FULL TRANSCRIPT OF THE RECOMMENDED DOSE WITH RAY MOYNIHAN - Episode 4 Professor Jimmy Volmink
9 November 2017
Ray Moynihan: Hello and welcome to another episode of The Recommended Dose. I'm Ray Moynihan. This week, we're talking with Professor Jimmy Volmink, one of Africa's leading advocates of basing our health decisions on good evidence rather than opinion, anecdotal, commercial interests. We caught up with Jimmy Volmink in the run up to the first ever Global Evidence Summit held in Cape Town last month, an event that saw over 1,400 of the best and brightest minds in evidence and health care from around the world travel from 77 countries to South Africa.
In our conversation, Jimmy Volmink explores what this means for Africa and he reflects on his own amazing journey, which took him stints at Harvard and Oxford University where a faithful meeting with the man riding a bike would change the course of his career, and how it all started as [00:01:00] a child in South Africa's apartheid era.
Jimmy Volmink: During apartheid, as you know, everything was segregated so the various so-called race groups were kept apart. In fact, kept in different worlds completely so there was no mixing. The first time I encountered a white person was probably in the form ... The person was in a form of a policeman who was enforcing apartheid and the first time I really could say that I had a friend who was white was when [00:01:30] I was in my 20s, when I was at university.
Ray Moynihan: Whether you're a clinician, a researcher, a student or just interested in the world, I'm confident you'll enjoy Jimmy Volmink's journey.
Jimmy Volmink, welcome to The Recommended Dose. I know you're in great demand especially in the run up to the Global Evidence Summit in Cape Town soon. [00:02:00] Thanks so much for making the time to come on the show. Today, we'll be asking you to share a bit about your extraordinary personal and professional journey. I know there's so much for us to cover from your stellar career and health research in EBM, Evidence-Based Medicine, to the incredible social and political struggles and changes you've seen and been part of in South Africa, which must have shaped your life and career in different kinds of ways.
With this mind, I'd like to start by putting [00:02:30] your current role in something of a historical context, something I found very striking. You now hold the position, prestigious position of Dean, I think, of the Faculty of Medicine and Health Sciences at Stellenbosch, one of South Africa's most preeminent universities. But back in the 1980's when you applied to do postgraduate studies there, you were turned down because you're black. This is a remarkable journey. Can we start by [00:03:00] briefly going back to the beginning and retracing some of the critical moments and influences that brought you to where you are today. Do you find that story striking still? Or having lived it, have you just got used to it?
Jimmy Volmink: Thank you, Ray. Thank you so much for the opportunity to talk to you. Yeah, I guess, so much has happened in my life and I feel exceedingly privileged and blessed [00:03:30] to have come on a such a long and successful journey so far. In terms of changes that have happened in South Africa, they have been very significant. I grew up during the era of apartheid in South Africa and they were significant difficulties attached to that.
At the same time, I think [00:04:00] that I came from a home where my parents believed in me and us as kids and made us feel that we could do anything that we put our minds to. While we had these social and political obstacles to contend with, we never let it get under our skin as it were and kept believing in ourselves and just kept forging [00:04:30] ahead.
Ray Moynihan: You were born in Cape Town in the late 50s, I think?
Jimmy Volmink: Yeah.
Ray Moynihan: With parents who instilled that attitude in you that you could do anything.
Jimmy Volmink: That's right.
Ray Moynihan: Take us back to Cape Town at that time. What was it like growing up there?
Jimmy Volmink: Yeah. During apartheid, as you know everything was segregated, so the various so-called race groups were kept apart. In fact, kept in different worlds completely so [00:05:00] there was no mixing. The first time I encountered a white person was probably in the form ... The person was in a form a policeman who was enforcing apartheid. And the first time I really could say that I had a friend who was white was when I was in my 20's, when I was at university.
I went to township schools that was segregated. The education system was bad, [00:05:30] and so a lot of self-learning had to take place. My own parents, because they came from very poor backgrounds, because of the apartheid system, although they were pretty bright people, they never finished primary school. They didn't have much education. There was no support in that sense educationally at home except that they believe very strongly in the value of education and made sure that we got as much of it [00:06:00] as we could.
