Lab Voices
Lab Voices, brought to you by Pathologists Overseas, elevates the experiences of laboratorians and pathologists around the world. Each month, we interview an individual who has worked to improve pathology and laboratory medicine in a resource-limited setting.
Lab Voices
Heinz Hoenecke Interview
Dr. Heinz Hoenecke is one of the co-founders and past presidents of Pathologists Overseas. Dr. Hoeneke completed his undergraduate and medical training at the University of Michigan, his anatomic and clinical pathology training in Detroit and Phoenix, and practiced pathology in Phoenix and San Diego until his retirement in 1995. After retirement, Heinz and his wife, Alice, raised funds and recruited volunteers for PO. He participated in projects in Kenya, Eritrea, Nepal, Madagascar, El Salvador, Peru, and Ghana.
Hello. Welcome to the Lab Voices podcast from Pathologists Overseas. This is Emily Glynn. I'm the secretary/ treasurer at PO and I'm honored to introduce our guest today, Dr. Heinz Hoeneke, one of the founders and past presidents of Pathologists Overseas. Dr. Hoeneke completed his undergraduate and medical training at the University of Michigan, his anatomic and clinical pathology training in Detroit and Phoenix, and practiced pathology in Phoenix and San Diego until his retirement in 1995. His first global health volunteer experience was in Swaziland in 1989, and as part of PO he built up anatomic pathology services in Nairobi, Kenya from scratch. Some experiences I'm sure he'll elaborate on today during this interview. So, welcome Dr. Hoeneke. We're so excited to have you today on the podcast.
Heinz:Thank you.
Emily:Hi, how are you?
Heinz:Well, I'm up and walking around. That's pretty good. Going on 92 next Monday.
Emily:Oh, well. Happy early birthday!
Heinz:Oh, thank you.
Emily:I just wanna make sure that I say your last name right? Uh, is it Hoe-necke?
Heinz:Yeah, it's"Heineke." It's a German umlaut. It sounds like, eh.
Emily:Uh, okay. So Hoeneke?
Heinz:Yeah, that's close enough for government work.
Emily:Okay[laughter]. Uh, maybe just to start, you could tell us a little more about your background before going into medicine and what drew you into global health.
Heinz:Well, I graduated from the University of Michigan, the pre-medical degree at age 20, and that wasn't worth much unless I got into medical school. So, it was at the time when all the veterans had come back from the conclusion of World War II, and I was only 20 years old, so I figured I'd have to wait a year or so. But during that time, I went to work in construction, which paid the most, since I was one of five children from a Lutheran minister, and had very little money. I worked as a laborer at a$1.35 an hour, and then I received a promotion to be a re-steel worker. That's tying the reinforcing steel for buildings and columns in the deck. And that was a wonderful experience in that there was no studying, no exams, fresh air, exercise. I slept well, and all this at$2 and 35 cents an hour. How can you beat it?
Emily:That's incredible.
Heinz:So, well that comes up about$94 a week, which was a lot of money at that time. So, after I was accepted into medical school, it was enough to give me a good start.
Emily:Great.
Heinz:And what drew me into global health? Going back in 1949, my father and another man started out from Cape Town, Africa, went up the west coast of Africa to Southwest Africa, Angola, and up to the Belgian Congo in a four wheel drive camper at that time. They crossed east to Northern Rhodesia and Southern Rhodesia, and the purpose of their trip was to find a place to start a mission. And so they found a place at the hook of the Kafue River, where they started their first mission. Now, they were just the exploratory team and other people followed. He came back from Africa with a hour and a half, 16 millimeter sound film, and during that year when I was waiting, I projected this movie over and over and over again. So, I grew to know Africa, as he saw it, quite well. I didn't realize it, but this influenced what I would do some 40 years later. So, from there on, I just went into medical school and practiced medicine. About 40 years later, about 1989, my wife and I accepted a position as a volunteer in Swaziland. I couldn't find anything in pathology. So, having had a rotating internship after a medical school, I was working as a general practitioner. So, that's how it started.
Emily:Oh, wow. So, in Swaziland you didn't do really any pathology, you were mostly doing clinical work?
Heinz:No, my first assignment was with another doctor, an internist, and we had 75 patients. I think about half of'em had AIDS. And, it was a very interesting experience because of a real variety of patients. Uh, it was a real cultural shock. I remember one situation where there's a 12 year old boy that had a pleural effusion, and the doctor said, you wanna do this arthrocentesis to draw off some of that fluid so he can breathe better? And so he handed me a large trocar that's a large bored needle, and he says, just put it in between these two ribs and we'll just draw out a pint or a quart of fluid. I said, aren't you going to anesthetize that? And he says, no, these people are real tough. So that's what I did.
