by Henry Marsh
‘Patient is thirty-five-year-old and has headache for five years. Bowels and bladder normal. On examination pupils equal and reacting. Cranial nerves intact, reflexes equal and plantars downgoing. Had MRI scan.’
‘Well, let’s look at the MRI scan,’ I suggested, which we did and which was, predictably, normal. How much does that cost? I wondered to myself. The answer, I learnt later, was an entire month’s income. I was completely nonplussed. Uncertain as to what I was supposed to recommend, I asked the MOs.
After some hesitant discussion with them, I discovered that a huge variety of drugs were widely used in Nepal, often in a largely random manner. As it is, the patients can buy virtually any drugs themselves from small pharmacies on the streets. There is one on my walk to work, always with a queue. Steroids, I discovered, were popular for all manner of complaints, as was diazepam – Valium. After a few weeks of outpatient clinics, I began to suspect that the entire population of Nepal was on the pain-killing antidepressant amitriptyline.
The first patient was hustled off to be given a prescription and the next, who had been sitting next to her, was moved sideways onto the chair she had left. The clinic was clearly run on ergonomic, assembly-line principles. There was a long line of patients with headaches and backache, sore joints and one with rectal bleeding. I realized that the outpatient clinic functioned more as a GP surgery than a specialist neurosurgical clinic and I had to reach back into my basic medical knowledge from more than thirty years ago. This was both interesting – I was surprised at how much came back to me – and worrying. I was anxious that I might have forgotten something obvious and important after so many years spent specializing in neurosurgery. At least there was internet access, and it was helpful to find answers to most of my uncertainties on my laptop.
The next patient is a young woman with complete paralysis of half of her face after surgery for a huge acoustic tumour. It’s a common complication and often inevitable if the tumour is as large as they usually are in Nepal because of delayed diagnosis. The patient and her husband are delighted when Dev comes into the room. They chatter happily. Dev puts his arm on the husband’s shoulder.
‘I was congratulating him on being a devoted husband. She was very ill after surgery but he stuck by her. They come from a part of the country where if the buffalo is ill, worth 63,000 rupees, they will spend money to treat it but not if the wife is ill. He’s a good man!’ And he slapped the man on the back again.
‘Twenty-two-year-old woman with headache for three months. On examination pupils equal…’
‘No, no, hang on a moment. What does she do for a living?’
There was a brief discussion between the MO and the patient.
‘She counsels victims of torture, sir.’
‘What? From the time of the Maoist insurgency?’
‘Yes, sir.’
‘Does she enjoy the work?’
Apparently she rather liked it. Had she received training for this? I asked.
‘Yes,’ came the reply.
‘For how long?’ I asked.
‘Five days,’ she said.
A skull X-ray was produced.
‘This is a waste of time for headache,’ I said.
‘No, sir,’ came the very polite reply. ‘It is of her sinuses and she has sinusitis.’ And now that I thought of it she certainly sounded as though she had a blocked nose.
‘Ah, yes. I missed that. Shall we send her to the ENT clinic?’
‘They are on holiday for Dasain, sir.’
‘Well, you’d better prescribe her a decongestant then.’
And every so often there might be a patient with a brain tumour about whom Dev wanted my opinion, or another serious and often rare problem, but most of the patients had chronic headache or dizziness or the peculiarly Nepali symptom of total body-burning pain, and were determined to have MRI scans, despite my assurance that the scan would not help. As they would have to pay for the scan, it was not worth arguing over.
I quickly learnt that many of the patients were very disappointed to see me as opposed to the famous professor, even for the simplest of problems. I might have spent thirty minutes explaining things via one of the MOs but I had to resign myself to politely disappointed patients insisting on seeing him, although a few declared themselves happy with my opinion.
Meanwhile, in the room next door, Dev would be conducting his own high-speed clinic. The patients all expected to see him and he tried to see all the new ones himself. His room was full of doctors, receptionists and relatives, all standing, with the patient sitting in the middle of the melee. It made you think of a king, surrounded by courtiers and petitioners.
