Admissions

by Henry Marsh

  The Health Camp took place in what had been a brand-new primary care hospital, but which had been badly damaged in the earthquake a few days before it was due to open. It had been abandoned until Dev had come to inspect it and found that most of the building was serviceable, although in a terrible mess. An advance party had arrived a day before us and I was very surprised to find a clean and tidy building – although with great cracks in the walls and one wing partially collapsed – when we arrived. The Neuro Hospital team of over thirty doctors, nurses and technicians had come with enough equipment to run two operating theatres, a pharmacy and five outpatient clinics, with plain X-rays and ultrasound and a laboratory. It was an impressive piece of organization – but they had done similar camps elsewhere before, especially after the earthquake, and had learnt from experience.

  Next morning there was a long queue of patients – several hundred, mainly women, all dressed in brilliant red – waiting outside the hospital. All the treatment would be free. They were sheltering under equally colourful umbrellas, as the temperature was soon in the 90s. They were held back at the hospital gates by armed policemen and allowed in, one by one, to be registered at the entrance and directed to the appropriate clinic – such as orthopaedic, plastic-surgical or gynaecological. Fifteen hundred patients were seen in three days and many, relatively minor, operations performed, some under general anaesthetic. Difficult cases were advised to go to larger hospitals long distances away. Patients came from far and wide – the Health Camp had been advertised for many days in advance.

  ‘Some patients are coming from the Tibetan border,’ I was told.

  ‘How far away is that?’

  ‘Four or five days’ walk. No roads. Ten days if you or I tried to do it.’

  Sick patients arrived on stretchers. Several old people arrived carried piggyback.

  Although I was treated like visiting royalty, and presented with bougainvillea garlands and silk scarves at the lengthy opening and closing ceremonies by the local people, and a framed certificate entitled ‘Token of Love’, I was completely useless. My days of general surgery and general medicine are long behind me. I was disappointed to find, as I watched Dev happily operating on inguinal hernias, hydrocoeles and similar lesions, that I had completely forgotten how to do them, even though I had spent a year doing dozens of such cases when working as a general surgeon. Thirty-five years ago, a year of general surgery had been a necessary part of qualifying for the final FRCS examination, which I had to pass before I could train as a neurosurgeon. I sat in on some of the Health Camp clinics, and I found that the junior doctors knew much more than I did.

  Dev is doing a clinic – a chair has been put next to him for me. A tidal wave of patients now flows in: an old woman with elaborate gold ornaments in her nose and a rectal prolapse, old men with inguinal hernias, old women with haemorrhoids, many patients with varicose veins – cases which remind me why I was pleased when my year of general surgery came to an end almost forty years ago, and I could devote myself to neurosurgery. But it also reminded me how modern medicine is not just about prolonging life – it has probably achieved as much good by finding treatments for all the chronic non-fatal conditions from which we would otherwise suffer and from which people in poor countries like Nepal still suffer.

  I remembered a rectal clinic I had done on Friday afternoons when I did my mandatory year of general surgery. Neither I, nor my patients, enjoyed the experience. They knew, and I knew, that I was going ‘to give them a ride on the silver rocket’ – the medical procedure of sigmoidoscopy, where an illuminated long stainless steel tube is used to examine the inside of the rectum. But I was happy enough when I was in the operating theatre.

  There is a young woman with unilateral proptosis – her right eye is bulging outwards; we will send her to Kathmandu for a scan. There is a girl with what are probably pseudo-seizures, hurried in by her anxious mother. If people have fits in front of the doctor – which is what is happening here – it usually means, although not always, that the problem is psychological rather than epileptic. Dev prescribes the antidepressant amitriptyline. There’s no question of any follow-up in such a remote country area. It is impossible to know what will happen to the patients. Many of them – most of whom are illiterate – produce plastic bags full of the many medicines they have been taking.

  It’s all in Nepali, of course. I am half asleep, lulled by the sound of hundreds of voices outside and the whirring of the ceiling fan. The temperature outside must be in the high 90s. The patients at the front of the queue are pressed up against the metal gates, and the police guards push themselves into the crowd from time to time to stop fights breaking out, or to allow urgent cases to be brought into the hospital. But inside the building everything is highly organized.

  There is a man with huge, wart-like growths on his hands and feet. Next we see a five-year-old boy and his ten-year-old sister, who both went blind at the age of two. They are led into the room and sit sightlessly while my colleagues thumb through the stained and dog-eared pieces of paper that comprise their medical notes. All we can do is confirm that there is nothing to be done. I ask whether there are schools for blind children in Nepal and am told that there are, but that it is unlikely that these children, from a remote mountain village, could go to one.

  At lunch on the baking-hot roof, sitting in the shade of a bright-blue UNHCR tarpaulin left over from earthquake relief, I talk to the gynaecologist.

  ‘How many PVs [vaginal examinations] have you done so far?’

  ‘Over five hundred.’

  ‘Do the women know any anatomy?’