Emily:Oh, wow.
Heinz:So, that's the sort of experience you had. And, and I worked in the emergency room where they'd come in with lesions on their head being clubbed or sometimes ectopic pregnancy, all sorts of things. So this gave me a real insight into what medicine is like on the ward in Africa. They were not the cleanest wards by a long shot. And I remember walking in First Ward and I thought, oh my golly, what's that smell? I thought, I want back out. What did I get myself into? And then I also worked in the clinic with patients. Um, saw a lot of women with pelvic inflammatory diseases, where their husbands had reinfected them over and over again, and I gradually picked up a lot of the medicine, although I had studied for months before, before going over there. But at the end of the term I said, you know, maybe they need pathology here more than they do me and general medicine because a lot of cases that they were not able to get biopsies on, and they never knew what these diseases were. So, maybe I should think about doing pathology in Africa. And I went up to Nairobi on the way back home and met a doctor, a pathologist, American doctor, who said, do you know we really need pathology here for the indigent people in the 50 mission hospitals in Kenya? And he said, yeah, I did a few cases, but I'll help you set up a laboratory. So, I went on home and thought about it. And in the interim, I was asked if I would go to Zaire, which is the Belgian Congo area. And we flew into the eastern part of the Belgian Congo, a very remote part at a hospital called Nyankunde. And there they said they had all the pathology equipment to do tissue biopsies and the laboratory. Well, when I got there, they didn't have any reagents.
Emily:Oh.
Heinz:So, I didn't have any alcohol, any formalin, and any xylene, wax or anything, and I could do nothing with the equipment. So, I ended up giving lectures. I brought along a lot of slides, Kodachromes, of the diseases, and they had some residents there, but most of all, I got to know a surgeon from Argentina named Carlos Somoza. And he said, you know, I have to take my boards. Would you teach me pathology and then you can work with me in surgery? And that's when I did. I worked with him in surgery and did a few cases like ovarian cysts and so forth. So, this gave me another insight into medicine in Africa and it is an entirely different. It again, it was another cultural shock, and it's from this I developed some commitment into trying to do some pathology.
Emily:That's great. I think that's an approach that a lot of volunteers nowadays don't have exposure to, to doing mostly clinical work on a volunteer basis and then transitioning into doing, pathology. You sort of alluded to it, but what insights did you gain in terms of the adaptations you would need to make a functioning pathology lab in a resource limited setting? You know, how did your clinical experiences inform your approach to setting up pathology?
Heinz:I had to look at a place where I could deal with several hospitals because it was not really efficient to have one pathologist at one of these hospitals. So, I went back to Nairobi, and I talked to Dr. Zimmerman, the pathologist I'd met there, and he says, I'll help you set up a project. So, I came back to America and I talked to Shelley Rice, editor at CAP TODAY. And I said I wanted to look into the possibility of establishing a pathology project. And so, she and I wrote an article and said we're interested in finding out if anyone is interested in joining such a project. Well, I got about 12 answers and, Victor Lee was one of those that answered, and I've projected ahead a little bit. He, was my partner throughout this whole thing. We were like brothers really. We were only a hundred miles away and we talked almost every day. But, the problem I had was you have to have a laboratory, you have to have reagents and equipment and the reagents, you have to have a technician, you have to have the money, and you have to set up a system. One of the things that we needed to do was find a way of getting all of these specimens from the 50 mission hospitals in Kenya. Well, all roads lead to Nairobi. So, this was a perfect place to set it up. So, I went back and I took a trip all around Mount Kenya north of Nairobi and visited maybe eight or nine hospitals and they said, yes, we would like this service. So, then I came back and I had a friend from Bozeman, Montana, another pathologist who said, I'll help you set it up. And he came over there and was able to gather all the equipment. Well, the interesting thing was that American hospitals were shipping their old, instruments and machines like the auto analyzers, like the tissue processors to Africa, but they had no use for it, and they were all stored in the basements of these hospital. So, he assembled all of these things. Meanwhile, I recruited people in America and together with Victor Lee, we set up a plan. And the plan was to recruit people to come over there at their expense because we had no money. Well, I did get some money. My family gave me$9,000, my sisters and brothers and so forth, and then my partners gave me another$2000. I got another$5,000 from Abbott Laboratories in Chicago. And we set up this lab and the first volunteers came and we just started in business. Dr. Zimerman helped us get the tissue lab going and it started out pretty slow at first. As a matter of fact, one of the volunteers came over and said, there isn't enough work for me to do, and he went back home.
