Ancestors
I don’t know who put together the family tree from 1067 but most seems to be gathered from Brill and Hedgerly Churches. There is also a Crest and Coat of Arms. I was sent a rather sweet illustrated diary which covers significant events in the 19th century. There is also a book on Whitelocke Bulstrode (not a true Bulstrode) who was ambassador to Sweden during the civil war. It is claimed that he changed sides no less than six times and was famed for not so much swimming with the current as galloping with the tide (the Improbable Puritan). Timbrell Bulstrode gained fame for discovering the link between the sewage outfalls in Chichester and typhoid outbreaks caught from the rich oyster beds there. Beatrice Bulstrode was a redoubtable lady who was the first woman to cross the Gobi desert in the 19th century. She was a large lady and when she had trouble with the Mongols, she would grab them by the hair and bang their heads together (so it is said!).
My mother
My mother was the second youngest of four daughters brought up in Newcastle. She studied bacteriology at Durham and met my father, so he says, when he invited her onboard his ship to see a microscope specimen of the syphilis spirochaete. I know nothing of her parents except that her mother was her father’s second wife. I met my grand-mother only once when I was very small. I kept on fidgeting from one foot to the other, and so she was convinced that I needed a pee, and kept on checking.
John and Jackie at their wedding
Jackie and Anne – the terrible sisters
Jackie, my mother, was prone to judgements based on pure prejudice and had the temper of the devil too. On one occasion her younger sister Anne had come to stay. They had a love/hate relationship mainly because they were so similar. On the last day of one visit, Jackie had cooked a lobster for a farewell dinner. This was something we never normally ate as it was too expensive. As she was taking it out of the oven Anne came into the kitchen and asked what it was. On being told it was lobster, she said that she did not like lobster.
Jackie and Anne
Without any hesitation Jackie said “You f****** wouldn’t” (dreadful language for those days) and threw the lobster and dish at her. It missed and splattered down the kitchen wall. I stood there stupified (I can only have been six) and then my father’s huge hand firmly grasped the back of my neck as I was propelled out of the kitchen. “You saw nothing” he said“Go to your room!” I did not argue.
Jackie
It is hard to see your own mother in any sort of perspective, but she was certainly capable of great kindness. She was also determined to have her own way, even when she was not sure that it was what she wanted herself. The result was fierce tantrums and her deliberate attempts to confuse love with obedience. She was hugely intelligent, but was frustrated with the life of a mother of three on a remote island in the English Channel. The most hurtful to me (and I suspect the others ) was her inability to praise. So, when I got an open scholarship to University College Oxford to read Medicine, at the age of 16, her only comment was “Well, I have never even heard of that College”
My mother Jackie
As I child I thought that Jackie despised John as she was always saying cruel things to him (and us). Now I am not so sure. Throughout my teens the rows between my mother and I became worse and worse, cruel comments made in the heat of the moment many years before were regurgitated again and again to prove something, I am not sure what. It made for a time of misery, anger, and guilt.
My father
My father, John, was the youngest of five sons, Cuthbert, Bernard, Godfrey, and Martin. His father Ernest was, I think, originally a miller at Brill in Oxfordshire but then moved to Cheam in Surrey. My father told me that Ernest used his carnassial tooth (pre-molar) to check the hardness of the corn and so did not have it removed when it went rotten. Unfortunately this led to cancer of the jaw and so he died young in 1924 when my father was only eight. Cuthbert inherited the mill, Bernard joined the Rhodesian police. Godfrey was in the Kenya Rifles then farmed in western Kenya, Martin became the vicar of Framlingham in Suffolk.
Godfrey with his mother Ethel
The mill was a big business and had Foden steam lorries for delivering the flour. It was taken over by Cuthbert who bankrupted it. He then tried to claim insurance after burning it down and when he was found out, committed suicide. Bernard and Godfey disappeared into the colonies while Martin was a larger than life vicar in Suffolk who was financially supported by my father for much of his life.
John was a kind man. He was also weak (certainly he could not stand up to my mother), but when I saw him for the first time in his white coat working as a radiologist in the hospitaI, I could not believe that this was the same person that I knew from home. In the hospital he was strong and decisive. He had a rule that if any radiology request card came without the word ‘please’ on it, he tore it up. He maintained that there was no reason why courtesy should not prevail whatever else changed. I don’t tear forms up but I do write ‘please’ on them when I write them. This produced a quirky interchange between me and the radiographers when I first arrived in New Zealand. One of them came round to see me to
ask what extra view it was that I was requesting as they couldn’t read my writing. When I explained that it was the word ‘Please’ the radiographer said in good broad New Zealand “Well f**** me, that explains it. We have never seen that word before on a request form before”.
John only got to medical school (Guy’s Hospital) because a friend of the family paid for him, as by then his mother was so poor that she was taking in washing. He then signed up for the Navy at the outbreak of the war having got the conjoint exam from the Apothecaries (the quickest way to a qualification). I once asked him why he volunteered for the Navy, and he simply said that to the young men then, it was simply the biggest rugby match going and that everyone he knew wanted to be involved. He was a good rugby player and represented his medical school, so the metaphor is highly appropriate.
My father, John
After the war he trained as a radiologist, and after a couple of years was summoned by the Professor who, in those days, handed out consultant jobs when it was felt that ‘You were ready’. He was offered Balham in South London, or Guernsey. He was told to talk it over with his wife that night and then bring his answer in the morning. He had no idea what Guernsey was like, but they both knew that they did not want to spend the rest of their lives in South London. And so he became the sole radiologist on the island of Guernsey for the whole of his career. That was how jobs were organized in those days. No advertisement, application, short-list, or interview, just a benign dictator placing people where he thought they would do best. Of course, it encouraged the rankest form of nepotism but probably minimized the terrible stress that our generation experienced trying to find a consultant job.
At first, my father had what is called a good war, nothing exciting. He played endless games of bridge with a colleague who went on to become a professional bridge player. He then volunteered to join a friend appointed to a mine sweeper in the Mediterranean. The ship
was torpedoed by a German submarine that they were hunting, and the ship capsized as she sank. Half the crew were in the water on one side of the boat and half the other when the depth charges loaded and primed on the afterdeck exploded. All those on the wrong side of the ship were killed. Nothing would persuade my father to talk about this devastating event but after his death, I found a short autobiography that he had written and which I am incorporating into this document.
He was a Freemason and assured me that all the important political decisions about how the hospital should be run in Guernsey were made at the Lodge. He tried to persuade me to become a Mason too and was mortified at my scathing criticism of secret societies. As young child, he would never tell us where he was going on these evenings out, just that he was going ‘brick-laying’. He always had a bath before he went out and there we could hear him practicing his ‘lines’. We would stand outside the bathroom door chanting “Our father which art in the bath”. He would bellow from inside “Go away, I am doing secret things”, so there was at least some humor to the situation.
Martin Bulstrode (John’s older brother – vicar of Framlingham)
The Foden Steam lorries at Great Grandfather Bulstrode’s mill in Wandsworth
The sofa table
He also made a beautiful Queen Anne sofa table at carpentry classes that he attended once a week for over ten years. It is a true master-piece, and took over 18 months just to polish. I would love to have created such a master-piece and certainly it gave him great pride.
He taught me one important lesson late in life. Just before he died he quietly told me that all he wanted to do was to die with dignity: nothing else mattered. I think for his generation, and maybe even for ours, appearances matter a great deal more than we care to admit.
As we children got older Jackie’s passion for organising the Pony Club became all consuming so that slowly he gave up his boating and focused on helping organise Gymkhanas. I think he was sad about having to give up his boating, but was proud of his chapter in Adlard Coles “Channel Harbours and Anchorages’ which covered Guernsey, Herm and Sark.
Guernsey, Society
Les Mourants
In Guernsey, where we had moved when I was two years old, we had first rented an ugly brick house called Jardin Cluet which I don’t remember at all, although it was always pointed out to me as a child. I always felt slightly uncomfortable that I had lived somewhere which I could not remember.
We then moved to a lovely traditional granite house called ‘Les Mourants’ with a garden, four greenhouses and a substantial barn. It was cold. Life in the winter revolved around the Aga stove in the kitchen and the fire in the living room.
Les Mourants from the road
The first noise in the morning was the sound of my father riddling the grate, and then the swoosh of coal as the Aga was refilled with coke. There was no double glazing, and the sash windows rattled in the wind as they leaked cold air around their frames. We children would sit crouched against the side of the Aga or fighting to get closer to the open coal fire in the living room. Either way the zone of warmth was very small indeed, and the rest of the time we were cold. Getting into bed was agony and the only way to warm up was to curl in a ball under the blankets and try to direct your warm breath onto your feet.
We first got a black and white television when I was eight. There was a terrifying science fiction serial called ‘Quatermass and the Pit’ which had me whimpering behind the sofa. Otherwise there were just board games like Monopoly but Jane and I used to fight over them and I certainly remember my father throwing one set into the fire in exasperation at our behaviour. I found reading very difficult and preferred books with lots of pictures.
Rabies
One terrifying book was a life of Louis Pasteur. In it there was a vivid pen and ink sketch of a boy being bitten by a rabid dog. For whatever reason I was already terrified of dogs and this gory story was the final straw.
From then on I was convinced that there was a rabid dog under my bed and that the only way that I could safely get into bed was to run as fast as I could across the room and leap high onto my bed and get under the bedclothes as quickly as possible. The crash as I hit the bed drove my parents mad, but they did not understand, I had no choice.
Guernsey
Guernsey was a very small rural community then. The farmer’s fields were tiny and scattered all around the island because the Napoleonic laws of inheritance required that farm land was split equally between the children. The result was a patch work of fragmented, and hopelessly uneconomic farms on which cows were kept for milk, while daffodils and potatoes were grown in the spring. There were very few trees in the 1950s. I suppose that most had been cut down for fire-wood during the German occupation, but there was a lovely stand of Elms straight across from our house, which roared when the gales blew from the West. These days the island has a much better cover of trees, but those Elms have all gone, smitten by disease. However, what the island lacked in trees it made up for in high banked hedges lining every small field and lane. In spring they were coated in violets, and primroses. In summer the gorse glowed yellow while the seed pods popped, and filled the lanes with their cloying scent. In autumn delicious blackberries tainted with salt could be found hiding in amongst the bracken stalks. The local farm and the lanes around it was a great playground for a child. It surprises me now how big it all felt then but what a small range of fields I actually knew. What seemed miles from home, is now, I find, only a couple of hundred yards away from our gate.
Society in Guernsey
The island of Guernsey was divided socially into three groups: locals, rentiers, and visitors. Rentiers were those who did not belong on the island but had come more recently to evade death duties etc. They were only allowed to buy certain houses which were said to be on the ‘open’ market (rather than the local market). These houses were bought for vast sums, done up, and then occupied by wealthy old people waiting to die.For the Rentiers, Guernsey was a retirement home by the sea that imported gin and exported empties.
For the visitors, it was a classic bucket and spade holiday with boats that took them to the off-lying islands of Herm and Sark and even a boat that took them down the East Coast of the island to a lovely inaccessible bay called Fermain.
The locals were basic Brittany peasant stock either tending tiny farms or fishing the local waters.For the locals there were some darker stories to cover-up. It appears that most locals collaborated with the German occupying force during the Second World War. They had little choice. But, some did not, probably far fewer than claimed to have resisted later. There was great bitterness about who had and who had not collaborated. It is said that the local girls who went out with Germans were tarred and feathered at the end of the war. Now no one wanted to talk about it.
