There was a minor earthquake in the evening, small enough to be exciting rather than frightening. We were sitting in the garden, in the dusk, the crescent moon in the west blood-red with the city’s polluted air, when there was a sudden low sound, almost like a breath of wind or a subterranean thought – a fleeting presence of something of immense size and distance. The bench I was sitting on in the garden briefly shook as though somebody had nudged it, and thousands of voices rose up all around us in the night from the dark valley below, wailing, crying out in fear like the damned on hearing that they are to go down to hell, and all the dogs of Kathmandu started barking furiously. And then, when it became clear there was not to be a major quake like the one which had killed thousands of people the year before, everything fell quiet and we could hear the cicadas again.
I slept very well that night and woke to the dawn chorus of the birds singing in the garden. A pair of syncopated cuckoos were calling, while the hooded crows croaked and quarrelled in the camphor tree and all the cocks in the valley crowed. At ten past eight I set off for the hospital – it is a walk of which I never tire and, for reasons I struggle to understand, I feel more deeply content as I go to work each morning than I have ever felt before. The rising sun casts long and peaceful shadows. The air is often hazy with pollution, but sometimes I am lucky and I can see the foothills that surround the city and, just peaking above them in the distance, the snow-covered summit of Mount Ganesh, the elephant god.
At first I walk in silence, apart from the birdsong, past houses with cascades of crimson and magenta bougainvillea at the entrance, and Buddhist prayer flags, like coloured handkerchiefs on a washing line, on the roof. The houses are all built of rendered brick and concrete, painted cheerful colours and look like stacked-up matchboxes with balconies and roof terraces and the occasional added gable or Corinthian column. Sometimes there is a peasant woman watching over a couple of cows, peacefully grazing on the thin and scruffy grass at the side of the cracked, uneven road. There is rubbish everywhere, and stinking open drains. Dogs lie sleeping on the road, probably worn out by a night’s barking. Sometimes I walk past women carrying huge baskets of bricks on their backs, supported by straps across their foreheads, to a nearby building site. After the houses there are then many small shops, all open at the front; looking into them is like opening a storybook, or peeking into a doll’s house.
Life here is lived on the street. There is the barber shaving a man with a cut-throat razor; another customer reads a newspaper while waiting, and the meat shop with ragged lumps of fresh meat and the severed head of a mournful, lop-eared goat looking blankly at me as I pass. There is the cobbler sitting cross-legged on the ground while he cuts soles from rubber sheeting, with cans of adhesive stacked against the wall. Cobblers are dalits, the untouchables of the Hindu caste system, and second only to the sweepers and cleaners, who are at the very bottom of society. He once repaired my brogue boots which have accompanied me all over the world, and which I polish assiduously every morning – the only practical activity I have when in Nepal, other than operating. He did a very good job of it and it was only when I later learned that he was a dalit that I understood why he at first looked awkward and embarrassed when I politely greeted him each morning as I passed his open workshop. There is the metalworker welding metal in a shower of blue sparks and a seamstress, with clothes hanging up at the front of her shop, while she sits at the back. I can hear the whirring of her sewing machine as I walk past. Motorbikes wind their way between the children in smart uniforms going to school. The children will look slightly askance at me – this is not a part of town to which expats normally come – and if I smile at them they give me a happy smile in return and wish me a good morning. I would not dare to smile at children back in England. There is a rawness, a directness to life here, with intense and brilliant colours, which was lost in wealthy countries a long time ago.
I walk past all these familiar sights to reach the main road, a melee of cars, trucks and pedestrians, with swarms of motorbikes weaving their way between them in a cloud of pollution, all blowing their horns. The broken gutters are full of rubbish, and next to them there are fruit vendors selling apples and oranges from mobile stalls that rest on bicycle wheels. There are long lines of colourful, ramshackle shops, and everywhere you look, hundreds of people going about their daily business, many of them wearing face masks which are, of course, useless against vehicle fumes. Electric cables droop like tangled black cobwebs from the pylons, which lean at drunken angles, and there are often broken ends with exposed wires, hanging down onto the pavement. I cannot even begin to imagine how any repair work is ever carried out. The women, with their fine faces, their jet-black hair swept back from their foreheads and their spectacularly colourful dresses and gold jewellery, transform what would otherwise often be depressing scenes of grinding poverty.
