1-7 December 2017 #886

The English Surgeon

In his new book, pioneering British neurosurgeon ponders the end of his own life and his work in Nepal and Ukraine
Niraj Shrestha

CAPTION:LEARNING BY DOING: Henry Marsh training Nepali surgeons at the Neuro Hospital in Bansbari, Kathmandu.

Henry Marsh began his 2014 memoir Do No Harm with a startling confession: ‘I often have to cut into brains and it is something I hate doing.’

Honest and sparing to a fault, he recounted his failures rather than his much more numerous successes which still haunt him. Now retired from the British National Health Service, Marsh’s new work Admissions looks inwards: pondering the end of his own life, and recounting his post-retirement work in Ukraine and Nepal.

In Kathmandu, he works with his friend Upendra Devkota (‘Dev’) a fellow trainee in London 30 years ago, at the Neuro Hospital in Maharjaganj. He finds a city still trying to find its feet a year after the 2015 earthquake.

‘There is a rawness, a directness to life here with intense and brilliant colors, which was lost in wealthy countries a long time ago,” he writes. Noticing a faded poster outside an NGO office, he observes: ‘All the world wants to help Nepal and vast sums of aid have been lavished on the country, yet much of it seems to have disappeared without trace, leaving only faded signs and notice-boards behind.’

Nepal, he finds ‘is a tragic mess ... the politics of the country is largely the politics of patronage and corruption’ and yet ‘as an outsider, it is almost impossible not to fall in love with the land and its people.’

Working in Nepal can be both exhilarating and frustrating. He finds the junior doctors and registrars ‘very polite and respectful. If they do not know the answer to a question, they find it quite impossible to admit this. Rather than say no, they will stand speechless. The silence can last for many minutes and makes teaching very difficult.’

Most patients come with outsized expectations ‘hoping for an instant cure, and with an exaggerated faith in medicines, perhaps connected to their belief in prayer and sacrifice.’ Due to poor primary care brain tumors are much larger than in the West and treatment is more difficult and dangerous. And yet, the surgeons are under tremendous pressure to operate even though the patient will end up in a vegetative state or worse.

‘Only in America have I seen so much treatment devoted to so many people with such little chance of making a useful recovery,’ he muses.

He marvels at Upendra Devkota single-handedly establishing and running a world class hospital and his relentless pace of work: ‘Dev does almost all the major operating himself. In six weeks working in Kathmandu I saw more major operations than I would have done in six months in London,” he adds.

Neuro Hospital’s outpatient clinic is full of doctors, receptionists, relatives and patients and Devkota is like a ‘king surrounded by courtiers and petitioners’. He also ventures out of Kathmandu to a free Health Camp in Devkota’s native Gorkha. It is a formidable undertaking carrying equipment to run operating theaters, laboratories, and a pharmacy. Here the atmosphere is that of a curious mix of a small hospital and a country fair. Some patients have walked for days to make it to the clinic with serious ailments.

On the Annapurna Circuit trek with his son he ruminates about his own life, his complicated first marriage and the lives of his parents, how his unrequited first love led to a failed suicide attempt and his dropping out of Oxford but ultimately to his improbable career as a neurosurgeon.

His father, Norman Marsh was an eminent lawyer who along with his mother was involved in the creation of Amnesty International. He fears if he too will suffer from dementia like his father, or some other serious ailment. He keeps a ‘suicide kit’ of a few lethal drugs at home but is not sure if he would ever dare to use it. As the Romanian-French writer Emil Cioran said: ‘Without the possibility of suicide, I would have killed myself long ago.’ Marsh doesn’t go quite that far but idea that, if need be, he can end his sufferings provides him some solace.

He takes the obligatory elephant ride in Chitwan. The look a Nepali elephant gave him, with its red-rimmed eyes ‘was of deep and infinitely sad resignation’. That sense of ‘sad resignation’ sometimes also washes into this book which is always insightful, and often wise.

Watch documentary The English Surgeon about Henry Marsh as he grapples with Ukrainian surgeons with moral, ethical and professional issues.


Excerpts from Admissions

How he first thought of going to work in Nepal after retirement

While I ran beside the river, I suddenly remembered a young Nepali woman with a cyst in her spine that had been slowly paralysing her legs. I had operated on her two months previously. The cyst turned out to be cysticercosis, a worm infection common in impoverished countries like Nepal but almost unheard of in England. She had returned to the outpatient clinic a few days earlier to thank me for her recovery; like so many Nepalis, she had the most perfect, gentle manners. As I ran – it was late summer, the river level was low and the dark-green water of the Thames seemed to be almost motionless – I thought of her and then thought of Dev, Nepal’s first and foremost neurosurgeon, more formally known as Professor Upendra Devkota. We had been friends and surgical trainees together in London thirty years ago. ‘Ah!’ I thought. ‘Perhaps I can go to Nepal and work with Dev. And I will see the Himalayas.’

On Neuro Hospital and its design

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.


Life as a Brain Surgeon

by Henry Marsh

Thomas Dunne/St. Martin’s. 271 pp. $26.99

On his personal relationship with Upendra Devkota (Marsh stays at their house while in Kathandu)

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.

On the close working relationship with Upendra Devkota while in Kathmandu

Dev and I had already decided that my principal role in his hospital would be to help him train his juniors so that they could learn how to do more than just the opening and closing and the emergency work at night. Within the first few days of coming to Nepal I knew, with the blind confidence of a lover, that as long as I could still usefully work, I would want to spend as much time as possible in the country.

On a visit to Bir Hospital ‘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.

Pperating with Upendra Devkota

I cheerfully volunteered to join Dev operating on a large brain tumour in an eight-year-old boy and was soon regretting it. The tumour bled like a stuck pig right from the start and there were extraordinarily large arterialized veins running in it that bled furiously and too heavily for the diathermy to work. I started sweating. The problem is that when you worry about the patient bleeding to death you rely on a close working relationship with the anaesthetist, and she didn’t speak English and was very uncommunicative. As I struggled to stop the child bleeding to death from a blood vessel in the centre of the tumour, I despaired of ever managing to train Dev’s juniors to do such operating. It becomes almost impossible if you are trying to train your junior and you have to watch passively while they fumble and stumble, putting the patient’s life at risk. It is easy to see why so often trainees are left to operate on their own, learning the hard way, on the poor and the destitute, who are unlikely to complain if things go badly. In all the countries where I have worked over the years, people with money or influence will make sure that they are not trained upon.

Threatened by the husband when his wife dies after operation

I found Dev, looking grim, surrounded by several of his juniors at the theatre reception desk, all looking equally serious. ‘The girl with a broken neck has just died,’ Protyush told me. ‘The husband is very angry.’ ‘Is Dev waiting to talk to him?’ ‘Yes, but we need backup – here in Nepal the families can assault us. We’re waiting for the security guards.’ Thirty minutes later, I stood in a corner of the theatre reception area where I had a view into the counselling room, and I could see Dev, but not the angry husband. Dev listened to a long outburst in silence and spoke quietly in reply. I crept away, not liking to eavesdrop on so much tragedy and unhappiness.

His love for Nepal

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.

On the way drugs are prescribed in Nepal

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.

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