by Henry Marsh
When I was told one morning that the MOs (medical officers) wanted me to stay for ever, I felt very happy and proud. But of course disillusion – or at least a more realistic understanding of Nepal and its sad and intractable problems – was to come quite quickly. There were periods of intense frustration and long periods of inactivity. At times I became deeply despondent. I felt that I was living in self-imposed exile. I often longed to return home, to my family and friends, and wondered why I had abandoned them. I thought of how I had always put work first, ahead of my wife and children, when I was younger, and now I was doing it all over again. But the deep contentment I experienced each day as I walked to the hospital in the low morning sunlight never faded.
I climb up the stairs to the third floor, past the locked suite with the letters VVIP over the door – built in case the president or prime minister falls ill – and go to the library. There are wide windows and on clear mornings you can just see the glittering snow-covered peak of Mount Ganesh, like a broken white tooth above the green hills of the Shivapuri National Park to the north of the city. There is an army base in the park, which was once a TB sanatorium. Some claim that during the recent civil war people were taken there to be tortured, and that many of them disappeared, but others deny it. Nepal has yet to come to terms with its civil war, and the atrocities carried out by both sides. I sit down and wait for the junior doctors to arrive.
The juniors drift in one by one – although the more enthusiastic of the registrars will already be waiting for me. Nepalis are not good time-keepers. About half of the ten medical officers have turned up.
‘Good morning everybody,’ Salima, the duty MO, says. She is wearing a short white coat and standing in front of a white board on an easel on which there is a handwritten list of the hospital’s admissions and discharges. Salima is rather nervous as she knows I am going to quiz her about the cases. She looks a little Chinese, but with enormous black eyes behind a large pair of spectacles. I was to see her at a hospital get-together a few days later, dancing exquisitely to Nepali music. The Nepalese, both men and women, are almost all very good-looking, with a complex mix of Indian, Mongol and Chinese faces. There has been a population explosion in the last thirty years as a result of declining infant mortality, so the streets are full of young people. So many of the men work abroad – 30 per cent of Nepal’s national income comes from remittances – that you see far more women than young men on the streets.
‘Eighty inpatients, seven admissions, mortality one and no morbidity,’ Salima rattles off quickly.
‘Well, what’s the first case?’ I ask.
‘Fifty-year-old lady present with loss of consciousness two days ago. Bowels open every day. Known hypertensive and alcoholic. On examination…’
‘No, no, no! What’s she do for a living?’ I ask. I have noticed they never describe the patient’s occupation, which is supposed to be a normal part of presenting a patient’s history, although in Nepal it seems that everybody is either a farmer, a driver, a shopkeeper or a housewife. Mentioning the patient’s occupation is important: not so much for the traditional reason, which is to alert us to possible occupational diseases, but more to remind us that the patient is a person, an individual, and has a life and a story beyond being a mere anonymous patient with a disease.
Salima looks embarrassed and fumbles with the sheet of paper in her hand. She probably hadn’t seen the patient herself and relied on what had been written by one of the other junior doctors, so I was being unfair.
‘Shopkeeper,’ she says after a while.
‘You’re guessing!’ I say and everybody laughs, Salima included.
‘Now tell us about this loss of consciousness.’
‘She comes from other hospital…’
‘So we have no real history? Whether she had a headache first, whether she fitted?’
Salima looks awkward and says nothing.
Protyush, the registrar who had been on call, takes pity on her.
‘Her husband found her on the floor at home. She was intubated at the other hospital and the family wanted her brought here.’
Dev’s hospital is a private hospital; patients only come here by choice, or by their family’s choice, and only if they can afford it. On the other hand they also have to pay if they go to a government hospital, where the treatment is only free in theory, and possibly worse.
‘OK,’ I said. ‘Salima, what did you find on examination?’
‘She localize to pain, not eye opening. Make sounds. Pupils equal and reacting. Cranial nerves intact. Power one on right, plantars up-going,’ she continued in high-speed Nepali English, ‘CT scan show…’
‘No, no,’ I interrupt again. ‘What’s your one-line summary?’
‘Fifty-year-old lady present with loss of consciousness with known hypertension. Bowels open regularly. On examination pupils equal and reacting, and…’
‘Salima – one line, not three!’
After a while we agree on a one-line summary. Presenting cases is a hugely important part of medical practice – about both communication and analysis. A short summary after presenting the details of a case forces the doctor to think about the diagnosis. I quickly learnt that most of the doctors were so shy in front of me that they found it very difficult to think analytically. It took them a long time to overcome this in my presence. I also suspected that much of their teaching had been entirely by rote.
‘Right, now we can look at the CT scan.’
The scan showed that almost all of the left side of the woman’s brain was dark grey, almost black. The woman had clearly suffered a massive and irreversible stroke – an ‘infarct’ caused by a blood clot forming in the left carotid artery. The left cerebral hemisphere, along with all her language and much of her intellect and personality as well as her ability to move the right side of her body, was dead, with no chance of recovery. Such damage cannot be undone. Some surgeons favour opening up the patient’s skull to allow the dead, infarcted brain to swell outwards and stop the patient from dying from the build-up of pressure in the skull, as infarcted brain swells and severe brain swelling kills you.