By all accounts, the locals were quite well treated, but Russian slaves were brought in to build gun emplacements and even an underground hospital. The cost must have been quite phenomenal. These fortifications were built on top of the old granite Martello towers erected in the Napoleonic war to protect the islands from invasion by the French and blighted every beach and cliff view in the island.
In the ruins near the cliffs on the east side of the island, there were buildings with pipe outlets all along the walls. Were they the remains of the gas chambers on the island? I am not sure but I do know that none of the forced labour brought to build the huge fortifications there left the islands alive.
Tomatoes
Next door to us on one side was a tomato grower, Mr Roberts, and on the other a farmer Mr Browning with two boys the same age as Jane and myself. Mr Roberts was a bachelor with (quite literally) green fingers, as for 355 days of the year he was up and down working in his huge greenhouses. Mr Roberts grew tomatoes and sometimes flowers: irises, and freesias. The key to profit was getting them to market early, and so the plants were grown under glass which were heated by coal boilers. These pumped hot water through large cast iron pipes set between the rows of plants. In the autumn steamer boilers were towed to each vinery in turn. The plants were up-rooted and the soil dug up. Then thin pipes were inserted through which steam was injected to sterilise the soil and kill all spores. The whole island smelt of coal and steamed soil for those months. Then in the spring, the acrid back-of-the-throat smell of coal started again as the growers heated their vineries to ‘force’ the tomatoes. It must have been an expensive business and tomatoes were only worth harvesting early in the season. Later on, cheaper tomatoes could be obtained from open-air farms. I just remember how hard work it all seemed. The soil had to be dug by hand to insert the pipes. The boilers had to be stoked and filled with coal by hand. The sterilizing pipes all had to be manhandled into place. Then the tomatoes had to be laid carefully into wooden boxes and the lids nailed down before they could be shipped to Covent Garden.
In the summer as soon as the price had glutted the tomatoes were dumped, and then we would hide behind the hedge by the road, mortaring cars coming past with over-ripe tomatoes. Mr Roberts then vanished for ten days to Cannes (which he called Canes) where he stayed at the same casino every year and gambled his profits away. When he returned, the greenhouses were dug over and the season started again. Once air freight started from Spain and the Canaries the whole early tomato industry collapsed and the lovely long wooden framed greenhouses all started to fall down. Between them in the narrow fields, daffodils were grown for the flower market. Once again that business was overtaken by early flowers from Holland. As soon as the flowers were over, the cows were put in to graze the grass and the daffodil leaves. For a few weeks, the milk had this strange taste brought on by the cows eating the daffodils.
In the middle of the summer, there were a series of Agricultural shows where huge floats made of flowers paraded around and were judged by the visitors. My mother made us take part on our horses parading in fancy dresses. These shows were called “The Battle of Flowers” I don’t know why, since as far as I know, there was no battle, but the visitors loved the show.
The Farm
The farm next door was a magnet. There was always something interesting going on there. There were fields with rabbits in the hedges, and flooded meadows where the stream ran through the farm. There were hay barns to hide in, and outlying fields to visit riding on the bars at the back of the tractor. Looking back I realize that the farm was terribly run down, with caved-in pig-styes and rusty corrugated iron sheds. But the farmer was kind, and there was always something to do.
Toothless with my sister Jane
Guernsey Bulls
The fields were so small and the grass so precious that the cows were always tethered by a short chain to a stake hammered into grass. They could only graze within that circle, and then at the end of the day they would be brought in for milking. The following day the stake would be moved to a new patch of ungrazed grass. The farm bull had an extra long stake, and we knew quite well that if the mood took him he could pull that stake up and then it was ‘to the trees’ for us. The bulls were normally very docile but Mr Browning warned us that many a farmer had been gored from turning his back on a ‘docile’ bull. He told us that it could happen ‘any day’ and frightened us witless with stories of the how the bulls kneel on their victims after goring them with their horns. The cows and bull were kept stabled all winter presumably to protect the ground from being cut up, as the grass actually grew all the year round in that gentle climate. When the bull came out for the first time in the spring he was very belligerent, and I remember Mr Browning standing four square with the big wooden mallet he used to drive in the tethering stakes. As the bull snorted ready to charge he stepped forward and struck him a mighty blow with the mallet between his horns. This seemed to settle the bull for a couple of minutes while he was led on up into the field. Then, as soon as he turned his back the bull would start snorting and pawing the ground again. Mr. Browning used to curse each time the bull played up. His favorite oath was “Hell’s Bells, buckets of blood!”. We thought that was a marvelous oath.
One day we children were playing rounders in the lower meadow where the bull was tethered. A beautiful strike (not by me) lofted the ball, which then struck the bull on the side with a solid thwack. None of us waited to see the consequences. We all ran for our lives and climbed the nearest tree. When the dust had settled we finally retrieved our ball. It was bitten and chewed and soaked in saliva. We stood in awe imagining how we would have felt if we had been that ball.
I suppose that Mr Bowning’s farm was modern for the 1950s. He had one small tractor, a plow, a buckrake, a hay cutter, a tedder, and a trailer: that was about it. For us kids the best fun was tunnelling in the hay rick, quite a dangerous past-time if the bales collapsed, but wildly exciting for us. The yard was full of chickens and was the centre of a game called ‘Kick the Can’. The person who was ‘It’ stood in the centre of the yard guarding a tin can, while the rest of us hid as near to the can as we could. As soon as the game started the search for the hiders would start, but if the ‘It’ got too far from the can, a bold hider could break cover, run in and kick the can as far away as possible. During that time everyone including those who had been found and captured could run and hide again.
That farm seems tiny now, it cannot have been more than 10 acres, but then it seemed a whole world to range in, with streams, cliffs, valleys, and even the odd tree to climb. Farming must have been heavily subsidized as there is no way that a family could make a living from such a small area of poor land.
Before I was sent away to boarding school the children on the next door farm were good friends. But once I had been sent to ‘away’ everything changed and I felt an iron curtain come down between us. I wonder whether it was me or them. How can you know at that age?
The Neighbourhood
Just up the road from us half a mile away was the German Underground Hospital, a set of tunnels driven into the granite walls of the valley that had housed a hospital during the German occupation in the Second World War. The main part was a tourist attraction and we certainly could not afford to go there, but there were other unsafe partially flooded tunnels and we could slip though the wire into these. The echoes were wonderful but we were assured terrible punishments if we were caught there.
Directly over Les Mourants, the planes came in on the final flight path to the airport. First, it was biplanes (Rapides) then Dakotas, and finally Viscount turbo-props and Handley-Page Heralds. The airport was often closed with fog and/or wind and then the island felt very cut off, as the ferry only came once a week in the winter.
Tourism
The island relied on the tourist industry in the summer. The ferries to Guernsey and Jersey were owned by British Rail and every employee and their family of this huge organisation had one free rail pass anywhere in the UK once a year. As the Channel Islands was the furthest point on British Rail and there were duty-free cigarettes and alcohol, a substantial proportion of BR employees took their annual holidays in the Channel Islands. When Beeching sold off the ferries as part of the re-organization of the railways, the poor company taking them over appeared not to realize where all the business was coming from and promptly went bankrupt. So the shipping line and the tourist industry all collapsed together just as the tomato and flower growing business were overtaken by warmer climes and more efficient production in Europe.
However, the islands were already starting to change as large numbers of elderly British, from the ‘mainland’, as we called it, came to retire and die there surrounded by their money. They were followed by the offshore banks whose brass plates litter the walls of the granite buildings in St. Peter Port. From a horticultural and tourist based economy, the islands have become reliant on off-shore banking or swindling as it might be better described. Apparently, the British Government tolerates it because they would rather it went on where a close eye can be kept on it, than in some remote archipelago where it would be mixed with drug running and money laundering.
Superstition
Then there was superstition! One day when I was six I was fiddling with my penknife (we all carried knives) I cut myself in the web of my hand between the thumb and index finger. All the other children in the playground gathered round for a glimpse of blood and gore. One of the girls said that her grandmother had told her that if you got a cut between the thumb and finger, you would shortly die of lock-jaw. She went on to describe the symptoms of Tetanus in gruesome detail as only a young girl could. My heart froze within me and without further ado, I set off and ran the two miles home weeping all the way, convinced that my death, a horrible one, was nigh. Now if I ask medical students if they were ever told this story in the playground, about 20% say that they have, but there doesn’t seem to be any regional bias to the distribution of this playground superstition.
I do wonder how many ‘old wives tales’ affect our thinking consciously or unconsciously. The idea of ‘catching a chill’ from getting cold is patently nonsense, so is the idea that reading in poor light damages your eyes. And what about “If you make that silly face and the wind changes, you will be stuck with it!”. Of course growing up as a child you take all this for granted. As we walked past the local church we were always taught to say “Bon Jour, Grand-Mere” to the statue which made up the gate post. For good luck we would lay a coin or a flower on the top of the stone. Many years later I was showing a visitor around the prettier parts of the island and mentioned this custom that we had been taught. As I told the story I ran my hand across the top of the stone, and damn me there was a fresh violet which must have just be put there. When Enoch Powell (a notable right-wing politician and expert on old churches) visited the island he recognized the postern as being a pre-Christian Druid statue long-stone which in Celtic or Roman times had breasts carved on it and was then be incorporated into the ‘new’ church to link the old with the new, a classic example of syncretism. He went further and explained that the stones were usually found in pairs and that the second stone was often built into the base of the church tower, facing inwards. The group with him went to look and sure enough there was the second statue. Despite his dreadful fascist politics, he rose in my estimation a lot after that. It was only many years later that I was part of a demonstration outside Oxford Town Hall when Enoch came to speak. It was a jolly demonstration and quite valueless. We blocaded the front door, and he was smuggled in the back. At an especially excitable moment one of the students bagged a policeman’s helmet while his arms were locked into his colleagues so that they could hold the line. We were jubilant until a senior officer climbed the steps and very politely asked us if we would give it back as otherwise the officer would have to pay for a replacement himself. We talked about this and agreed that the proletariat revolution would not want one of our ‘brothers’ to suffer, so we handed it back.
The West coast of Guernsey (indeed all the Channel Islands) were important to the Druids so there were quite a few Dolman burial sites. On the Southwest corner of Guernsey at a place called Pleimont, there was a ring of stones with a well dug out circular trench around them. This was called the fairy ring and we children used to run around it as fast as we could. Later on one of the girls from a Guernsey family told me that she had been brought there at puberty and made to dance around the circle at the full moon so that her fertility would be improved. I have to say that her fertility was certainly not foremost in her or my mind while we were having this discussion in the back of a car.
I think the superstition remains that you may drown with stomach cramps if you swim within an hour of eating. It was thought that all your blood would be diverted to your bowel from your muscles and so starve them of oxygen. Whoever thought of that? My childhood was blighted by a mother who kept feeding me. Just as my hour was nearly up so I could go swimming my mother would give me something to eat and the clock started again.
Fishing in Guernsey
My father taught me trout fishing. He belonged to a club that fished on the reservoir in Guernsey. It was a very peaceful place with lots of wildlife (for Guernsey) and frankly, I just loved going there for the peace and because my father was so keen for me to do it. He would be so pleased when he got home from work to find the rods ready on the car. It was also an occupation where we did not have to talk as it was talking (with me) that seemed to worry him a lot. His day’s work was so remote from what we do now that it is hard to imagine. At ten to nine in the morning, he would leave in his car for the 1.5-mile journey to the hospital where he had his own reserved car parking space. At 12.30 exactly he would arrive home for lunch. His briefcase contained the Daily Telegraph and the cross-word had always been finished. At 2 pm he drove back to the hospital and then at ten past five he was home for the day. He never got called out at night, and he never worked weekends. A locum was brought in for his annual holiday. What a different life we consultants live today.
