The medical lot of a Palestinian in Lebanon is not a happy one. Money is unavailable for private care, while Government-run hospitals do not always offer the full spectrum of possible treatments. As a result, diseases, wounds and children’s deformities can remain untreated for years. This was the country into which we stepped. Like Northern Ireland, every eye that stared was a potential kidnapper, every backfiring car a terrorist assault. Though it was early evening, I felt the cold trail of sweat run an isolated course down my back as I searched the mass of unfamiliar faces crowding the passenger reception area. Were we expected? God knows. Please come and meet us, somebody, I silently cried.
‘You must be Richard Villar,’ I heard a gentle voice say to my left, interrupting my incipient panic. I turned to see who it was and was glad to see a woman of European appearance, tanned, well-dressed and smiling in welcome. A gentle hand was extended as greeting. ‘Hi,’ she added. ‘I’m Miranda.’
It is always a shock to meet someone for the first time to whom you have previously written on numerous occasions. So it was outside Beirut airport that evening. The occasion was slightly awkward, but we both had work to do, so there was little time for discussion. With the briefest of handshakes I was ushered into her dilapidated, certifiable, though much-loved car and driven south along the coastal road towards the town of Sidon. My colleagues were squeezed into a more modern version of the same, following close behind.
Miranda was a remarkable person. As a physiotherapist she spent much of her time dealing with bone and muscle problems, many of which had been caused by the ravages of war. A bullet through a child’s spine, for example, can cause paralysis of everything below the point of injury and spasticity of the muscles. Spasticity makes the arms and legs rigid and tight, so the patient can barely move them. A physiotherapist can work wonders, loosening them up, eliminating the inevitable deformities prolonged spasticity creates. This is one tiny example of the many conditions they can treat, but however much physiotherapy you offer, some deformities will not correct without surgery to allow treatment to start. Once tight tissues have been released, the physiotherapist steps in once more. Miranda largely masterminded our visit as a result. Scheduled to leave the country shortly, after a long tour of duty with MAP, she wanted to be sure she had done as much for her patients as possible.
As we thumped our way along the cratered and potholed road in her rattly car, Miranda explained in her mild New Zealand accent what was involved. I was feeling uneasy. I always feel uneasy in war zones. Though Lebanon was reported to be quiet, such terms are relative. I now realize I was being unnecessarily alarmist, but my mental image of Lebanon then was one of bombs and kidnappers round every corner. Miranda, meanwhile, was completely relaxed, continuing her briefing as if she was driving down the centre of England’s safest motorway.
‘You’ll be working from Hamsharry Hospital. It’s in Sidon, next to one of the refugee camps,’ she explained, it is the main Palestinian hospital in Lebanon. You are badly needed.’
As she spoke I felt the car slow. We were approaching a haphazard arrangement of oil drums on the road. I had heard of Lebanese roadblocks, the second most common point of kidnapping after Airport Road. The isolated trickle of sweat on my back was fast becoming a torrent. Miranda was unfazed, oblivious of the unnecessary worries continually flashing through my mind. She must have been through hundreds of the things. Road blocks were two-a-penny. I never did learn who controlled them though I believe the majority were run by the Syrian Army. On this occasion a good-looking young man, no more than twenty years old, put his head through the driver’s window and smiled. On his shoulder was a gleaming Kalashnikov, oiled perfectly. I could tell from the way it lay against his shoulder the magazine was full. Most so-called armed guards in the UK carry a rifle loaded with thirty rounds of fresh air. The bullets either have to be kept in a tunic pocket or in the guardroom nearby. Whoever thought that rule up had never been in a real-life contact with an enemy. The opposition is hardly going to wait while you run to retrieve your bullets so you can return fire. This young man had a fully loaded, and cocked, weapon. Arguing with him was not an alternative.
