Homage to Gaia

by James Lovelock

  Next morning, I awoke fresh and ready for the operation. I knew that all my hair would have to be shaved off, and this caused me mild anxiety, because I was old-fashioned enough to have qualms about a young nurse shaving off my pubic hairs. Would I get an erection as she did it? What could I say other than something like, ‘I’m afraid he’s up early this morning’, or something equally banal? But it did not happen like this. They gave me a razor and some shaving soap and asked me to get in the bath and shave myself completely. I had breakfast, but they warned me that there would be no lunch or indeed anything until after the operation. The round of visits went on, including one from Mr Keates, who explained in full detail what he would do, and then asked if I would like to see the intensive care recovery room, where I would be for the next day. I took him up on this offer, and the sister in charge showed me round. It was the only disturbing feature of the whole operation. Here I saw figures, wrapped like mummies, attached to a bewildering array of pipes and cables. Some carried air, some were intravenous drips, and others were drains leaking fluid away from damaged tissues; and then there were the electrical leads to the various instruments monitoring the patients. This long, quiet room filled my mind with the image of a mortuary full of corpses, and it was not what I needed just then. The Sister who was showing me round sensed my disquiet, and led me to the door and back to my room. It is not my nature to dwell on the unpleasant, and my mind soon turned to the less personally disturbing thought of the cost of the surgery. I started to calculate just how much I was to cost the health service, and how fortunate I was not to have to pay for it myself, and my mind was at ease again. Waiting for me in my room was a young assistant surgeon who told me that his job was to take out my saphenous vein, which goes from the thigh to the ankle, and would give the material for the bypasses between my aorta and the lower part of the left coronaries. I asked him, curiously, how they worked out the flow rates, and what diameters of vein would be needed. He looked startled at first, but then warmed, and began to explain his craft in full detail. Yes, of course they calculated the flow rates, and it was quite a business getting just the right-sized piece of vein or artery to do the job. Both he and Mr Keates were patient in explaining in full detail exactly what they would be doing. I did not dwell too deeply on the thought of my lifeblood circulating through a heart-and-lung machine for thirty minutes or so; the possibilities of things going wrong—like bubbles or clots—were all too familiar to me. The thought of my heart chilled and anaesthetized by potassium chloride, to stop its beat, was fascinating and brought back memories of the reanimation of frozen animals nearly thirty years previously.

  In the course of conversation with the surgeon, I recall telling him that I had worked as a biochemist in that famous surgeon Michael DeBakey’s department in Houston in the 1960s. He seemed impressed. ‘DeBakey,’ he said, ‘is certainly the great pioneer of all that we do today in cardiology. Why, a sizeable number of the surgical instruments that I will be using in your operation are named after him.’ I then recalled an odd conversation I had had with DeBakey when we were both members of the faculty of Baylor College of Medicine. It was during a rather boring faculty meeting, something that we had to attend at frequent intervals. Dr DeBakey turned to me and said, ‘You know, I don’t buy this notion that coronary disease is just a matter of biochemistry, that it just depends on what fats are in your diet, and so on.’ I had my own doubts about the biochemistry, thinking it to be a typical crusading piece of pseudo-science and not based on verifiable facts. ‘Go on,’ I said. DeBakey replied, ‘I have seen the inside of more arteries than most, and quite often I see what looks like an inflammatory process, something that might be caused by a virus or bacterial infection, and I wonder if this also is a part of coronary artery disease.’ Time has shown that DeBakey’s speculations in 1962 were correct.

  Then I had another bath, and they put me in one of those gowns that do up at the back—irritating and awkward things to wear, and almost impossible to do up, but they do serve to mop up spilt blood. Back on my bed, my wrist and ankle were fitted with plastic tags bearing a number, and I was then, so to speak, trussed and ready for carving. Lunchtime passed. I telephoned Helen to tell her that all so far was well, and that my surgery was due at 5.30 that evening. Around about 4 pm I was given a pile of pills by the young surgeon, who explained what they were all for. One was cimetidine to stop my stomach digesting itself away during the long course of the operation, and the rest were premedication of various kinds: Valium I recognized but not the long, dark, dried-insect-like pills of some other preparation. He said that after taking these I would remember nothing until after the surgery; the last I do, indeed, remember is that they wheeled me on a trolley to the theatre. In the anteroom, they marked me in places with a felt tipped pen. I also remember the anaesthetist telling me that the only anaesthetic that I should receive for the whole operation would be morphine.

