A life spent in service of better health for all South Africans has led to Jimmy Volmink’s unexpected position as Dean of the School of Medicine and Health Sciences at Stellenbosch University.
Professor Jimmy Volmink of Stellenbosch University will receive an honorary doctorate from KU Leuven, but what merits the honour? Consider that Professor Volmink is one of the foremost proponents of evidence- based medicine, and has argued passionately that people at all levels of society must make medical decisions based on good-quality evidence, not on any preconceived notions. So it is only appropriate that we put his own candidacy to the test, gathering our evidence from a life spent in medicine, social outreach, and education. Only then can we draw our conclusion based on an honest appraisal of that evidence. Professor Volmink would expect nothing less.
Professor Volmink’s rise has been long and remarkable, from his start as a family doctor in Khayelitsha township in Cape Town to his current position as dean of the medical school at Stellenbosch University. As a practicing doctor he helped to fight epidemics amongst the poorest and most at risk, particularly amongst those suffering from TB and HIV/AIDS. Professor Volmink’s influence is perhaps most strongly felt in the systematic improvement of medical access for disadvantaged students across all of South Africa. This holds especially true in his current role, where his status as first Black dean in the medical school’s history has helped him institute change on both a practical and symbolic level. In Professor Volmink’s own estimation, “My career has been defined by three Es: Education over ignorance. Evidence over dogma and myth. Equity over social injustice.” In all of these efforts, Professor Volmink has succeeded almost beyond measure.
This is strong evidence, a good indication that KU Leuven has found the right individual for the honour. But to be fair to the very concept of evidence- based medicine, we must thoroughly examine each of the arguments for his nomination in turn. Doing so will give us sufficient evidence to understand Professor Volmink’s work, to better understand the man himself, and to see the full extent of the long path that has seen him do so much good for so many in South Africa
My career has been defined by three Es: Education over ignorance. Evidence over dogma and myth. Equity over social injustice.
Evidence-based medicine (EBM) is an interesting specialty, in that in a perfect world it wouldn’t exist. All of our medicine would be based on strong, clear evidence grounded in unbiased clinical trials and best practices.
But we don’t live in that world. We live in a world of biases and blind spots. According to Professor Volmink, “EBM sounds rational, but it’s a dangerous idea to think that people base their ideas on the best evidence. Sometimes they do, sometimes they do not.” This is the fight Jimmy joined whilst a doctoral student at Oxford University, and it is a fight he brought to South Africa as the founding director of Cochrane South Africa, part of a network of Cochrane centres that spread the message of EBM around the world.
EBM faces many obstacles to its acceptance. Part of the problem is that money influences politics, and politics influences medical outcomes: “The first big challenge that we had was fighting our own government, which was promoting unproven treatments for people with HIV/AIDS. They came to us and the minister said, ‘We want you to look at the evidence and show us that these drugs are toxic and they cause more harm than good.’ We said we couldn’t do that, but we would look at the evidence carefully and we’ll give you whatever the answer is, whether it’s what you want to hear or not.” In the end, Cochrane refuted the government’s position; a win for EBM, but politically risky for the nascent Cochrane South Africa. As Professor Volmink notes, “When policy makers want to go in a particular direction, they are very quick to embrace evidence in support of that direction, but if the evidence goes the other way, they will find reasons why that evidence cannot be believed.”
Evidence-based medicine sounds rational, but it’s a dangerous idea to think that people base their ideas on the best evidence. Sometimes they do, sometimes they do not.
There are many other drivers of biased medicine besides politics, including myth, folk wisdom and ideology. The dictates of traditional medicine in South Africa can be difficult to overturn should those treatments prove ineffective or harmful, a difficulty seen throughout the HIV/AIDS crisis. Influences on a scale as small as personal hubris can also be involved, such as when laboratory scientists extrapolate that successful tests in lab animals will work in humans without undertaking the rigorous clinical trials necessary to prove their efficacy.
The coronavirus pandemic has created an opportunity for Professor Volmink to highlight EBM in practice, and to gauge the South African response. Much of the early course of the pandemic was rife with uncertainty, including well-intentioned measures that nonetheless would not, or could not, halt the spread of the virus. Professor Volmink sees a pressing need for EBM in this sort of situation: “EBM means basing your clinical practice or policy decisions on the best available evidence, but you have to have the evidence upon which to make those decisions. With corona-virus it’s been hard. EBM requires a degree of rationality and calm to find the relevant evidence and see if the evidence is biased. But you can’t go with just one study, you have to synthesise all studies to see what the evidence says. It’s been a very difficult time for people practicing evidence-based medicine because things are wild at the moment.”
With this in mind, Professor Volmink has been relatively happy with the South African response to the coronavirus. The government has years of experience dealing with epidemics, such as TB or HIV/AIDS, and this experience has lent a sort of institutional expertise to its coronavirus effort: “The leadership at the top of government has been active in explaining the measures needed to pull through, to develop good social cohesion … we have a majority Black government now, so people will listen.” The widespread acceptance of EBM is far from a certainty. It is an ongoing proposition, one that must be actively pursued by strong advocates. Thanks to the effort of Professor Volmink, it is well on its way to having a meaningful, lasting future in South Africa.