Emily:Oh[laughter].
Heinz:And so it was sort of a rocky time, but we went on and gradually more cases came and Victor had written up beautiful instructions about what to do in Africa, how to get the tickets and what you can expect. And he presented a beautiful book of directions for these pathologists. And they started coming. We started in July and about March I realized that we're running outta money. Well, I happened to have a contact, who knew a billionaire who gave me$31,000. Well, that carried us through. In the meantime, I'd also gone to USAID and applied for a grant, and Victor and I put together the projection of costs and we were able to get a grant for$200,000, but it wouldn't come around till the following December. And that's how it started. This project was to last four years. And the intent was to build them a laboratory, get it going so it was at least partially self-sufficient and then leave it to a person be trained. No one wanted to be trained in Africa. And interesting enough the Jomo Kenyatta Hospita at that time, the university hospital, had a backlog of cases they never even opened the bottles on. And these were cases that had come from all over Kenya. So, there was a real need for it, and the demand grew and grew. And, o ver a period of four years, we were able to develop it into a laboratory. In the grant, we got a vehicle for picking up specimens and, we transferred this to a nearby hospital just outside of Nairobi called Kijabe, K I J A B E. And that laboratory is still going to this day. And then they serve mainly Kenya and maybe some other places like Djibouti maybe a few from Zaire. So, that's how that sort of took off.
Emily:Yeah, I actually, volunteered in Kijabe when I was a resident, so...
Heinz:So, you where kijabe is! We built a house there for the pathologists overlooking the Rift Valley. And I said, you know, if you're gonna send pathologists over here you gotta have a good place for them to stay. So, I said, how much would it take? And they said, oh,$15,000. And I said, look, could you build'em a real nice house if I can get$25,000? And that's how that house was built. Do you remember that?
Emily:I do. I stayed in that house. It was lovely.
Heinz:Oh yeah. That was near the end of the project, of course, but during the course, the pathologists really enjoyed coming over there. They usually come over with their wives. My wife and I go over there twice a year. Victor would come over sometimes. And the costs were minimal. It was your airfare at that time, you can get as low as$1,300 and up to say 17 or 18, and the cost of your food, because in our grant we had a cook and someone that maintained the house, did the laundry, and all the cleaning and everything. So, the wives really enjoyed it because they could go into Nairobi, shopping, and then on the weekends, when there wasn't any work to do, we went to the game parks or to the coast. What, what did you do at Kijabe?
Emily:Oh, well, so I volunteered as a surgical pathologist, so I was a resident, so one of my attendings, she goes there every year and she takes a resident every year, so.
Heinz:Oh yeah. So, you saw the lab and the house and everything?
Emily:Mm-hmm. Yep.
Heinz:Well, how was the experience?
Emily:Oh, it was amazing. That was really the first time that I had done any global health work, and that's kind of what made me interested. And since then it's, been a big part of my life and career and something I'm really committed to, so it definitely changed how I looked at health equity and who has access to healthcare and pathology services.
Heinz:Well that's wonderful that you did that so young. I had to wait till I was almost 60. I commend you for that.
Emily:Oh, well, I was just lucky you know, right place at the right time I think, so.
Heinz:Yeah. Yeah. And you know, the wonderful thing about it where I in Ghana, and I went down to the gross lab, and I looked through the cases. It's just amazing the number of things that I found. Maybe 10 or 12 cases you'd never seen in the United States. And I know a lot of our people appreciated that the variety of specimens you had. It not only was it cultural experience, but it was very an intellectual experience. And, I remember a lot of cases that we didn't have special stains and so forth. And one example is one Saturday night, I was leaving Nairobi to come back and a big Mercedes pulled into the driveway and the man came in an Indian man, and he had a bottle. And he had some tissue in it and he said, this is my son' s specimen. He has this brain tumor. Could you, do something with this?" I said, okay. So, I went to the kitchen and I cut off a little piece of it, wrapped it in formalin. It had already been formalinized. I flew back to San Diego. And between the airport and my home was the laboratory. So, I went into the laboratory and I cut off a piece and put it in the tissue processor and left a note. This is Sunday afternoon. Call me when you get this done. So, I went in Monday morning, and there were the slides, and so, my partner was an electron microscopist, took a bit of it. We faxed back our impression and two days later, on Wednesday, we faxed back the electron microscopy interpretation, which really didn't add anything, but it just shows what you can do if, really want to get results back in a hurry.