I have to cross the road to reach the hospital. I found this at first an unnerving experience. The traffic is chaotic and if you wait for a break in it, you will be there for a very long time. You must calmly step out onto the road, join the traffic, and walk slowly and predictably across, trusting the buses, vans and motorcycles to weave their way around you. Some of the motorcyclists have their helmets pushed back over their heads, so they look like the ancient Greek warriors to be seen on Attic vases. If you break into a run they are more likely to hit you by mistake. My guidebook to Nepal helpfully told me that 40 per cent of victims of road traffic accidents – RTAs, as they are called in the trade – are pedestrians. We admitted such cases every day to the hospital. I was to witness several fatal accidents. On one such occasion I passed a dead pedestrian on the Kathmandu ring road. He was sprawled on his face across the gutter, his legs bent out akimbo at an improbable angle like a frog’s, with a group of curious onlookers watching silently as the police made notes. I have come to enjoy crossing the road – there is a feeling of achievement each time I get across it safely.
When I was a student almost fifty years ago, Kathmandu had been the fabled, near-mystical destination for many of my contemporaries. This was partly because cannabis grows wild in Nepal – and still does on building plots and derelict land in the city – but also because it was a place of pristine beauty and still living a life of medieval simplicity. They would trek overland. The world was a different place: you could safely travel through Syria, Iran and Afghanistan. Since then Kathmandu has also changed, almost beyond recognition. The population of Kathmandu has gone from a few hundred thousand twenty years ago to two and half million and it is the fastest-growing city in South East Asia. The new suburbs are entirely unplanned, without any proper infrastructure, occasionally with a few pathetic scraps of rice paddy or wheat field left as an afterthought between the cheap concrete buildings. There are open drains and dirt tracks, with rubbish and building materials strewn about everywhere. The roads are chaotic and the air is dark with pollution. You can rarely, if ever, see the high Himalayas to the north.
Nepal is one of the poorest countries in the world, shattered by a recent earthquake and with the ever-present threat of another catastrophic one to come. There are minor tremors every week. I am working with patients with whom I have only the most minimal human contact. The work is neurosurgical, so there are constant failures and disasters, and the patients’ illnesses are usually more advanced and severe than in the West. The suffering of the patients and their families is often terrible, and you have to fight not to become inured and indifferent to so much tragedy. I can rarely, if ever, feel pleased with myself. The work, if I care to think about it, is often deeply upsetting and, compared to Public Health, of dubious value in a country as poor as Nepal. The young doctors I am trying to train are so painfully polite that I am never sure what they really think. I do not know whether they understand the burden of responsibility that awaits them if they ever become independent neurosurgeons. Nor do I know what they feel about their patients, or how much they care for them, as their English is limited and I cannot speak Nepali. What I do know is that most of them want to leave Nepal if they possibly can. Their pay and professional prospects here are poor compared to what they can find in wealthier countries. It is a tragedy affecting many low-income countries such as Nepal and Ukraine – the educated younger generation, the countries’ future, all want to leave. I am working in a very alien, deeply superstitious culture with a cult of animal sacrifice, centred on blood.
Few, if any, of the patients and their families understand the unique and overarching importance of the brain, of the physical nature of thought and feeling, or of the finality of death. Few of the patients or their families speak English, and I feel very remote from them. They have wholly unrealistic expectations of what medicine can achieve, and take it very ill if things go badly, although they think we are gods if we succeed. I lead a life of embarrassing luxury compared to most people here – in my colleague Dev’s guest house, with its little paradise of a garden – but I live out of a suitcase, with none of the property and possessions that dominate my life back in England. I am in bed by nine in the evening and up by five, and spend ten hours a day in the hospital, six days a week. I miss my home and family and friends intensely. Yet when I am here I feel that I have been granted a reprieve, that I am in remission, with the future postponed.
The day before my flight to Nepal had not been uneventful. I had reported to the private hospital where, for many years, I had worked in my own time, in addition to my work for the NHS, although I had stopped all private practice two years earlier. Over the preceding weeks I had noticed a slightly scaly lump growing on my forehead. One of the privileges of being a doctor is that you know to whom to go if you have a problem, and a plastic surgeon I knew well, and greatly liked, had told me the lump should be removed.