  I awoke the next day in the intensive care room to find a breathing mask over my face. I tried to remove it, at which a young nurse appeared saying, ‘Don’t do that, your blood gases aren’t right.’ ‘Well, I feel fine,’ said I, ‘are you sure there’s nothing wrong with your instruments?’ Startled by this liveliness from a patient, she turned to look behind her, and then returned and took off my mask. Soon after, they wheeled me along to Lonsdale Ward and a very different world from the high-tech, ultra-clean environment I had just been in. In the first hours and days of my stay in the ward, I was still under the spell of morphine, and I felt amazingly well, cheerful, and entirely free from pain. Having once damaged a rib in a fall, I remember well how long it was before I could breathe without feeling the pain of it. Yet, only a day ago they had cut open my ribcage and drawn it back to allow the surgeon to work on my heart. In spite of it, I could now breathe just as easily as if nothing had happened.

  On that first day in the ward my brother-in-law Neil and his wife Pauline Hyslop came to visit. I think they were expecting to find a weak, feeble, and barely talking relative, instead of which they found a strange mummified figure that seemed full of life. I was so euphoric that I am sure that they left thinking that I was fine physically after the operation, but that my mind had become addled because of it. Looking back, I can understand the appeal of opiates to those who use them for pleasure. The first few days, when these powerful painkillers were still being administered, were in every way pleasant, but treatment involves a diminuendo, and by the fifth day we were down to ordinary codeine and paracetamol painkillers, and only if needed. The only time I felt pain during the first days was when they took out the catheter dwelling in my bladder. The insertion of an in-dwelling catheter is usual during long surgery, to allow the bladder to empty, and to provide a continuous supply of urine for biochemical analysis. When my nurse deflated the small internal balloon that holds the head of the catheter inside the bladder and prepared to pull it out, she said, ‘Don’t worry, you’ll probably feel nothing at all.’ She was wrong, and in spite of the opiates I was still receiving, withdrawal was acutely painful. The catheter came out covered in blood and dotted with shreds of adhering tissue. She was clearly concerned, and fetched the young surgeon who was on ward duty. They talked, but now my pains had gone again and I dozed. I did not know it then, but this small incident was the forerunner of years of pain and misery, something still present nearly twenty years later.

  By the third day, I grew fully aware of the ward and my fellow inmates. Before the operation, I had always imagined that the best way to stay in hospital would be in a private room, separated from the problems of personal encounters at a time when one felt least like making the effort. In spite of its problems, Lonsdale Ward gave me my first lesson in the virtues of Florence Nightingale’s plan of an open ward, a plan where rows of beds, side by side, faced each other across a wide space. This layout ensured space for hospital traffic to pass without disturbance or hold up, and made sure that the nursing staff and patients were visible to one another. These wards have some of
the air of an army barracks. Normally, there is strong discipline exerted by the ward Sister over both the nurses and the patients. The physicians and surgeons occupy the roles of the officer class, and are less often seen; their uniform is also distinctive and different. There is blood and pain and suffering around, and death at times as well. It is an atmosphere where discipline overrides fear, where camaraderie cheers and overcomes the pain—an atmosphere that afterwards one remembers with affection.

  I have made over forty separate visits to National Health Service hospitals for surgery during the last nineteen years. These experiences have convinced me that the open wards of the NHS are not just for the care and cure of the sick, but that they also serve to keep our society decent. A stay in a ward is like a lottery: in the next bed can be a tramp or a millionaire; a wise man or a fool; the kindly or the malign. The thing is, after ten days in such an environment, you cannot but get to know them well. In peace time there is nowhere else in our society that provides such a complete social education. If you have never been a patient in a ward, I can understand that you would regard such enforced acquaintance as intolerable, but you would be wrong. I am by nature a private person and choose to live with the nearest neighbour about one kilometre away, yet, when I go to hospital again, I would never willingly choose a private room over the open ward. It can be miserable lying in pain alone, wondering if ever someone will come; wondering if the pain warns of something serious about to happen or is just the normal state. In the open ward there are always those who had the operation a few days ago and who will cheerfully tell you, from their state of recovery, ‘Oh, yes, the second day is the worst; you’ll feel fine tomorrow.’ Then there is the never-ending entertainment, the laughter to join in with, and the sadness; so much goes on in a ward that we need no other entertainment. I always take a novel intending to read it, or even some serious books, but rarely ever get beyond the first few pages.