‘We are travelling to Sidon, al-Hamdu lillah,’ Miranda announced in excellent Arabic. ‘This man is a surgeon who has agreed to work there.’ She pointed towards me disdainfully, as if I was a piece of baggage. I felt exactly like one at that moment - a very sweaty mess.
The young man smiled further, revealing a sparkling gold filling in a lower tooth. Looking at me carefully, he inspected me in detail. Then, with a brief closing of his eyes, a mild facial sneer and a casual wave of his right hand, we were ushered past.
Hamsharry Hospital is a dominant building, standing immediately beside a Palestinian Refugee Camp in the city of Sidon. Of 1960s design, square and ugly, it is for most Palestinians their only real medical hope. Pockmarked by shrapnel, it houses several wards and two operating theatres. All around is evidence of rebuilding and reconstruction, an attempt to eliminate any trace of war. In some areas of Lebanon, particularly the Israeli Occupied Zones, this is a forlorn struggle. As fast as rebuilding progresses, another assault knocks it down.
In the cellar, now a storehouse, sit the remains of an old courtroom. Now untidy and neglected, one can imagine the earlier scenes of judgements made and punishments issued. Many would have been terrified to enter that room. Outside the hospital perimeter, day and night, gunfire can be heard. Normally intermittent, it can occasionally be continuous and severe. Stand on the hills that surround Sidon and you would be forgiven for thinking full-scale conflict was still in progress. Admittedly there are no major explosions, but rifle fire is persistent, the sound of either skirmishes or sniping. Southern Lebanon is unquestionably a paradox. It really is a land where you can sit outside in the evening with your ice-cold drink, looking at a sunset in one direction, but murder being committed in the other. Peace and war can take place at the same time in the same street. After a long day in the operating theatre, we would occasionally play games, trying to identify a weapon by the noise it made. As there was no way of confirming our various opinions, I imagine we were always hopelessly wrong.
Hospital staff were a hard, motivated crowd. They welcomed us with open arms, particularly as our way had been paved by Miranda. Most were very fit and very tough. Many had been fighters at some stage. Firm handshakes, and incredible courtesy, were the order of the day. You would always look a man in the eyes when you spoke to him. The slightest hint of an Israeli assault on a refugee camp or village, and the hospital would empty immediately. Staff of all grades would disappear to the area under threat to help. For most, an attack on any Palestinian was the same as an attack on themselves.
I never understood the various groups - Sunnis, Amal, Hezbollah, Palestine Liberation Organization, Popular Front for the Liberation of Palestine and many others - it was best not to ask as it would mean entering a political conversation that I wished to avoid. The uniting factor for all groupings was their universal dislike of the other side. Being a fighter, for whatever Palestinian cause, was respected. Those I met were astonishing people and had led a precarious existence for years. In certain of the camp wars, when the refugee camps had come under direct attack, irrespective of the vast number of defenceless civilians within them, the Palestinian fighters could spend weeks defending a tiny area no more than 200 metres square. Pinned down from all sides, and shot at if they showed themselves for more than a second, it was little wonder these people were tough. If it had not been for my Army experience I would have been daunted.
As well as the Palestinians, there are certain doctors who have upheld the best name of the profession under the most arduous of conditions. None more so, I believe, than Pauline Cutting in Lebanon. I had, of course, heard of her. Working as a surgeon during Beirut’s Bourj al-Barajneh Camp siege, she continued supporting sick and injured Palestinians under the most deprived and stressful conditions imaginable. To read her book Children of the Siege is to see war
surgery in its true perspective. Quiet-spoken, charming, I have never before met a doctor so admired by her former patients. Mutual danger and discomfort bonds mankind tightly - I had experienced that with the SAS. The same applied to Pauline and the Palestinians. They love, cherish and admire her. I know she would be too modest to admit it. It was certainly my privilege to meet her. One cannot underestimate the enormous stresses placed on someone under the terrible conditions she was forced to endure. Scars can remain for life.