‘You must have got the supra-orbital nerve. I can’t feel a thing. The top of my head feels like wood,’ I said to David once he had started, although I could feel the pressure of the scalpel cutting into my forehead. I had often subjected my own patients to this – although usually with much longer incisions and more local anaesthetic. This had been in order to saw into their skulls and expose their brains for an awake craniotomy, an operation I had pioneered for brain tumours, where you operate on the patient’s exposed brain while they are awake. This was the first time that I could understand a little of what they would have experienced. I could feel David mopping up my blood as it ran down into my ear.
‘Hmm,’ he said. ‘There are two points to it. It looks a bit invasive. You may need wider resection and skin-grafting.’
I felt a sudden surge of anxiety: although he was avoiding the word, he was obviously talking about cancer. I had thought removal of the little lump growing on my forehead was all going to be very simple. I now imagined myself with a large and ugly skin graft on my forehead. Perhaps I would need radiotherapy as well. I couldn’t help but remember some of the patients I had treated with malignant scalp tumours that had eventually eaten their way through their skulls and bored into their brains.
‘But it is curable, isn’t it? And they don’t normally metastasize do they?’
‘Henry, it will all be fine,’ David said reassuringly, probably amused by my anxiety.
‘And can it wait two months?’ I asked.
‘Yes, I’m sure it can, but we’ll have to see what the microscopy shows. How invasive it is. I’ll email you.’
Doctors traditionally pay their colleagues for their services in wine, and before I left I arranged for some to be sent to David. Many years ago I operated on a local GP’s wife with a difficult cerebral aneurysm, and she died immediately afterwards; I felt I was to blame. I was deeply ashamed when he sent me a case of wine some weeks after her death but it was, I now understand, an act of great professional kindness.
So I was on the plane to New Delhi next day, en route to Kathmandu, sporting a large, sticky plaster on the right side of my forehead, which I inspected gloomily in the mirror whenever I went to the cramped little toilet on the eight-hour flight, cursing my prostatism and skin cancer.
Having braved the traffic, I walk down the steep drive to Neuro Hospital, as it is called, set in a small valley off the main road. When the hospital was built ten years ago this was a rural area of paddy fields, but now it is almost entirely built up, although there is still one small paddy field left stranded, with a banana tree, next to the hospital.
The full name of the hospital Dev built is the National Institute for Neurology and Allied Sciences. It is large and spacious and spotlessly clean, with good natural light almost everywhere. The hospital is surrounded by gardens, just like AMH, the old hospital in Wimbledon, where Dev and I had trained together many years ago. Many of the patients – the women in brilliantly coloured dresses, deep reds, blues and greens, often with gold decorations – wait on the benches in front of the entrance. Dev planted a magnolia tree there, in memory of the magnolia tree that grew in front of AMH (that particular tree has now been felled as part of the conversion of the old and famous hospital into luxury flats). At night there will be many families sleeping on mats outside the side entrance. It is strange to come to a country as poor as Nepal and find such a sympathetic hospital, with so many windows and so much space, and so clean and well cared for. It incorporates all the lessons Dev learnt from working in small, specialist hospitals in Britain. It is a perfect embodiment of the architectural adage – so neglected in the hospital construction in Britain of recent years – that the secret of a successful building is an informed client. Dev knew exactly what would make his hospital work efficiently.
There are uniformed guards in military caps at the entrance, who snap to attention as I enter.
‘Good morning sir!’ they say, whipping off smart salutes. The receptionists, in elegant blue saris, smile at me while pressing their hands together in respectful greeting.
‘Namaste, Mr Marsh!’
This is rather different from entering my hospital in London in the morning.