Emily:Yeah, definitely. It's amazing how many hurdles folks have to overcome just to get a diagnosis, a correct diagnosis, in a timeframe that's relevant to their clinical care. I think it's definitely something we take for granted, certainly in the United States. So, it's very humbling to go to a place where the majority of people don't have access to those kind of services.
Heinz:That part appeals to me. And the idea of challenging to see what, what you can do.
Emily:Yes. It's definitely, a different kind of problem solving than were used to. I really like that aspect of it as well.
Heinz:Yeah. Well that's what we do all the time in pathology. We're looking for the answer, so how to get there is noise with a special stain.
Emily:Yeah, that's a good lesson, yeah. You know, now I believe Kijabe is doing some limited immunohisto chemistry for like ER, PR, HER2. So, it's amazing to see the trajectory of what you started from scratch in Nairobi to what it is today serving that hospital and several other hospitals in the area.
Heinz:Yeah. Going back to clinical pathology. When my wife and I went to Zaire, we had a technologist in our lab here in San Diego, who was very interested. So, we took her along, and she worked on the clinical laboratory. But I remember one night we were doing a case on a cesarean section and she said, the patient looks sort of pale. And I said, well, why don't you get a hemoglobin hematocrit? And she says, no, we don't bother. The lab isn't that good. We just look at the eyeballs. And so of course you are always concerned because of the danger of AIDS in the blood that you gave patients. So, I said at that time, I remember telling Victor and I told Jack Ladenson later on. You know, I think there's a greater need for clinical pathology than there is for anatomic pathology in Africa. And I still feel that it is a terribly important field, that it has to be improved. And Jack Ladenson has done a lot for that.
Emily:For sure. Yeah, that's definitely something we've focused a lot on now is improving really quality of clinical laboratory testing. So, providing proficiency testing for labs, installing laboratory information systems. So, in addition to the historic emphasis on histology that you and Victor had, you know, we have also branched out to provide more support for clinical pathology services.
Heinz:I think the anatomic pathology doesn't need much help, but the clinical pathology portion does. And I think one of the most remarkable things that Tim told me about was the experience in Namibia. I set up an elaborate system to collect specimens from all of the hospitals all throughout Kenya. I'd had experience because I directed to the laboratory in Phoenix had covered the state of Arizona and there's some of the Indian reservations had minimal services. Well, we had a good salesman. and it always depends on someone else's ideas that you don't have. He says, I'll go up there and see if we can work some way of getting those specimens down to Phoenix." So, he found a vegetable truck that came up from Flagstaff every day. So, he had a box set up, where all of the specimens and the mainly, clinical specimens were put into this box. They were taken down to Flagstaff, and then there was an Arizona bank truck that came up there to collect receipts and so forth. Then the box was passed on to them. They took us to our laboratory in Phoenix about seven or eight at night. The laboratory is open all night long. They processed those specimens and at four o'clock in the morning, they went back, so they had overnight service to all of these hospitals up there. So, I used the same system, although it didn't work as smoothly as it did in Phoenix. But we did get the specimens and when they brought specimens down, we sent back the results. At that time, there was no telephone connection, only some radio connection, so you couldn't just phone the results back. So, it was delayed, but they did get results.
Emily:Yeah, so, were you sending back paper results then?
Heinz:Yeah, sure. Anything, tissue results or any lab studies they wanted. A lot of'em, they could take care of themselves because they did have clinical laboratories at these hospitals of varying degrees of excellence.
Emily:Yeah, yeah. I I was wondering what were some of the biggest challenges you faced in setting up that lab? It sounds like you were able to get equipment, that had been donated, but how did you get a constant supply of reagents, train the technical staff? Maybe you could talk a little bit about those aspects of setting up the lab.
Heinz:Okay. This is a tissue lab. This is not a clinical lab.
Emily:Yes, for sure. Yeah.
Heinz:Dr. Zimmerman had a tissue lab. It was for English speaking people there. It was a more or less, it was a good lab, just like we have in the United States. So, the reagents were available in Nairobi. And so, that was the main thing. The thing we were concerned about is these whole tissue processors. So we had to cannibalize several of'em to keep the tissue processor working, so that was always a problem. The other problem was microscopes. I smuggled in several microscopes hoping not to get caught because then they charged a big duty on them. I remember one day I left here on a Saturday morning, and I got into an Nairobi carrying one of these microscopes, and it was heavy and we had a rainstorm here, so the flights were switched around. I said, I know my baggage will never get there in time. And, it wasn't until three weeks later and I got it. But here I am, landed at one o'clock in Nairobi and all these customs agents were standing there. And, I didn't know what to do. So, I went over to the baggage claim. I spent some time there until everyone was gone through. Then, I walked over to one of these three agents, and I said, I don't know what to do. I, was sort of hysterical. I had this microscope in my hand and she says go on through. So, I was a smuggler.
