Admissions: A Life in Brain Surgery

6

THE MIND–BRAIN PROBLEM

‘Patient is thirty-five-year-old man. He thinks there is insect in his head.’

‘And you got an MRI scan?’ I said.

‘Yes, sir. No insect.’ We looked at the scan.

‘Well, you can tell him it’s OK,’ I said, though I had already seen so many cases of neurocysticercosis in the brain resulting in epilepsy or filariasis causing painful, swollen limbs and other problems that were entirely new to me that I had momentarily wondered if the man really did have some unusual skull-boring Nepali insect in his head.

‘Shall we send him to see psychiatrist, sir?’

‘Good idea,’ I replied.

Once the day’s operating is done the outpatient clinic is started. The patients will have been waiting all day, clerked by the juniors in the morning, and various investigations organized, and then seen by the more senior doctors, including the professor, once they have finished in the operating theatres.

I was ushered into the outpatient room on my first day to see a row of three patients and their families sitting next to the desk. In front of the desk stood five junior doctors. The patients looked startled and anxious. A receptionist brought some notes and one of the junior doctors, freshly out of a Chinese or Bangladeshi medical school, read out the history to me in stumbling but gabbled Nepali English, much of which I struggled to understand. The patient was an anxious-looking woman in a beautiful red dress.

‘Patient is thirty-five-year-old and has headache for five years. Bowels and bladder normal. On examination pupils equal and reacting. Cranial nerves intact, reflexes equal and plantars downgoing. Had MRI scan.’

‘Well, let’s look at the MRI scan,’ I suggested, which we did and which was, predictably, normal. How much does that cost? I wondered to myself. The answer, I learnt later, was an entire month’s income. I was completely nonplussed. Uncertain as to what I was supposed to recommend, I asked the MOs.

After some hesitant discussion with them, I discovered that a huge variety of drugs were widely used in Nepal, often in a largely random manner. As it is, the patients can buy virtually any drugs themselves from small pharmacies on the streets. There is one on my walk to work, always with a queue. Steroids, I discovered, were popular for all manner of complaints, as was diazepam – Valium. After a few weeks of outpatient clinics, I began to suspect that the entire population of Nepal was on the pain-killing antidepressant amitriptyline.

The first patient was hustled off to be given a prescription and the next, who had been sitting next to her, was moved sideways onto the chair she had left. The clinic was clearly run on ergonomic, assembly-line principles. There was a long line of patients with headaches and backache, sore joints and one with rectal bleeding. I realized that the outpatient clinic functioned more as a GP surgery than a specialist neurosurgical clinic and I had to reach back into my basic medical knowledge from more than thirty years ago. This was both interesting – I was surprised at how much came back to me – and worrying. I was anxious that I might have forgotten something obvious and important after so many years spent specializing in neurosurgery. At least there was internet access, and it was helpful to find answers to most of my uncertainties on my laptop.

The next patient is a young woman with complete paralysis of half of her face after surgery for a huge acoustic tumour. It’s a common complication and often inevitable if the tumour is as large as they usually are in Nepal because of delayed diagnosis. The patient and her husband are delighted when Dev comes into the room. They chatter happily. Dev puts his arm on the husband’s shoulder.

‘I was congratulating him on being a devoted husband. She was very ill after surgery but he stuck by her. They come from a part of the country where if the buffalo is ill, worth 63,000 rupees, they will spend money to treat it but not if the wife is ill. He’s a good man!’ And he slapped the man on the back again.

‘Twenty-two-year-old woman with headache for three months. On examination pupils equal…’

‘No, no, hang on a moment. What does she do for a living?’

There was a brief discussion between the MO and the patient.

‘She counsels victims of torture, sir.’

‘What? From the time of the Maoist insurgency?’

‘Yes, sir.’

‘Does she enjoy the work?’

Apparently she rather liked it. Had she received training for this? I asked.

‘Yes,’ came the reply.