Swimming, Boats and Herm
Clothes
Clothing in Guernsey was simple for me before I started school. In summer it was canvas shorts, a canvas shirt, one set of red and one of blue. Once a week my clothes were removed, boiled and replaced by the other set. In winter it was gumboots without socks, and in summer no shoes at all. Your feet hardened up pretty quickly, and the only time I was cold was when I went swimming in the sea. My sisters seemed able to stay in the water for hours. For me, it was minutes and then I was chilled to the bone. At that time there were no wet suits, so when my father went spearfishing he would wear an old Guernsey and a pair of flannel trousers. There was something rather quaint about a fully clothed man waddling into the sea with flippers on.
Swimming
Swimming was the most frightening (and therefore fascinating) thing to me as a child. I know, because my nightmares were full of it. Not only was I bitterly cold but I was also very scared of swimming in the sea and yet could not resist trying it.
Freezing as usual
At the North end of the island there was a beach called Portinfer (Devil’s harbour would I suppose be an apt translation). It was only good for surfing at low tide when a strip of sand was exposed. At any other stage of the tide the waves broke in over rocks and swimming was impossible. Then long hours were spent above the high tide mark where, if the sun was shining, the sand became quite hot and lovely to lie on. It faced the prevailing wind from the West so must have been useless as a harbour but excellent for body surfing. The problem was the undertow, a savage sucking current that seemed to drag you down and out, each time a wave broke. We surfed with small sheets of plywood which had a slightly upward curved nose. Even so, they had a nasty habit of nose-diving as you came down the breaking wave. The front would dig into the sand and you would be punched in the solar plexus by the back-end of the board. The result was that you were winded and buried in the foam from the breaking wave, unable to breathe. This was an agony only matched by the horrors of whooping cough.
At half-tide lots of rock-pools became exposed, inhabited by small but greedy little fish and equally ravenous crabs. A small hook with a bit of limpet as bait never failed to catch one or the other. The crabs were then carried off to put in the girl’s swimming bags.
Rock-pooling
Boating
My father loved boats and everything about them. He had crewed in the Fastnet race as a medical student and had obviously loved his time in the Navy up until the moment they were sunk. His language was peppered with nautical phrases. He had a motor-boat called Moulinet. She was an elegant 26 footer built of pine on oak frames.
Moulinet in St. Peter Port Harbour
Technically she could sleep two and initially had a methylated spirits stove, which was then replaced by gas where he could brew up tea. Her engines were typical 900cc Morris 1000 engines adapted for Marine use. To start them they needed petrol, but once running and warmed up they could be switched over to run on paraffin which was cheaper and safer. They were devils to start on the crank handle and required continuous tinkering from my father who loved those engines dearly. The cover over them in the cockpit was warm, and I was invariably cold, so my favourite spot on the boat was to curl up on them and hum tunes to myself. The vibration of the engines made it easy to hum in tune, as I am completely tone deaf. When I was young we seemed to be out in the boat all the time, and my father loved to teach me all the nautical knots and terms. He obviously missed his time in the Navy and had clearly enjoyed all its traditions. Whenever a naval ship visited he insisted on sailing out and dipping his ensign so that they were obliged to dip their ensign back in return. What a bloody nuisance for them, but what pleasure it gave him. My mother hated boats with a passion, so there must have been some tension there. She would block outings in the boat for all but the mildest weather and insisted that we had a motor boat with twin engines and no sails as safety had to be paramount.
Moulinet towing her own tender (Winkle) and the Duckling sailing dinghy back from Herm
My father was fascinated by inshore navigation and ended up writing the chapter on the Channel Islands in the definitive book Adlard Coles’ ‘Channel Harbours and anchorages’. So, every voyage in Moulinet was a major navigational exercise with charts, forward and back marks, and the setting of tides. I was fascinated.
Herm at high(yellow) and low (blue and green) water
The chore was preparing the boats in winter. I have never been good at painting, I have not got the patience, but wooden boats of all things need great attention to detail if they are to look half reasonable. I would always start off with the best of intentions and then things would slide downhill from there. When my father stored the boat in the yard at the harbor, there were a group of like-minded buffers with similar boats stored there. They had ladders up the sides to get on board and were continually inviting each other for brews of tea, while they discussed the problems of boat maintenance.
Horses
Later my mother and sisters became interested in riding and we acquired three horses. Riding came to dominate our lives and boating became less and less and important. I think they always realised that my heart lay with boats, but my father was committed to helping with the Pony Club, so boating became a rare event.
My boats
My first boats were blocks of wood with a nail on the front to which I attached a string. They were towed everywhere by me, behind Moulinet, and behind me over land, until the string snapped and they were lost. When I was sent away to boarding school at 8 years old we had to take a model boat with us, and I was allowed to choose mine. She was a gorgeous Bermuda-rigged yacht with a lead keel. I adored that boat. My little sister has it now. I wonder if she realizes how much it meant to me. I hope so. It felt like my only link with home when I was sent away. You could trim the jib and main so that she sailed in a straight line across the swimming pool at school. She did not have a rudder-like the more expensive boats that many of the other boys had, but in my eyes, she was quite the loveliest on the lake and even looked good when she broached, which she often did.
My second boat was a red balsa wood catamaran that my father made me for Christmas. Jane had a varnished one, and both had clearly been finished in a hurry as they smelt strongly of paint. We sailed them on the model yacht pond in St. Peter Port. They were fast but never captured my heart like my Ailsa yacht.
Moulinet had a tender (a clinker-laid wooden dinghy called Winkle) which my father converted into a lovely little sailing dinghy for me, with a balanced lug-sail
Winkle working for her living – Jane rowing
It was real Swallows and Amazons stuff except that there were no swallows or amazons to play with. My sisters rode horses and once I was sent away to boarding school friends were few and far between. Sailing a boat alone did nothing for me, and I had no interest in racing. Winkle was quickly replaced by a lighter and better rigged ‘Duckling’ dinghy which I was allowed to sail around inside the harbour. Later, much later, I bought a small catamaran, a Swift called Mpaka (the Swahili for swift).
Mpaka
It had belonged to Tim Barton, Jane’s future husband and he now had the larger and much faster Shearwater catamaran called Haraka (fast one) which I admired unreservedly from afar. I had never imagined that a boat could sail so fast. My Swift was only 14 feet long but Tim’s Haraka must have been over 16 feet and seemed enormous to me. He could sail to the island of Herm over 3 miles away in what seemed like only minutes.
Even now, if I want to get to sleep I have only to imagine that I am turning a boat away from the shore, hopping over the gunwhale and sheeting in the mainsail and I am asleep. However, racing is a different matter. It seems to me to be the antithesis of everything I love about sailing. I will race with Simon because it obviously gives him such huge pleasure, but I would much prefer to settle down and feel the boat going well, than to fret whether we are beating the others or not. Give me a windsurfer and I will go as fast as I can, but try and beat someone – never. It is probably sour grapes because so many of my friends and relatives are such good sailors that I would never be able to beat them anyway, however hard I tried.
Peter Heyworths Irriquois cruising catamaran. She was really fast Helming
My other passion as a child was sitting on an inflatable airbed (a Lilo) and paddling round the rocky inlets of the bays on the east side of Guernsey. The tiny airbed was a virtually indestructable canoe and the worst that could happen was a dunking after being rolled by a breaking wave. But the fun and sense of adventure of creeping up the narrow gaps in the granite cliffs where the waves roll you in, then suck you back out again, was a real joy to me.
Herm
Herm was a dream island, only a short distance from St. Peter Port and surrounded by reefs, strong currents, and huge areas of sand which were exposed at low tide.
Shell beach at the North End of Herm with Sark in the background. A wonderful paradice of currents, rocks and huge tides
Each side had different challenges and just beyond it between Herm and Sark was the Petit Bouillon an area of swirling whirl-pools where the tide ripped around the island. This place filled me with a mixture of fascination and fear. The deep swirling currents – would they suck you down if you tried to swim there? Who knew? The island was small – only a mile or so long. Walking along the paths on a hot summers day nearly burnt your feet. To the North were sand dunes: to the east was a wonderful beach with sand eels which could be netted and cooked over a fire.
Barbecue on the beach in Herm
To the south were cliffs with a blow-hole in them which had been literally blown apart in a storm, and on the west side was a small harbour which dried out at low tide. Just south of it was an area – Rosaire steps – which at high water looked like a series of rocks, but as the tide fell it became a lagoon protected from wind and tide where we could play.
It was there that my parents organised a party with a barbecue of grilled sausages and a proper sea-battle between the dinghies of the various boat owners. We loaded our dinghies with plastic bags filled with water, irrigation syringes from the garden and went to war. It was the most delightful fun, except that I think that the anticipation of the event was even more fun than the event itself.
Herm presented my father with a navigational challenge which clearly gave him huge pleasure. Our small boat would have to weave between the rocks with evocative names like Anfre and the Creux, swept by the strong currents which pass between the islands.
At the North End of the island there was a lovely sandy beach where my mother could sunbathe and gossip while my father hunted for mullet and bass with a speargun, brewed tea and tinkered with the engines.
Long Beach -towards the North of Herm Island
My father’s finest catch with a spear gun off Long Beach
There was a strong current running along that beach. It then swept round a small rock promontory and out to sea where the end of the island curved away. I lived in terror of being swept away by that current, and the corner around the rock was where I knew that, beyond that point, there would be no hope whatsoever of saving me. I had nightmare after nightmare about that rock outcrop. In fact the beach on the other side of the outcrop was lovely. The high tide mark was coated with tiny cowrie shells and there were the collapsed stones of a Dolmen burial site right at the end, so my fears were probably completely unfounded. Beyond that beach, and around the corner were high sand dunes with hot sandy slopes. You could run along the grassy top and hurl yourself outwards into the air, landing far below in swirl of steep sloping sand. Except that it was not grass on top. The ground was coated with spiky Marram grass and a small yellow sand rose with vicious thorns. So, the run to the edge was always tinged with a volley of agonising pricks to the soles of your feet.
The Humps
Out beyond that north facing beach there were large reefs which at high water appeared as solitary rocks foaming in the rip tide. But at low water the island of Herm doubles in size and a whole world of sand dunes, rock pools, and rocky reefs, looking like mountain ranges, appears. I was fascinated by this conversion every tide from a few solitary rocks to a whole new unexplored world, which had the added attraction of a crashed second world war plane tucked in amongst the rocks.
The Humps at low water springs
On rare days the tides and the weather were right, and my father would take the boat gingerly around that north end of Herm and out to a great sand bar called ‘The Humps’. When we arrived there just after high water it looked as if we were anchoring in the open sea with a few scattered rocks peeping out around us. As the tide fell a whole new country would appear until we were completely surrounded by sand banks, left floating in a small placid lagoon. To me, this was heaven. My passion was to make model boats out of a piece of wood. In truth, these were just blocks of 2 x 1 with one end cut to a V shape to make a bow. I was allowed to tow these behind the boat as we headed for Herm, but woe betide me if the string broke, or the knot that I had used to attach it came undone. My father would rarely turn back to rescue them and I was miserable when a well-loved boat bobbed away into the distance. However, once out at ‘The Humps’ there was a whole new uncharted land to discover. My boat would be towed up rapids, portaged across sand banks and traverse new ponds (lakes). It was a time of utter contentment, alone with my dreams and imagination. The end of those days was even more miraculous. Throughout the ebb and start of the flood, our placid anchorage would be surrounded by the roar of the tide cutting each side of the Humps. As the tide rose the Humps would vanish and then we were at sea again, as if the whole day had been a dream.
