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Reflections from South Africa
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Released: June 30, 2026

John Marshall
John Marshall, MD
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MedBuzz – Reflections from South Africa

John Marshall, MD: John Marshall, Oncology Unscripted. It is June, and for the first time, I think maybe forever, right after ASCO this year, our family went on a 2-week vacation. It’s a vacation that I am still trying to incorporate into my heart and soul. It’s made me very, very reflective about our world, about our science, about health care, and the like. So, I wanna spend just a little bit of time telling you about my vacation.

We went to South Africa. My daughter is very interested in the world and making the world a better place, and she thought, “Dad, you know what? You need to go down to South Africa.” And most every time, if I tell anybody we went to South Africa, the first thing they say is, “Did you go on safari?” The answer is, yep. It was the last thing we did, but we went on safari.

Well, what going on safari means, if you haven’t been lucky enough to do this, is you go out to a park usually or some open area. We were near Kruger National Park, and you stay in a place. We were a little glampy, ’cause look at me, I’m a hothouse flower, so I need some luxuries around me. But nonetheless, we went to a sort of glampy campsite, and 6 hours a day you get in a Jeep—3:00 in the morning, 3:00 at night, sunup, sundown—you drive around, and what everybody is there to do is see one of the Big Five. And these are the big animals that you know are out there: the elephants and the rhinos.

By the way, none of the rhinos has a horn, and the reason they don’t have a horn is that they literally dart the rhinos and cut their horns off because if they didn’t do that, poachers would come in and kill the rhinos. And so, to keep the rhinos alive, they take their horns off. And I was thinking about precision medicine. So, in immunotherapy, basically by taking the horn off, the poachers don’t care anymore, sort of like PD-L1. But anyway, that’s an aside.

But what everybody wants to do is find all of the Big Five: the lions and the leopards and et cetera. We were lucky enough to find all of the Big Five during our 5 days that we stayed on safari.

But honestly, that’s not what I was that interested in. I know I’m crazy. It was cool to see the Big Five, don’t get me wrong, and you see them very, very close. You have to be safe. You have to stay within the Jeep to be safe. But what I was thinking more about is how do they exist, this Big Five? I mean, how do you have these huge animals exist, just live out there and reproduce and grow and wander around? Well, what they need is down below.

And so, I actually shifted pretty early on—of course, I’m a colon cancer guy—not looking up so much, although I did really like looking at the trees and the birds, but what I was doing is looking down. And my quest became a little different. Not the Big Five, but who made the best poop? And by far, the best poop is made by the wildebeest. I’ve taken a picture. We’re sharing it with you now. The coolest-looking poop you’ve ever seen.

You know, elephant poop is huge. It’s really big, big poop. And only about 40% of what they eat is digested, so what they pass on, they’re passing on to some other creature who’s gonna live off of the elephant poop. So, the cycle of eating the vegetables and the grasses and all of the stuff that’s out there, digesting some, adding some microbiome to others, pooping it out so others might eat, is really what the whole safari for me was all about. It was trying to understand how these giants—the stars of the show—survived, and they survived based on what was on the ground from the various animals and what was at the base.

But before we went on safari, we actually did a very different thing in South Africa, and we really followed, if you will, the apartheid story. So, we spent some extra days in Johannesburg just to do this. And I really knew a little bit about apartheid, but I didn’t really know a lot. I was alive during all of this stuff. Many of you were, too.

It was a terrible time there, where the white people, the European white people, basically began to exclude people based on skin tone. You were ranked according to your skin tone, and you had to keep a book, and you only had certain permissions depending on what your skin tone was. And you were jailed and tortured if you didn’t behave and do the right thing. And that was scary.

We went to visit prisons and where people stayed and sat and thought and wrote, to try and begin a resistance movement that Mandela is sort of the name that goes with this as the leader of this movement, the anti-apartheid movement. But there were many, many, many, many people who were involved in that.

And I began to appreciate the sort of persistence, the patience, the grace—it’s a very important word to me right now—the grace that these people had, knowing that they couldn’t do it quickly, that they were gonna have to be patient to ultimately take the leadership of their country back. The excitement that must have been felt when Mandela was elected president after all these years of separation and apartheid—I can’t imagine the joy that was felt by these people.

But what they ended up having at the end was they were still very poor, and the houses that they lived in and what we went through and viewed were very, very poor areas. Stuff that you see pockets of here and there around the world, but I’d never seen it on the magnitude that we saw in Johannesburg, so it was very impactful for me.

So, for actually all of these 2 weeks, I actually didn’t think much about cancer. I was thinking about existence and community and relationships and oppression of people, and I was thinking about what’s going on here in this country right now as we’re excluding people based on where they came from and where they were born. And that was even true in South Africa, where they were deporting people from other parts of Africa that had made their way down to South Africa because that’s where the money was.

And then I was reflecting on the safari and in Johannesburg. Giants there are these sections of the city which are where the rich people live, right? Mostly white, but it’s multiracial, to be fair. And it’s where all the money is, and they literally have fences around, and you can walk around in there, but you don’t get out of your car if you’re outside of the fence, just like we didn’t get outside the Jeep when we were on safari for fear that it would be dangerous to us.

Then I thought, how do those giants, the ones in Johannesburg, exist? And they exist for the same reasons that the giants exist on safari, and that is what’s down here, what’s on the ground, what’s on the base. These are the people who fought for their freedom, who fought for their vote, who fought for their right to exist. Even though they’re very, very poor, they are the base that are allowing all of that other fancy existence to occur.

You might think, “Well, what does that have to do with cancer?” And there’s so many connections to what we’re doing. Do we have the grace, the patience, the persistence to do what we need to do to cure cancer? And I think we do, even though I’m very, very impatient. I want it to happen tomorrow. I’m eager to move things forward faster. There is an urgency, but there also needs to be a grace and a persistence going forward.

But then I was thinking about why I didn’t talk about cancer for the last 2 weeks or think about it very much, and that’s because what I was thinking about is existence. And when I think about what we provide here at this cancer center, what you provide to your patients and to your community, it’s really a luxury item to be able to give cancer care right now. We’re one of the few areas of the world that can provide the level of cancer care that we are providing. We’re one of the few areas of the world that’s excited about a new RAS inhibitor because that means bad cancer can be treated even better, where most countries, most parts of the world won’t even be able to afford the basic treatment for pancreatic cancer.

And so, we’re at this luxury giant level already, but we have to remember that we are living off of what’s down here on the ground, and we need to appreciate each other and join together with each other, partner, whether it’s through clinical trial platforms, whether it’s through economic reforms so that more people have access to health care, whether it’s through innovative research that allows us to develop medicines more quickly or prevention strategies more quickly, not just for those of us inside the gates, those of us who are safe within our Jeep, but those of us who are out there in the wild, at risk, just trying to make it day by day. Think about it.

John Marshall, Oncology Unscripted.