  ‘Most know none at all. It’s a waste of time trying to explain anything to them. A few of them can understand. But usually I just say take the medicine and this is the name of your illness. The women in the queue outside the room,’ she adds, ‘were starting to fight each other, trying to get in…’

  One room is reserved for people who are too weak to sit or stand. There is a young woman with diabetes who is now in severe ketoacidosis. She lies on a stretcher, with dulled eyes and a deeply resigned expression on her face, coughing and retching into a plastic bowl from time to time. The MO fails to get a drip up on her and I reconfirm my uselessness by also failing. One of the anaesthetists succeeds. We give her IV fluids and find some insulin from another patient.

  ‘What’s her outlook?’ I ask.

  ‘Not good. Poor peasant in a remote village. Can’t afford insulin. Diabetes is still a fatal disease here for many people. But we’ve told her husband to take her to the nearest big hospital. They may be able to help.’

  I find an empty room in the ruined part of the hospital. There are large cracks in the wall from the earthquake. The many windows look out onto some tall mango trees and the room is full of the sound of the wide River Budhi Gandaki rushing past, coming down from the glaciers of the invisible Mount Manaslu. I sit there quietly for a while, trying to write, until two playful Nepali boys find me and peer over my shoulder at what I am doing and will not leave me alone, so I return to the clinic to watch more patients come and go.

  After three days, Health Camp comes to an end. By the early evening there are only a few patients left waiting outside the entrance. I sit outside on a white plastic chair looking at the dim, blue hills around me. It is still very hot, and there is a strong wind, so the giant mango trees wave and shake. A noisy wedding party passes on the nearby road, dust swirling about them, the women all brilliantly dressed, with two men at the head of the procession blowing on long, curved horns. The bride is carried in a palanquin, and is veiled and dressed in red and flashing gold. The groom walks behind, his face heavily made up, wearing an elaborate and decorated coat. Three young girls are playing in the hospital courtyard and come up to me. We exchange a few words, which we don’t understand, and they happily laugh and dance around me for a while, before running away. I so wish I spoke their language and could talk to them. My inability to speak any language other than English is the deepes
t of all my regrets. So I sit by myself and watch dust devils spiral up off the dry ground, driven by the wind, as the light slowly fades.

  12

  UKRAINE

  Igor, as always, is waiting for me at the airport, his head in a tight woollen cap, bobbing up and down in the crowd outside the exit, trying to spot me. His characteristically stern expression breaks into a brief smile when he sees me, but in recent years the smile has become briefer and briefer. His serious enthusiasm, which had so impressed me when we first met, seems to have changed into something grim and rather different.

  I awkwardly accept his kisses. We argue over who should carry my suitcase (often full of second-hand surgical equipment) and climb into his van. We drive into the city to the hospital, and Igor holds forth in his broken, staccato English. It was only when I heard Ukrainian spoken by the Ukrainian poet Marjana Savka in Lviv, in the west of the country, that I realized Ukrainian could be very beautiful, and not the rather harsh, declamatory language spoken by Igor.

  ‘Financial crisis terrible. Everybody have money problems. Everybody unhappy. Before crisis my doctors make maybe two thousand dollars in month, now only four, maybe five hundred.’ This monologue continues until we reach the hospital. I know that there will be a long queue of patients in the corridor outside the small, cramped office waiting to see me, almost all of them with large and terrible brain tumours and other, often hopeless, neurosurgical problems.

  ‘Two acoustics to see,’ he says, as we pass the tall and ugly apartment blocks on the city’s outskirts, looking bleak and unwelcoming in the winter mist. There is a thin layer of snow on the ground. I think, not for the first time, how grim Ukraine can be, and how tough its inhabitants have to be to survive. ‘Many interesting cases, Henry,’ he says happily.

  ‘Well, interesting for you,’ I reply grumpily.

  ‘You lose enthusiasm since you retire,’ he replies in a disapproving tone of voice.

  ‘Maybe I’m just getting old.’

  ‘No, no, no!’ he cries, and then, reverting to his favourite topic, goes on to tell me that twenty Ukrainian banks have collapsed in the preceding year.

  We cross the great River Dnieper on one of the many massive bridges built during the Soviet era. The river is frozen, but only in places, and I can see below us the small figures of dozens of people on the shelves of ice, close to the oil-black water, fishing through holes they have cut.

  ‘People drown every day,’ Igor observes. ‘Twenty this year. It is disaster. It is silly.’

  We drive up the steep cobbled street leading from the banks of the River Dnieper to the centre of Kiev and turn onto Institutskaya Street, where a few months earlier dozens of protesters had been killed by snipers in the Maidan demonstration. The SBU hospital where Igor rents space for his private clinic is just round the corner on Lipska Street. The SBU, once known as the KGB, being an important organ of the State, naturally had its hospital in the centre of Kiev. I had been in Kiev on several occasions during Maidan. I spent as much time as I could mingling with the thousands of demonstrators, proud to feel a small part of it.