Exploring Guernsey
My adventures with model boats took me to streams on the main island of Guernsey and far further afield than I had ever been before. My bicycle became a wonderful means of escape, but I also used it to ride to school. This ride, when I was seven, must have been around 2 miles and I did this journey every day unsupervised. What freedom! It would be against the law now, but it must have given my mother a blessed release from the interminable school run.
Schools
Blanchelande
My first school was a catholic convent and I was clearly not welcome. Coming from a non-religious family the nuns regarded me as some sort of infidel. I remember being sprinkled with salt in an attempt to purify me! I also remember being taught about mortal and venal sins, and being warned that already I was doomed to a substantial time in purgatory for talking too much. My fascination with astronomy at that time became very tangled with all this high church clap-trap. I was convinced that Venus and Venal had the same derivation and that therefore my extensive sentence in purgatory would be spent on Venus. My astronomy book had an especially vivid artist’s impression of the surface of Venus; rocks and sand – emptiness. Many an evening reading in bed was spent speculating on what I would find to do in this empty but rather exciting-looking place.
When we were all given luminous (and radioactive) models of the Virgin Mary to put by our beds, my father, a radiologist finally lost his cool. He was not having us exposed to unnecessary radiation in the cause of a superstition-riddled religion, so we were removed from the school.
Blanchelande College
The Monnaie
I was then sent to a small school run by a missionary who had returned from India. Well, it certainly wasn’t ‘out of the frying pan into the fire’. He was a gentle and kind man who was a quite inspirational teacher. He seemed to understand children and their world of adventure and imagination. He filled us with Rudyard Kipling-esque stories of his time in India. I was mesmerised. When I was summoned to his study having been reported by some busy-body lady for pedalling my bicycle to school while going DOWNHILL, he frightened the beejeejus out of me by describing in graphic detail the death of a boy my age in India who had done that very thing and crashed.
Hopscotch
In the playground we learnt hop-scotch, and British bulldog. Hop-scotch seemed to appeal more to the girls. It involved throwing a pebble into a square then the rapid repetition of a complex set of what were really dance moves, as you hopped across squares chalked on the ground. You were not allowed to touch the lines or fall over. I am sad that I never see a hopscotch pitch drawn out on the pavement anymore. I would not be able to resist trying that hop-hop-split-hop-split-hop-hop and turn, hop-hop-split-hop-split-hop-hop and home.
Hopscotch pitch
British Bulldog
British bulldog was much more the boy’s cup-of-tea, with the brilliant fast chases and captures. It needed a pitch at least the size of a tennis court. The ‘catcher’ guarded the midline of the pitch, while all the rest tried to cross from one back line to the other without being caught (touched) by the catcher. As soon as you were caught, then you became another catcher. At each sweep from one end of the court to the other, there were more catchers and fewer players until only one (the winner) was left.
Cheam
I suppose that I must have been bright because the headmaster told my father when I was just eight that there was nothing more he could teach me and that I should be sent away to boarding school, having already sat and passed the eleven plus. My father says he was convinced that I should go to a main line boarding school so that I would meet the right people, and be able to get a job in the city even if I was stupid. He also wanted me to be at least competent in every sport so that I would not let myself down if invited to ‘week-ends in the country’. I realise now that this all relates to his upbringing in the Edwardian era, but he was right to get me out of the islands as I would have been big trouble there as a teenager. However, I wonder how many children took this transition of being sent away to school easily. For me it was the end of a world in the islands. I don’t remember wearing socks or vests before I went away to boarding school. Buying all the uniform was a horrifying business. It all arrived from Harrods and was much too large. I can remember the smell of it now, newly pressed flannel, and the claustrophobic sense of wearing a tie, vests, pants and shoes. The other problem that I discovered on arrival in the mainland was that I had no concept of money. If I wanted something in Guernsey I went in to a shop and asked for it to be put on my father’s account. If he didn’t have an account at that shop then they opened one there and then; they all knew my father. I must have sounded like royalty when I got to boarding school.
Cheam School
Suddenly it was time to go. Today, I realise that it is worse for those staying behind but at that moment I just felt abandoned. There were four of us all going to the same school, and we were ushered onto the biplane (a Rapide) with our large ‘Unaccompanied minors’ badges dangling round our necks.
De Haviland Rapide
Dakota DC3
For the start of my first term my parents and sister came over and we all went to London to see the sights. I had read somewhere that ‘the streets of London were paved in gold’, and had my new penknife at the ready to gouge any pieces out that I could find. There were indeed flecks of something shiny in the pavements and as I dawdled along trying to decide which one to dig at, my older sister Jane asked me what I was doing. To my everlasting mortification I explained my plan to her. She thought this was the funniest thing she had ever heard. My inability to distinguish metaphor from fact gave her something to tease me about incessantly for the next days, until I was almost glad to be going away to school.
Scrum half in rugby – I loved it but my parents never came once to watch
While I was away both my father and mother wrote every single week. What a labour of love that must have been. I wonder if they realised how important that contact was.
Leaving Cheam for Radley aged 12
Prince Charles
Prince Charles started at Cheam the year before me, so we had detectives around the grounds day and night. They were lovely to talk to, showed us their pistols, and even gave us a demonstration of how the dogs worked. I had nothing to do with Charles himself. Any difference of age is a yawning gap of maturity at that stage and anyhow he had his own circle of friends. However, on Father’s Day Prince Philip came down to play cricket. We were not remotely interested in him except that he arrived in a brand new black Sunbeam Tiger sports car which he parked right on the boundary with the other dads who had smart cars to show off. No, the interest for us was Edrich’s dad John Edrich, a test match cricketer, and therefore an absolute hero of ours. When he came in to bat his first shot was a tidy forward defensive. But his next was a beautiful off drive taken on the volley and driven effortlessly to the boundary. This is what we had come to watch. The ball lifted and lifted and then dropped in a soft parabola until it landed with a smack on the bonnet of Prince Philip’s new car, caving it in. You could have heard a pin drop around the ground. Nothing was said then, but at the prize-giving Prince Philip gave out all the awards and then stopped, stood up straight, slapped his hands behind his back, and turned glowering towards the Head Master. “Now then,” he said “About that car!’ He paused for what seemed like an eternity then continued “…….What am I going to tell the wife?” It was a lovely moment, a witty remark, and perfect timing.
I met Charles again fifty-five years later when he presented me with the CBE. As you step forward to receive your award, his aide de camp whispers in his ear, priming him on what to say. I was duly congratulated on my humanitarian work. You are not supposed to speak, but I could not resist reminding him that the last time we had met was when he hid behind me in Geography classes at Cheam, leaving me to the wrath of the redoubtable Colonel Shipway, who taught Geography and the History of the Empire, punctuated by loud blows on the floor from his pointer. For a moment Charles was non-plussed, then grinned from ear to ear as we remembered the terror of those classes.
Cheam was a lovely small gentle school set in the most delightful grounds, and I didn’t know how happy I was there until I moved on to Radley.
Sport – Conkers, cars and dibs
Sport was everything at a boy’s school, both on and off the pitch. In the autumn term it was conkers. There was a whole language that went with this game. Conkers were collected from under Horse Chestnuts and a hole bored through their centre with a skewer. They were then threaded onto a string with a fat knot on its end. We took it in turns to strike the other’s conker with our own. I don’t know why the struck conker was much more likely to be destroyed than the striker, but that seemed to be the case. Each time your conker destroyed another, it took on its tally as well – the number of kills that the defeated conker had achieved. So, if a conker which had already destroyed 5 new conkers (a five-er) destroyed a ‘Three-er’ it became an “Eight-er’. If its outer brown layer was damaged it was called ‘skin-damaged’. If the central white meat had a split it was ‘deadly-damaged’. So the cry would go out. “Who will play a deadly damaged sixer?” and we would all descend on the doomed conker eager for its tally. However there were tricks for the unwary. Older boys pickled conkers from previous years in vinegar, or baked them in the bottom oven of the aga for days on end. These wrinkly specimens were indestructable. They could always destroy a fresh conker even when they were deadly damaged. So, James de Saumarez had a horrible wizzened deadly damaged several hundred-er (I cant remember the exact number) and we all soon learnt to steer well clear of it.
Playing conkers
Marbles, car-he, and dibs were also very popular once the conker season was over. The huge smooth polished parquet floors were ideal for marbles and for chasing our cars through under the desks and out into the corridor. Each different type of marble had a special name depending on its colouration and those which were rare were very valuable, being ‘swopped’ for up to twenty more common ones. The contents of your marble bag which swung from your belt was a great status symbol.
Marbles. Each pattern/size and colour has a name
Car-he required tough Dinky toys which had stiff axles and no self-steering. At that time Dinky toys were bringing out cars with little crystal lights (they didn’t light up) suspension and steering (if you pressed on one side of the car it turned the other way. These new cars were useless for car-he as they did not run fast and straight, and the key to success in this game was to hit your opponents car from a long distance. My mother knew that I had to have Dinky toys for school (it was on the check-list) but insisted on buying me a Rolls-Royce with lights and suspension (useless!). But my second car was an E-type Jaguar which had no add-ons and it went straight as a die!
Dibs was a game played with sheep knuckle bones. It is like Jacks which is played with a small ball and little crosses of metal. Just as in jacks there are a series of more and more complex manoeuvres which are performed in the time achieved by throwing one of the dibs in the air then catching it again before it hits the table. The rituals were complex with wonderful names which I have now forgotten, and at the end of term there was a Dibs competition when the best boys in the school would compete. I wonder if that is yet another game which has died out. The complexities of the game are well described in Wikipedia under knuckle-bones, a synonym for dibs.
Dibs/sheep knuckle bones
Every Saturday evening a film was shown. The favourites were ‘Pop-eye the Sailor man’ or wildly exciting adventure films like ‘Ivanhoe’. Those who had been been naughty that week were sentenced to detention during the film. They were obliged to spend from ten minutes to one hour (depending on the accumulation of bad marks) sitting at a desk, bolt-upright, looking straight ahead, arms folded in front of them, while down-stairs they could hear the film going on. I can think of no worse torture for a young boy. If the detention was longer than one hour then it was converted into a beating. Some crimes like talking after lights-out attracted an automatic beating, all the more painful because you were only in pyjamas.
