The Color of a Heart
26 November 2016 (online)
For 5 years—until the end of 1989—I was the successor of Professor Christiaan Barnard and therefore Head of the Cardio-Thoracic Units of the Groote Schuur and the Red Cross Children's Hospitals in Cape Town. Although both belonged to the University of Cape Town, a strictly nonracist institution, things were not easy during those last years of Apartheid. Chronic underfunding was a constant problem, since the great majority of my patients belonged to the “black” population who seldom had money or health insurance. As a European there were diseases I had never seen before. I had to learn how to treat tuberculosis, valve diseases due to acute rheumatism, and, of course, stab wounds (HIV was not yet known). My heart transplant program had to deal with the vast distances of the donor-runs within the country, and also the strict refusal of the black population to donate organs. As black leaders told me in the Dean's office during one difficult afternoon meeting in early 1985—they first demanded the end of Apartheid and only then would consider contributing. As a newcomer to South Africa, skin color was not important to me. As a cardiothoracic surgeon hearts all looked the same, a pinkish-brown color. But I had to accept to a certain extent that some colors counted more during those times in South Africa—in one way or another.
It was true that almost all my heart recipients were “white” with the exception of a few from the Durban area, who were of “Indian” descent. None of my transplant patients were “black”—that is until November 1989. On a bright Saturday afternoon, my telephone rang and the ICU nurse in charge, Sister Hanekom, told me they had just admitted a 14-year-old Xhosa girl from Transkei, at that time one of the most poverty-stricken indigenous homelands of South Africa. She presented with obvious signs of end-stage heart failure; however, there was a not unusual South African twist to the case.
Nobody knew who had made the diagnosis nor where it had been done; at least there were no referral papers. An unknown doctor in a remote mission hospital must have done the job—of course, remember those times, without the help of an echocardiography machine. He had had to rely on the patient's history, his stethoscope, and a chest X-ray. Anyhow, Nobomi—that should be her name for this story—had in effect admitted herself when she told the driver at the beginning of the 1,200-km bus journey that she would need a new heart and she would get it in Cape Town at the Groote Schuur Hospital and Prof. Barnard would operate. The bus driver, also Xhosa, agreed since Nobomi had enough money to pay for the one-way trip. Her mother accompanied her to the station then waved her farewell; there was no money for a second ticket.
Fortunately, the bus driver was somewhat experienced, because he delivered Nobomi directly to the Children's hospital and not Groote Schuur or even to the remote Mowbray, the usual final destination, which lay in a rather notorious area of Cape Town. This was a good decision since this patient looked very sick at that time. No wonder, after the exhausting one-and-a-half-day trip she was desperately in need of urgent medical help. The man at the hospital entrance, who could also speak Xhosa, had no problem. He knew that the pediatric cardiac surgeon's ward was located on the first floor where they managed malformations on a daily basis. Money or even hospital insurance was not an obstacle for him. If the patient was poor, he or she needed only a tax payer's exemption to prove it and get any necessary treatment for free—the Government and the University would later take over. Nobomi obviously was an exemption since she had only a few belongings with her and no money.
It must have been a fantastic, but rather odd, scene that Saturday afternoon. The blue sky over Table Mountain, the white clouds driven by a south easterly breeze carrying the mild salty smell from the nearby South Atlantic; the ancient looking Children's Hospital (the only South African institution totally dedicated to all kinds of pediatric diseases), the rotunda in front of the building with some flowers in bloom, a little fountain with a small bronze statue of Peter Pan. Between the small piece of garden and the unspectacular entrance, this huge shabby bus full of black passengers drew up and parked. All watched curiously as the driver helped Nobomi to the wooden door. They, of course, knew the story behind her journey.
And this was when my telephone rang.
I accepted Nobomi and the treatment started, first at the ICU, then at the ward. During the following days, we performed the necessary investigations. I talked to Nobomi with the help of a South African colleague who—like all the others—spoke the native language, a skill they had to acquire during their medical training. I asked: “Why do you want a new heart?” She smiled and replied in a calm collected way: “I want to live, doctor.” For me, she just had passed her psychological test.
Nobomi had end-stage dilated cardiomyopathy and was indeed in urgent need of a new heart. However, there quickly arose an intense discussion between my South African colleagues as to how the time after the transplantation would be managed. Nobomi would clearly need lifelong expensive immunosuppressive treatment and regular in-depth investigations—neither of which were available in rural, poor Transkei. Finally, I proposed that Nobomi should stay in Cape Town with the Catholic nuns at St. Joseph, an African-style missionary house on the outskirts, close to the then small local airport. This would only cost a small amount of money, and the necessary funds could surely be raised with Christmas soon approaching. Nobomi was a smart and well-behaved little girl, who softly spoke the few English words she had quickly picked up. Later, I was sure, she would learn a profession and ultimately be able to provide for her own future. I phoned the Head Nurse of St. Joseph and she agreed. We sent money to her mother and she also agreed with the solution we had found.
When everything was settled and satisfactory, all major hospitals in South Africa were phoned and the core patient data were submitted: height, weight, and, of course, blood group. Ernette du Toit, our immunologist, tested for preformed human leukocyte antigen antibodies, using the most common South African antigens. A flight on a private jet would be donated to shorten travelling time should a suitable donor be found for instance in Johannesburg or Durban. We would then explant the organ, protect it with three plastic bags filled with a preservation solution, and put it into a box full of ice cubes. After arriving at Cape Town airport, an ambulance would meet us for the transfer to the hospital.
I performed the transplant in mid-December at the Children's Hospital not Groote Schuur, which was and still is the hospital for adults. It was one of my last interventions in South Africa and the heart was, of course, from a white donor. It was a big early Christmas present for Nobomi, although I was not sure whether she knew the exact meaning of that event (the Catholic nuns would no doubt teach her later). She survived the intervention without any complications, and wore a funny hat on Christmas day as did all other little heart patients. There were even small toys.
I saw Nobomi each day until I left South Africa at the end of that year. Back in Munich I was regularly informed about her progress. She was later transferred to St. Joseph, where she lived happily for 4 and a half years until she died suddenly from accelerated graft vessel disease. One major coronary artery must have blocked unexpectedly and caused a lethal myocardial infarct—a late complication that is rather rare in children compared with adults. So, Nobomi was unfortunate but I am confident she suffered no pain. Her transplanted heart remained denervated and therefore caused no angina.
A long time has since passed and Apartheid has gone forever. Skin color is no longer a stumbling block for transplantation, heart color had never been. New problems arose, though—not least infectious diseases like HIV. But nothing in the world of medicine is perfect, especially in Africa, and one has to deal with it. I occasionally travel back to South Africa and visit Cape Town. After arriving in the now big and busy airport, on my way downtown I pass St. Jo's, as we called St. Joseph, and always remember Nobomi, the brave little girl from the former Transkei.