The door between our rooms was open and I could hear him coaxing, cajoling, declaiming, reassuring in rapid Nepali, depending on the class and education of the patients. They ranged from impoverished peasants from the mountains to teachers and politicians.
‘How many patients actually have a neurosurgical problem?’ I asked him.
‘One point six per cent,’ came the answer.
‘Do other doctors refer you patients?’
‘No, they all have their own connections and hate me. They try to refer them elsewhere but the patients come and see me anyway.’
As I left my first outpatient clinic I was stopped by a man I did not recognize.
‘I am the girl’s father,’ he said in passable English. ‘Thank you, sir, thank you so much,’ pressing his hands together and holding them against his chest in Nepali greeting. Dev must have told him that I was involved in the surgery. I smiled, I hope not too sadly.
‘My son had a brain tumour,’ I told him, ‘I know what you are feeling.’ He thanked me profusely again, and I nodded in acknowledgement and sympathy and went to the management office to wait for Dev and to be driven home.
I have never enjoyed swimming – I was taught to swim at school at the age of eight, in the muddy river at the edge of the school playing fields, with a canvas belt around my waist attached to a rope and wooden pole, which one of the schoolmasters held like a heavy fishing rod. I dreaded having to climb down the slimy wooden ladder attached to the landing stage, with the cold, wet belt around me, seeing the master’s shoes above me through the stage’s planks, into the dark water. I would hang onto the ladder, half submerged, before being tugged by the master controlling the rope. I floundered into the water like a hooked fish. You were just expected to keep afloat by dog-paddling. There was no attempt to teach you to swim and the rope and pole were used to stop you drowning. I remember one of my schoolmates being flung into the river by the master when he was too frightened to descend the ladder. I used to wet myself with fear when changing into my swimming trunks for this character-building experience.
At my next school I was taught to swim properly by the kindly headmaster, but after that there was a notoriously sadistic ex-commando PE master who once hit my face so hard that it was numb for hours afterwards. I was so frightened of the man that I would slam my classroom desk’s hinged lid on my hand to bruise it and claim that I had fallen and couldn’t swim. That only worked once, so I then took to sticking my finger in one of my ears for many hours, mimicking an ear infection. The school doctor was very puzzled by this, as it only happened once a week. I was marched off to an ENT clinic at St Thomas’s Hospital accompanied by the school matron. A sceptical consultant, with a row of medical students, looked in my ear and expressed some doubts. I can’t remember what was said, but I do recall trying to persuade myself that there really was a problem with my ear even though I knew that I was malingering. It was my first experience of cognitive dissonance – entertaining entirely contradictory ideas – and the importance of self-deception in trying to deceive others. I then discovered that music lessons for playing the trumpet were on the same day and at the same time as the swimming class with the vile ex-commando, so I took up the trumpet but did not get on with it. Eventually I would just hide in a cupboard and skip the swimming lessons – an act of some bravery, I though
t – and I got away with it.
I was at my weekly brain-tumour meeting twenty-five years later when a brain scan with a familiar name appeared on the screens in front of us. It was the PE master from my past and it showed a malignant brain tumour.
‘He’s a most unpleasant person,’ my oncology colleague said. ‘We’ve had no end of trouble with him but it’s a frontal tumour, so maybe he’s suffered personality change.’
‘No, he hasn’t,’ I said, and explained my connection with the unfortunate man.
‘The tumour needs to be biopsied,’ my colleague said.
‘I think it might be better if you got somebody else to do it,’ I replied.