Pranks
We got up to the usual pranks of climbing on the parapets at night, and having feasts in the grounds with bonfires and cider. The cider came in heavy brown glass bottles with stone toppers and we decided to see if we could make one explode by putting it on the fire half full of water. Nothing happened for a long time and we crept closer and closer. Hartley, a small boy with round milky-bar -kid glasses (who got bored easily) pushed his tuck-box really close. He was poking his head round the side when the bottle exploded. The fire was completely obliterated. Pieces of brown glass flew through the trees with wonderful whizzing noises. When the dust settled we found Hartley staggering around half-pleased and half-horrified. He was pouring blood. His ear had been split clean in half by a flying piece of glass. Even more fascinating was the lid of his tuck box which had huge chunks of glass embedded in it. A lucky escape for all of us, and Hartley’s tuck-box became a place of pilgrimage where the story of the cider bottle was told and retold. We were all beaten for this crime, and I certainly remember it hurting a lot. As I walked back down the corridor trying not to cry, I could feel deep welts in my buttocks. We must have been seriously frightened the head master. Certainly it was only luck that no one was seriously injured. Now that I think of Hartley, he appeared on my radar several times. Each week we were given an allowance of four ounces (125 grams) of tuck (sweets). We could choose these and in fact they were not graded exactly by weight but more by cost I suspect. A Mars bar was two ounces (half a weeks ration) but Aniseed balls were 20 to the ounce and lasted much much longer. However the most important part of ‘tuck’ was that it was the school currency. Marbles, dinky toys, you name it, were all traded in tuck, so many of us hoarded our tuck against the day when we might need to buy something big, or maybe we just hoarded it because we were middle class. Hartley went one step further. He set up a ‘tuck-bank’ where he stored any tuck deposited with him under lock and key. He packed it all very tidily and kept immaculate records of who owned what. If you invested in Hartleys ‘tuck-bank’ you received no interest but you were allowed to ask to inspect it. With great solemnity he would take you to his tuck box, unlock the huge padlock, and open it up to allow you to feast your eyes on the incalculable wealth that he controlled. I cannot think why we deposited tuck with Hartley except for the great thrill of seeing your tuck as part of a greater thing.
In my last year, a new head master insisted that we should do physical exercise outside before breakfast. One morning the master was late so we were left in our serried ranks larking about. Hartley, whose outward appearance with his Milky-Bar-kid glasses, belied a very extrovert interior suddenly decided that he would try to climb the corner of the 4 storey school building (an old manor house) using the offset bricks which ornamented each corner. Of course, we egged him on, but when he was about ten feet up, the master taking PT appeared and at once ordered him down. I think the combination of being the centre of attention for the whole school and the danger was too much for him, or was everything that he ever wanted – so he went on climbing, despite the increasingly anguished orders of the master. We were all hurried indoors and I never heard the outcome. We last saw Hartley heading for the parapets, and then we heard that he was ‘taken away’ by his parents later that day. I wondered what he ended up doing!
I loved cricket. I loved the sounds, the smells, the traditions, the discipline of a score book, BUT and it was a big but – I was useless at it. I could catch but I could not throw, I could not bowl and and I was hopeless at batting. I would have given anything to be as good as Sedgwick-Brown at cricket; he could bat bowl and throw effortlessly. Many years later, in my thirties, I agreed to play in a hospital match at my hospital in Essex. The words of the cricket master at Cheam, Colonel Shipway, once more rang in my ears. “Get your front foot to the bounce of the ball, and your bat tight against your pads. Drive forward!” I did, and I scored more than 20 runs including a couple of fours. That evening I went to sleep almost happier than I ever remember. Why on earth could I not have done that when I was young?
Cricket at Cheam
Radley
When I arrived at Radley I was 12, short, fat and very frightened. I spoke Latin pretty well and could read ancient Greek, and was ready to take GCE in maths, but I was not ready for Radley. It was a rough school and for the first year all twenty of the new recruits to the social (house) were in one room with a desk, a tuck-box, and a partition to separate us. At night we were in a dormitory of over 100 boys of every age, with only a low partition between you and the next room. As soon as lights went out there was pandemonium. To a new boy used to small dormitories of no more than eight this was something else. I had no idea of one half of what was going on and perhaps it was better that I did not. On top of that, beatings were carried out by the prefects in the central aisle. I just hid under the bed clothes and hoped for dawn.
One evening in social hall the prefect announced the death of President Kennedy. We were all ordered to look straight ahead for 30 minutes and reflect on the implications of this for the world order. My world order was centered around the social hall, and who was going to hit who next. I couldn’t see how President Kennedy or his successor was going to have much effect on that.
For the first two weeks at Radley, you had to learn off by heart everything about the school. Who could walk where, what colors did a Colt 1st team cricketer wear, and so on? I was quite unable to grasp this and failed the test. This made me into a permanent fag. When any prefect shouted for a fag, we all had to run and the last to arrive would be given the task (such as going to the shop to buy the perfect chocolate or something equally trite). As a permanent fag I had extra duties. I had to run the senior prefect a bath every morning (correct depth and temperature) and for Mr Nathan (another prefect with his own personal lavatory seat) I had to sit and warm it for him but on no account was I allowed to perform through it. Our house-master was old and discipline had gone to the dogs. At the end of a terrifying first year, a new housemaster arrived. Four boys were expelled immediately, four more were thrashed (quite literally) and the social settled down to a much safer, if closely disciplined, atmosphere.
I had arrived at the school with an Exhibition and was expected to get a scholarship at the end of the first year, but I had been completely unhinged by that first year and lost my Exhibition. I still got 13 GCSE but I was not doing well enough and was terribly unhappy.
Latin and Greek
I had to learn Latin and Greek at school up to GCSE. I was no good at either. Latin was still a requirement for entry to medical school, but Greek was simply gratuitous torture. I have to admit that later in life I did use my Latin once. A Portuguese ship’s crew all came in together to see me when I was a GP in Mombasa when their ship berthed. I spoke no Portugese and they spoke no English. In a moment of inspiration I started to ask them questions in Vulgate Latin the most simple form of this universal language, and the only kind I know. After each question they would confer together like a University quiz team, decide by consensus what I meant and then answer. My questions had to be simple and require only the answer ‘yes’ or ‘no’ but it worked. ‘Yes’ They did have a discharge from their penises and ‘yes’ it hurt to pee. Diagnosis made! However, I do question whether it was necessary to torture me for so many years with these dead languages when there are so many important living languages which need to be learnt. While I am banging on about what is taught in school, I really felt that we should have been taught a little about Modern History especially the Irish situation. It would have given me some perspective to the Irish troubles, the single most important domestic political issue in my life time. It cannot be beyond the wit of man to put together a module on issues that are important to our times. For example I think we should all be taught about the creation of Israel and the Palestinian situation. As one reporter explained, there is only 90 seconds on the news to present a story about anywhere abroad. If you are the correspondent for that area you know the geography and you know the history, so there is a danger that you assume that your audience does too. But do they? How many of us can draw the position of the Golan heights on a map, or describe the Balfour Declaration? If we are going to educate our children we might at least teach them what they need, not what the last generation were taught.
Sport at Radley
Sport was everything at Radley but you had to make the choice between being a dry Bob (rugby in the autumn, hockey in spring, cricket in summer) and a wet bob (rugby in the autumn then rowing for the rest of the year. I was hopeless at cricket so opted to be a wetbob). But really I was too small to row so I was made into a cox. This is a cold and miserable job. At least those rowing are taking exercise and keeping warm. There was also a lot of bullying and one of the worst was Radcliffe, the stroke of the boat I coxed. I lived in terror of him. Luckily I was not pretty as otherwise it would have been more than punches that I would have received. There was a strict hierarchy on the river. College (school) boats took priority over social (house) boats and eights took priority over fours.
One day we were in the house four and Radcliffe decided that in practice for the racing between the socials we would do a racing start and then row flat out 500 metres up the river. I remember him leaning forward and snarling in my face that I was to steer a straight course and on no account stop. I don’t know what he thought he was doing as the river was full of boats and we were one of the lowest on the pecking order. Anyhow off we went, and at about 200 metres going straight and well I saw an eight-ahead stop and start to turn around. It was the 3rd College eight and I was of no importance to them. But what they did not know was Radcliffe’s orders. I looked at him, and he was straining at his oar sublimely unaware of my dilemma. In the end, inertia won and we carried on. We hit the third eight at full speed just behind their cox (who was a good friend of mine). We cut the stern clean off and the eight sank where it was. Radcliffe could not believe what I had done, but I stuck firmly to the statement “you told me not to stop!” As we came into the dock, Radcliffe lent forward and snarled again in my face “If you say one word about what I said, I will kill you”. I was hauled before a court-martial of rowing masters but said not a word. I think they must have realized that there was more to this than met the eye, and I was banned from coxing ever again. Radcliffe, the skulking rat, never said a word to me or to anyone else about how or why this had happened. My first lesson in being scapegoated.
Bumps racing
The most exciting part of the racing year was bumps between the social eights which was run on exactly the same basis as torpids and summer eights in Oxford. We all started two lengths apart strung out down the river. When the gun went off, you rowed like hell to try to catch the boat ahead of you before the boat behind caught you. The key was the start. The boat had to be dead straight otherwise the cox would have to use lots of rudder, and the boat would slow. The back of the boat was held still by the cox holding a string attached to a peg on the shore, but the bow of the boat could only be held straight by frantic single strokes by oarsmen on one or other side. This was distracting and could ruin the start. By then I was a good swimmer and a confident diver. I knew that it did not take long for an eight to pass over you, so I volunteered to stand up to my chest in water holding the bow of the boat straight and steady. When the gun went I dived to the bottom of the river and stayed there until the eight had gone over me. It was very exciting and gave me great kudos in the social. However, I doubt that it helped our performance.
Despite being banned from coxing I still had to take exercise every afternoon. Radley always had something else on offer and just around the corner were the gravel pits where I could go sailing, fishing, and bird watching and escape the brutality of Radley. It has never ceased to amaze me that some of my colleagues who were sent to Radley or a similar school did the same to their own children. Did they have a lovely time there themselves, or is there selective amnesia, something similar to what occurs in women after childbirth? I had no money or desire to send my children to the Guantanamo Bay of Oxfordshire.
Bumps racing
Tribalism
The competition between the houses (socials) at Radley was intense and actively encouraged by the house masters. Most of this aggression was channeled into inter-social sports matches which were infinitely more fierce than inter-school matches. However even that was not enough to allay the intrinsic tribal aggression of small boys and I certainly remember one evening when we all piled out of our social to ‘attack’ another social, who had also somehow got themselves into a lather about us. Watching David Attenborough’s films of lemurs in Madagascar attacking other groups for no clear reason brought back to me the wild excitement of racing through the dark with a host of your fellow house-mates to attack another social who had now been designated ‘enemy’.
Looking back now there were all sorts of rituals that were presumably subconsciously designed to bond us. Before the prefect came into the social hall in the evening to supervise prep, the central table where he would work had to be polished. So the four most junior boys had to remove their gowns (we always wore gowns) and polish the table with these expensive items of clothing. The rest of the hall would egg us on so that when the prefect finally arrived we would be found in a frenzy of polishing. Order would then be called by the prefect and everyone would settle down well satisfied that one of the daily rituals had been successfully completed.
Chapel
Radley was a high-church school and so every effort was made to put us off religion by forcing us to sit through interminable rituals in church while there was a whole outdoors which we could have been enjoying. Services were in Latin and had psalm after droning psalm. They certainly succeeded admirably in putting me off. As the liberal attitudes of the 60s started to percolate into the school we started to rebel. We discovered that the organ pipes were situated under the gallery where some of us sat. As the masters could not see us in the gallery we could slide out of our seats and down between the stained glass windows and the seats to reach the organ pipe area. You could then ride the organ pipes like a horse. Each time that pipe’s note was played you got the most wonderful massage of your nether regions. A position on the longest 32 foot pipe was hotly competed for. Our house master wanted our social to be different from others and better in everything. So we were volunteered for the gallery where he insisted that he should be able to hear us singing louder than the rest of the school. We duly obliged but also managed to sing more and more slowly. The result was that over a couple of verses we could get a whole line behind and make a shambles of the service.
