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Angelita Habr-Gama: Victory in a mine field

The surgeon Angelita Habr-Gama, a pioneer on many fronts, talks about the development and progress of coloproctology in Brazil

MIGUEL BOYAYANThe medical doctor Angelita Habr-Gama has three personality traits common to successful professionals: perseverance, a huge capacity for work and contagious optimism. Together with these qualities is an enormous talent in her specialty, surgery of the digestive tract, which is sufficient to separate out professor Angelita from the role of the highly successful person and place her in a higher ranking, among those who make history. In order to reach such a height it was necessary for her to do something daring: she was the first women resident in general surgery at the Hospital das Clinicas of the Medical School of the University of São Paulo (FMUSP) in 1958, at a time when this was an exclusive redoubt of men. This pioneering fact was only the first of many. She was also the first woman to train in this medical specialty at the conservative and traditional Saint Mark’s Hospital, in the United Kingdom in 1961, the first full  professor in surgery at the Gastroenterology Department (FMUSP) and the person responsible for making coloproctology a discipline in itself, during 1995, instead of leaving it as a sub-specialty of surgeries of the digestive system.

Angelita improved surgical techniques and was important in the structuring, development and advance of coloproctology in Brazil. For example, it was her who organized the first practical and theoretical course in colonoscopy, the examination of the inside of the colon. She does not forget about the clinical practice that she runs with her husband, the surgeon Joaquim José Gama Rodrigues, a full professor of surgery at the FMUSP, to whom she has been married since 1964. She also keeps her finger on the pulse of research. And participated in the first stages of the Genome Projects – her laboratory worked on the sequencing of the Xylella fastidiosa bacterium and she continues working within the Human Cancer Genome Program. Over the last few years she has given special emphasis to the prevention of cancer of the intestine. She has even founded an organization to this end, the Brazilian Association for the Prevention of Intestine Cancer, which sponsors events throughout Brazil.

The daughter of Lebanese immigrants, born on the island of Marajó, in state of Pará, during April of this year the surgeon received her most recent honor in Zurich, Switzerland. She was the first Latin American specialist and the first woman to be awarded the title of honorary membership of the European Surgical Association for her medical career, an award only given out until today to 17 doctors in the world.  Angelita attributed a good part of the repercussions of her work to the feminine condition. “Even today it causes strangeness for a woman to have been so successful in a specialty dominated by men”, she stated.

What led you to choose surgery at a time when few women were taking a medical course and practically none of them had opted for this specialty?
I looked over various sectors of medical science and my initial choice was that of clinical practice. I began the internship training at the Medical School where the students pass through various specialties. It’s important to see different types of illnesses, of sick patients, of doctors and professors. The student is going to feel which is their true vocation within medicine. Everything has an influence since up until the fifth year he or she doesn’t know exactly what they wants to do, if it’s pediatrics, dermatology, orthopedics. When I had a lesson in surgical technique I didn’t interest myself very much. I had thought that I was never going to be a surgeon because at that time this was not a specialty for women. It was clinical practice or gynecology, at the maximum. At that time the students were allowed to undergo training at the Maternity Home of São Paulo. I went there as an academic and began in obstetrics. However, I went into an operating theater and they gave me a needle to close up an abdominal wall. At that moment I felt that the act of operating was natural for me.

As simple as that?
It was. Immediately I felt that I could develop within this sphere because I have a practical, combative spirit. The results of treatment at that era were somewhat precarious. In cardiology the medicines that existed at that moment in time were few, mainly digitoxin. The cardiology patients evolved poorly, they lived with a lack of air. In gastro-clinical practice the illnesses were of long duration, and weren’t resolved easily. I have a surgical temperament, which likes to treat and to see the result. You see a sick patient, you operate on him and, in general, he becomes well again. It’s something fantastic.

You were born on the island of Marajó, in the state of Pará, and came to São Paulo at seven years of age. Was it difficult to manage to get into the FMUSP?
I had studied something there, but I knew hardly anything. In São Paulo I only studied at public schools, which were exceptional at that period. When I had the science courses [a course from that period given in parallel with classics, currently  high school], I was without direction. I knew that I had the facility to study and that my vocation would be in the area of biology. I ended up being influenced by my volleyball group. Coincidently, those people wanted to study medicine because they had a doctor in their family. I didn’t know any doctors, my parents were Lebanese immigrants with limited means. I was a nobody in life. But this was not a problem as I was optimistic. A surgeon needs to be an optimist. I never say to someone who’s ill that he’s doing badly, this is bad. I believe that everything will be fine. I do everything possible for things to be fine and I always believe that it’s going to be.