Ray Moynihan: You went on. You got your medical degree. You went on to work as, I think, a doctor in hospitals and clinics around Cape Town in your early part of your career. How did those early medical or clinical experiences shape your attitude to medicine, and your later interest in research?
Jimmy Volmink: Right. Initially, I did my internship in Cape Town and [00:06:30] I felt very frustrated. Uncomfortable, I guess, is the word within the hospital hierarchy system. I just felt that this was not a place where I could be happy in my work. I needed to go out to communities. What I did was I went to ... I applied for a job in Rural Swaziland. For a year or so, I worked as [00:07:00] a rural doctor in a community, which was completely different from the one that I knew in Cape Town.
I think it's during that time that my interest in public health really started growing. I eventually came back and rotated to more hospitals in Cape Town just to get more experience, for example, in pediatrics and other areas. But I was then convinced that the secrets for me as [00:07:30] a health practitioner was really to concentrate on prevention and health promotion rather than just treating people who are already ill.
Then, subsequent to that, I realized that I needed some more skills and it's during that time that I wanted to do some training in research. I then applied to Stellenbosch University where I'm dean at the moment and that's [00:08:00] after I had my medical degree that I was turned away from this institution because of color, yeah. Then, that sort of blocked my path forward because Stellenbosch at that time was the only university in the Western Cape where I live to offer a post-graduate degree in epidemiology, which is what I wanted to do. As things turned out, [00:08:30] I then applied for overseas scholarships and was successful. I did most of my post-graduate training overseas.
Ray Moynihan: Well, I think, I'm right in saying that one of the places that you went early on in your career was Harvard, that quite well-known institution in Boston in the United States. I was lucky enough to spend a year there myself and have very fond memories of Boston riding across the Charles River when it was frozen. What [00:09:00] was it like for you as a young man going from South Africa from the Cape, from apartheid to Harvard at that time?
Jimmy Volmink: Yeah. It was very interesting because it was a mixed experience. First of all, it was great freedom in just being outside part of South Africa and being able to do and go wherever I pleased already. That was really great. It was also very interesting from the point of view that [00:09:30] as a black person in South Africa, I never felt even at that stage when I had my medical degree and I practiced as a doctor, I never really felt that I'd been taken seriously as a black person by white people.
It's a weird thing to say but when I went to Harvard and I sat in class and I expressed a view, suddenly, people were acknowledging [00:10:00] that I have a point and appreciating the contribution. For me, that was a new experience. That being said, this was the 80's we're talking about and Boston ... I think they were race issues in Boston and as they probably still are today in the US. They were places that were unsafe for me to go to [00:10:30] and I was warned about certain places that I should avoid as a black person in Boston.
A little bit of that as well, which I was more familiar with, but primarily just the openness, the wonderful opportunity to engage with people from all over the world and just feeling that I was being taken more seriously I think was great.
Ray Moynihan: With pathways to advancement firmly closed off in apartheid South Africa, Jimmy Volmink was [00:11:00] forced to continue his studies elsewhere. And following his scholarship to Harvard, he won another scholarship, this time to Oxford University where he famously met one of the founders of the Cochrane Collaboration and a champion of the evidence-based approach to medicine, Iain Chalmers, a meeting that happened by accident while bike riding.
Jimmy Volmink: I was riding my bicycle with my 18-year-old son and very slowly down a little road called Middle Way [00:11:30] and coming in the opposite direction was a middle-aged man and a younger woman. And as he passed me, he kind of stopped and greeted me very warmly. Well, not by name but just said, "Welcome to Oxford. I haven't seen you in these parts before. What are you doing here," and so forth. We had this interesting conversation.
At the end of that conversation, he must have mentioned his name [00:12:00] initially but I didn't pick up on it. But he gave me his card and said, "Well, I work over here, which is the UK Cochrane Centre. When you settle down and you have a moment to come and have some coffee, come and visit me and we can talk about what I do." That was how it all started, and then some three weeks later, we had this life changing for me, life-changing conversation in which again Chalmers [00:12:30] told me that why getting the evidence straight is so important and that's the most important thing, a contribution that I can make in my career.