‘For how long?’ I asked.

‘Five days,’ she said.

A skull X-ray was produced.

‘This is a waste of time for headache,’ I said.

‘No, sir,’ came the very polite reply. ‘It is of her sinuses and she has sinusitis.’ And now that I thought of it she certainly sounded as though she had a blocked nose.

‘Ah, yes. I missed that. Shall we send her to the ENT clinic?’

‘They are on holiday for Dasain, sir.’

‘Well, you’d better prescribe her a decongestant then.’

And every so often there might be a patient with a brain tumour about whom Dev wanted my opinion, or another serious and often rare problem, but most of the patients had chronic headache or dizziness or the peculiarly Nepali symptom of total body-burning pain, and were determined to have MRI scans, despite my assurance that the scan would not help. As they would have to pay for the scan, it was not worth arguing over.

I quickly learnt that many of the patients were very disappointed to see me as opposed to the famous professor, even for the simplest of problems. I might have spent thirty minutes explaining things via one of the MOs but I had to resign myself to politely disappointed patients insisting on seeing him, although a few declared themselves happy with my opinion.

Meanwhile, in the room next door, Dev would be conducting his own high-speed clinic. The patients all expected to see him and he tried to see all the new ones himself. His room was full of doctors, receptionists and relatives, all standing, with the patient sitting in the middle of the melee. It made you think of a king, surrounded by courtiers and petitioners.

The door between our rooms was open and I could hear him coaxing, cajoling, declaiming, reassuring in rapid Nepali, depending on the class and education of the patients. They ranged from impoverished peasants from the mountains to teachers and politicians.

‘How many patients actually have a neurosurgical problem?’ I asked him.

‘One point six per cent,’ came the answer.

‘Do other doctors refer you patients?’

‘No, they all have their own connections and hate me. They try to refer them elsewhere but the patients come and see me anyway.’

As I left my first outpatient clinic I was stopped by a man I did not recognize.

‘I am the girl’s father,’ he said in passable English. ‘Thank you, sir, thank you so much,’ pressing his hands together and holding them against his chest in Nepali greeting. Dev must have told him that I was involved in the surgery. I smiled, I hope not too sadly.

‘My son had a brain tumour,’ I told him, ‘I know what you are feeling.’ He thanked me profusely again, and I nodded in acknowledgement and sympathy and went to the management office to wait for Dev and to be driven home.

I have never enjoyed swimming – I was taught to swim at school at the age of eight, in the muddy river at the edge of the school playing fields, with a canvas belt around my waist attached to a rope and wooden pole, which one of the schoolmasters held like a heavy fishing rod. I dreaded having to climb down the slimy wooden ladder attached to the landing stage, with the cold, wet belt around me, seeing the master’s shoes above me through the stage’s planks, into the dark water. I would hang onto the ladder, half submerged, before being tugged by the master controlling the rope. I floundered into the water like a hooked fish. You were just expected to keep afloat by dog-paddling. There was no attempt to teach you to swim and the rope and pole were used to stop you drowning. I remember one of my schoolmates being flung into the river by the master when he was too frightened to descend the ladder. I used to wet myself with fear when changing into my swimming trunks for this character-building experience.

At my next school I was taught to swim properly by the kindly headmaster, but after that there was a notoriously sadistic ex-commando PE master who once hit my face so hard that it was numb for hours afterwards. I was so frightened of the man that I would slam my classroom desk’s hinged lid on my hand to bruise it and claim that I had fallen and couldn’t swim. That only worked once, so I then took to sticking my finger in one of my ears for many hours, mimicking an ear infection. The school doctor was very puzzled by this, as it only happened once a week. I was marched off to an ENT clinic at St Thomas’s Hospital accompanied by the school matron. A sceptical consultant, with a row of medical students, looked in my ear and expressed some doubts. I can’t remember what was said, but I do recall trying to persuade myself that there really was a problem with my ear even though I knew that I was malingering. It was my first experience of cognitive dissonance – entertaining entirely contradictory ideas – and the importance of self-deception in trying to deceive others. I then discovered that music lessons for playing the trumpet were on the same day and at the same time as the swimming class with the vile ex-commando, so I took up the trumpet but did not get on with it. Eventually I would just hide in a cupboard and skip the swimming lessons – an act of some bravery, I thought – and I got away with it.