Sometimes it doesn’t work out.
Truly, at times it doesn’t go well. We live with reality, very often distressing, in which the doctor needs to be optimistic.

I imagine that your spirit had contributed to you yourself confronting some adverse situations within the university.
Many. When I went to college I had only one colleague who was a specialist in plastic surgery, but she moved to the interior and I have never had any news of her. In college, and after as a qualified surgeon, I had a non-stop drive, I had worked vigorously. In order to demonstrate that I had the capacity of coming out on top as a surgeon I always worked more that the average of those who had worked well. I keep myself among the best in my sector because I continue working a lot. This was not easy here in Brazil and was even more difficult abroad. In England, the Saint Mark’s Hospital took two years to accept me in 1961. They said to me that it was a hospital for men. But I managed to convince them and was the first woman trainee there. They had not been accustomed, and I was going to break all of the tradition at Saint Mark’s. I remember very well, during the lunch hour, all of the assistants would sit down and the oldest was the one who served the meal. They had called me “big mother”, or that is, pretend that she is our mother and serve us. The hospital was very famous and very, very conventional. All at once I, a woman, a surgeon, had arrived and there was not even a changing room to change my clothes. Indeed, this also happened in Brazil.

And what did you do?
I used the nurses’ changing room. They quickly came around to accepting me, becoming my friends and clients. Little by little I managed to reverse the situation. The sick patients had looked at me and had asked “where’s the doctor?” Years later, when I went to the meetings of the American College of Surgeons, or to that in Europe, I was the only woman. Today no, it’s full of them.

You yourself occupied leadership posts for many years. There have always been female doctors and researchers of an excellent level who have had difficulties in reaching management positions. Is there a prospect of change?
Little by little this situation is being changed. At the Medical School there are various female full professors. There is one in infectious illnesses, one in rheumatology and another in endocrinology. This is something recent, perhaps five or ten years at the most. This was a men’s world, at the Faculty Congregation there were no women. I was the first head of the Gastroenterology Department, before becoming a full professor, and I was the first full professor within a surgical career. It has to be said that the Faculty also always had another problem: there is enormous competitiveness to becoming a full professor, when there should be a larger number of places for incumbents. During my acceptance speech in front of the Congregation, I pleaded that the title of full professor must be open. The associate professor who is producing, teaching, lecturing, should have the right to compete for the position of full professor and not wait for someone to die or to retire. To reach the end of a career is still an exceptional fact, and the good quality of the staff doesn’t come into play. I completed my doctoral degree in 1966, associate professorship in 1972 and I became an full professor in 1998. Can you see the gap? And I already had prestige, everybody knew that I had the conditions needed to become a full professor. But there was no opening. It should be possible to attain the final position through merit and not to eternally wait for openings.

Is there a possibility of this taking place?
I believe so, because there are already some departments with a higher number of places for full professors. It’s the tendency of the university, in countries such as ours, to facilitate the progress of a career. Don’t confuse this with cheapening the career. Those that are of value must be allowed to reach the high point of a career. My success, in the professional life, as well as in the societies to which I belong, wasn’t because I’m a full professor, but because I worked my entire life. I taught many residents, post graduate students, trainees from all over Latin America. Many of the doctors who have helped to change coloproctology in Latin America did their traineeship with me. Also, I research and write scientific papers. Over the last few years perhaps I’ve acquired greater prestige because of the pioneering work that I began in 1991 about rectum cancer.

What exactly are you talking about?
I dedicated much of my professional life to rectum cancer. My 1972 thesis, for becoming an associate professor, was already about a technique for the conservation of the anus with rectum cancer. At that time it was rare to do this type of operation. I had believed that many patients who had this type of cancer didn’t have to carry out a definite colostomy, after the removal of all of the rectum, anus and sphincters. I avoid a colostomy to the maximum.