Ray Moynihan: You're listening to The Recommended Dose, and today, we're talking with Professor Jimmy Volmink from Stellenbosch University in South Africa and a long time promoter of the evidence-based approach to medicine across Africa. Right from the start, even as a medical student, Jimmy was not satisfied [00:13:00] being told what treatments to give patients. He wanted to see the evidence for himself, and he soon discovered that when you look closely for that evidence, sometimes, it's not there. Sometimes treatments don't work and sometimes, they're even harmful.
Jimmy Volmink: I remember as a medical student, being taught about diseases, the courses of diseases and how to treat them. There was never really an [00:13:30] attempt by my professors to explain the basis or the foundation on which they are providing these recommendations of different treatments. In other words, the research or evidence-based was never transparent.
So, you ended up doing things, receiving the knowledge from your seniors and implementing them without really knowing why you're doing it. [00:14:00] That, at some level already bothered me because I really didn't feel very comfortable just accepting. I never ever as a child felt comfortable accepting things without knowing why. All the time, that bothered me but then later on, I realized that there were some of these treatments that actually didn't work, or that potentially could [00:14:30] cause harm. The only way that one could tell the difference is through proper reliable research that actually tested which treatment works or does not work or which one works better, et cetera.
There was a movement in medicine called initially evidence-based medicine which is saying that [00:15:00] we need to be more transparent about the evidence on which our decisions our based and we need to convey that to future practitioners, patients, et cetera. And that is in fact a necessity because of the potential for doing harm. We might be doing things with good intentions but in fact, in the process might be causing more [00:15:30] harm than good if we don't have reliable research on which to base our decisions.
Ray Moynihan: Armed with this growing passion for evidence, Jimmy Volmink would set up the first Cochrane group in Africa helping produced systematic reviews of evidence relevant for the setting. One example is a review in the early 2000 of the evidence for antiretroviral therapies, the drugs used in the fight against HIV aids, the example of his fascinating insight [00:16:00] into the complex relationship between what the science says and what politicians want to hear.
Jimmy Volmink: I was then the director of the South African Cochrane Centre and the newly appointed Minister of Health contacted me and said, "We'd like you to do a review to look at antiretroviral therapy for the prevention of mother-to-child transmission of HIV. We would you to look very carefully at the [00:16:30] potential harms or toxic effects. We think that these chemicals are poisoning people and we'd like you to provide us with the evidence."
We said, "Well, we're not going to prejudge the outcome but we're certainly going to be systematic in reviewing what the evidence shows." We did a big piece of work. Cochrane Review plus an extension of the Cochrane Review to look at animal [00:17:00] studies as well and our conclusion was that although there were some relatively minor adverse effects with the use of then antiretroviral Zidovudine and Nevirapine at that time. The overwhelming effect was benefit in terms of prevention of mother-to-child transmission and therefore, illness and death. Based [00:17:30] on the evidence we had, these drugs should clearly be used for this purpose.
Ray Moynihan: Did that change policy?
Jimmy Volmink: No. That did not. Sometimes, when decision makers have already decided what they want to do, they can ignore evidence. They're very keen to use evidence if it supports what they already want to do and that's just not in South Africa. We found that in many places.
[00:18:00] At that time, it was government policy not to use antiretroviral drugs as a policy for the country. That was very sad because at that time, many people were dying of HIV infection and in excess of 25% of babies who were being born in some of the provinces with HIV infection. [00:18:30] It was really criminal that we were not offering the drugs.
There was no immediate change of policy. In fact, after hounding us for the evidence during the few six months or so, or five months that we were doing this work, once we released the report to government and asked for a meeting to discuss what we found, [00:19:00] we were completely stonewalled and never again were we spoken to about this. But, it's interesting. Things sometimes take time.
