher.

Fellow surgeon David Cooper said that, as a heart surgeon, Barnard had “almost unequalled range; there was no operation he could not perform “from valve replacement, to the correction of complex birth defects, to repair of an aortic aneurism (weakening of the wall of the main blood vessel of the body), and so on”.

But the jury of his peers was not unanimous on Barnard’s achievements. Some questioned his surgical skills. Others, his research outputs, even while they acknowledged not having read his journal articles. There was no consensus that his decision to forge ahead with the Washkansky operation was ethically correct at the time. His failure to properly acknowledge the work of Norman Shumway and Richard Lower remained a bone of contention with many. Barnard’s colleagues in Cape Town resented his almost incessant globe-trotting following the breakthrough operation.

Shumway and Lower had perfected in the laboratory the orthotopic procedure, which involves removing the recipients diseased heart completely and putting the donor heart in its place in the chest cavity. The perceived plagiarism of their work haunted Barnard for many years and in 1975 he suffered the ignominy of being dis-invited to a conference of 500 cardiologists and cardiothoracic surgeons in Detroit because of the claim that he had not credited the prior work by Shumway and Lower, although in later years he sought to correct the perceived slight to the American duo.

It bears mentioning in this context, however, that a few years after the first transplant, Barnard very successfully also introduced the heterotopic or piggy-back transplant into his programme, a further indication of his willingness to innovate on top of other’s discoveries.

The most significant criticism of the Washkansky-Darvall moment, which continued for almost a decade afterwards, was the matter of brain death.

In South Africa, the medical profession was bound by three criteria in determining death: no brain activity at normal temperatures, no spontaneous breathing for three minutes when the respirator was disconnected and no electrical activity in the brain indicated on the electroencephalogram.

Walt Lillehei, who had taught both Barnard and Shumway at Minneapolis, stated candidly that, despite being ready to move from the experimental laboratory to the cardiac clinic, Shumway lacked the courage to make the move. Lillehei confessed that he, too, “as open-minded or maybe even radical” as he was in those days, might have hesitated about proceeding with a transplant. “It took a great deal of courage from Barnard.”

Certainly, Barnard himself seemed unconcerned about having to deal with legal and ethical impediments. This was brought into sharp relief years later when the heart of a black woman, Evelyn Jacobs, was transplanted into recipient Pieter Smith, a 32-year-old white man. Barnard faced public acrimony when it emerged he went ahead with the transplant even though the donor’s family had neither been consulted nor given permission for her heart to be donated.

One anonymous ex-colleague whose comments on Barnard were sought by colleague David Cooper for a book on Barnard, wrote back that while he had great appreciation for the work Barnard did and particularly for the quality of patient care which he gave, “I think it ends there. We have different philosophies of life – that is assuming that he has one”. Another noted that if “Chris was a more sympathetic human being and not only interested in Chris Barnard I would gladly have participated”.