Why was the work with this type of cancer pioneering?
In 1974 a North American surgeon, Norman D. Nigro, introduced the concept that cancer of the anus could be treated, from the beginning, with a program that combined radioactive medicines and chemotherapies. In a good number of the cases the tumor disappeared and there was no need to operate. So I thought: if it’s possible to cure cancer of the anus, why not that of the lower rectum? We began to treat the illness with radio-chemotherapy before surgery. And differently from the practice of other surgeons, I went on to not operate immediately when the tumor disappeared. Other doctors, in Europe, North and South America, always suggested surgery after treatment, even when there had been total regression of the tumor. I didn’t. I have case histories [the detailed registration of clinical cases] that include 360 patients with cancer of the lower rectum. The rectum is 15 centimeters. When the cancer is in the upper rectum, in general, it’s not necessary to carry out radiochemotherapy. We operate immediately. Now when the cancer is very close to the sphincter, in order to cure the illness, if we don’t apply radio-chemotherapy, we have to amputate the rectum and the sphincters and carry out a definite colostomy. When one carries out radio-chemotherapy in around 25% to 39% of the cases the tumor disappears.

Without operating?
Without operating. In the case of cancer of the anus, 70% disappear; for the lower rectum it’s 30%. I operated on some of these patients with complete regression and in the surgical part removed there was no tumor. Thus I decided: I’m no longer going to operate on the patient if there’s no tumor. How does one know if the tumor has disappeared? We examine by touch and endoscopy in an evaluation made eight weeks after the treatment and we carry out a CAT scan. As the patient as well doesn’t want the amputation of their rectum, we create a partnership: the patient and I. Afterwards, I follow these patients very closely. They always come back to consult because they know that I only operate when a residual lesion remains after the treatment. I make it clear that the tumor could return and be even worse. I warn them: “If it comes back we have to operate”. From a group of 360 patients, I have 99 patients on whom I didn’t operate and I’m still checking. Clearly there were various relapses, the patients were operated and some had to have a colostomy. In the 260 patients for whom the tumor didn’t disappear, but diminished a lot after radio-chemotherapy, very often instead of amputating the rectum, we carried out surgery for sphincter conservation, protecting the suture with a temporary stoma [an opening surgically made into the abdomen]. When I began to present out work, starting from 1991, I encountered difficulties in its acceptance.

There was lots of resistance on the part of doctors, who believed that not operating immediately wasn’t ethical because the tumor could return. I had argued the following: what is ethical for the sick patient? Would it be ethical to operate on the patient who clinically didn’t have a tumor, to carry out a definite colostomy and on the surgical part removed not to find a tumor? Our team clearly spoke with the patient and explained: “My friend, today the tumor has disappeared, but at any moment it may return. If this doesn’t happen, we’re satisfied and you as well. But, if it returns, we will have to operate”. We have already operated many because of a relapse, but in the vast majority the tumor didn’t return. Now our work concerning this strategy of treatment has been published in top class magazines. In countries such as the United States it’s different, the surgeons don’t have the same type of relationship with their patients as we have here. As well as this, the medical processes are very frequent.

Was this an important contribution for your area?
It was, in my opinion, a good contribution to demonstrate that some cancer illnesses of the lower rectum, with an initial indication for carrying out a colostomy, can be saved from an operation when they are submitted to radio-chemotherapy. Not all of them, but a minority. But that’s not important. The patient who was not operated gained a lot with this. We’re continuing with research in this area. More recently we’ve increases the radio-chemotherapy dosage and obtained a higher percentage of complete response, that is, of tumor regression.

Where is the work being done?
At the Hospital das Clinicas. Today radio-chemotherapy for cancer of the lower rectum is consensual. Our work pattern of not operating, is what is not consensually accepted, not even here in Brazil. This is reserved for research centers. Because, clearly, if the service of specialized radio-chemotherapy was not available and if the doctor responsible for the treatment didn’t follow up the patient rigorously, a major problem could occur.

You yourself are also working in such a way as to rebuild the sphincter, is that not so?
I was always enthusiastic about the conservation of the sphincter’s function. My professorship thesis dealt with this. I’ve already made use of all of the described techniques and improved some of them. But it’s rare to carry out something really new. As to fecal incontinence, there are people with congenital defects, others who have damages from childbirth of from traumas etc. At the HC we’re conducting research into an implant of an artificial sphincter. This is a simple system: it consists of a tape that goes around the anal canal and of a receptor in the scrotum or in the inside of the vagina, and of a pump implanted in the pubic region. The device functions as a system of communicating tubes and the individual himself manipulates it when he needs to go to the bathroom.