Sometimes, when a patient walked into my consulting room I could sense the power inside him. Take Kayed, for example. He was both leader and fighter, standing high in local society; he came surrounded by several tall, heavily armed bodyguards. Running a clinic with Kalashnikovs in the room takes some getting used to. Fatimah, my young interpreter, did her best to translate.
‘My knee,’ said Kayed, his voice little more than a growl as he rolled up one trouser leg to mid-thigh. ‘I cannot bend it. Please cure me.’ His request made it appear as if success was a foregone conclusion. His guards nodded their heads silently in sympathy and agreement as they toyed ostentatiously with their weapons.
‘How did the knee get like this?’ I asked, trying hard to bend the stiff leg at the joint. It would not move. The skin was scarred and pockmarked like a Beirut wall.
‘Israelis,’ he replied. I could see the hatred in his eyes. ‘I managed to kill several before they did this to me.’ I knew I was on dangerous ground. It was important to take neither one side nor the other. I could see he was searching for compliments. I stuck to my trade, kept my head down and looked intently at the knee. However hard I looked, the thing would not budge. If he was to walk normally again, I would somehow have to free the knee up.
From a large, tatty, brown envelope one of the bodyguards produced two equally tatty X-ray films. Holding them to the dim window light I could see the white, metallic specks of shrapnel still buried deep inside the leg. Much of the thigh bone was missing, though time had done its best to fill the gap with irregular, thickened scar tissue. I nodded as sagely as I could.
‘It’s bad,’ I said. ‘Very bad. But I think I can help.’
‘Can you make it normal?’
‘No. That is impossible. But I can help you bend it slightly.’
‘Can you be certain you will succeed?’
‘No.’
‘Why not? The people say your team is the best in Europe.’
‘The damage is too great,’ I replied, not wishing to be drawn into discussion as to whether we were good, hopeless or indifferent. ‘There are some things even we cannot achieve,’ I added, capitalizing on whatever reputation was being given us behind the scenes.
It never pays to bluff in surgery. In many countries patients will travel from surgeon to surgeon, physician to physician, faith healer to faith healer. Each will give a different opinion. Some will offer guarantees that are scientifically impossible. Being truthful and open is always best.
For a brief moment Kayed fell silent, then glanced either side to his bodyguards. All three nodded quietly. ‘Then you must do it,’ he eventually replied. ‘You must do what you can.’
Kayed’s problem was a straightforward one, despite the horrible appearance of his knee. He had been caught in a mortar burst two years earlier, a large number of shrapnel slivers, over twenty, penetrating his leg. The bigger fragments had been removed at the time, the wounds healing over the remainder, now lying deep inside him. The residual shrapnel was best left where it was, it was doing no harm. It is a common misconception that it needs to be removed. Trying to find tiny metal shards deep inside a bleeding wound is difficult. A surgeon’s efforts may do more harm than good as the messy tissue makes it so easy to cut the wrong thing. Kayed’s stiffness was due to much of the muscle having been destroyed at the time of the injury. His previously muscular thigh was now wasted and thin. When tissue is damaged, by whatever means, the body tries to heal the area. It does this by the formation of scarring. Though we normally talk about scars on the skin, they also occur anywhere in the body that damage has previously occurred. That includes muscle. In Kayed’s case, scar tissue had replaced the muscle and scar tissue does not bend. If he was to bend the knee again, all scarring had to be removed - surgically excised.
Fred performed the operation while I looked on. It took ages. With a scalpel he made a long, vertical cut down the front of Kayed’s thigh and knee, dividing the skin to expose the underlying bone and scar tissue. Scar is white in colour, like a tight, inelastic band covering a joint. You have to cut transversely across it first, so it is completely divided, then you force it further apart, bending the joint by hand. It requires both surgical dexterity and muscle power. You must be strong enough to grasp a large knee in both hands, bending it until it gives way. Orthopaedic surgery is not for the faint-hearted. Painstakingly slowly the knee began to flex, degree by degree. By the end of the operation the once stiff joint was able to move to a right angle or more. It was a masterpiece of surgery.
