by Henry Marsh
On the other hand, a fixed salary can breed complacency and an irritating moral righteousness, to be found in some doctors who disdain private work. It is indeed a delicate balance, and Dev and Igor, both doctors of great integrity, have mixed feelings about running private hospitals.
‘I am the country’s highest taxpayer,’ Dev tells me with a laugh, pointing to a photograph on his office wall of the Finance Minister recently handing him a certificate to this effect. Yet it seems highly unlikely to me that Dev is the highest earner in Nepal.
In Nepal and Ukraine – and many other countries – government is widely seen as corrupt and, understandably, people are reluctant to pay taxes, doing everything they can to evade them. There’s another parallel here between Dev and Igor: both are scrupulous in paying their taxes. But it is difficult to be honest in a dishonest society, and many people will hate you for it.
Low tax revenues mean that governments in poor countries like Nepal and Ukraine have little money to spend on health care and infrastructure projects that would benefit the country. Besides, Ukraine is involved in a war and Nepal is still recovering from a vicious civil war. The lack of government spending on welfare and infrastructure only serves to reinforce the public’s reluctance to pay taxes. It is a vicious circle from which it is very hard to escape. Driving in Kathmandu can be a vision of hell and Hobbesian anarchy, especially at night in the suburbs. There is no street lighting. Trucks, cars and motorbikes are crammed together in narrow, rough lanes, driving in a cloud of dust and diesel fumes, eerily lit by undipped, dazzling headlights. Nobody gives way, each driver tries to go first – if you give way you will never move. There is no argument or shouting, nobody loses their temper, there is only the occasional blowing of horns. Everybody is resigned to the grotesque struggle which they have no power to end. Pedestrians join the crush to cross the road like ghosts in the dust. The unfortunate traffic police must inhale the poisoned air all day when they stand at the crossroads, trying to direct the chaotic vehicles. The city is asphyxiating, but the government appears to be utterly helpless and apparently has no plans to do anything about it at all.
The only certainties in life, as Benjamin Franklin once observed, are death and taxation. We all try to avoid both. But health care is getting more and more expensive – in most countries the population is ageing and needs more medical attention, and high-tech modern medicine is ever more extravagant. We all want to see cancer cured, but this will only drive costs up and not down. Not just because the complex genetic and drug treatments involved are so costly but because more of us will then live longer, to die later from some other disease, or slowly from dementia, requiring constant and expensive care. And rather than discover new antibiotics – the human race, especially in poor countries, faces decimation within a few decades from bacterial antibiotic resistance – the pharmaceutical companies concentrate on drugs for cancer and the diseases, such as diabetes and obesity, of affluence.
So health care is becoming ever more expensive, but most governments fear that putting up taxes or insurance premiums will lose them the next election. So instead, in the West, a small fortune is spent on management consultants who subscribe to the ideology that marketization, computers and the profit motive will somehow solve the problem. The talk is all of greater efficiency, reconfiguring, downsizing, outsourcing and better management. It is a game of musical chairs where, in England at least, the music is constantly being changed but not the number of chairs, and yet there are more and more of us running around the chairs. The politicians seem unable to admit to the public that the healthcare system is running out of money. I fear that the National Health Service in England, a triumph of decency and social justice, will be destroyed by this dishonesty. The wealthy will grab the chairs, and the poor will have to doss out on the floor.
As the weeks went by I took to absenting myself from the ITU rounds, unless there was a patient with whose operation I had been involved. I found the rounds too depressing.
After the ITU round Dev spends up to an hour on ‘counselling’. The patients’ families will stay in or near the hospital throughout the time their family member is there. There is a small hall in the centre of the hospital’s first floor, well lit by a glass roof and decorated with palms in large planters. A prayer room with colourful Hindu and Buddhist icons is on one side. The families of the patients on the ITU wait here to be seen, one by one, by Dev and his colleagues in the counselling room next to the prayer room. They are updated on their relative’s condition, questions are answered, and then they sign the medical notes, confirming what they have been told.
‘I had problems to begin with,’ Dev said. ‘Some of the families denied that they had had things explained to them, so I now do it formally every day.’
Although it was all in Nepali, it was fascinating to see Dev at work. As all good doctors do, he adjusted his style to the people he was talking to – sometimes joking, sometimes grave, sometimes consoling, sometimes dictatorial. On one occasion the patient’s daughter was a nurse who had been working in England and spoke good English. Her elderly mother had suffered a huge stroke and the whole of the right side of her brain had died. She had undergone decompressive surgery and had therefore not died within the first few days but was now lying in the ITU, half paralysed and unconscious.
‘You talk to her,’ Dev muttered to me, ‘and you’ll see the problem.’
So I spoke to the daughter as I would speak to the families of my patients in England. I told her that if her mother survived she would be utterly dependent and disabled, with grave damage to her personality and intellect.
‘Would she want to survive like that?’ I asked. ‘That’s the question you and the rest of the family should be asking yourselves. I would not want to live like that,’ I added.