This evidence together with other evidence produced by lots of other people were entered into the pool of evidence that was available in South Africa and that would turn out very well because [00:19:30] at that time, an NGO called a Treatment to Action Campaign, took government to court to try and force them to adopt the policy and they could draw on this evidence to make their case in court.
The courts, they've then mandated the use of antiretroviral drugs in South Africa, which has made a huge difference. If you talk about mother-to-child transmission of HIV now, it's less than 1%. It just [00:20:00] took longer but we still feel that the contribution we made was a meaningful contribution towards the change that followed.
Ray Moynihan: You're listening to The Recommended Dose with me, Ray Moynihan. Today, in conversation with Jimmy Volmink in South Africa.
You're hosting the first so-called Global Evidence Summit in Cape Town next week. It's an extraordinary meeting, lots of different organizations involved. Many, many people coming [00:20:30] with you as the host, many people coming from around the world. What are you hopeful from this event and why is it significant that it's being held in Africa?
Jimmy Volmink: We're very excited that this happening, a, because this is the first summit of its kind where the five major evidence networks Cochrane, Campbell, Joanna Briggs, [00:21:00] Guidelines International Network and the International Society for Evidence-Based Health Care are having a joint meeting, joint conference. Why this is so important, I think, is that it presents an opportunity for exchange of ideas about generating, synthesizing and communicating evidence [00:21:30] that can lead to change.
On the one level, that exchange of ideas has never happened in that sort of formal setting before. But I think why it's also important is that some of the organizations primarily work in health. For example, Cochrane focus on health care interventions. But Campbell, for example, they focus on social interventions, behavioral [00:22:00] education, criminal justice issues and others would focus more on downstream clinical educational interventions. GIN focuses on how does one get guidelines into practice.
They're all slightly different but mutually supportive in the sense of trying to get evidence into practice. Because it's multidisciplinary and [00:22:30] because it's intersectoral, I think it can be particularly powerful. We have so far about almost 1,400 people that have registered from 70 different countries. It's also very exciting from just an inclusivity perspective that we have-
Ray Moynihan: It sounds like a movement in the making, the evidence movement. The fact that it's being held in Africa, is that an example of ... [00:23:00] Does that signify to you this kind of growing importance of lower and middle-income countries in the health care landscape, in the health research landscape, in the evidence landscape. There's more and more systematic reviews being produced. I think still only a fraction of them are conducted or focused in lower and middle-income countries, but is this summit significant in changing that [00:23:30] equation?
Jimmy Volmink: Yeah, so you may or may not know, I've been banging the drum for quite a while about addressing inequalities of all kinds probably resulting from my own experience growing up in apartheid South Africa. We've worked very hard at Cochrane in Africa to build networks and to include people from a range of different countries. [00:24:00] We now have a Cochrane African Network that has representation from all the major regions in Africa but that's Cochrane.
Then, there are other people that have also developed quite a strong sort of footprint across Africa. The interest and the capacity for using evidence [00:24:30] and for generating evidence in Africa has certainly grown as you've indicated and I think it's, therefore, really appropriate that we are hosting this joint conference. I should also mention that one of the things that Iain Chalmers did when I first met him and we talked about the Cochrane Centre, he made sure that I would happy to ... Not happy but I would be willing [00:25:00] to host a Cochrane meeting in South Africa.
We've actually, in the year 2000, hosted the first Cochrane Annual Conference but that was Cochrane. Now, we're having this combined and we've never had a combined conference of this nature and I think it's a great honor to be hosting this in Africa. I think that some of these organizations perhaps have never, of the five that I've mentioned, [00:25:30] have never had a major conference in Africa. From that point of view, it's great to be able to bring them to Africa to see for themselves firsthand what's going on and to interact with local people here.
Yeah, I guess the old colonial model is that knowledge from the rich countries need to flow to the poor countries and it's almost the missionary [00:26:00] kind of approach. I think that has started to change. I think the era of global health has raised, I think, to the foreground the importance of an information exchange between countries wherever they are so that often knowledge generated in low and middle-income settings can be extremely valuable [00:26:30] for people.
