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Elmi Muller, MBChB, MMED: Head, Transplantation Service, Groote Schuur Hospital and Professor of Surgery, University of Cape Town, South Africa

Muller, Elmi MBChB, MMED

doi: 10.1097/TP.0000000000001017
In View: People in Transplantation
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What got you into surgery and transplantation?

EM: When I started studying medicine I had no idea what I wanted to do. In the first few years I was often frustrated, feeling that the degree required very little creativity and reasoning and that mostly I had to regurgitate facts for examination purposes. It was only in the clinical years that I started to enjoy the work more, and when I finished my MBChB at the University of Pretoria in 1995, I was convinced that I would do something like medicine or become a GP. I did a housemanship in England where I enjoyed the surgical specialties and was privileged to do what the British call a “Basic Surgical rotation.” This exposed me to a range of surgical subspecialties. When I returned to South Africa in 2001, I was appointed to a registrar position in General Surgery at Groote Schuur Hospital in Cape Town, but my mind was not made up in which direction my career would go. As is often the case, one's career develops in a certain direction because of role models and supportive people. I worked with Professor Del Kahn at the University of Cape Town, and he was such a person. He encouraged me to stay in transplantation and taught me kidney transplants, vascular access, donor surgery and later on liver transplantation. The teamwork in the Transplant Unit at Groote Schuur Hospital was great and people worked together in a positive and constructive environment. It made all the difference to me, so I stayed on, finished my training and in 2004 and joined the faculty thereafter.

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Was there a particularly formative experience in your career?

EM: When I started transplanting human immunodeficiency virus (HIV)-positive individuals with renal failure in Cape Town, I went through a very difficult time at my own institution. I had to justify my decisions and was heavily criticized for transplanting HIV-positive recipients with HIV-positive organs. In many ways I learned to deal with difficult situations during this time. I also had exceptional support from my colleagues worldwide, still close friends to this day; without them I would not have been able to go on. But in the end the best experience was when one of my very early HIV-positive transplanted patients came to clinic one day with her young boy and introduced him to me. He was the same age as my youngest son and I realized what an impact his mother's transplant had had. Even if I could just do this for one patient, this was enough for me.

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What would you consider the most pressing problem of transplantation in South Africa?

EM: South Africa is an amazing country: in the last 20 years we went through major transitions (which are still continuing) and we have managed to avert the devastation of a full-scale conflict. All of this was based largely on remarkable qualities of ordinary people persevering despite political resistance. South Africans live by Ubuntu—a Zulu word that is often translated as “humanity toward others,” but is also used in a more philosophical sense to mean "the belief in a universal bond of sharing, that connects all humanity.” This means we place deep value in people and relationships, and hence, I think, we have managed to stave off disaster for the time being. Unfortunately, the socioeconomic imbalance of the country has not really changed for many who are still living without running water, sanitation and education. Although this problem is politically recognized, progress has been far too slow. To drive transplantation in a country with many unmet needs is a challenge. I do believe that South Africa must continue to build on the very advanced medical therapies that are available in the country, and transplantation is one of them. We should aim to have these treatment modalities available to every single person in South Africa. But because basic medical care (understandably) has to be prioritized, there are very limited resources to improve things like deceased donation in the country. We are understaffed, for instance. To give an example: In the whole of South Africa, with its population of 53 million people, we only have 20 transplant coordinators.

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What recommendations do you have for young clinicians and scientists going into surgery and transplantation?

EM: Things changed for me professionally when I started to pursue the issues and projects close to my heart. It takes time to find the right field of interest and to develop it into something special, so be patient and probe towards that discovery. As long as you work for somebody else and with someone else's ideas, it is difficult to have the necessary drive and commitment to do the work. However, when you own your professional life, your work, your vision and your dream, things change dramatically. I also think it is important to be a complete person—to do the things you love and cherish and to spend time on them. I have a family, and I do spend a lot of time with them. As human beings, we are nourished by so much; one has to be careful not to impoverish one's humanness by restricting it to a profession.