I wake with the dawn, the crack between the curtains facing my bed going from dark to light, to the sound of cocks crowing, dogs barking and birds singing. I go for a run every morning, but it took me a few weeks to overcome my fear of the local dogs – the guidebooks warn of rabies but my Nepali friends assured me this is more of a problem with the temple monkeys than the street dogs. So at first I ran in slightly absurd small circles and figures of eight in Dev and Madhu’s garden, and up and down the many steps, for half an hour. Later, a little braver, I took to running for longer along the local lanes, between the tightly packed houses that didn’t exist even ten years ago, past the rubbish and open drains, past sagging power and phone lines and bougainvillea hanging over garden walls. The road is uneven earth and rock, but there are a few short stretches of rough concrete, prettily patterned with the street dogs’ pawprints. There is a small shrine on my usual route, and passers-by ring the bell that hangs by its entrance. All around me there is the sound of people coughing and hawking as they start the day. Neither the dogs nor the local people take any interest in me – it seems that there is nothing unusual in the sight of an elderly and breathless Englishman in football shorts stumbling along the road, but Nepalis are very polite and so perhaps are the dogs.
In England I run for longer. I used to run close on fifty miles a week, but one of my knees started to complain and now I only run twenty-five miles a week. I rarely enjoy it – I find it a considerable effort and my body feels stiff and leaden – but I do it for fear of old age and because exercise is supposed to postpone dementia. But there were occasionally wonderful moments when I was still running long distances – up to seventeen miles at weekends in the countryside surrounding Oxford. One early spring morning I was in Wytham Woods, the low sunlight falling diagonally through the trees, when I came across a leveret – a young hare – eating grass beside the path. It appeared completely unafraid of me and I was able to stand only three feet away as it quietly grazed, looking at me with its bright eyes. It was a unique moment of innocent trust from a wild animal, and I felt deeply moved. There is a beautiful ink and sepia drawing by the mystical early-nineteenth-century artist Samuel Palmer in the Ashmolean Museum in Oxford which shows the very same scene – a young hare in a wood, early in the morning, with the sun rising.
On another occasion, as I ran along the Thames, I noticed a duck desperately flapping in the water at the end of a broken-down pier. It appeared to be caught on something, so I crawled out along a steel beam projecting over the river, all that was left of the pier, feeling heroic. I found that the duck had a fish hook in its beak, with the fishing line wrapped around the beam. I managed to free it without falling into the river. The duck promptly dived into the water without stopping to thank me. Nevertheless, I like to think that if one day I ever get into trouble when swimming, the grateful duck – as in the fairy stories – will come and rescue me.
After running round Dev and Madhu’s garden, I do fifty press-ups and a few other exercises, all of which I also hate doing, but I feel much better for it afterwards. I finish with a short swim in the small swimming pool outside the guest house. There is a very brief moment of ecstasy as I push out into the cold, mirror-calm water, which reflects the early-morning sky, with a view of the nearby Himalayan foothills in front of me. I momentarily forget my deep dislike of swimming. I complete this morning ritual with a cold shower – something I started doing two years ago. At first, admittedly in England in the winter, I thought I had discovered the elixir of life. A feeling of exhilaration, of intense well-being, would last for up to two hours afterwards. To my great disappointment, this wonderful feeling – acquired so easily within a couple of minutes – became shorter and shorter within a matter of weeks. I continue to have a cold shower every day, but the feeling now lasts only a few seconds at best, although the cold water still makes me jump about and gasp. I suppose my physiology has adapted, although health fanatics claim that cold is good for ‘vagal tone’ – the activity in the vagus nerve, which controls many of our body’s functions in ways that we scarcely understand. It is a long nerve, which bypasses the spinal cord and reaches from the brain to the heart and many other organs, carrying information and instructions in both directions. It is an extraordinary nerve. Stimulation of the nerve with an electric current can help epilepsy, though nobody knows why. It can allow the generation of orgasms in women who are paralysed and have suffered complete destruction of the spinal cord. Apparently, people who have had it divided (an obsolete operation for gastric ulcer) will not develop Parkinson’s disease.
After all this I sit beside the swimming pool in the little paradise of Dev and Madhu’s garden, with flowers and birds all around me, and drink a cup of coffee before setting off for the hospital. Sometimes a bird with brilliant turquoise plumage dives down onto the surface of the pool, its wings and the splashing water flashing in the sunlight.