Ray Moynihan: You talked before about banging the drum about inequality and surely, there's no better thing to bang the drum about. How do you think health evidence can affect that particularly when so much in evidence-based medicine is focused on clinical questions rather than the broader social determinants, the economic determinants of health that you'd be so aware of in South Africa? When you bang the drum about inequality today, what are you thinking about?
Jimmy Volmink: [00:27:00] I guess one looks for every opportunity to highlight inequality and to challenge people to think of how to address them. But let me just refer to somebody called Henry Mintzberg, who you may or may not know, but he's a management guru from, I think, McGill University. He speaks about healthy society. The first thing I want to say is that I think beyond health when I think about inequality [00:27:30] because you can't limit it to health because health and inequality is often a consequence of other types of inequalities. I think you have to think broader than that.
But Henry Mintzberg has talked about healthy society as one in which you have three things. One is a respected public sector, or if you like government. Government is important. Two, a responsible private sector [00:28:00] and then what he calls a robust plural sector, by which I think he means civil society and civil society would include things like universities, NGOs, churches, or other faith-based organizations, et cetera. That all of us have a role to play in producing the society that we want and that is a balancing act so that the plural society often would be the one [00:28:30] to hold the others accountable.
I always remember that and so, I see, for example, the university being a place where we talk about democracy, and we try and instill in our future health practitioners and others who spend time at universities to think about the need to show [00:29:00] leadership in making society better in whatever way they can. We spend a lot of time doing leadership development.
We look at inequities in terms of gender, race, geography, et cetera, my students, academic and other staff and try and address those things deliberately. Then, we're banging on about the importance of mentorship, for [00:29:30] example, both academic and career mentorship because we have made a deliberate decision at Stellenbosch to create greater access for people that have been historically disadvantaged. Many of our students come to university having had very poor schooling, so we need to provide additional support. We invest in that.
Then, I'm personally involved [00:30:00] in an NGO that I help out in a township close to where I live doing youth mentorship. It has nothing to do with health but on a Saturday, I spend several hours working with high school kids just doing everything from just talking to them and being a witness to their lives and being excited about their achievements, to actually providing tuition [00:30:30] and other exposures to cultural and sporting activities and so forth. All of those are just attempts to promote more equality and making the world just a happier place.
Ray Moynihan: How ironic that this is happening at Stellenbosch University with you as dean, given that I think I'm right in saying that Stellenbosch provided the kind of intellectual, moral, philosophical justification for apartheid and was deeply important as a part of the engine [00:31:00] that drove apartheid, was it not?
Jimmy Volmink: Absolutely, that's correct. Now, I think things have swung almost completely the other way. It's very invested in development and creating opportunities for people that had been left out before. I've been here for 13 years and very excited to be here.
Ray Moynihan: Stellenbosch is also very well-known apart from those reasons for its wine. Can I ask you whether you enjoy any of that wine?
Jimmy Volmink: Yes. [00:31:30] I'm a bit of a philistine when it comes to wine but I enjoy a good wine and Stellenbosch definitely is a place for it. I usually rely on my much wiser colleagues, some of whom, my academic colleagues as hobbies, they actually make wine at home. They're that familiar and comfortable with wine. It's a great place. We live now among the vineyards in Stellenbosch and it's [00:32:00] just a great, great place to be, yeah.
Ray Moynihan: Do you get much time to read anything other than systematic reviews?
Jimmy Volmink: Yeah. You have to create time for important things. This is a lesson I've learned perhaps much too late, but if you don't set aside time for things, then some important things may never get done. I do enjoy reading especially outside of my health field. [00:32:30] I enjoy books. I enjoy music and I try to get some exercise.
Ray Moynihan: Thanks for listening to another episode of The Recommended Dose with me, Ray Moynihan, today in conversation with Jimmy Volmink, Dean of Medicine at Stellenbosch University in South Africa. The show is funded by Cochrane Australia. Thanks to Shauna Hurley for production and Jan Muths for editing. If you like our podcasts, please subscribe, rate us or leave a review.
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