I was at my weekly brain-tumour meeting twenty-five years later when a brain scan with a familiar name appeared on the screens in front of us. It was the PE master from my past and it showed a malignant brain tumour.

‘He’s a most unpleasant person,’ my oncology colleague said. ‘We’ve had no end of trouble with him but it’s a frontal tumour, so maybe he’s suffered personality change.’

‘No, he hasn’t,’ I said, and explained my connection with the unfortunate man.

‘The tumour needs to be biopsied,’ my colleague said.

‘I think it might be better if you got somebody else to do it,’ I replied.

I wake with the dawn, the crack between the curtains facing my bed going from dark to light, to the sound of cocks crowing, dogs barking and birds singing. I go for a run every morning, but it took me a few weeks to overcome my fear of the local dogs – the guidebooks warn of rabies but my Nepali friends assured me this is more of a problem with the temple monkeys than the street dogs. So at first I ran in slightly absurd small circles and figures of eight in Dev and Madhu’s garden, and up and down the many steps, for half an hour. Later, a little braver, I took to running for longer along the local lanes, between the tightly packed houses that didn’t exist even ten years ago, past the rubbish and open drains, past sagging power and phone lines and bougainvillea hanging over garden walls. The road is uneven earth and rock, but there are a few short stretches of rough concrete, prettily patterned with the street dogs’ pawprints. There is a small shrine on my usual route, and passers-by ring the bell that hangs by its entrance. All around me there is the sound of people coughing and hawking as they start the day. Neither the dogs nor the local people take any interest in me – it seems that there is nothing unusual in the sight of an elderly and breathless Englishman in football shorts stumbling along the road, but Nepalis are very polite and so perhaps are the dogs.

In England I run for longer. I used to run close on fifty miles a week, but one of my knees started to complain and now I only run twenty-five miles a week. I rarely enjoy it – I find it a considerable effort and my body feels stiff and leaden – but I do it for fear of old age and because exercise is supposed to postpone dementia. But there were occasionally wonderful moments when I was still running long distances – up to seventeen miles at weekends in the countryside surrounding Oxford. One early spring morning I was in Wytham Woods, the low sunlight falling diagonally through the trees, when I came across a leveret – a young hare – eating grass beside the path. It appeared completely unafraid of me and I was able to stand only three feet away as it quietly grazed, looking at me with its bright eyes. It was a unique moment of innocent trust from a wild animal, and I felt deeply moved. There is a beautiful ink and sepia drawing by the mystical early-nineteenth-century artist Samuel Palmer in the Ashmolean Museum in Oxford which shows the very same scene – a young hare in a wood, early in the morning, with the sun rising.

On another occasion, as I ran along the Thames, I noticed a duck desperately flapping in the water at the end of a broken-down pier. It appeared to be caught on something, so I crawled out along a steel beam projecting over the river, all that was left of the pier, feeling heroic. I found that the duck had a fish hook in its beak, with the fishing line wrapped around the beam. I managed to free it without falling into the river. The duck promptly dived into the water without stopping to thank me. Nevertheless, I like to think that if one day I ever get into trouble when swimming, the grateful duck – as in the fairy stories – will come and rescue me.