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What advice would you have for female clinicians-scientists in transplantation?

EM: I think it is possible to have it all: a family, children (if you want this), and a career. I see a lot of women who try to be like their male colleagues with very defined gender and normative identities, who basically try to “fit in.” In my opinion, we rather need to bring our own gender sensibility, distinctiveness, and individual perspectives to the workplace. Importantly, I think that this approach applies for both men and women. What can be difficult in the work environment is that traditionally many social events are planned around male interests, and of course a lot of networking and discussion takes place at these meetings. So on a lighter note, I believe it is necessary to liberate those male colleagues who dread the annual golf day and would love to come to the cooking course instead, while always understanding that there would be women who would prefer a round of golf over making a chocolate ganache. More seriously, I think we should not postpone our personal lives to have a career. We should rather make them work in tandem and try to change attitudes at work so that work is an aspect of being fully human—a kind of 21st century professional holism, if you will. To a certain extent this is changing already, but if we do not continue to push, the process will be much slower. I believe that the key to change is to treat men and women equally. One example: when there is a new baby in the house, the father should be entitled to just as much paternity leave as the mother. My husband did a lot for our children from the day they were born, and it meant that today my children are very close to him. When we have equal rights for mothers and fathers, employers will stop considering pregnancy or maternity leave when they interview future employees.

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How would you advise a resident who is looking for recommendations to combine clinical and research training?

EM: It is so important to do research early on in your career. In Cape Town we are integrating undergraduate students into research projects from a very early stage, and I think it shapes your way of thinking for the rest of your life. In South Africa the clinical workload is enormous—mainly based on staffing issues—and because there is always pressure to get clinical work done, many doctors do not have time for research. One has to make time for research, as this is rarely the first priority for clinicians, especially in the developing world. Flexibility and protected time to do research would greatly help. If I were to start my career now, I would search for a topic that interested me at a very early stage and work towards getting a job that allows me to spend time on this.

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What do you think will be the most relevant developments in the field in the future?

EM: I recently read Kazuo Ishiguro's Never Let Me Go. I sincerely hope this is not where we are going: a future in which people become cloned commodities for spare parts. I see a future with major developments on a cellular level, so that we will be able to culture islet cells and transplant them to cure type I diabetes, for example. I also hope the field of immunosuppression will change with some of the important work that is being done to recreate a tolerant environment for transplanted grafts.

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The first cardiac transplantation performed at the groote schuur hospital had been a historic event. How did this event impact transplantation in South Africa?

EM: In South Africa, people are very proud of Chris Barnard's achievement. I know this historic event was quite controversial elsewhere, as Barnard spent a lot of time in the United States where people were already working on this problem. I think South Africans (rightly) admire the fact that he could come back to an environment where medicine was not as far developed and build up the necessary infrastructure in a short time to do this procedure. Because of Barnard's work and the worldwide attention it received in the decades after the procedure, I think South Africans are more aware of transplantation compared to people in other developing countries. Unfortunately, Barnard did not establish any academic legacy at Groote Schuur Hospital. Given the extent of Barnard's achievement and subsequent fame, it is remarkable that there is no research chair in transplantation at Groote Schuur Hospital, or a dedicated laboratory doing expert work in the field. In a sense the legacy of that historic event is less an academic one, than the sort of legacy that one might connect with a celebrity or a film star.

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What excites you outside of your clinical and research interest?

EM: I think of myself as a creative person. I used to play piano and organ, but now I have very little time for this. I am fortunate to have a husband who works in musicology and through him I get exposed to wonderful people who have careers in the arts and humanities. I enjoy cooking, and I love to try out new recipes and invite people over for dinner. My boys are now 17 and 11 years old, which means I am also getting constant exposure to young and new ideas, to technology, and to different ways of thinking. This is a wonderful time of my life, and I enjoy it everyday!

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