  Some people learn best to swim when thrown in at the deep end, and so it was for me in Lonsdale Ward. It was mostly for men who had had heart surgery. I remembered these wards from my childhood days at the Strand School, which had a connection with King’s College Hospital. Each year they took some of us from the school to see a ward that the school supported by our donations. In those days of the 1930s, the wards were immaculately clean and tidy; they had to be because then there were no antibiotics and freedom from infection depended upon strict cleanliness and aseptic techniques. To us the nurses seemed powerful figures who ruled with calm authority. We knew about, although we never saw, that formidable authoritarian figure, the Matron, who presided over it all. Her firm rules and strong discipline set the environment in the way of her great predecessor, Florence Nightingale. Lonsdale Ward of December 1982 was an outrageous exception to this ordered scene and, I hope, to the National Health Service generally.

  At the time of my admission, King’s College Hospital was suffering its own illness. It was the site of a smouldering tribal war, aggravated by a trade union out to gain members from one of the tribes, and consequently taking sides in the conflict. I grew up in Brixton, which is part of the neighbourhood close to King’s College Hospital. It has always been a comparatively poor area: the looming pile of Brixton Prison no doubt has something to do with it. Criminals tend to repeat their offences, and their families gravitate to the neighbourhood of the prison to make easier the journeys to visit their imprisoned relatives. Brixton in 1982 was a very different place from the Brixton where I had grown up. It was now the site of a West Indian settlement whose inhabitants were painfully adjusting to a wholly different culture from that of the sunny Caribbean. As my recovery progressed, it slowly dawned on me that the ward was in fact a battleground of a war between the West Indian ward staff and the hospital establishment, some of whom, but not all, were white. It was no simple racial contest, if there are any such. Here, Trinidadians, who seemed to dominate union membership, saw themselves as the most superior of all the black races, and bitterly resented having to take orders from black African nurses. I was astonished to hear a Trinidadian ward maid call my favourite night sister, a huge, warm and wonderful Nigerian woman, black African trash. Ordinarily the strong discipline of the hospital could have coped but not now.

  We were in the midst of ‘industrial action’ by the trade union, NUPE (the National Union of Public Employees). The union had recruited the West Indian hospital staff, including the ward maids, whose normal task would have been to keep the ward clean, and, by their cheerfulness, raise the spirits, and hasten the recovery of the patients. But they were now going slow, and were far from cheerful. NUPE—or as it is now called Unison—claimed to take great care to ensure that if there was industrial action patients would not be harmed. My experience in Lonsdale ward showed me how false was this claim. At every level, from our comfort and feeling of security, to the risk to our lives, we were threatened. It was more than just a strike, because at that time, Brixton had passed through a series of racial disturbances. I do believe that the West Indians had real cause for complaint, but to make the ward of a hospital their battleground was no way to gain our sympathy. So blinded were these union members by their grievances that they seemed to see us, the mostly white patients, as enemies. It was an outrage—the ward sisters, who ordinarily would have kept order and an environment suitable for recovery, were wholly frustrated. The least reprimand to one of the ward maids brought the threat of an all-out strike. This blackmail did not merely undermine their authority; it also put our lives at risk.

  The ward had two lavatories and, soon after I could move, I asked to use them and not the bedpan. When I reached these lavatories, dragging my intravenous drip and catheter bag behind me, I was sickened to see the floors of both smeared with faeces. On the door, where once there had been a hook to hang one’s dressing gown, there were just the screw holes. It had been broken off and never replaced. My long experience researching problems of hospital cross-infection had never shown me anything so gross as this—not even in the Second World War. I felt that I was a casualty in a battlefield hospital somewhere in the developing world, and in many ways, this was the truth of it. I began to think that the greatest threat to our health service came not from the political right or from private medicine, but from the brutal abuse of trade-union power, perversely the power that enabled socialism itself.