After running round Dev and Madhu’s garden, I do fifty press-ups and a few other exercises, all of which I also hate doing, but I feel much better for it afterwards. I finish with a short swim in the small swimming pool outside the guest house. There is a very brief moment of ecstasy as I push out into the cold, mirror-calm water, which reflects the early-morning sky, with a view of the nearby Himalayan foothills in front of me. I momentarily forget my deep dislike of swimming. I complete this morning ritual with a cold shower – something I started doing two years ago. At first, admittedly in England in the winter, I thought I had discovered the elixir of life. A feeling of exhilaration, of intense well-being, would last for up to two hours afterwards. To my great disappointment, this wonderful feeling – acquired so easily within a couple of minutes – became shorter and shorter within a matter of weeks. I continue to have a cold shower every day, but the feeling now lasts only a few seconds at best, although the cold water still makes me jump about and gasp. I suppose my physiology has adapted, although health fanatics claim that cold is good for ‘vagal tone’ – the activity in the vagus nerve, which controls many of our body’s functions in ways that we scarcely understand. It is a long nerve, which bypasses the spinal cord and reaches from the brain to the heart and many other organs, carrying information and instructions in both directions. It is an extraordinary nerve. Stimulation of the nerve with an electric current can help epilepsy, though nobody knows why. It can allow the generation of orgasms in women who are paralysed and have suffered complete destruction of the spinal cord. Apparently, people who have had it divided (an obsolete operation for gastric ulcer) will not develop Parkinson’s disease.

After all this I sit beside the swimming pool in the little paradise of Dev and Madhu’s garden, with flowers and birds all around me, and drink a cup of coffee before setting off for the hospital. Sometimes a bird with brilliant turquoise plumage dives down onto the surface of the pool, its wings and the splashing water flashing in the sunlight.

After a few weeks I decided to rearrange the way my clinic was run. I had the junior doctors sitting down, I would politely greet each patient when they entered, as I would do in England, which seemed to be less expected here. We would only have one patient in the room rather than a whole queue. The patients would usually come into the room looking expressionless, but my saying ‘Namaste’ and pressing my hands together would almost invariably produce an utterly charming, slightly shy smile in reply. I insisted that every consultation had to end with asking the patient if they had any questions. This made the consultations feel a little less like assembly-line work but greatly reduced the number of patients I could see with the MOs, as the patients had so many questions to ask. They rarely spoke English and often were poor historians, as doctors call patients who have difficulties describing their symptoms. Many of them were subsistence farmers who could not read or write, and the MOs’ English was often very limited as well. Making any kind of diagnosis could sometimes be impossible as the patients seemed so uncertain about their symptoms and were so determined to be given some new drug treatment. On the other hand, some of the patients had diseases such as TB and filariasis, with which I was unfamiliar. I found conducting the clinic extremely difficult, and had to be careful not to miss a serious problem in the constant stream of patients with chronic low back pain, headaches and total body-burning pain.

‘Do you know what somatization is?’

‘No, sir.’

‘Well, it’s the idea that if people are unhappy or depressed – marriage problems, things like that – rather than admit it to themselves, they develop headaches or total body pain, or strange burning feelings. They attribute their unhappiness to these symptoms, rather than consciously admit that they are unhappy in their marriage or that there is some similar problem. Such symptoms are called psychosomatic. You can see it as a sort of self-deception. Is the diagnosis of depression recognized here?’

‘Not really, sir.’

‘All pain is in the brain,’ I explained as I pinched the little finger of my left hand in front of the MOs on the other side of the desk. ‘The pain is not in the finger – it’s in my brain. It’s an illusion that the pain is in the finger. With psychosomatic symptoms, the pain is created by the brain without a stimulus from the peripheral nervous system. So the pain is perfectly real, but the treatment is different. But patients don’t like being told this. They think they’re being criticized.’

‘Many of the women are seeking attention,’ Upama, the MO said. ‘Their husbands are away working abroad and they are unhappy.’