It is one thing making a knee bend under anaesthetic, as in Kayed’s case. It is another to ensure the patient maintains the improvement once he wakes up. Bending a knee that has been stiff for two years, and has required radical division of scar tissue, is very painful. The natural temptation is for the patient to lie motionless after surgery, not daring to move his leg for pain. Within a few days the scar tissue reforms if the knee is not kept moving. Fred’s work would have been in vain.
Our plan had been for Miranda, or a Hamsharry physiotherapy colleague, to provide intensive treatment once surgery was complete. We had not reckoned on Kayed’s demands. He felt his bodyguards would do the job better. Perhaps he had something to prove. No sooner had he regained consciousness, back in bed on the hospital ward, than his men set to work. Ignoring their leader’s cries for mercy, they worked the long stiffened knee to and fro. Straight and bent, straight and bent, straight and bent. You could almost hear Fred’s carefully placed stitches breaking, one by one. It is difficult to argue with an armed physiotherapist, even if he is unqualified, but within a day the careful surgery had been ruined. Try as I might to explain to the bodyguards that operations of this nature needed careful handling after surgery, they would not listen. The result, within forty-eight hours, was that Kayed needed his operation repeated. This second time the bodyguards stayed their distance and Kayed’s knee was a success.
Not all injuries in war are caused by bullets. Mines, particularly antipersonnel mines, are major problems. To a doctor they represent an unforgivable act of war. So often the injured are defenceless civilians. Should you see a civilian in a war zone minus an arm or leg, you can be fairly certain a mine has caused it.
The Hamsharry clinics were full of women and children with horrific injuries. It is immensely distressing to see a beautiful six-year-old girl, radiating health and charm in every way, yet absent a leg. Staggering into my consulting room on crutches, young Lamia was a pitiful sight. Her wide brown eyes begged me to do something that might help. ‘Can I have another leg?’ she asked. I could only say no, tears stinging my eyes. The best I could offer was a lifetime with an artificial limb. Hamsharry highlighted the immense civilian toll of the Palestinian-Israeli conflict. More than 90 per cent of the patients we treated were civilians. People without any clue as to how a weapon should be handled.
You only have to see an amputee child in a war zone once to hate mines for life. There are millions scattered worldwide. They are of two sorts: anti-tank (AT) and anti-personnel (AP). As an ex-soldier, the former I can understand, the latter I cannot. The object of anti-personnel mines, from a military viewpoint, is to deny certain areas to an enemy. For example, should you have to withdraw from a building or trench system, scattering antipersonnel mines is a quick, simple method of being certain the enemy cannot use the same building or trench for his own ends. Being small, the mines may also be used for booby-traps. For example, under toilet seats, behind doors, under doormats. Once the enemy moves on, the AP mine
stays behind. Children frequently play on wasteland and derelict areas, favoured locations for mines, and are prime victims for AP injuries.
The object of an AP mine is to maim, though some are designed to kill. The intent is to place as much strain on the enemy’s logistics as possible, by having to evacuate the wounded. There are two sorts of AP mine: blast mines and shrapnel mines. Blast mines are normally buried in the ground, requiring the victim to step on the device in order to trigger it. The dreaded Black Widow mine from Russia is barely two inches high and five inches wide, and needs only three kilograms of pressure to set it off. It can kill, but will certainly cause major leg injuries to above the knee. Amputation is likely.
Shrapnel mines are designed to maim or kill over a wider area, perhaps up to twenty metres from the device, often injuring more than one unfortunate at a time. They can be activated by pressure or a trip wire and will frequently spring to chest height before exploding. They are manufactured in many countries, including China, Portugal, the Czech Republic and, I am afraid, the United Kingdom.
Knife Edge: Life as a Special Forces Surgeon Page 30