  My mother’s family proudly remembered their famous relative, Samuel March. For a time, he was Mayor of Poplar, an activist who spent time in prison for a political offence. He was an early Labour Member of Parliament, and an early leader of what is now the Transport and General Workers Union. In those days, we needed the trade unions to fight the gross exploitation that was part, but not all, of Victorian industry. Great-uncle Sam March represented Poplar, and many of his constituents were Irish Dockers who suffered privation and appalling conditions of work. With such a background, I had always voted Labour. The events in Lonsdale Ward were to shake that simple loyalty.

  The fourth day after surgery was Christmas. We were delighted by a traditional Christmas dinner, enhanced by having one of our surgeons personally carve the turkey and serve the meat to us, on a table set up in the ward. We were by then strong enough to sit at the table to enjoy our meal and a glass of wine. As the days went by, the reaction to the withdrawal of the opiates set in, and by the sixth day several of us behaved as if we were unhinged. We became exquisitely sensitive to the squalor of the ward, and the pervasive smell of a sticky disinfectant fluid spread on every horizontal surface. At about this time, a West Indian maintenance man came to replace a bulb in the reading lamp of a patient near me. He came, examined the bulb and pronounced it broken; he went away and did not return with a new bulb for about two hours. He looked at it and the lamp and said, ‘I will have to fetch my ladder, to put it in.’ Another two hours passed and he returned with the ladder but without the bulb. He went away and I do not think he ever returned. By now, we realized that we had watched a particularly creative act of ‘going slo
w’, the tactic unions use to force a bad firm to recognize their call for more wages or better conditions. Suitable in that context, but what possible justification did it have in our ward? We are foolish to allow our public servants, secure in their jobs, to behave in this uncivilized way. Surely crude and brutal ‘industrial action’ is no way to meet their genuine needs.

  I have reason to believe that the ‘go slow’ at King’s has harmed me grievously. I have been unable to uncover the whole story as, quite naturally, the hospital authorities are not happy about telling me everything that happened on the evening of 21 December 1982. I can well understand their caution: in these litigious times, there is too great a risk that their revelations might serve as the basis of a lawsuit. The facts, as I understand them, are these: when the time came for my surgery, the instruments needed were not available because of ‘industrial action’. The surgical team therefore chose—quite reasonably—to proceed, after sterilizing the instruments used in the previous operation. The method used was to place them in an autoclave chamber and expose them to the gas, ethylene oxide, which is a powerful and effective method for sterilizing metal scalpels and forceps. The gas can also sterilize catheters and flexible airways but, unfortunately, unlike metal, the elastomers used to make catheters absorb the gas, and if the catheter is used soon after sterilizing this way, it slowly releases its burden of toxic and carcinogenic ethylene oxide into whatever tissue it touches. For me this was my urethra. The sequence of events may not have been exactly as described, but there is no doubt about the damage done, and had the hospital been running normally and free of industrial action there would have been no need for the emergency sterilization of equipment at the start of a major operation. I am telling this story because of my anger at the impropriety of overt trade-union activity in the health service and its hospitals. Accidents rarely come from a single cause; they are usually the consequence of a cascade of errors that culminates in disaster. Poor maintenance is a frequent cause of errors that lead to accidents—the chemical and aircraft industries know this well. Accidents in hospitals, I suspect, also arise through a sequence of errors in which poor maintenance plays a part. Because of this, the claim by health-service unions that their actions will not affect patients is cynical and disingenuous. In case you think this is just the complaint of a single patient, I know that I was not the only one in the hospital to suffer from the union’s industrial action. However, the surgery itself was good, and by the ninth day, I was walking around the hospital, climbing stairs, and delighting in the absence of angina. On the tenth day, I walked again with my small bag up the stairs to the exit from King’s College Hospital to meet my friendly car driver who was to take me the 250 miles to Coombe Mill.