Nepal has a very strong caste system. Ritual burning of widows and slavery were abolished only in 1924. Although discrimination on the grounds of caste or ethnicity is illegal, caste is still very important. Nepal was entirely closed to outsiders until the 1950s, and ruled by an absolute, feudal monarchy where the king was believed to be the incarnation of the god Vishnu. The end of the monarchy was precipitated in 2001 by the crown prince taking a submachine gun to his own parents, killing them and several other family members. He was then shot in the head – there are conflicting accounts as to whether he did this himself or not. Dev operated on him, carrying out a decompressive craniectomy, but – I suspect to everybody’s relief – he died. There are over a hundred ethnic groups, often with their own languages and castes. It is a nation of immigrants – Mongols from the north and Indians from the south, often living in isolated mountain valleys. It remains a deeply divided and hierarchical society, although most people still look up to foreigners, who are treated with respect, verging on servility. Landlocked, stuck between China and India – described by one of its most famous kings as a ‘yam between two rocks’ – ethnically so diverse and hierarchical, desperately poor and damaged by the recent earthquake, over-dependent on foreign aid and NGOs, Nepal is a tragic mess. The politics of the country is largely the politics of patronage and corruption, with little sense of the public good and public service which we take for granted in the West. The towns are festooned with advertisements for foreign language courses, promising work abroad. Most Nepalis, if they possibly can, want to leave Nepal. And yet, as an outsider, it is almost impossible not to fall in love with the land and its people.
Can you really fall in love with a country, with a people? I thought that you could only fall in love with a person, but in my first weeks there I started to feel for Nepal as I felt for the women with whom I have fallen in love – seven in total – over the course of my life. Yet I knew that the intensity of my feelings for Nepal would be just as ephemeral as my feelings for the women with whom I had been in love (and much of the love was unrequited anyway). Furthermore, I was leading an utterly spoilt and luxurious life, waited on hand and foot, and in one of the poorest countries on the planet. Some people would probably view my feelings with disdain. But at least I am trying to be helpful and of service, I told myself – not so much with the operating but with trying to help the young doctors become better doctors.
When I was told one morning that the MOs (medical officers) wanted me to stay for ever, I felt very happy and proud. But of course disillusion – or at least a more realistic understanding of Nepal and its sad and intractable problems – was to come quite quickly. There were periods of intense frustration and long periods of inactivity. At times I became deeply despondent. I felt that I was living in self-imposed exile. I often longed to return home, to my family and friends, and wondered why I had abandoned them. I thought of how I had always put work first, ahead of my wife and children, when I was younger, and now I was doing it all over again. But the deep contentment I experienced each day as I walked to the hospital in the low morning sunlight never faded.
I climb up the stairs to the third floor, past the locked suite with the letters VVIP over the door – built in case the president or prime minister falls ill – and go to the library. There are wide windows and on clear mornings you can just see the glittering snow-covered peak of Mount Ganesh, like a broken white tooth above the green hills of the Shivapuri National Park to the north of the city. There is an army base in the park, which was once a TB sanatorium. Some claim that during the recent civil war people were taken there to be tortured, and that many of them disappeared, but others deny it. Nepal has yet to come to terms with its civil war, and the atrocities carried out by both sides. I sit down and wait for the junior doctors to arrive.
The juniors drift in one by one – although the more enthusiastic of the registrars will already be waiting for me. Nepalis are not good time-keepers. About half of the ten medical officers have turned up.
‘Good morning everybody,’ Salima, the duty MO, says. She is wearing a short white coat and standing in front of a white board on an easel on which there is a handwritten list of the hospital’s admissions and discharges. Salima is rather nervous as she knows I am going to quiz her about the cases. She looks a little Chinese, but with enormous black eyes behind a large pair of spectacles. I was to see her at a hospital get-together a few days later, dancing exquisitely to Nepali music. The Nepalese, both men and women, are almost all very good-looking, with a complex mix of Indian, Mongol and Chinese faces. There has been a population explosion in the last thirty years as a result of declining infant mortality, so the streets are full of young people. So many of the men work abroad – 30 per cent of Nepal’s national income comes from remittances – that you see far more women than young men on the streets.
‘Eighty inpatients, seven admissions, mortality one and no morbidity,’ Salima rattles off quickly.
‘Well, what’s the first case?’ I ask.
‘Fifty-year-old lady present with loss of consciousness two days ago. Bowels open every day. Known hypertensive and alcoholic. On examination…’
‘No, no, no! What’s she do for a living?’ I ask. I have noticed they never describe the patient’s occupation, which is supposed to be a normal part of presenting a patient’s history, although in Nepal it seems that everybody is either a farmer, a driver, a shopkeeper or a housewife. Mentioning the patient’s occupation is important: not so much for the traditional reason, which is to alert us to possible occupational diseases, but more to remind us that the patient is a person, an individual, and has a life and a story beyond being a mere anonymous patient with a disease.