Helping a patient survive a stroke with this operation of ‘decompressive craniectomy’ is perhaps justifiable if the stroke is on the right side of the brain (so that they do not lose the ability to communicate, speech usually being on the left side) and if the patient is young, but it seems a strange thing to do in patients who are going to be left dreadfully disabled if they survive. And yet it is recommended in articles in various learned journals claiming that such patients are happy to be alive, and is widely practised. You might wonder how the victims’ happiness can be established if they have lost much of their intellect and personality, the part of their brain responsible for self-respect, or the ability to speak. You might also wonder whether their families are of the same opinion as the patients. Patients with severe brain damage, as far as you can tell, will often have little insight or understanding of their plight, whereas those that do are often deeply depressed. In a way, the true victims are the families. They must either devote themselves to caring, twenty-four hours a day, for somebody who is no longer the person that they once were, or suffer the guilt of consigning them to institutional care. Many marriages fail when faced with problems of this sort. It is worst for parents, who are tragically bound to their brain-damaged children, whatever their age, by unconditional love.
‘So the patient’s going to die?’ I ask the room at large.
‘We operated,’ Protyush says. I express surprise.
‘I spent half an hour trying to persuade the family that we shouldn’t operate but they wouldn’t accept it,’ he adds.
After the morning meeting I go downstairs, take my shoes off outside the operating theatre and ITU area, get the uniformed guard to open the locked door for me and choose a pair of ill-fitting pink rubber clogs from a rack in the theatre corridor. Nepali feet are mostly small so I hobble uncomfortably to Dev’s office, which is conveniently l
ocated between the ITU and the theatres.
Dev and I had always got on well together as colleagues when we were training together thirty years earlier, but it had been little more than that. I regret to say that I was far too ambitious and concerned for my own career at that time to take much interest in my colleagues, although I suppose that working a 120-hour week and having three young children at home left me with little spare time. And yet as soon as I came to Kathmandu, Dev and his wife Madhu were so welcoming that it felt as though we had always been the oldest of friends, even though we had only seen each other briefly at a few conferences over the intervening years. Dev is also charismatic, a man of great integrity and very determined. Like most Nepalis he is quite short and slight, although now a little rounder (which he blames on my presence and the beer we drink in the evening). He has a prominent, stubborn chin but slightly hunched shoulders, so that he looks like a cross between a bulldog and a bird. His intensely black, wavy hair has now turned grey. He has a chronic cough which he attributes to breathing the polluted air of the city centre when he worked for many years in the government hospital known as the Bir. He speaks very fast, with great animation, as though in a permanent state of excitement, about his past achievements and the great difficulties he had to overcome in trying to bring neurosurgery to Nepal. He also talks of how difficult it is to run a major neurosurgical practice more or less single-handedly.
He told me that it had been much easier when he was the only neurosurgeon in Nepal – if he gave bad news to patients they had little choice but to accept it. But now there are other neurosurgeons, most of whom have worked with him, from whom they get second opinions, and it would seem that there is little love lost between the professor and some of his former trainees. So he sometimes now has major problems with patients’ families when things have gone badly, which they so often do with neurosurgery. When he told me this, I pointed out that in England there was more and more litigation against doctors, and this always involved doctors giving evidence against each other as expert witnesses.
‘Yes, but here the families threaten us with violence, demand money and have even said that they’ll burn the hospital down,’ he retorted. ‘Of course, we don’t really have malpractice litigation here – it’s almost unheard of to sue doctors.’
Doctors, especially surgeons, are often intensely competitive, and we all worry that other doctors might be better than we are, although I can think of a few famous international surgeons who are so supremely arrogant that they seem to have suppressed this problem by completely forgetting their bad results. We need, of course, self-confidence to cope with the fact that surgery is dangerous and we sometimes fail. We also need to radiate confidence to our frightened patients, but deep down most of us know that we might not be as good as we make out. So we feel easily threatened by our colleagues and often disparage them, accusing them of having the faults that we fear we have ourselves. It is made all the worse if we surround ourselves with junior colleagues whose careers depend on us, and only tell us what they think we want to hear. But it is also because, as the French surgeon René Leriche observed, we all carry cemeteries within ourselves. They are filled with the headstones of all the patients who have come to harm at our hands. We all have guilty secrets, and silence them with self-deception and exaggerated self-belief.
Dev remembers all sorts of details of our time spent working together in London, which I have long forgotten. His determination and energy are remarkable and I quickly came to understand why he has had such an extraordinary and brilliant career and is famous throughout Nepal. This has not been without its disadvantages. Driven and ambitious people can achieve great things, but often make many enemies in the process. Patients come to his outpatient clinic with all manner of non-neurosurgical problems, hoping that he can cure everything. A few years ago one of his daughters was abducted from the family home at gunpoint and Dev had to pay a large ransom. Since then he goes everywhere with a bodyguard.