Chapel
Combined Cadet Force
We were also all compelled to take part in the Combined Cadet Force. The uniforms did not fit and this was clearly a marvelous opportunity to cock a snoot at authority. The military exercises were great fun especially as we were issued with thunder flashes. These explosive fireworks were a source of great pleasure, the best fun being to climb a tree and then drop one into a platoon of youngsters marching underneath. Once a year there was a General Inspection. Again, we managed to anticipate the antics described in Catch-22 and by marching more slowly than the band, managed to cause collisions and traffic jams between patrols. There was no one individual to blame for this corporate wickedness and even the prefects of Radley could not beat everyone, much as they would have liked to.
David Hardy
David Hardy, the biology master had spotted me even before I went into the sixth form where I was destined to do maths. I had not done biology ‘O’ level but had gone racing to him having seen a spotted and irridescent bird. At first he was bewildered by my extravagant description, then with a roar of laughter realised that I was talking about a common starling. From then on our friendship grew. He was a guru about natural history, knowing the names of, and something interesting about, every bird, flower, butterfly and moth. I was already a keen coarse fisherman, live baiting for pike and then fishing for trout on the school lake on flies that I had tied myself. I had been adopted by a group of farmer’s sons who took me beagling (the school had its own pack), fishing and poaching. I loved it. This world did not depend on how big you were or how hard you could throw a ball and it allowed me to explore some of the most beautiful parts of Oxfordshire, places that even now I come across by chance and am carried back to some of the happiest times of my childhood. The high point was when we caught a big pike on a Sunday morning having left the line out overnight in one of the gravel pits. We had sneaked down in our Sunday clothes straight after first chapel to see what luck we had. When we started to bring in this leviathan, we did not have a landing net, so I was delegated to jump in (in my Sunday suit) embrace this thrashing beast and haul him ashore. He was 12.5 lb, six times bigger than anything that we had ever caught. We carried him the mile back up to school and because he was still not dead we put him in one of the baths. The rest of the social queued to see our prize. Cribb then decided that we should stuff and mount the fish, so we set to work to skin it and make the relevant plaster castes. To my eyes it was completely perfect though I have no doubt that it was a shocking job. However, we did make one huge (quite literally) mistake. The glass eyes for stuffed fish came from a mail-order firm. When we received the catalogue we discovered that eyes for a 40lb fish were only slightly more expensive than those for a 20 or 10 lb fish. To our eyes, this was a forty-pound fish so we duly ordered the largest size. Of course, they were far too large and made the pike look thyrotoxic.
Caldwell’s poets
We were not the only group of misfits in the school. We had to play sport every afternoon and for some this was purgatory. I enjoyed Rugby and sculling, but for others, they were the worst part of the school program. On Wednesday afternoon we were supposed to do army training, but pacifism was already creeping in so there were options. One of the most macho-sounding ones was forestry, run by a large chemistry master with two great Danes and a passion for peonies. Those who did forestry would not say a word about what they did, but were all fairly feeble physical specimens. It was only after I had left the school that I discovered that Forestry was by invitation only. Dr. Caldwell, the master who ran it selected those of a more artistic or even poetical bent and took them far off into the forest at one end of the grounds. There they collected enough dry wood to make a bonfire and then sat around it reading their poems to each other. What an inspirational and paradoxical way of saving these more delicate souls from the horrors of a muscular school. Andrew Motion, the poet Laureate was, I believe, one of that group.
Field Trips
David took us on wonderful field trips to nature reserves like Bic’s bottom (for orchids) or Mimsmere and Havergate (for avocets). Just as Peter Scott describes in his biography I found my passion for killing wild-life being turned into a fascination in it.
Diving
With David’s support, we started a sub-aqua club in the school, making our own wet-suits. In the next summer holiday I was out with my father in his boat when quite suddenly he went down into the cabin and brought out a huge box of anaesthetic equipment and before I could say a word he tipped it overboard. I was amazed and asked why he had done this. He explained that now that I had shown an interest in diving he did not want me going near the equipment that he and his friends had designed in the 50s for diving. He had read Jacques Cousteau’s books and decided to use obsolete anaesthetic equipment to build a diving set consisting of oxygen and a re-breath bag with a CO2 scrubber in it. Those of you into diving will know that this is one of the most dangerous systems which you can use. Pure oxygen is highly toxic at depth, and the CO2 scrubber is also highly unreliable. It was one of those moments when my estimation of my father went up in a great leap and a bound.
Trout fishing
Radley College was set in the most beautiful grounds with huge playing fields, and a trout lake. It was a real joy to go down fly-fishing just after dawn on a summer’s morning. The school was equidistant between Oxford and Abindgon so there were no dens of iniquity within striking distance. This meant that we were socially very naïve. The bike ride to Oxford took an hour, Abingdon not much less and as we were only allowed out for a limited period at a time, there was very little scope for drinking and drugs. However the countryside was lovely and one of the joys for me going beagling was to be taken to yet another lovely farm and then roam across the land. I hardly ever saw a hunt as I enjoyed the walking more. At the end of the day there was also a lovely cream tea.
Getting out of the school
I spent as much time as I could out of the social, and David made that easier by getting me special dispensation to do my evening work down in the labs rather than in the social. Once we had completed our first year in the social hall we went into studies sharing with one other person. You worked with a plywood board rested on the arms of your chair and your feet jammed against your study mate, hardly conducive to study.
Gravel pits – Wildlife havens and a great escape
It was a violent place and fights could break out at any time. I was very small and aggressive so had to watch my back.I was still only 4ft 10in (147cm) when I left Radley. One Sunday lunch we were all standing while grace was said. As the ‘Amen’ rolled out one of the boys next to me picked up his fork and stabbed his next-door neighbour in the groin. There was no special reason for this, I think his hormones just got the better of him, like an elephant in Must. The fork went straight into the femoral vein and there was pandemonium. I was quite interested in this because I knew what to do. So I got pressure on the wound and started organizing things. I could see my housemaster watching from afar. He was a hard man but no good with blood and was clearly horrified that I seemed to be enjoying myself.
Fights
The key to fights was to anticipate that they were going to happen and if you were involved, to go in fast and hard so that you had a reputation that you really had no mercy and could hurt people. As all the others had reached puberty and I had not not, I am afraid I just went straight for the testicles and grabbed and twisted as quickly and hard as I could. Boys at that age are very sensitive about their genitals, and after a few nasty episodes people left me well alone.
Hot housing
Under David Hardy’s tutelage, I made it a rule that I would always get 20% more than anyone else in the class even though I was two years younger. The only person I could not beat consistently came to Oxford too and read Zoology, then came to Cambridge and did medicine. His dissections were a joy to behold and so of course he went on to become an eye surgeon.
David took us to lectures in the Zoology department in Oxford and exposed us to the cutting edge of science. I found this all incredibly exciting. He also took us on field trips, the best one being to the Calf of Man a small island nature reserve just off the southern tip of the Isle of Man. We camped there for a week, drinking beer and smoking pipes. My! We were real men! But bad things happened too. One of the keenest bird watchers was a little strange and was teased about it all the time. One night we went out chasing rabbits and the idea came that we would lock him in the tower in the centre of the island which was full of rats. When you are being teased/bullied or harrassed it is difficult to know whether to stay jocular and hope that everyone loses interest, or beg them not to and risk stirring them up. He tried both and failed. As we left him alone in the keep he was weeping and begging piteously. I felt awful but as one who had his fair share of bullying, I did not dare to say a word. When David heard what we had done he was furious and we all raced back to release him. He was hysterical, and I don’t think he ever recovered from that night. I certainly have never forgotten being involved in a gratuitous piece of cruelty. I suppose that the potential is within us all.
Riding
Horses
When I was six, my mother bought an ex-pit pony which was being starved by a local farmer. I think she felt sorry for it and it was going cheap. We called this tiny welsh pony Stig-in-the-dump and as she put on weight she became almost unmanageable, not at all the sedate pony you want to have to start children riding. This impetuousness suited me fine. She did not need asking twice to gallop, and I loved to gallop. Other children would be flogging their fat lazy ponies, trying to get them to trot, but I had only to touch her sides and she was away. We were all members of the Pony Club and there was interminable class-work learning the names of the parts of a horse. There was also a huge amount of grooming, mucking out and cleaning of tack, none of which interested me in the slightest. Despite my mother’s passion for horses she never seemed to ride much. She seemed to get pleasure from looking after the horses and organising the Pony Club with interminable rallies, where we rode round and round in circles learning to keep our heels down, our toes in, and our hands low.
Mealey standing still for a moment
Girls seem to like horses because they are men without sex. Horses are big, stupid and sometimes a little naughty and need lots of looking after. As soon as the girls in the Pony Club discovered men, their interest in horses waned rapidly. They had the real thing.
Hunting
There were no foxes in Guernsey so there was no proper hunting, but once a year the pack of hounds on Jersey, used for drag hunting would be brought to Guernsey and a drag hunt held. The line would be prepared in advance, permission obtained from the farmers, and barbed wire fences taken down. But as the wealth of the Island increased so did the number of horses, and pretty soon farmers were refusing permission to ride over their land because so much damage was being done. We could still ride on the beaches and take the horses into the sea, but eventually that was banned in the summer because it upset the tourists. I loved riding in the sea as you went bare back to avoid getting salt on the saddles. Once the horses got into deeper water they would drop their hind legs and bound along like kangaroos making it very difficult to stay on.
Riding the horses into the sea. It meant riding bare back as it damaged the saddles
Knocked out
The number of horses at home rose to three and riding became the dominant activity for the whole family. Jane and I were sent out one afternoon to bring the horses in from pasture. We were also told to bring in some buckets and aluminum wands that we had been using to practice gymkhana games. Jane’s horse Bush Baby was very neurotic and had to be ridden with great care. The horse I was riding (Moussec) was a stolid gelding who rarely caused trouble. However, today was his day. To save two journeys to the field Jane decided that I should ride Moussec, carrying the aluminum wands under my arm. At the last minute she decided that I should carry the bucket too, but as I had no spare hands she put it over my head. I was now riding a horse bare back with only one free hand and blinded by a bucket. I imagine that she thought this was very funny. Suffice to say Moussec became spooked by the rattling of the aluminum wands and bolted. I fell off backward and was knocked out. Obviously, I have no memory of this but I do remember waking for a moment and noticing that half the world was green and half of it was blue. I also had a terrible pain in my groin. All this has been pieced together from Jane afterward. She thinks this memory comes from the fact that when I fell, I lay still in the grass. She thought I was faking an injury so dismounted, walked up to me and kicked me hard in the balls. She admits that she was expecting me to dodge the blow, but when I didn’t, but instead groaned, rolled up my eyes and vomited, she realized that something was wrong. She fetched help and I was put to bed for 2 days where I lay comatose. Note that in a medical family there was no thought of taking me to hospital. My only memory of that time was of terrible headaches and in the brief periods of consciousness, my sister’s face glaring at me and hissing “Don’t tell them what happened” As I did not have a clue where I was, never mind what had happened this was redundant advice.
Dislocated finger
Sometime later we were show-jumping and for some reason, I had been allowed to ride Bush-Baby. I had a stupid habit of loosening the reins as I approached the jump, to give the horse its head. That is alright for a sensible horse, but for a psycho-neurotic like this one, it invites disaster. Sure enough, Bushbaby got his footing wrong, tripped, and dropped into the fence rolling right over and luckily throwing me clear. At first there was no concern for me. Everyone rushed to the horse to make sure that it was OK. However, when I looked down at my right hand I noticed that my little finger was pointing completely the wrong way. When I finally got my father’s attention, he was delighted and called my sister over (who was by then a medical student). “Look,” he said “A classical dislocation of the finger. Watch!” And without further ado, he grasped the finger, pulled it, and clicked it back into place. I was too surprised to feel any pain. He then swiftly dislocated it again and said to me “Now, You put it back yourself. You need to be able to do that you know.” I was shocked and furious but there was no time to think about it as it was already starting to ache with great waves of pain. So, I put the finger back and then vented my anger on him. Some years later, I dislocated my finger when I slipped running. I had cause to thank him because within seconds of it happening, I was able to relocate it, before the pain even started.