Amidst the flood of patients with minor problems, there are terrible cases as well – a young woman with much of her scalp infiltrated by a malignant skin tumour, a man dying from a brain tumour. There was a child, a thirteen-year-old girl, with half her face paralysed. The scan showed a complex congenital malformation of the joint between the spine and skull, which was the likely, though a very unusual, cause of her paralysis. Neither Dev nor I are very expert in such problems, and we had agreed that surgery was probably too difficult and dangerous. Upama explained this to the girl and her father, and the girl started sobbing silently.

‘She is a girl,’ Upama explained. ‘Her face…’

While I watched the child cry, I thought about my detachment from her suffering – detachment both as a doctor and also because of the great gap of culture and language between us. I have to be detached, I thought, and it is something I learnt as soon as I qualified as a doctor. I cannot help this child, and there is little point in being emotional about it. But I also thought of the research into bonobos (previously known as pygmy chimpanzees), our closest evolutionary relatives, which shows that they have compassion and kindness, a sense of fairness and console each other over pain – at least for their own group. They have not been told to do this by priests or philosophers or teachers, it is part of their genetic nature, and it is reasonable to conclude that the same applies to us.

For most of us, when we become doctors, we have to suppress our natural empathy if we are to function effectively. Empathy is not something we have to learn – it is something we have to unlearn. Patients become part of the ‘out-group’ as anthropologists call it, people with whom we need no longer identify. But the child went on crying and I started to feel uncomfortable. Besides, I told myself, the only way that doctors can lay claim to any kind of moral superiority over other professions is that we treat – at least in theory – all our patients in the same way, irrespective of class or race or nationality, or even of wealth. So my detachment wilted as the child cried and I thought I might just see if Dev and I could be wrong. I used my smartphone to photograph the girl’s scans and emailed them to a colleague on the other side of the world, an expert in problems of this sort, for an opinion. He replied thirty minutes later, saying he felt that surgery was both possible and relatively straightforward.

I showed his opinion to Dev.

‘Isn’t the internet wonderful!’ I said. ‘We can get a world-class opinion so quickly.’

‘We’d better get the child back and talk to the family,’ he replied, but the girl and her family had disappeared.

While the patients come and go, the day outside grows dark. The high Himalayan foothills on the horizon disappear. The ragged leaves of the banana tree in the paddy field next to the hospital start to shake and flap in the wind. A flock of small birds is suddenly flung up into the sky like a handful of leaves, to be quickly swept from sight. The windows of the outpatient room are open – the room fills with the intoxicating smell of wet earth and the patients’ notes in front of me blow off the table. There are frequent power cuts and every so often the room plunges into darkness for a few minutes. Thunder crashes directly overhead, to echo away into the distance.

‘Patient is sixty-five-year-old man with numbness in his fingers.’

The MRI scan shows slight compression of the sixth cervical nerve roots in his neck.

‘How much is he troubled by his symptoms?’

‘He has difficulty climbing trees and milking buffalo, sir.’

We decide to continue with conservative treatment.

‘It is proxy case, sir. Father has brought scan. His two-month-old daughter is in other hospital. They have diagnosed bacterial encephalomeningitis. Child is fitting, and they grew enterobacter in the blood. They have recommended three weeks of IV antibiotics. He wants to know if the treatment is right.’

The CT scan was of poor quality and I found it difficult to interpret, but it looked as though the child might have suffered extensive brain damage.

‘He wants to know if it is good idea to spend money treating the child.’

‘How many other children does he have?’

‘Three, sir.’ But then we worked out that two of them had already died.

I looked at the scan for a long time, not knowing what to recommend.

‘I think I’d get an MRI scan,’ I eventually said. ‘If it shows severe brain damage, perhaps it is better to let the child die.’

Jaman, the excellent MO, spoke to the father.

‘It is economic problem for the MRI scan,’ he told me.

‘Then it’s very difficult,’ I said.

I left Jaman and the other MOs to have a long conversation with the father. I don’t know what was decided, but the father said ‘Namaste’ to me very politely as he left.

‘Patient is forty-year-old lady who has had headache for twenty years, sir.’

My heart sinks a little.