Emily:Oh. It's for a good cause overall.
Heinz:Well, Victor smuggled in a computer and so forth. Well, then we went to several different countries. Over the period of time the Kenya lab has been going for almost 30 years and the Madagascar lab for 20 years. Victor handled the Western end. He was most interested in Nepal, Bhutan. Um, he started the project in El Salvador and in Peru. And, we just worked together on these things. But we'd always go to a place before we'd start the project to survey it because we didn't know what we were going to encounter. But, he handled all of the money and did a beautiful job of that. And, the reports we had to submit because we were organized as a 501(c)3 charitable corporation. So, all the money that the pathologists spent on going over there and all the contributions were tax deductible. So, it was a self-sustaining organization supported by the volunteers who paid their way and by sources of income. We got an Eritrea USAID Grant and Madagascar grant and, uh, those are the main ones, most of'em are hundreds of thousands of dollars. And I have to say my favorite country was Eritrea because the people were so wonderful and it was so safe. Victor's written all, all of that up in his history of our project. He was a wonderful partner. He still is a wonderful friend, and we talk about it. He's just a very good pathologist and a very good man.
Emily:Yes, definitely, definitely. So, maybe we can close by having you describe when you founded Pathologists O verseas and kind of in the early days, what were you envisioning for the long term impact of the organization? Or did you think it would still be around decades later as it is now?
Heinz:Well, I had hoped that the laboratories that we established, we trained pathologists too, in Madagascar, by the way. And I had hoped that these laboratories would continue, but I used the same philosophy with my kids. You get'em through a certain point in life and it's theirs. If they don't want carry it on from there, that's too bad. And my children have all done well, but I feel that things have to become indigenous. They have to become self-supporting. And, if we can act like architects or whatever you want to call it, then help them set up things that were difficult for them to set up. I think that's enough of a contribution. And as a result of these grants, they got all sorts of equipment, vehicles, books, and so forth. So, it was just setting'em up to go on and, and two of'em have done well. Eritrea is no longer part of ours because it has a communist background and except for Pathologists Overseas for a long time, they sent away most people. But, we were the last ones, I guess, to leave Eritrea.
Emily:Yeah, I hopefully in the future. I know that that is something both Tim and Merih are interested in starting again, but currently we don't have any projects there.
Heinz:Sure. Great appreciation to is Jack Ladenson. He has been wonderful. He's handled this whole clinical pathology very well, and he's been a great guy to work with. So, Jack and Victor. been great, plus dozens of other people, pathologists that went over there. I think at one time we had three or 400 applications for service.
Emily:Oh, wow.
Heinz:So, I think a probably total of 250 to 300 pathologists trips went over there. One of'em here in Phoenix, Harriet Frelin was over there 15 or 20 times in different sites. This world is changing. I think that depending on what happens to the American economy in the next few years, that'll influence people some because, people are reluctant as we are anymore to use our life savings. My wife and I have been building schools since then. We built five schools in Africa.
Emily:Oh, wow.
Heinz:One in Madagascar, one in Malawi, two in Zambia, and one in, Liberia. We had over a thousand students in the schools we built, so...
Emily:Oh my gosh. That is very generous and that's quite an accomplishment. That's a lot of kids educated.
Heinz:Well, it doesn't take much to build a school there. But it's the support of the school. That's hard. But, it's the thing that motivated us. My brother died of AIDS just before we went to Swaziland.
Emily:Oh, wow.
Heinz:He was industrialist and he received bad blood in Chicago. And, uh, we never found anything to do for people with AIDS. My wife did a project for 10 years in Madagascar and solar cooking, and one day she walked into this village. We had about a hundred villages that were involved. And there's a man standing next to a tree; under the tree was a blackboard and on the ground were the children. So, we decided to ask him about a school there. So that was the first school, but we found that that's been very rewarding too.
Emily:Yeah. Thank you so much for sharing your story with us and the story of Pathologists Overseas and giving us some insights into, what it takes to start a laboratory in a resource limited setting. I really appreciate you taking the time with us. Thank you so much.
Heinz:Okay, thank you.
Emily:Happy birthday again.
Heinz:Bye.
Emily:That was Heinz Hoeneke. Thank you so much for listening to the Lab Voices podcast. I'm your host, Emily Glynn. To find out more about Pathologists Overseas and our projects, Visit us at www. pathologistoverseas. com and follow us on social media. Podcasts edited and produced by Taylor Harris, theme music by Tim Amukele.