‘I hear what you are saying,’ she replied, ‘but we want you to do everything possible.’
‘You see?’ Dev said to me later. ‘They’re all like that. I’ve even had it with families of doctors. They just can’t face reality.’
The child’s head was completely shaven and had already been fixed to the operating table with the pin headrest. The juniors had had problems inserting a central intravenous line into one of the major veins in the neck and had ended up hitting the carotid artery. They then decided to rely on two large peripheral lines in the smaller veins of her arms for blood transfusion, in case there was heavy bleeding from the tumour. So there had been long delays before I came into the operating theatre. Much of her face was hidden by the plaster strapping holding the endotracheal tube in place, but despite all this and the disfiguring shave, she looked painfully sweet and vulnerable, with a broad Tibetan face, light-brown skin and slightly red-tinted cheeks.
Dev was standing by the patient’s head. ‘You and I trained together,’ he said. ‘We think along the same lines.’ He has six trainees whom he has trained to do the simple emergency work and the ‘opening and closing’ of the routine surgery. Dev, however, does almost all the major operating himself. Occasionally he has been joined by foreign surgeons, but only for short periods of time. There are major cases to be done every day, six days a week, and the pressure is relentless. In six weeks working in Kathmandu I saw more major operations than I would have done in six months in London.
This was the first time I had seen the child, although I had looked carefully at her brain scan with Dev earlier that morning.
‘She was operated on by one of the other neurosurgeons here in Kathmandu,’ Dev told me, ‘but I don’t think he removed much of it. Just did a biopsy. It’s said to be a Grade Two astrocytoma.’
‘It’s not a good tumour,’ I said, looking unhappily at the scan. ‘It may be benign but it’s involving all the structures around the third ventricle and God knows where the fornices are.’
‘I know,’ said Dev.
The fornices are two narrow bands of white matter, a few millimetres in size, that are crucial for memory. White matter consists of the billions of ins
ulated fibres – essentially electrical cables – that connect the eighty or so billion nerve cells of the human brain together. If the fornices are damaged, people lose a large part of their ability to take in new information – a catastrophic disability.
Average income in Britain is forty times greater than in Nepal. Primary health care in Nepal is poor (although better than in many other low-income countries) and diagnosis of rare problems such as brain tumours is invariably delayed. The tumours, therefore, by the time they are diagnosed, are much larger than in the West and treatment is more difficult, more dangerous and less likely to achieve a useful result. Brain tumours in children are very rare but very emotive, and although the rational part of myself considered that operating on this child was a waste of time and money, it is almost always impossible, wherever you are in the world, to say this to the desperate parents. And I myself had once been the parent of a child with a brain tumour. But the decision was Dev’s responsibility and not mine.
Once I had checked that they had positioned the child correctly, I left them to start the operation, returning when a nurse came to Dev’s office and silently beckoned me to come to the operating theatre and join Dev.
I am becoming little better than a vet, I told myself as I scrubbed up at the long zinc sink with its row of taps and iodine dispensers. I am operating on patients without knowing anything about them, without even seeing them other than as unconscious, impersonal heads in a pin headrest.
4
AMERICA
One year before I went to Nepal, and before I had retired, I attended a cerebrovascular workshop in Houston, intended to help trainee surgeons learn how to operate on the brain’s blood vessels. I was to be one of the instructors. I arrived from London after a ten-hour flight. The workshop started next morning at eight, after I had delivered a lecture at seven to my colleagues in the neurosurgical department which I was visiting. American hospitals start early – the interns, the most junior doctors, often begin their ward rounds before five in the morning. I once asked a group of them about the physiological effects of sleep deprivation on their patients and they seemed quite startled by the suggestion that their immensely hard work might actually be harming the patients.
My lecture was about how to avoid mistakes in neurosurgery, but only a handful of people had turned up to listen to me, presumably because they felt that they had little to learn from the mistakes made by an obscure English surgeon such as myself. The large breakfast laid out in the room outside the lecture theatre remained uneaten. There was a short briefing at the beginning of the workshop. We sat on tiered seats in a small room with three enormous LED screens in front of us. Everything looked new and immaculately clean. A businesslike woman dressed in scrubs told us that under no circumstances was photography permitted and that everything we would be doing was regulated by federal law. She cited various specific statutes which were flashed up on the screens, each one with a long reference number. She also told us that we must respect the subjects of the workshop. Different-coloured hats were then handed out – mine was blue as I was a member of the faculty. The medical students’ were yellow and the neurosurgical residents’ were green. We were then ushered through a pair of large security doors into the research facility.
This looked like a cross between an operating theatre and an open-plan office, with several bays. Floor-to-ceiling windows looked out onto the many glittering skyscrapers that form the Texas Medical Center, the largest concentration of hospitals anywhere on the planet. There are 8,000 hospital beds here – fifty-one clinical institutions in total, I was told – practising some of the most advanced medical care anywhere in the world. There were half a dozen shapes lying on operating tables; I suppose each one was about the size of a ten-year-old child. They lay entirely hidden under blue surgical drapes, with anaesthetic tubing and cables coming out of one end, connected to the same ventilators and monitors with colourful digital displays that I see every day at work. I walked up to one of them and put a hesitant hand out – it was strange to feel the hoofed trotters under the drapes at the end of the operating table.