‘Well, tell me more about the headache.’

We discuss this for a few minutes. The patient has been on a long list of drugs over the years.

‘She suffers from panic attacks. She finds diazepam helps, sir.’

I deliver a little lecture on the evils of diazepam and the way that millions of housewives became addicted to it in the past in Europe and America. It is very difficult to know what to suggest.

‘Do you know the word stigma?’

‘Yes, sir.’

‘Is there stigma in Nepal against seeing psychiatrists?’

‘Yes, there is, sir.’

‘I think you should suggest she sees a psychiatrist. I find it helps if I tell patients that I had psychiatric treatment myself once. It was invaluable.’

There was a rapid exchange in Nepali.

‘She wants MRI scan, sir.’

‘It’s a waste of her money.’

‘But she lives in Nepalgunj.’

‘How far away is that?’

‘Two days by bad road.’

‘Oh all right, get an MRI scan then… it won’t show anything but I suppose she hopes that somehow it will make her unhappiness real.’

Afterwards the MO tells me that the patient has already tried to kill herself twice.

‘How do people kill themselves in Nepal?’

‘Usually by hanging, sir.’

The patients come from all over Nepal, often from remote mountain villages accessible only on foot. They come to the clinic hoping for an instant cure, and with an exaggerated faith in medicines, perhaps connected to their belief in prayer and sacrifice. The idea that drugs can have side effects, that there is a balance to be struck between cost and benefit, seems very alien to them. It is impossible to treat effectively chronic problems such as headache, epilepsy, raised blood pressure or low back pain on the basis of a single visit. So the patients end up on a bewildering variety of different drugs that they either acquire themselves or from different doctors over the years. They come with plastic bags full of shiny foil blister packs of coloured tablets of many shapes and sizes, which they spread out on the table in front of me and the MOs.

‘She is thirty-year-old lady with headache, sir.’

Oh dear, I thought, not another one. She sat diffidently in front of me with her husband beside her.

‘And she cannot stop laughing, sir.’

‘Really? Pathological laughter? That’s interesting.’

I was handed the scan. It was indeed very interesting, but very sad.

‘What do you see, Salima?’

After a while, Salima, with my help, worked out that we were looking at a huge brain tumour – technically a petroclival meningioma. I had once had a similar case in London who also had the very rare symptom of uncontrollable, pathological laughter. I had operated, and had left her in a persistent vegetative state. It was one of the larger headstones in my inner cemetery.

‘Tell them to come back tomorrow when Prof is here,’ I said.

Once she had left the room I told the MOs that without surgery the poor young woman would die within a matter of years – slowly, probably from aspiration pneumonia. She already had difficulties swallowing, from the pressure of the tumour on the cranial nerves that controlled her throat, a sure harbinger of death. But surgery, I told them, was almost impossibly difficult – at least, it was very difficult to operate without, at best, inflicting lifelong disability on the patient. So what was better? To die within the next few years, or face a longer life of awful disability?

‘Prof needs to talk to them,’ I said, but she never came back.

‘All is well apart from the child… the baby where we tried to do an endoscopic ventriculostomy yesterday.’ This had been another patient, a baby only a few months old, with a huge hydrocephalic head.

‘In what way?’

‘Not doing well…’

‘Does the mother have other children?’

‘Yes.’

‘It’s best if we let her die, isn’t it?’

Dev said nothing but silently conveyed his agreement.

‘In England we wouldn’t be allowed to do that,’ I said. ‘We’d raise heaven and earth and spend a fortune to keep the child alive even though she will have a miserable future with severe brain damage and a head the size of a football. My old boss, at the children’s hospital where I trained, sometimes said to me, after we had operated on a particularly hopeless case who was doomed to live a miserable and disabled life, that he wished he could tell the parents to let the child die and go and have another one. But you’re not allowed to say that.’