What is the material made of?
Of silicon. But it’s expensive and we only managed to carry out the research because we had the support of FAPESP. Currently it costs around US$ 7,000. There’s also another technique for restoring incontinence, which is called neuro-stimulation. This is a system that makes use of a pace maker. For the person who suffers from incontinence and doesn’t have a serious sphincter lesion, it works very well. We have implanted two at the HC because the company that produces the suture offered them to us. However, abroad the experience in this area is accumulating. FAPESP is the major sponsor for our research.

Didn’t you participate in the Human Genome Cancer Project?
I participated in the genome projects right from the very first of them, which was that of the Xylella fastidiosa bacterium. I went in together with José Eduardo Krieger, from cardiology. Afterwards FAPESP initiated the Humane Genome Cancer Project, in which we also participated together with the other groups from Gastroenterology at the HC-FMUSP. We collected material from 450 parts of tumors of the intestine. I believe there’s nobody who has more of this material in the world. We’re waiting for the on going sponsorship by FAPESP for the evaluation of genes.

How much does genetics play in the evolution of an intestine tumor?
A considerable amount. Today we know that, firstly, all cancer has a genetic origin, but colon cancer has a very strong genetic influence. Since 1976, I’ve belonged to a cancer prevention group that acts in the United States. This provided enthusiasm for me for our work here in Brazil. In May of 2004, our group established in partnership with various associations that deal with digestive cancer, the Brazilian Association for the Prevention of Intestine Cancer, namely Abrapreci. We redesigned the educational material for distribution and we built a model reproducing a 30 meter intestine. In the inside of the model pathologies such as hemorrhoids, polyps, diverticulums and cancer were represented. We put the gigantic intestine on show during an international conference in Recife and various North American and European colleagues responsible for the cancer prevention programs were present and visited the gigantic intestine. They liked it so much that they asked the association to take it to Montreal, in Canada, during last year’s world congress on gastroenterology. During the month the model circulated through various Canadian cities.

Who came up with this idea?
I had seen a small model in the United States. And here there were young people with excellent idea. We made the first model and then the second, larger, some 30 meters, dismountable, in order to facilitate transportation. We’ve already taken it to Rio de Janeiro, Maceió, Goiânia, Belo Horizonte, Vitória, São José dos Campos, São Bernardo do Campo and Fortaleza. This action of drawing attention to the problem is important because, if there is a cancer whose prevention can be emphasized, then it’s intestine cancer.

In the other types of cancer, breast, lung, pancreas, for example, when a prevention campaign takes place in reality what is done is a precocious diagnosis. For example, in the case of a campaign against breast cancer, when the mammography is carried out a tumor can be detected. If it were to be very small, it can be treated well. In intestine cancer, when one does a preventative colonoscopy and a polyp is detected, it’s enough to remove it to prevent the cancer. Differently from breast and lung cancer, it’s known that the intestine begins with a small benign lesion, which is the polyp. And it’s so friendly that it takes 10 to 12 years to grow and become a tumor. It’s highly curable. The bad part of the story is that the incidence of intestine cancer is increasing throughout the entire world.

How can one know if a polypus exists, if there are no symptoms?
Anyone’s  50 years of age and has not had any previous case in the family should carry out a colonoscopy test, even if there are no symptoms. Now, if in the family there was a father, mother, brother, grandfather or grandmother who had intestine cancer, that person should carry out the examination at 40 years of age because the genetic influence is very important. If the person has a polyp at 40 years of age, it can be detected. If the test is done at 50 years of age, it’s highly possible that the person already has cancer.

Why is the incidence growing in the world?
If you look at the statistics the south of Brazil is in second place, it only loses out, in the case of women, to breast cancer. The problem lies in peoples’ quality of life. We eat badly, with lots of fat. The majority of foodstuffs that we currently consume have to be conserved and, for this reason, they demand additives, preservatives and coloring matter. Those that are pre-packaged – salami, mortadella – cause serious damage. I ate them and found them delicious, but… I no longer eat them. One has to teach the population to eat better and this makes up part of the Abrapreci program, which is mainly directed towards the young. When we set up the gigantic intestine in Ibirapuera Park, in Sao Paulo, a number of schools took their pupils and students to visit it and they listened to instructions from nurses, nutritionists and doctors.