Helping the most disadvantaged
Professor Volmink’s career is also characterised by his efforts to help those who have suffered from a lack of access to quality healthcare. Much of this lack of access stems from the social and economic inequalities that remain as painful leftovers of apartheid. For Professor Volmink, this means that good health must be created outside of the realm of healthcare: “The main drivers of health are social and economic. If you don’t start there, then all you’re doing is patching people up and sending them back into very difficult circumstances.”
Professor Volmink’s efforts to deliver healthcare to the most disadvantaged has taken many forms. He is a member of several international organisations, such as the International Red Cross – Flanders, where he is a member of the Scientific Advisory Board. But his efforts are not reserved for grand international organisations; a regular weekend activity for Professor Volmink is to return to Khayelitsha township with current students from the medical school at Stellenbosch. This personal, active role in the health of most disadvantaged citizens has been a hallmark of Professor Volmink’s entire career.
Professor Volmink holds out hope that better health-care can become a reality in South Africa. The South African government has improved access to primary healthcare across the country, but the quality of that healthcare is not yet always where it needs to be: “Most people who have good specialist care in South Africa need to get it from the private sector, and yet 80% of people depend on state services for their healthcare.”
A new Stellenbosch
Professor Volmink has brought his fight for improved healthcare to the field of education, serving as Dean of the School of Medicine and Health Science at Stellenbosch University for the past 10 years. Stellenbosch is infamous as the intellectual home to the apartheid regime, a symbol of White, and especially Boer, supremacy. In the 1980s, Professor Volmink himself was denied admittance to Stellenbosch because he was Black: “As a university and town, Stellenbosch has much to answer for in terms of its history with apartheid.” Yet so much has changed at Stellenbosch in the 21st century. The university is opening itself to the larger world, and much as he has shepherded the spread of EBM and community health in South Africa, Professor Volmink is helping to guide this institutional change. Stellenbosch is fair game for the South African tradition of open reckoning with the historical involvement with apartheid: “Stellenbosch drove an agenda that favoured white Afrikaners, with the university created as a counterpoint to the White English and Jewish communities in power before the Nationalist Party took over, seeking to alleviate White Afrikaner poverty.” The curious outcome is that Stellenbosch’s racist past created a track record of success in achieving its development goals: “While they were in power, [the Boers] did uplift that group of people to become some of the most affluent people in the world, but it was at the expense of the majority of the population. In a way, Stellenbosch has created some-thing that can be replicated for the whole population, and not just for an exclusive group.”
Although hailing from nearby Cape Town, it was difficult for Professor Volmink to join the faculty of a university so intrinsically tied to such a traumatic period in South Africa’s history: “I thought, ‘How could I possibly join an institution that invented apartheid? This doesn’t seem right, I should avoid this like the plague.’ And there are still many people of colour in South Africa who would not go near Stellenbosch because they still have in their minds that perception that I had.” Nevertheless, Professor Volmink found a home at the university and the opportunity to facilitate change: “Things are not what they used to be, things have shifted, but people’s perceptions take much longer to shift. I’m hoping that we could become a catalyst for more unity in the country, for working together to address issues of social injustice and inequity I think there is an energy there, a serious ness there, a genuineness there. I’m not saying there are no pockets of conservatism that want to go back to the past, but they are a minority, and there’s a much larger group of people who are much more forward-looking and wanting change.”
Professor Volmink was set to finish his second term as Dean at the end of 2020, but he is staying on for another year to help guide the school’s medical programme during the coronavirus pandemic. He is using this time to create a curriculum that teaches skills and critical thinking, but also a sense of perspective in his students: “Our students come here and stay for years, and it’s a chance to help people to become better citizens. Our students should learn what the social, political and economic challenges are in South Africa that impact our health, our social cohesion, our ability to work together. This is an opportunity for people to learn how to live together with people who are different from them.”
In furtherance of this aim, Professor Volmink established the Department of Global Health within the medical school. The intention is to redefine global health to better address health issues outside of developing nations: “Global health is that branch of healthcare that focuses on problems of inequity, problems of injustice and how that impacts health. Often there are transnational forces that exert pressure and that promote ill health, whether you’re talking about the food industry, big tobacco, even when you’re talking about the pharmaceutical industry, alcohol, etc. These are things that cannot be dealt with in one country only, you have to have a global focus when dealing with these things.”
I think there is a commitment and a genuineness in terms of wanting to work for a better country at Stellenbosch that I find quite refreshing.
Stellenbosch is now a global university. The Afrikaans language remains a language of instruction, but the university has embraced a dual- language curriculum, its language policy driven by the needs of its students, not political dictate. Every year the students are surveyed as to what language they’d like to be taught in, and nowadays they largely say English, both to travel overseas to study and work, but also because there are more students coming in whose first language is something other than English or Afrikaans.
In the long run, this diversity and flexibility will help Stellenbosch serve South Africa: “I never thought in my wildest dreams that I would end up at Stellenbosch, but I believe it was one of the best decisions of my career. I’m not going to argue that Stellenbosch is where it should be, but I think that there have been huge shifts at Stellenbosch, and I think there is a commitment and a genuineness in terms of wanting to work for a better country at Stellenbosch that I find quite refreshing. So I think we need to take the best that Stellenbosch has to offer, and we need to take that into a bigger arena, and I think we could see some really interesting things happening in South Africa.” Though he has only one year left as Dean, Professor Volmink has made that expansion possible.
In the final analysis, does this evidence of a long and fascinating career merit Professor Jimmy Volmink an honorary degree from KU Leuven?
Of course it does. Sometimes the evidence is crystal clear.