Admissions Page 6

  ‘I’m not supposed to attack the nurses in front of the patients,’ I said. ‘I’m really sorry.’

  ‘No, no, not at all,’ he replied with a croaking laugh. ‘I told them I didn’t need the tube and could swallow perfectly well but they wouldn’t listen to me and just shoved it in. I was on your side.’

  My last operation here, I thought, as I cycled home in the evening.

  I finally left my hospital two weeks later, having cleared my office. I disposed of the accumulated clutter that a consultant surgeon acquires over the course of his career. There were letters and photographs from grateful patients, presents and plaques, and outdated textbooks, some of which had belonged to the surgeon whom I had replaced almost thirty years earlier. There were even some books, and an ophthalmoscope, that had belonged to his predecessor, the famous knighted surgeon who seventy years ago had created the neurosurgical department in which we worked. I spent days emptying eight filing cabinets, occasionally stopping to read with amusement some of the pronouncements and plans and protocols, reports and reviews, generated by a labyrinth of government offices and organizations, mostly now defunct, renamed, reorganized or restructured. And there were files dealing with cases where I had been sued, or bitter letters of complaint, from which I quickly averted my eyes – the memory was so painful. Having done all this I left my office, empty, for my successor. I had no regrets whatsoever.

  3

  NEPAL

  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-g
rowing 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 opera
ted 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.