Salima looks embarrassed and fumbles with the sheet of paper in her hand. She probably hadn’t seen the patient herself and relied on what had been written by one of the other junior doctors, so I was being unfair.
‘Shopkeeper,’ she says after a while.
‘You’re guessing!’ I say and everybody laughs, Salima included.
‘Now tell us about this loss of consciousness.’
‘She comes from other hospital…’
‘So we have no real history? Whether she had a headache first, whether she fitted?’
Salima looks awkward and says nothing.
Protyush, the registrar who had been on call, takes pity on her.
‘Her husband found her on the floor at home. She was intubated at the other hospital and the family wanted her brought here.’
Dev’s hospital is a private hospital; patients only come here by choice, or by their family’s choice, and only if they can afford it. On the other hand they also have to pay if they go to a government hospital, where the treatment is only free in theory, and possibly worse.
‘OK,’ I said. ‘Salima, what did you find on examination?’
‘She localize to pain, not eye opening. Make sounds. Pupils equal and reacting. Cranial nerves intact. Power one on right, plantars up-going,’ she continued in high-speed Nepali English, ‘CT scan show…’
‘No, no,’ I interrupt again. ‘What’s your one-line summary?’
‘Fifty-year-old lady present with loss of consciousness with known hypertension. Bowels open regularly. On examination pupils equal and reacting, and…’
‘Salima – one line, not three!’
After a while we agree on a one-line summary. Presenting cases is a hugely important part of medical practice – about both communication and analysis. A short summary after presenting the details of a case forces the doctor to think about the diagnosis. I quickly learnt that most of the doctors were so shy in front of me that they found it very difficult to think analytically. It took them a long time to overcome this in my presence. I also suspected that much of their teaching had been entirely by rote.
‘Right, now we can look at the CT scan.’
The scan showed that almost all of the left side of the woman’s brain was dark grey, almost black. The woman had clearly suffered a massive and irreversible stroke – an ‘infarct’ caused by a blood clot forming in the left carotid artery. The left cerebral hemisphere, along with all her language and much of her intellect and personality as well as her ability to move the right side of her body, was dead, with no chance of recovery. Such damage cannot be undone. Some surgeons favour opening up the patient’s skull to allow the dead, infarcted brain to swell outwards and stop the patient from dying from the build-up of pressure in the skull, as infarcted brain swells and severe brain swelling kills you.
Helping a patient survive a stroke with this operation of ‘decompressive craniectomy’ is perhaps justifiable if the stroke is on the right side of the brain (so that they do not lose the ability to communicate, speech usually being on the left side) and if the patient is young, but it seems a strange thing to do in patients who are going to be left dreadfully disabled if they survive. And yet it is recommended in articles in various learned journals claiming that such patients are happy to be alive, and is widely practised. You might wonder how the victims’ happiness can be established if they have lost much of their intellect and personality, the part of their brain responsible for self-respect, or the ability to speak. You might also wonder whether their families are of the same opinion as the patients. Patients with severe brain damage, as far as you can tell, will often have little insight or understanding of their plight, whereas those that do are often deeply depressed. In a way, the true victims are the families. They must either devote themselves to caring, twenty-four hours a day, for somebody who is no longer the person that they once were, or suffer the guilt of consigning them to institutional care. Many marriages fail when faced with problems of this sort. It is worst for parents, who are tragically bound to their brain-damaged children, whatever their age, by unconditional love.
‘So the patient’s going to die?’ I ask the room at large.
‘We operated,’ Protyush says. I express surprise.
‘I spent half an hour trying to persuade the family that we shouldn’t operate but they wouldn’t accept it,’ he adds.
After the morning meeting I go downstairs, take my shoes off outside the operating theatre and ITU area, get the uniformed guard to open the locked door for me and choose a pair of ill-fitting pink rubber clogs from a rack in the theatre corridor. Nepali feet are mostly small so I hobble uncomfortably to Dev’s office, which is conveniently located between the ITU and the theatres.