After a few weeks I decided to rearrange the way my clinic was run. I had the junior doctors sitting down, I would politely greet each patient when they entered, as I would do in England, which seemed to be less expected here. We would only have one patient in the room rather than a whole queue. The patients would usually come into the room looking expressionless, but my saying ‘Namaste’ and pressing my hands together would almost invariably produce an utterly charming, slightly shy smile in reply. I insisted that every consultation had to end with asking the patient if they had any questions. This made the consultations feel a little less like assembly-line work but greatly reduced the number of patients I could see with the MOs, as the patients had so many questions to ask. They rarely spoke English and often were poor historians, as doctors call patients who have difficulties describing their symptoms. Many of them were subsistence farmers who could not read or write, and the MOs’ English was often very limited as well. Making any kind of diagnosis could sometimes be impossible as the patients seemed so uncertain about their symptoms and were so determined to be given some new drug treatment. On the other hand, some of the patients had diseases such as TB and filariasis, with which I was unfamiliar. I found conducting the clinic extremely difficult, and had to be careful not to miss a serious problem in the constant stream of patients with chronic low back pain, headaches and total body-burning pain.
‘Do you know what somatization is?’
‘No, sir.’
‘Well, it’s the idea that if people are unhappy or depressed – marriage problems, things like that – rather than admit it to themselves, they develop headaches or total body pain, or strange burning feelings. They attribute their unhappiness to these symptoms, rather than consciously admit that they are unhappy in their marriage or that there is some similar problem. Such symptoms are called psychosomatic. You can see it as a sort of self-deception. Is the diagnosis of depression recognized here?’
‘Not really, sir.’
‘All pain is in the brain,’ I explained as I pinched the little finger of my left hand in front of the MOs on the other side of the desk. ‘The pain is not in the finger – it’s in my brain. It’s an illusion that the pain is in the finger. With psychosomatic symptoms, the pain is created by the brain without a stimulus from the peripheral nervous system. So the pain is perfectly real, but the treatment is different. But patients don’t like being told this. They think they’re being
criticized.’
‘Many of the women are seeking attention,’ Upama, the MO said. ‘Their husbands are away working abroad and they are unhappy.’
Amidst the flood of patients with minor problems, there are terrible cases as well – a young woman with much of her scalp infiltrated by a malignant skin tumour, a man dying from a brain tumour. There was a child, a thirteen-year-old girl, with half her face paralysed. The scan showed a complex congenital malformation of the joint between the spine and skull, which was the likely, though a very unusual, cause of her paralysis. Neither Dev nor I are very expert in such problems, and we had agreed that surgery was probably too difficult and dangerous. Upama explained this to the girl and her father, and the girl started sobbing silently.
‘She is a girl,’ Upama explained. ‘Her face…’
While I watched the child cry, I thought about my detachment from her suffering – detachment both as a doctor and also because of the great gap of culture and language between us. I have to be detached, I thought, and it is something I learnt as soon as I qualified as a doctor. I cannot help this child, and there is little point in being emotional about it. But I also thought of the research into bonobos (previously known as pygmy chimpanzees), our closest evolutionary relatives, which shows that they have compassion and kindness, a sense of fairness and console each other over pain – at least for their own group. They have not been told to do this by priests or philosophers or teachers, it is part of their genetic nature, and it is reasonable to conclude that the same applies to us.
For most of us, when we become doctors, we have to suppress our natural empathy if we are to function effectively. Empathy is not something we have to learn – it is something we have to unlearn. Patients become part of the ‘out-group’ as anthropologists call it, people with whom we need no longer identify. But the child went on crying and I started to feel uncomfortable. Besides, I told myself, the only way that doctors can lay claim to any kind of moral superiority over other professions is that we treat – at least in theory – all our patients in the same way, irrespective of class or race or nationality, or even of wealth. So my detachment wilted as the child cried and I thought I might just see if Dev and I could be wrong. I used my smartphone to photograph the girl’s scans and emailed them to a colleague on the other side of the world, an expert in problems of this sort, for an opinion. He replied thirty minutes later, saying he felt that surgery was both possible and relatively straightforward.