‘The child died during the night,’ the registrar told me when he saw me next morning looking at the space where she had been. The child had gone, leaving only a sad little huddle of sheets on the bed, as the nurses had not yet had time to change the bedding.

I had some difficulties setting up a patient for an MVD, an operation for facial pain which involves microscopically manipulating a small artery off the trigeminal nerve, the nerve for sensation over the face. It is an operation I have done hundreds of times in London – but doing it here feels very different. Turning the patient was somewhat problematic.

‘In London we say one, two, three and then turn the patient,’ I said. ‘Do you do that here?’

‘Yes, sir,’ the registrar assured me happily.

‘One,’ I said, and he grabbed the patient and started pushing him off the trolley.

‘No! No!’ I shouted. ‘One, two, three… and then roll.’

It felt more like a rugger scrum than a coordinated manoeuvre, but we managed to get the patient safely face-down onto the table.

*

It was a twenty-minute drive from Neuro Hospital to the Bir, past a few small demonstrations with heavily armed police in attendance. Nepal is in a constant state of political chaos. The civil war only ended a few years ago. The monarchy collapsed four years after the royal massacre. The democratically elected Marxist government which replaced it is riven by continuous political infighting. The streets around the hospital were packed with pedestrians and motorbikes. An emaciated young woman was selling a few halved cucumbers, daubed with a red relish, from an empty oil drum that served as a stall, at the hospital entrance. There was a row of ramshackle pharmacies across the road from the entrance, with crowds of people standing in front of them.

‘That was the first pharmacy in Nepal,’ Dev said, pointing to an old brick building behind the pharmacy shacks with wide cracks in its walls from the recent earthquake.

The hospital itself was more like a dirty old warehouse. It reminded me of some of the worst hospitals I had seen in Africa and rural Ukraine. It had been built in the 1960s by the Americans, and although some of the wards had plenty of windows, it was a typical example of the style of architecture that treats hospitals as being little different from factories or prisons, with long, dark corridors and lots of gloomy spaces. The wards were very crowded and everything felt sad and neglected. Dev was greeted with many delighted smiles and ‘Namastes’ by the staff, but he told me afterwards that he had been deeply upset by the visit.

‘I created my own neurosurgical unit here,’ he told me. ‘The first in Nepal. We had to build everything from scratch with second-hand equipment. I used to do my own cerebral angiograms by direct carotid puncture in the neck. Jamie Ambrose at AMH had shown me how to do it. We painted the ward every year – I paid for the paint myself – we had a painting party. And look at it all now! All gone, filthy, neglected.’

‘When I came back here from the UK,’ he continued, ‘nobody would work after two in the afternoon. So I sat in the office by myself, the only senior doctor in the building. Eventually everybody else stayed as well. We had no money then. I was working all the time.’

We left the hospital and stood outside, waiting for Dev’s driver. Dev was recognized by many people – he is famous throughout Nepal, let alone at the hospital where he used to work – and while he chatted and joshed with them I stood and watched the endless flow of people coming and going. There was a large pool of dirty water from a leaking water main, and rubbish and broken bricks – probably left over from the earthquake – in the gutter opposite. And yet, as the women picked their way across the road in their brilliantly coloured and elegant clothes, I thought, with a slight feeling of shame, that the scene was rather beautiful.

As Ramesh, Dev’s driver, manoeuvred the car past the long and chaotic queues outside the petrol stations, Dev returned to the subject of the Bir.

‘I need a rest after what I have just been through. It was terrible, terrible… people would come to appreciate just how good a ward could be… all gone. That floor was something different. Nice working environment. It was recognized by the Royal College in England for training. All gone, all gone.’

A few months later I met an English neurosurgeon in New Zealand who, when a medical student, had visited Dev’s department at the Bir. He fully confirmed just how different the department had been from the rest of the hospital.

‘It was a beacon of light in the darkness,’ he said.

‘We came back here with such high hopes,’ Madhu told me over supper that evening, ‘and everything has got so much worse.’