Dev and I had always got on well together as colleagues when we were training together thirty years earlier, but it had been little more than that. I regret to say that I was far too ambitious and concerned for my own career at that time to take much interest in my colleagues, although I suppose that working a 120-hour week and having three young children at home left me with little spare time. And yet as soon as I came to Kathmandu, Dev and his wife Madhu were so welcoming that it felt as though we had always been the oldest of friends, even though we had only seen each other briefly at a few conferences over the intervening years. Dev is also charismatic, a man of great integrity and very determined. Like most Nepalis he is quite short and slight, although now a little rounder (which he blames on my presence and the beer we drink in the evening). He has a prominent, stubborn chin but slightly hunched shoulders, so that he looks like a cross between a bulldog and a bird. His intensely black, wavy hair has now turned grey. He has a chronic cough which he attributes to breathing the polluted air of the city centre when he worked for many years in the government hospital known as the Bir. He speaks very fast, with great animation, as though in a permanent state of excitement, about his past achievements and the great difficulties he had to overcome in trying to bring neurosurgery to Nepal. He also talks of how difficult it is to run a major neurosurgical practice more or less single-handedly.
He told me that it had been much easier when he was the only neurosurgeon in Nepal – if he gave bad news to patients they had little choice but to accept it. But now there are other neurosurgeons, most of whom have worked with him, from whom they get second opinions, and it would seem that there is little love lost between the professor and some of his former trainees. So he sometimes now has major problems with patients’ families when things have gone badly, which they so often do with neurosurgery. When he told me this, I pointed out that in England there was more and more litigation against doctors, and this always involved doctors giving evidence against each other as expert witnesses.
‘Yes, but here the families threaten us with violence, demand money and have even said that they’ll burn the hospital down,’ he retorted. ‘Of course, we don’t really have malpractice litigation here – it’s almost unheard of to sue doctors.’
Doctors, especially surgeons, are often intensely competitive, and we all worry that other doctors might be better than we are, although I can think of a few famous international surgeons who are so supremely arrogant that they seem to have suppressed this problem by completely forgetting their bad results. We need, of course, self-confidence to cope with the fact that surgery is dangerous and we sometimes fail. We also need to radiate confidence to our frightened patients, but deep down most of us know that we might not be as good as we make out. So we feel easily threatened by our colleagues and often disparage them, accusing them of having the faults that we fear we have ourselves. It is made all the worse if we surround ourselves with junior colleagues whose careers depend on us, and only tell us what they think we want to hear. But it is also because, as the French surgeon René Leriche observed, we all carry cemeteries within ourselves. They are filled with the headstones of all the patients who have come to harm at our hands. We all have guilty secrets, and silence them with self-deception and exaggerated self-belief.
Dev remembers all sorts of details of our time spent working together in London, which I have long forgotten. His determination and energy are remarkable and I quickly came to understand why he has had such an extraordinary and brilliant career and is famous throughout Nepal. This has not been without its disadvantages. Driven and ambitious people can achieve great things, but often make many enemies in the process. Patients come to his outpatient clinic with all manner of non-neurosurgical problems, hoping that he can cure everything. A few years ago one of his daughters was abducted from the family home at gunpoint and Dev had to pay a large ransom. Since then he goes everywhere with a bodyguard.
The ITU is a large room with good natural light, as there are windows all the way along two of the walls. There are ten beds; they are rarely empty. The hospital admits strokes as well as head injuries and many of these patients have undergone decompressive craniectomies. Most of the patients are on ventilators, with pink bandages around their heads and the usual array of monitors and drip-stands and flashing lights and noisy alarms beside them. I had forgotten how grim neurosurgical ITUs can be – in London I had only been responsible for a small proportion of the patients since I was only one of many consultants.
Many of the patients on the ITU here would not survive, few would make a good recovery, especially in Nepal.
‘You do far more decompressive craniectomies here than I would do,’ I say to Dev. ‘Only in America have I seen so much treatment devoted to so many people with such little chance of making a useful recovery. And yet Nepal is one of the poorest countries in the world.’
‘I have to compete with many other neurosurgeons – trained in India or China – and they’ll operate on anything, and it’s always for the money. Like in America. If I tell the family now that no treatment is possible, they’ll go and see somebody else who’ll tell them the opposite and then they’ll kick up a big fuss. So I am forced to operate now when in the past I wouldn’t have. I often wish I still worked for the NHS,’ he adds.