  I had first gone to Ukraine in 1992, just after the collapse of the Soviet Union. Entirely by chance I had met Igor in one of the hospitals I had visited. We became friends and I had been travelling to Ukraine for a few days each year ever since to help him with his surgery. At that time medicine in Ukraine was decades behind the West. I found many secondhand instruments and microscopes for him and taught him everything I knew. At first this was all spinal surgery, and Igor was soon probably the most accomplished spinal surgeon in Ukraine. As his fame spread, more and more patients came to his outpatient clinic with problems in the brain. He badgered me constantly to help him develop brain surgery, insisting that the large and difficult acoustic tumours he had seen me operating on in London could not be treated properly in Ukraine. In Ukraine, because of delays in diagnosis, these tumours are usually very large and the operations correspondingly difficult and dangerous. These are tumours which grow off the hearing nerves within the skull and can become large enough to compress the brain and slowly kill the patient. On my very first visit to Kiev in 1992 I went with two other colleagues from my hospital, one an anaesthetist and the other a pathologist. We visited the major State neurosurgical hospital, one of the two major centres for brain surgery in all of the Soviet Union, where we delivered lectures. My pathology colleague was taken on a tour of the pathology department and came back afterwards to tell us, looking a little shaken, of a series of buckets he had been shown containing the brains of patients who had died after surgery for acoustic tumours.

  When Igor and his wife Yelena came to London to Kate’s and my marriage in 2004, all he could talk about was the need to develop acoustic neuroma surgery. Eventually Kate told him that she could stand it no longer. ‘Igor,’ she said, ‘I’m sorry, but we’re going to have a moratorium on the word acoustic. We have to talk about something else. We cannot spend every mealtime, every day, with you trying to persuade Henry to show you how to operate on acoustics.’ Just for once, Igor did what he was told for a few days. Even I found his intense enthusiasm for neurosurgery and utter commitment to it rather tiring at times. Eventually I agreed to help him, but not without misgivings, as the treatment of patients with brain tumours involves much more than just operating.

  In the years before Maidan I would return to England and enthusiastically tell people: ‘Ukraine is a really important country!’

  This was usually met with a puzzled expression.

  ‘It’s part of Russia, isn’t it?’

  And I would then deliver a little lecture on how Ukraine was one of the great historical watersheds, where Europe met Asia, where democracy met despotism.

  I think most of my colleagues and friends in England regarded my slight obsession with Ukraine as an eccentric hobby, but when Maidan started and all of Europe saw the images of the fighting between the demonstrators and the Berkut riot police, resembling medieval battle scenes with staves and shields and catapults, and blazing car tyres filling Independence Square with flames and black smoke, I think I could claim some prescience. Igor had had many problems during the twenty-four years we had been working together. He had been something of a medical revolutionary and dissident, using what he had learnt from me to try to improve neurosurgery in Ukraine. The medical system in Ukraine was as authoritarian as the political system and he made many enemies and had many difficulties. But his patients did very well and eventually his clinic became well established. The many attempts by senior colleagues and administrators to thwart him failed. There was something heroic about what he had achieved, and I felt that my work with him over the years was part of the same struggle against corrupt autocracy as the Maidan protests.

  There is a turnstile in the small lobby at the entrance to the hospital. The tiled floor is wet with thawing snow brought in on people’s boots. Patients and their families can come and go quite freely, but as I am a foreign doctor I am regarded with suspicion by the SBU. When I arrive I have to show my passport to the unsmiling young soldiers behind the glass window next to the turnstile.

  ‘You might be terrorist!’ Igor says as the turnstile is unlocked and it clanks in an authoritarian sort of way as I push through it.

  ‘They are SBU soldiers, and hospital has no control of them,’ he added.

  ‘It must be an awfully boring job.’

  ‘No, no, no. They are happy not to be at frontline.’

  I feel imprisoned once I am inside – imprisoned by my lack of Ukrainian or Russian, and intimidated by the soldiers at the entrance. It is probably quite unnecessary. I once arranged to wait for a film-maker to meet me at the entrance to the hospital. One of the soldiers had to keep me company on the pavement outside until she arrived. When she came she translated what the soldier had started to say to me. I thought he was threatening me with arrest or something similar, but apparently it was a long speech of thanks for my helping Ukrainian patients.

  I l
ook back with some shame on the years of my training. It is complete torment to assist a less experienced surgeon than yourself to do a difficult and dangerous operation. Some of the senior surgeons I had worked for simply couldn’t do it and left me to get on with it – the so-called ‘see one, do one’ method of surgical teaching which was one of the more egregious aspects of some English surgical training in the past. I look back with horror on some of the mistakes I made when I was a trainee and, even worse, on some of the mistakes made by my trainees – for which I must hold myself responsible – once I became a senior surgeon myself. But some of my trainers, I now realize, had shown great patience and kindness (and courage) in taking me through operations. I had not thought for a moment how difficult it might be for them, so self-important was I, and so engrossed in what I was doing. Igor, I now realize, is no different. I don’t think he ever saw how difficult I found the long outpatient clinics, which could easily last ten or twelve hours, or the agonies I went through as he operated on major brain tumour cases. The more I let him do, the more he would learn, but the greater the risk to the patient and the more anxious I would become. If it seems that it is safe for him to carry on, I retire to the recovery room next to the operating theatre and stretch myself out on the trolley by the window, resting my head on a cardboard box. I would be simultaneously bored and tense, going into the theatre at regular intervals to see how he was getting on and whether I should take over.