Professor Bruce Biccard is the recently appointed Nuffield Professor of Anaesthetic Science, which is one of the major statutory chairs in NDCN. Lord Nuffield, who endowed all the Nuffield chairs, wanted anaesthetics to be represented as a specialty in Oxford and it has a distinguished history of innovation and development in the field. The post was previously held by now Vice-Chancellor, Irene Tracey.
Kevin: Bruce, welcome. Tell us a little bit about your previous role?
Bruce: Before this, I was at the University of Cape Town, I was the second chair there. It’s a very different department to this, in that the leadership of that department spans the clinical service and academic service. Being in a middle-income country, the vision is a bit different, they provide services with limited resources. For someone who’s really interested in academics and clinical research it’s not the sort of place where you want to lead a department, because you’ll just be overwhelmed with providing the clinical service and not really having the space to do the clinical research that you’d want to do.
Kevin: So why don't we go back to your childhood. Tell us what it was like to grow up in Cape Town?
Bruce: I was born in 1969, which means I started school in 1976, which in South Africa, in apartheid history, is a terrible year. I lived, I suppose, in a bit of a cocoon, and I only really became aware of what was going on in South Africa when I started university. At that time, Cape Town was known as ‘Moscow on the hill’. I did medicine there, and the only thing I knew at the end of doing medicine was that I would never be an anaesthetist. I always wanted to be a general practitioner in a South African environment where you do everything.
Kevin: You touched on apartheid. Did that shape your thinking as a medical student?
Bruce: It did. It's a big topic. My wife and I say we are both socialists, we always wanted to be in South Africa. Being here has never been an intention. It was more of an accident. I never expected to be eligible for this job. Then when I was shortlisted, my wife and I felt that the only reason we would come here was if we could further the work we do in Africa. I was asked to speak about my vision at the interview, and I basically spoke about global health, and if the University's not interested in that, then this is not the place for me, but there seems to be interest.
Kevin: Was your interest in global health seeded by your experience as a student?
Bruce: As a young person I read the book Cry, the Beloved Country - a 1948 novel by South African writer Alan Paton set in the prelude to apartheid which I’m actually rereading now. Then later on I met my wife, who is from where it’s set, and then actually understanding the geography and the culture of that area also makes it more powerful for me.
Kevin: Why did you want to do medicine in the first place?
Bruce: It was that typical thing, when you are really young, if you did well at school, you did medicine or law, or otherwise you did engineering, it was almost sort of an expectation. If I had chosen or I had more insight at the time, I probably would have ended up in something more mathematical. But the reality is, through the course of my career, I found the space that I feel really comfortable and passionate about and I think that's the amazing thing about medicine: it's so broad.
Kevin: We probably both have the experiences of going to medical school and there's the array of different personality types that you are confronted with, but they all find a home. Sometimes it's journalism, or law, but it can accommodate people who have got rather different ways of looking at the world, which is wonderful. What drew you into anaesthetics?
Bruce: When I started I had this vision: I'll be this great doctor who can do a caesarean section in the morning and do something else in the afternoon. hen I just realised, wow, that's brutally hard, the scope of work is massive. When doing my internship, we had to do, I think, 40 anaesthetics or something. I really enjoyed giving anaesthetics, and I worked in a very small hospital. The whole hospital used to meet for tea at 11 o'clock, it was beautiful. They knew I’d enjoyed it, so when I did my surgical rotation they allowed me to just to do anaesthetics. I wasn't really too excited about the surgery, and that's how it started.
Kevin: At what point did you say to yourself, actually, I need to do some research?
Bruce: When I finished my register time, I really enjoyed the academic side, and at that time there was quite a big movement with beta blockers and improving cardiovascular outcomes, and it was quite powerful. Professor Pierre Foëx was the Nuffield Professor at the time here, was very big in that field, and so was John Sear. I applied for a Rhodes scholarship and in that application I got to know Pierre, and I said, ‘this is what I'm interested in’. I didn't get the Rhodes scholarship, but I did come over here to work with Pierre and John, which was amazing. They were incredible mentors, and they set me on my way. At that time, my whole world was just cardiovascular research. When you’re back in South Africa, you realise that all the surgical outcomes are bad. I then went from cardiovascular into general outcomes, which was even more distressing.
Kevin: You've written a book about this, which I think really vividly portrays the differences in environment. Does your research simply point to economic factors as driving differences in perioperative mortality or is it more complicated than that?
Bruce: It’s much more complicated unfortunately. We've been doing lean research across Africa, by clinician investigators. We found that if you're an adult and you have surgery in Africa, you're twice as likely to die than if you had surgery anywhere else in the world. There's this big signal that a patient has surgery, that they go to the ward and they die, which is known as a failure to rescue: that is they develop a complication, and then they die. And we thought, oh, this is really simple. All you have to do is you just flag these patients, put all your attention on them, and you'll increase survival and decrease 'failure to rescue'. So, we did this massive randomized controlled trial across Africa, which was unfunded. Nearly 30,000 patients in 28 countries, trying to focus on the sick patients and just provided increased post-op surveillance. We worked so hard and there was zero difference. Twice as many patients continued to die. Fortunately, we had done a process evaluation with the trial, which looked at what was actually going on. It was all the things that we spend no time thinking about in our profession that was killing the patients. It was teamwork, resources, those sorts of things, and I think that's what led to the book. It's the things we are never taught, and now we've gone right back full circle, and all the work is going to be focused on these factors. So, the confidential inquiries into maternal death, the national audit projects, such as cardiac arrests done here in the NHS and other things, are models we’re going to take and do it for perioperative death in Africa.
Kevin: The Department probably doesn't have a very big history of global health, but I think with your arrival and other things that are going like Arjune Sen’s Centre for Global Epilepsy, we are definitely now starting to build that. What advice would you give people, doing all sorts of neuroscience and other research, about how to make their research global, why they should or how they can do that?
Bruce: Firstly, I think it's hugely important. By the end of this century, 80% of the population is going to be based in African and Asia. High-income countries, numerically, will have become totally unimportant. It's not something you can ignore because it's going to become more and more relevant in our lives.
Secondly, we’re quite lucky because we’re all in a caring profession and that's why we’re here, so we do care about these things. The biggest burden of disease lies in low- and middle-income countries.
The third thing I think is, from a research perspective, it helps you focus your mind on priorities. You can have a parsimonious model for something which might be five or six risk factors, or you could have this very complex model for something, which might be 100 risk factors, but the reality is the biggest impact are in those five or six. When you're doing really cutting-edge research like most of you are doing, you mustn't lose sight of the impact those few things can make on a global health perspective. In a global health environment, it really is possible to test those big factors. We've got a massive network across Africa, which is managed very respectfully, and it is an opportunity for all of us here to maybe do some impactful global health research in that environment.