My colleague Igor in Ukraine often faced similar problems. I have been in countries where the surgeons sometimes have to operate with the patients’ families outside the operating theatre wielding guns, threatening to kill the surgeon if the operation is unsuccessful. As a visiting doctor from the West it is hard, at first, to understand the difficulties our colleagues face working in countries with very different cultures and without the rule of law. It is easy to feel superior, to pass condescending judgement. I hope that over the years I have learnt to observe, and no longer to judge. I want to be useful, not to criticize. Besides, so often I find that I have misunderstood or misinterpreted what I have seen or been told – I have learnt not to trust myself. All knowledge is provisional.
‘Many of these patients are going to die anyway, aren’t they?’ I say as we look at the next comatose patient with a bandaged head, labelled ‘No Bone Flap’. After a decompressive craniectomy the patients are left, for a few weeks or months, with a large hole in their skull, like a giant version of the fontanelle with which we are all born. The ‘No Bone Flap’ label is to remind the medical and nursing staff that part of the brain is no longer protected by overlying bone. This particular patient – like so many in Nepal – has been involved in a motorbike accident.
‘Cultural case,’ Dev says. ‘The family ties here are so strong. The family just can’t accept that there is no treatment. If I hadn’t got the boys to operate last night the family would say: “Oh Neuro Hospital doesn’t want to operate!” Can you imagine the situation? Next thing they take the patient out of my hospital and somebody else will operate. The patient will be a vegetable but the family are happy and my reputation will be rubbished…’
Dev turns to look at me.
‘When I was the Minister of Health under the last king – before the Maoists abolished the monarchy – I saved more lives by making crash helmets for motorcyclists compulsory than I will ever save as a neurosurgeon. Most of the families are uneducated,’ he goes on. ‘They have no conception of brain damage. They are hopelessly unrealistic. They think that if the patient is alive they might recover, even if the patient is just about brain-dead. And even if they are braindead they still won’t accept it.’ I was to learn more about this later.
So much for the value of commercial competition in health care, I thought, in a poor country like Nepal. And all this on one man’s shoulders, day in, day out, with never a day off, for thirty years.
Neurosurgery is something of a luxury for poor countries. Illnesses requiring neurosurgical treatment are relatively rare compared to problems affecting other parts of the body. It requires very expensive equipment, and for problems such as cancer and severe head injuries treatment often fails or achieves little. We operate in the hope that patients will make a good recovery, and many will. There can be wonderful triumphs, but the triumphs wouldn’t be triumphant if there weren’t disasters. If the operations never went wrong, there would be nothing very special about them. Some patients will be left more disabled than they were before surgery and others, who would have died if we had not operated, will survive, but terribly disabled. At times, in my more despondent moments, it is not always clear to me whether we are reducing the sum total of human suffering or adding to it. So for countries like Nepal and Ukraine, with impoverished and weak governments and poor primary health care, it makes little sense to spend large sums of money on neurosurgery. Dev in Nepal and Igor in Ukraine have had little choice other than to move into private practice, albeit reluctantly, and yet both feel a little tainted by it, even though they often treat poor patients for free. But there is a limit to how often you can do that if your hospital is to survive.
There has always been a tension at the heart of medicine, between caring for patients and making money. It involves, of course, a bit of both, but it’s a delicate balance and very easily upset. High pay and high professional standards are essential if this balance is to be maintained. The rule of law, after all, in part depends on paying judges so well that they will not be tempted to accept bribes.
Many medical decisions – whether to treat, how much to investigate – are not clear-cut. We deal in probabilities, not certainties. Patients are not consumers who, by definition, always know what is best for themselves, and instead must usually accept their doctors’ advice. Clinical decision-making is easily distorted by the possibility of financial gain for the doctor or hospital, without necessarily being venal (although it certainly can be). Increasing litigation against doctors also drives over-investigation and over-treatment – so-called ‘defensive medicine’. It is always easier to do every possible test and treat ‘just in case’ rather than run the risk of missing some very obscure and unlikely problem and being sued. This combination of paying doctors on a ‘fee for service’ basis – the more we do, the more we get paid – and increasing litigation against doctors in many countries is one of the reasons why health-care costs are running out of control.
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 insulated 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.