It’s known that historically a woman’s health was not as well studied as that of a man, which especially occurred in the area of cardiology. Is this also true for gastroenterology?
No. In our area of illnesses, the studies are equal. For example, in operations such as that of the rectum the mortality rate for the female sex is lower. When I stated to my beloved professor Alípio Correa Neto that I wanted to carry out surgery, he thought for a moment then said: “Young woman, I believe that you really could do surgery, and you’re going to have a lot of luck. At the beginning of your career only operate on women, the men are not going to want to be operated on by you. But as women don’t die, as the woman is more resistant, you’re almost not going to have deaths”.

Stimulating advice.
And very funny too. Shortly afterwards my career was highly successful. Now I operate equally on men and women. Perhaps on more men than women.

Are you optimistic in relation to the future of stem cell research?
I believe this is the way forward until we reach the point of making new organs starting from stem cells. Technology is bringing about incredible things, such as minimal invasive surgeries. Today there are projects for totally virtual operating theaters, such as a place without doctors or nurses, only the patient with robots that will carry out all of the surgery. In fifteen to twenty years from now, much of what is done today will be substituted by robots. Endoscope capsules, which will pass through the digestive tube, for example. The sick patient will go home and the capsule will pass through his inside capturing information. Operations made without opening up the stomach and other unbelievable things. Recently I saw incredible things at a congress in the United States dealing with virtual advanced technology.

Will you yourself not become a little frustrated by the possibility of being substituted by machines?
I would like to be born again now, that’s for sure. Each day we see something different that we believe to be absurd only to find, a little later, that is has been proven that it’s not absurd. But at times I think that it was good to have worked in an era in which surgery was an art, in which sewing up was done one stitch and a time. Now we do lots of sewing up using stapling machines. What had differentiated one surgeon from another, basically, had been the ability to make stitches. Today it’s the ability to use the equipment. The surgeon has ended up needing to study bio-engineering. I still see surgery as an art. But everything is changing quickly: computer programs already exist into which data on the patient is fed and all of the hypotheses in order to reach a diagnosis are carried out and even a solution is presented. I saw one of these programs in the United States.

Isn’t it dangerous to believe that the program will make the correct decision?
I believe that it’s dangerous. For the person who is accustomed to being a real doctor it’s difficult to believe. Nevertheless, when I saw the first laparoscope surgery on the vesicle, some years ago, I said to some other colleagues, “how absurd to remove the vesicle by way of a laparoscope”. Shortly afterwards we had to learn the technique.

How many surgeries do you do per week?
On average eight. Many are major operations. There are days in which I dedicate myself entirely to operating.

And do you manage time for research?
I do this with my colleagues who are competent and dedicated. Even here in my institute there are academics working.

You opted not to have children in order to invest in your career. How did you come to this decision?
When I decided on surgery, they said the following in the college: “What for? Isn’t she’s going to occupy a residency and afterwards abandon it and not work any more?” Of the 80 doctors who graduated with me I believe half of them wanted to be surgeons. There was competition for eight places. There was this fear that I would earn a place, marry, have children and stop with surgery. In fact, at that time it so happened that women graduated and gave up almost everything to look after their family. Today the woman has children and continues her career. Why? Because she has assistance and the modern husband is different from the husband of yesteryear. My nephews look after their children as much as their wives. They change the nappies, give baths, take them to school, to the doctor, feed them, and even know how to cook. In days gone bye it wasn’t like that. So I passed in the competition in first place and when I married, my husband and I agreed not to have children.

If it were to be today you would have had children?
Perhaps. With all of the types of assistance and change in customs, I believe that I might well have been able to. The family is essential. I have many nephews, grand-nephews, and a very good family life. My husband is exceptional, at the same academic level as myself. If not, things wouldn’t have worked out as they did.

There’s no envy or jealousy between us. He’s a digestive tract surgeon, one of the best in Brazil. And he’s also a full professor. But, with him, there are various surgeons of the same caliber. With me, in my group, being a woman, there’s only myself. My work brought about many repercussions. I worked a lot and my glory appears much greater than that of my equally capable peers. But it’s no better than my peers nor that of my husband. What happens is that my work appears more.

To what do you accredit this recognition?
Much to the fact of being a woman. People will say: “Was it a woman who did this? How can it be that this woman thought about this? How is it that she operates so well?”. And I, modesty apart, do operate well and have excellent results.

You have never talked about your age. Doesn’t it count?
When they ask, I say: “I don’t know, it’s unknown”. I really don’t know. Because time has passed and I don’t feel it. I can operate the whole day and be able in the evening to go to the cinema, a restaurant, to a party, and even to go out dancing.