‘Isn’t this just fantastic!’ said my colleague, a trainee of mine from many years ago, who had recently become the chairman of the neurosurgical department which was staging the workshop, which he had organized. ‘Nobody anywhere else is doing anything like this! Come on, guys!’ he said to the residents in their green hats. ‘Enjoy!’
One of the faculty pulled back the blue drapes off the head of one of the pigs and started to operate. The pig was lying on its back with its broad, pink neck stretched out. It had probably been shaved, and although it was clearly not a human neck – it was far too flat and wide – the skin looked disconcertingly similar. He used cutting diathermy to dissect down to the carotid artery, one of the main arteries for the brain – a smaller vessel than in a human. The plan was to dissect out a vein and graft it to the artery, creating an aneurysm, a model for the life-threatening aneurysms that occur in people and cause fatal haemorrhages. The artificial aneurysm can then be treated – with an ‘endovascular’ or ‘coiling’ technique where a microscopic wire is inserted into the aneurysm via the artery, involving only a simple puncture in the skin, and the aneurysm is blocked off from the inside. Alternatively the aneurysm can be treated with the more old-fashioned method of open surgery, where it is clipped off from the outside. Most aneurysms in people in the modern era are treated with coils, but a few still need clipping. The purpose of the workshop was to give trainee surgeons some practice in the techniques without putting a human life at risk. I am sentimental about animals, and felt sorry for the pigs, but reminded myself that they were doing more for humanity by being used for surgical practice than by being turned into bacon – and there were all those federal statutes protecting them, after all.
My fellow instructor started to stitch the vein graft to the artery. It was a rather slow business and I wandered off towards a group of doctors gathered in a corner of the room. A blue-capped faculty member was talking with great enthusiasm.
‘This is awesome! This is so much better than specimens preserved in formaldehyde!’
I looked over his shoulder. Two trainees were operating on a severed human head. It was held in the steel head clamp most neurosurgeons use when operating and the skin of the neck had been formed into two flaps; these had been stitched together with a few broad sutures to form a stump, although some slightly obscure fluid was dripping out between the sutures. If I had not done my year of cadaveric dissection as a medical student forty years ago I think the sight would have given me nightmares for many days afterwards. It was bizarre and disturbing to see a head in a standard head clamp – something I must have experienced thousands of times with living patients when I operate – and yet with no body attached to it.
So I joined the small group standing around the two trainees who were carrying out a craniotomy under the guidance of a fellow instructor – sawing open the severed head with surgical tools, looking down an expensive operating microscope. I was staggered by all the equipment which surrounded the various stations, six with anaesthetized pigs and now one with a dead person’s head. All of it had been provided by the manufacturers – hundreds of thousands of dollars’ worth, all to be used for practice. As I watched the two trainees uncertainly drilling into the severed head, a young man behind me – dressed, to my surprise, entirely in black scrubs like a ninja – accosted me.
‘Professor!’ he said, with the passionate conviction of an equipment rep. ‘Have a look at this.’ He pointed to the beautiful array of miniature titanium plates and screws and tools, each in its own perfect moulded cavity on a black plastic tray in front of him. These plates are screwed in place to reassemble the skull after sawing it open – although in this case only for practice.
‘Have you tried our latest electric screwdrivers?’ he asked, handing me a neat little battery-powered screwdriver which I suppose would save about five seconds, and needed only marginally less effort than
the manual screwdriver I normally use when putting patients’ skulls back together again with titanium plates. I switched the electric screwdriver off and on, marvelling at the extravagance of the American medical system.
‘How d’ya like it?’ asked the rep.
‘Outstanding,’ I replied, thinking of how, on my flight the previous day, the pilot had told us over the intercom when the plane was about to begin its descent that now would be an outstanding time to visit the restrooms.
‘Guys! We have a master here!’ the instructor called out when he saw me. ‘Professor, can you give us some surgical pearls?’ I thought a little apologetically of the swine in the nearby bay undergoing surgery.
Happy to have something useful to do, I pulled on a pair of gloves and went up to the microscope to reposition it and look down into the dead brain.
‘Have you got any brain retractors?’ I asked. ‘“Ribbons” you call them here in the US.’ It seemed they did not, so I used a small chisel to gently lift up the frontal lobe. There was, of course, no bleeding, but the consistency of the dead tissue was not unlike that of the living thing.
‘Formaldehyde makes it all stiff and solid, and it smells awful,’ I said. ‘But where do they get these freshly dead heads?’ I asked of nobody in particular.
‘Maybe a John Doe scraped off the sidewalk,’ somebody offered.
Using the small chisel I dissected out the anterior cerebral arteries, explaining how you approach an anterior communicating artery aneurysm by resecting – that is, removing – part of the brain called the gyrus rectus to find the aneurysm.