Oxford University Riding
I gave up riding when I was fifteen. The trade-off was that if I worked for my Pony Club B test and passed it, I could then get my own catamaran and go sailing and so I did. Later, at University my riding came in useful and I was for one year part of the Oxford University Riding team, but more importantly I represented both Oxford and Cambridge in Modern Pentathlon (running, swimming, shooting, fencing and riding). The only reason that I got a place and scored any points at all was because I could get top score in riding and no-one else could ride at all.
Gap year
I was 16 when I left Radley. I had good ‘A’ levels and an open scholarship to Oxford but I was still only 4ft 10in (148cm) tall and had not reached puberty. Clearly, I needed to do some growing up, and once again David came up with the solution. He found me a job working as an animal housekeeper (Tier Pfleger) in a Max Planck Institute in Bavaria, Southern Germany. But not just any Max Planck. This was where the Nobel prize-winning ethologist Konrad Lorenz worked with Frisch (who had worked out the bee dance) and Jurgen Aschoff the master of Circadian rhythms. I was to have a room, subsidized food and a salary of £20 per month. There was however one problem: I did not know one word of German.
I was desperate to get away from home and I suspect the feeling was mutual. So off I went on the train. The final part of the journey was harrowing. I was tired and also did not know where to get off. Everyone was very kind and tried to help, but none spoke English. All they kept saying was ‘ende’. What they were trying to tell me was not to worry. Heershing was the end of the line. Obvious now, but I was frantic with worry as the train moved deeper and deeper into the hills of Bavaria. This was 1968 and Bayern was still a deeply conservative rural community speaking a German with a very strong accent. I remember one Bavarian explaining to me over a very large Mass (litre glass) of beer that Eichornschen Schwanz (red squirrel tail) was pronounced ‘Orkotzel schwoff’ in Bavarian!
Fasching
I must have been collected at the station but have no memory of it. I suspect it was Ulla, the departmental administrator, who spoke no English. I was shown to a lovely new room and went to sleep. At seven the next morning I got up, got washed and dressed and went outside where there was deep snow (it was late February). For several hours I wandered about, but no one appeared. It was as if a bomb had dropped. Then one of the girls appeared (there were about five female tierpflegers) saw me, burst out laughing and dragged me off to the communal kitchen where they got me some brunch. After that nothing much happened so I wandered around the grounds of the Schloss (Manor house) which made up the institute. As evening fell the girls found me again and this time they started to put me into fancy dress and did the same themselves. We then went to a party where there was free beer. The girls danced. I got drunk and fell asleep under the table. The same process was repeated the following day, and I decided that I had come to some fairy tale land where they slept all day and partied all night. Actually, I had arrived at the beginning of Fasching zeit (or carnival) a three-day orgy before the start of lent which the Bavarians have taken to new heights of fun.
After three days the job started. We began work at 7.30 am but stopped at 8.30 for breakfast. Because I was new and the youngest I was sent down to the village to buy the small bread rolls (Brodschen) which are the staple of breakfast. Everything was astoundingly cheap. There were 20 deutch marks to the pound (when the Euro was created it had risen to 2 to the pound).
The institute where I worked was Abteilung Aschoff so it focused on the study of diurnal rhythms in both animals and humans. Ten kilometers away in the forest were the other departments of Lorenz and von Frisch, working on navigation in bees and the behavior of geese.
The animal work
Most of our work was done in darkness. Huge cellars contained animal cages with running wheels which logged the activity of the animals. The animals were subjected to various light regimes and then their activity logged on white paper drums with red ink pens. When the animal’s cages were cleaned or fresh food put in, the worker had to work in complete darkness so as not to affect the rhythm of the animals in the cages. We then had to put ink into the recording drums, take out the sheets which had recorded the last 24 hours of activity, and put in new ones, then tiptoe back out of the dark rooms.Once cleaning and feeding was complete our work was to cut up the paper records into strips which were then glued onto large charts for each animal. By sticking each day’s record sequentially down the chart, it was possible for the research workers to see whether the animal or bird was cycling at 24 hours or cycling faster or slower. There must have been at least five of us doing this incredibly monotonous work. I had been working there for several months before we tierflegers were given a talk to explain what this research was trying to discover. Looking back now it was clear that experiments were just being repeated for the sake of doing more experiments. The concept of the ‘circadian rhythm’ was well known and the effect of light on it well defined. The darker it is, the slower the rhythm, so most of these experiments were a complete waste of time.
Max Planck
At that time Max Planck Institutes were set up to reward one person who had made a major breakthrough in science. The idea was to focus all your research money where there was likely to be a major discovery. The recipient then gathered the research workers and equipment that they wanted to do their work. The only problem was that by the time the value of the original work was recognized, the originator was old and had probably lost most of the drive and any originality they had when they did their seminal research. When the head of a Max Planck Institute retired the whole Institute was dismantled, the staff dismissed, and the buildings sold. Very germanic!
We hardly ever saw our head of department, Jurgen Aschoff. He was a hard-looking aloof man always away at important meetings. He had a dueling scar running down his cheek from his time in Heidelberg and would stroke it as he spoke. However, for me he created a seminal moment. For months I had been struggling to learn German and had got to the stage where I could understand what was being said, but could not formulate a sentence quickly enough in German to take part in a conversation at anything more than the most trivial level. It was a very frustrating stage. We used to have lunch at the main Institutes 10km up the road in Seeweisen where there was a good canteen. None of the tierflegers had cars so we would stand by the Insitute gate and hope to scrounge a lift from one of the senior researchers. On this day Aschoff was around, and was driving across in the departmental BMW. As he swept out of the drive he saw three of us tierflegers waiting for a lift and in a moment of unusual magnanimity shouted across “Einsteigen schnell!” (Get in quickly!). So we set off for Seeweisen with the boss driving. I was anxious to show off my new German, and as there was complete silence in the car decided to ask him a question. At the time the USSR had just invaded Czechoslovakia which was only a few hundred kilometers to the east of us. This had caused great alarm in Germany as there was felt to be a real risk that the Russian army might decide to continue West. The German government was having an urgent debate on whether they should be allowed to suspend the constitution if this did happen. As I understood it, some people were implacably opposed because it might allow the rise of another Hitler. Others felt that a country being invaded by a superior power would have to take Emergency Measures. So the country was divided and there was to be a referendum on it. My question to Aschoff was whether he was going to vote for Notstandgesetz or not. I thought it might start an interesting discussion on the pros and cons which I might be just able to join in. His answer was quick and to the point “You will all vote for Notstandgesetz”. There was a moment of silence. No one was going to say a word, but I was so keyed up about speaking German that without thinking I responded in German (to my enormous pride) “Ah so that is the difference between British and German Democracy. In Britain it is one man one vote, in Germany it is one Professor, four votes.” The Professor stroked his scar for a moment and then slammed on the brakes. The car skidded to a standstill in the gravel beside the road. “Englander, aufsteigen!” I got out of the car, and without another word the car drove on off to Seeweisen leaving me in the forest to walk. As the car roared away not one of my fellow tierflegers looked round. All sat looking straight ahead and it was clear that nothing more would be said. I had shown the audacity to challenge Herr Professor and had clearly overstepped the mark. I suppose 1967 was a little too close to the war, and as I was later to discover there were still deep feelings, especially in Bavaria, about what had happened then.
Dieter Scmiedl
Things really looked up for me there when a new chief animal keeper was appointed. Dieter knew everything about birds. He was also a falconer and brought a Goshawk and a Merlin with him. Lorenz had given a talk to all of us about ethology and suggested that we should spend as much time as possible out of doors observing wild animals. He suggested that for a start, every time we heard a bird call in the forest, we should follow it, find out what species of bird it was, and why it was making that call. Spring had arrived, the Institute was surrounded with forest on the edge of a deep valley with a stream in its floor where Dippers were nesting. On the far side of the valley, there was a monastery which brewed its own famous beer. It had huge drinking halls where beer was served by the liter, and although I could not afford to go there often, Dieter got a Buzzard for me which we tamed. If we went to the Kloster together each with a bird of prey on our arms, we were bound to be bought a beer by inquisitive visitors.
Dieter also knew all his bird calls, so was able to help me learn the meaning of calls, not just the species.
The institute also had its own Alpine hut high in the mountains which we could use free of charge. There was no road to the hut so after a long drive there was a glorious walk in to the hut carrying everything that we needed for the weekend. I was always supernumerary and so got to sleep in the hay barn. The smell and the peace were simply wonderful, and of course, there were a completely new set of birds to follow and to place. Under Dieter’s tutelage, I learnt to hand rear birds, mist net migrating birds, train a falcon and identify bird song. He had worked as a bird warden on the North Sea coast and had an encyclopedic knowledge of birds. He told a riveting story of being the only bird warden on one of the North German Islands, I think it was Norderoog. It is a tenuous island that appears and changes its shape after storms and then some years later may change again after another storm. The warden’s house was built high on stilts to keep it dry. On this occasion it was winter and a large storm blew up. The frail house shook in the wind and when dawn came he looked out to find that the whole 13 acre island had vanished. His house on stilts was standing in the centre of a cold grey and rough North Sea. As the tide fell some of the island reappeared and he was eventually rescued. What an experience! Dieter showed me how birdcalls could be mimicked and how if you listened carefully birds have dialects just as clearly as humans do.
Ant’s eggs
One of the junior post-docs at the Institute was working on bird migration. This involved traveling out into the countryside and finding nestlings of warblers and bringing them back to the Institute to be hand-reared. Helmut worked on Garden Warblers and Blackcaps so we needed to know their calls so that we could follow them back to their nests. The chicks then needed scrupulous care. I felt a little less guilty about robbing all the nests when shortly after we had collected our quota, a large hail storm in our collection area destroyed all the small bird nests anyhow. Once they were back in the Institute, Dieter’s skills came into action and he got them into incubators at the right temperature. There was only one food they could tolerate and that needed to be given to them on tweezers every twenty minutes.So the work involved was enormous with shifts of us working round the clock to feed these birds. The food that suited them was ant’s eggs.
The best eggs were from the Wood Ant (Formica fomica) a big brown/red ant that lives in pine forests and creates large nests out of piles of pine needles. The Latin name gives a clue to the bite which injects formic acid. It is just about tolerable on ordinary skin but when they get inside your trousers and into the genital area it leads to the fatal mistake of taking your trousers off to remove the beast. As soon as you do that, 100 more ants take advantage of the breach (literally) in your defenses and the situation spirals out of control as you try to run away through the forest with your trousers at half-mast. However, the most spectacular sight is when one of these ants latches on to someone’s eye. I think the technical medical term is opisthotonus.
From being crouched over the nest collecting eggs, the individual lets out a short agonized yell and flips backward with their back arched into a hollow curve of pain, just as if they were in the final stages of Tetanus.