The ITU is a large room with good natural light, as there are windows all the way along two of the walls. There are ten beds; they are rarely empty. The hospital admits strokes as well as head injuries and many of these patients have undergone decompressive craniectomies. Most of the patients are on ventilators, with pink bandages around their heads and the usual array of monitors and drip-stands and flashing lights and noisy alarms beside them. I had forgotten how grim neurosurgical ITUs can be – in London I had only been responsible for a small proportion of the patients since I was only one of many consultants.
Many of the patients on the ITU here would not survive, few would make a good recovery, especially in Nepal.
‘You do far more decompressive craniectomies here than I would do,’ I say to Dev. ‘Only in America have I seen so much treatment devoted to so many people with such little chance of making a useful recovery. And yet Nepal is one of the poorest countries in the world.’
‘I have to compete with many other neurosurgeons – trained in India or China – and they’ll operate on anything, and it’s always for the money. Like in America. If I tell the family now that no treatment is possible, they’ll go and see somebody else who’ll tell them the opposite and then they’ll kick up a big fuss. So I am forced to operate now when in the past I wouldn’t have. I often wish I still worked for the NHS,’ he adds.
My colleague Igor in Ukraine often faced similar problems. I have been in countries where the surgeons sometimes have to operate with the patients’ families outside the operating theatre wielding guns, threatening to kill the surgeon if the operation is unsuccessful. As a visiting doctor from the West it is hard, at first, to understand the difficulties our colleagues face working in countries with very different cultures and without the rule of law. It is easy to feel superior, to pass condescending judgement. I hope that over the years I have learnt to observe, and no longer to judge. I want to be useful, not to criticize. Besides, so often I find that I have misunderstood or misinterpreted what I have seen or been told – I have learnt not to trust myself. All knowledge is provisional.
‘Many of these patients are going to die anyway, aren’t they?’ I say as we look at the next comatose patient with a bandaged head, labelled ‘No Bone Flap’. After a decompressive craniectomy the patients are left, for a few weeks or months, with a large hole in their skull, like a giant version of the fontanelle with which we are all born. The ‘No Bone Flap’ label is to remind the medical and nursing staff that part of the brain is no longer protected by overlying bone. This particular patient – like so many in Nepal – has been involved in a motorbike accident.
‘Cultural case,’ Dev says. ‘The family ties here are so strong. The family just can’t accept that there is no treatment. If I hadn’t got the boys to operate last night the family would say: “Oh Neuro Hospital doesn’t want to operate!” Can you imagine the situation? Next thing they take the patient out of my hospital and somebody else will operate. The patient will be a vegetable but the family are happy and my reputation will be rubbished…’
Dev turns to look at me.
‘When I was the Minister of Health under the last king – before the Maoists abolished the monarchy – I saved more lives by making crash helmets for motorcyclists compulsory than I will ever save as a neurosurgeon. Most of the families are uneducated,’ he goes on. ‘They have no conception of brain damage. They are hopelessly unrealistic. They think that if the patient is alive they might recover, even if the patient is just about brain-dead. And even if they are braindead they still won’t accept it.’ I was to learn more about this later.
So much for the value of commercial competition in health care, I thought, in a poor country like Nepal. And all this on one man’s shoulders, day in, day out, with never a day off, for thirty years.
Neurosurgery is something of a luxury for poor countries. Illnesses requiring neurosurgical treatment are relatively rare compared to problems affecting other parts of the body. It requires very expensive equipment, and for problem
s such as cancer and severe head injuries treatment often fails or achieves little. We operate in the hope that patients will make a good recovery, and many will. There can be wonderful triumphs, but the triumphs wouldn’t be triumphant if there weren’t disasters. If the operations never went wrong, there would be nothing very special about them. Some patients will be left more disabled than they were before surgery and others, who would have died if we had not operated, will survive, but terribly disabled. At times, in my more despondent moments, it is not always clear to me whether we are reducing the sum total of human suffering or adding to it. So for countries like Nepal and Ukraine, with impoverished and weak governments and poor primary health care, it makes little sense to spend large sums of money on neurosurgery. Dev in Nepal and Igor in Ukraine have had little choice other than to move into private practice, albeit reluctantly, and yet both feel a little tainted by it, even though they often treat poor patients for free. But there is a limit to how often you can do that if your hospital is to survive.
There has always been a tension at the heart of medicine, between caring for patients and making money. It involves, of course, a bit of both, but it’s a delicate balance and very easily upset. High pay and high professional standards are essential if this balance is to be maintained. The rule of law, after all, in part depends on paying judges so well that they will not be tempted to accept bribes.
Many medical decisions – whether to treat, how much to investigate – are not clear-cut. We deal in probabilities, not certainties. Patients are not consumers who, by definition, always know what is best for themselves, and instead must usually accept their doctors’ advice. Clinical decision-making is easily distorted by the possibility of financial gain for the doctor or hospital, without necessarily being venal (although it certainly can be). Increasing litigation against doctors also drives over-investigation and over-treatment – so-called ‘defensive medicine’. It is always easier to do every possible test and treat ‘just in case’ rather than run the risk of missing some very obscure and unlikely problem and being sued. This combination of paying doctors on a ‘fee for service’ basis – the more we do, the more we get paid – and increasing litigation against doctors in many countries is one of the reasons why health-care costs are running out of control.