Our technique was to approach a nest with shovels and lay out a tarpaulin beside the nest. On the word “Löss” (‘Let’s go”), we would all dig in as fast as possible to the centre of the nest where the eggs are to be found. As soon as we reached this zone we would shovel eggs, ants, and pine needles onto the tarpaulin until the attack on us became intolerable and we were all running in different direction while seeking a bit of privacy to allow us to remove the biting ants from delicate areas. When we had enough material, the mix of ants and eggs was bagged up and brought back to the Institute where it was spread out in the centre of a large tarpaulin whose edges were rolled inwards over bricks to create dark ‘safe’ areas for the ants, but no route of escape. The pile was left for a couple of hours in the sun. In that time the ants would seek out and carry every egg to the safety of the gaps between the bricks sitting under the rolled-in edges of the tarpaulin. The separation of a sack of pine needles, ants and eggs had been performed for us, and we could scoop up litre after liter of pure ants’ eggs and freeze them down for feeding the warbler chicks. Actually they tasted rather good, like condensed milk, but if an ant was mixed in, the formic acid soon removed your appetite. The baby warblers thrived and once they were weaned their diet was changed to mealworms. Once again we produced mealworms in industrial quantities. Large playpens were created full of bran. The mealworms were seeded into these bran bins, grew and reproduced. We then worked with sieves to capture mature meal worms which are toxic to warbler chicks but OK for the adults. The adult birds then went into cages with a perch attached to an electric switch. As autumn approached the birds would become more and more agitated hopping too and fro, on and off their electronically activated perches. The activity would reach a crescendo every night when they are trying to migrate; then as autumn ended the activity would die down. It was clear from this simple experiment that migration was an instinct and that the distance flown on migration was also probably programmed in the genes and related to the length of time the birds had ‘zug lust’ (the desire to migrate).
Abu Gwinner
One of the other very nice researchers was netting and measuring Garden Warblers whose summer range extends from Northern Norway right down to Southern Europe. He found that the ones which had furthest to migrate (from the far north) were a different race with longer wings, adapted for long migration. This became even more interesting when he discovered from capture/ re-capture studies that the migration of these birds all over Europe had a complex pattern. Instead of all the birds sliding south a bit for the winter (like a carpet being dragged across the floor) the Northern-most birds took off first, flew over the Southern birds, and then flew further south than the southern birds ever went. So the carpet of birds covering Europe actually flipped over itself, further emphasising the racial differences between North and South. The Northern birds are very long migrators going from the far north to Central Africa. The southern birds hardly migrate at all, hopping from Southern Europe only as far as Northern Africa. This of course raised some fascinating questions about how migration evolved. Could it really only start with short hops and then be stretched out by a sea or desert subsequently appearing between the summer and winter grounds? It was a chance to try linking evolutionary history with geological changes, both of which occur over the same time scale. Many years later Vicky and I visited the island of Malta situated smack in the middle of the migration route. There thousands upon thousands of warblers drop down exhausted by their crossing of the Mediterranean, and there a small group of short-legged, macho, testosterone laden individuals trap, shoot and slaughter them just when they are at their most vulnerable. They are far too small to really be worth eating, but sell for a lot of money. To call this sport makes a travesty of the word. Our Maltese host begged us not to even discuss it with him. He just claimed that it was too deeply embedded in their culture to change. Bird migration began to fascinate me more and more. This tiny brain with embedded in it instinctive information which tells them when to migrate, which direction to go in, and how far to go is extraordinary. And then the sheer energy requirements to fly almost non-stop for thousands of kilometers defy belief.
Jakob
The junior post-docs were all enthusiastic and interesting. The old guard were not. I had managed to hand-rear a jackdaw called Jakob. As soon as he could fly he was everywhere doing what jackdaws do – stealing bright things, and crapping on everything. One of the senior researchers had alread ordered me to keep my Jackdaw under control. How do you keep a jackdaw under control for heavens sake? Clearly it was a warning. A few days later Jakob flew in Hoffman’s open window, while he was presumably dreaming of Germany’s past glories. Apparently Jakob tried to steal a pencil. Hoffman grabbed him and wrung his neck. I was a bit upset but was getting the first glimpse of how deeply feelings ran in Bavaria. I was young and had no idea of the politcal undercurrents which I later discovered were everywhere. Bavaria was full of traditions, lederhosen, Dierndel dresses, oompah music, and drunken Germans smashing their beer mugs down on the table in the big hall at the monastry calling incomprehensible toasts in broad Bavarian. Perhaps it was lucky that I did not understand what those toast were to or against!
Nuremberg
Many years later, just after the Berlin Wall had come down, I was in Nuremberg for a conference. I had never seen the triumphal arch and monumental architecture of that ghastly place. It was winter with freezing fog, and the buildings loomed through the half-light. As I walked along the triumphal path made famous by Riefenstahl I kept on being passed by elderly German men with silver hair, short crew cuts and black bomber jackets, marching along leading large Alsatian dogs. No prizes for guessing what they had done in their youth. I had not realized that Nuremberg was the site of one of the earliest Jewish programs when in 1298 the Jewish quarter was burnt down to create space for a new market. The city has a renowned museum and I spent a fascinating couple of hours there. In the evening at dinner, I was sitting with a delightful Austrian who I knew of old, and an aggressive and rather drunk German who was dominating the conversation. That afternoon I had come across the words Deutsche (German) and Germanische (?German) used interchangeably. I asked the Austrian what if any was the difference. Carefully he explained that Germanische was a cultural word and represented that area of Europe where German architecture and farming practices were found. The Germans disagreed. He said that it was the land (including Austria) that ‘belonged’ rightfully to Germany! I think that both of us were pretty cross at this rather crass intervention, so to change the subject, I asked the German how it was now with re-unification. “Shrecklich (terrible)” he said.”The East Germans are lazy and stupid.” Before I could say a word the Austrian leant across and said “But surely it is the best thing that could have happened to West Gemany.” The German riposted with a sharp “Warum so? (Why?)” and the Austrian answered softly but with great relish “Because at last it will bring some culture (civilization) to your country”. The shot went home but the answer by the German was not at all what I expected. He leant forward too and hissed at the Austrian “Listen my friend. Last time you did what you were told, and next time you will do the same, and it won’t be long now”. Without a moment’s hesitation, the Austrian rose to his feet, clicked his heels and begged my leave. “I no longer wish to sit at this table” he said as he turned and strode away. I took the first opportunity to leave as well.
Birds of Prey
As well as Jakob, I also had a kestrel and a buzzard. The buzzard was huge and grumpy and was completely untrainable. The kestrel was however a complete delight, spending most of the day on my shoulder peering out of my long hair and looking for prey.One of his favorite games was to sit on the bookshelf in Dieter’s room gazing down at the sheepskin rug on the floor. Clearly it appeared to him as some sort of super mouse. His claws would clench and unclench and his gaze would become more and more fixed on the rug. Finally, he and we could take the suspense no more and he would stoop down onto the rug and tear great chunks out of it. Dieter also had a tame Hoopoe and many pleasant evenings were spent with Dieter playing his banjo and birds of all types flitting around the room.
The Bunker
The Institute did not just work on birds. There were large numbers of small mammals, and of course, we worked on humans. At the back of the site dug into the hill-side was the bunker. This was an underground suite of rooms completely isolated from the outside world. The thick wall kept out light, sound and all other forms of radiation. It had a large double-door system. The outer door could only be opened when the inner one was closed and vice versa. In the large space between the doors there was a large fridge, where food supplies were put.
When you ran out of money as a Tierphleger (as we all did), one of the options to make money was to volunteer for the bunker. Minimum length of stay was one week but some stayed as long as one month. Once you went into the bunker you were completely cut off from the outside world but they (the outside world) monitored everything you did. You were permanently connected to a rectal thermometer which came out on a wire from your trousers and which then fed to a rose in the centre of the ceiling. So this blasted wire followed you around and if it caught on the edge of the table it gave you a good jag in the anus. You rapidly learnt to scoop up your wire with one hand whenever you were moving around. You could always tell when someone had just come out of the bunker because every time they walked around a table or a chair you would see one hand reaching behind them to catch their wire and prevent it from snagging. But, not only did a stint in the Bunker make you money, it was a rule that you could have as much of any food that you wanted. If you left a note in the fridge then the lab assistant would watch and wait until you were asleep (they monitored all movements) and then sneak in through the outer door and collect the list. They then bought what you wanted, and then sneaked back in again to leave it all in the fridge. It was like a Hans-Anderson fairy tale for a teenager who was growing fast. As much free food as you wanted. That was the good bit. The bad bit was that the lights never went out. They were absolutely constant so that your brain got no clue as to what time of day it was. There was no radio or television but there was a record player. The problem was that it only had two records Ravel’s Bolero and Rhapsody in Blue by Gershwin. I don’t know how many times I listened to both. Bolero, I never want to hear again, but Rhapsody in Blue is still one of my favourite pieces of music.
What these experiments showed was that the human body has an endogenous rhythm which is different for every person and varies between 22 and 25 hours. So if you are left in the bunker your days will slowly move out of synch with the 24 hour day outside. However it is even more interesting than that. If you drop the constant light level, then the endogenous rhythm slows so that a 23 ½ hour person becomes a 24 hour person. Increase the brightness of the constant light and the opposite occurs. The theory that the Institute was looking at was whether in spring and autumn when the amount of light being perceived changes, the person’s internal rhythm might get out of phase with the external rhythm just like jet lag. In that case they would be unable to sleep at night (their internal day-time) and during the day they would just want to sleep. After a few days the internal and external rhythm would come into alignment, and then the patient would sleep well and feel fine during the day. To test this possibility experiments were being done to see if drugs which treated depression altered the endogenous rhythm. They didn’t, but then they didn’t seem to do much for depression either!
Helmut Klein
My fascination with bird watching and wildlife led me further and further afield. One of the post-docs, Helmut Klein, shared my passion and knew everything. He knew about frogs in the ponds in the forest, birds, insects, and plants. I was a sponge. As a treat he drove me across Southern Germany to the Black Forest and took me to see Blackcock lekking. The Blackcock males gather in a forest clearing just before dawn and then start dancing and displaying to each other. It looks like a giant male-only eightsome reel. The females lurk in the bushes around the clearing, their lust being roused by this splendid sight. Eventually, they are drawn into the lek and mate with the male of their choice. However, lurking in the bushes there are also males who have a genetic polymorphism which stops them from lecking. They are called ‘Sneaky fuckers(SF)’. They creep up and mate /rape the females watching the lek who have not yet been drawn in. The SFs cannot breed unless the females are brought into breeding condition by the lek so they rely on the normal males for their reproductive success. I identified very strongly with the SFs in my adolescent male condition.
He also took me to see Capercaillie. They are really European Turkeys, huge black birds who display at dawn in the depths of the forest. Their call is a loud and rapidly speeding up ‘Tick-Tock’ followed by a period of a couple of seconds hissing. Hunters have found that when they are hissing they are deaf, so you can play a game of grand-mothers footsteps with them. While they are quiet you too must be absolutely still and silent as they are very shy. When they start Tick-tocking you get ready and the moment they start hissing you can take two steps towards them, then you must freeze again. It was a glorious game in the gloaming before dawn stepping through the snow and freezing with cold. Eventually one of us tripped and we all doubled up with laughter as the Capercaille flapped away into the forest. Stalking Capercaille has to be one of the greatest wildlife events that I have ever experienced.
I came back to the Max Planck the following year. That was a mistake. As a general rule in life you should never go back and this was the proof of the rule. The atmosphere in the Institute was poisonous. The young post-docs had finally lost their patience with the old guard who were doing nothing, so there was total war. However, one bright point was that I got to see Konrad Lorenz on his own. He was a larger-than-life figure with his silver beard and his leather trousers. At his institute there must have been seven or eight tier-flegers all young girls whose job it was to hand-rear the young goslings. They would lounge around on the grass in front of the Institute gossiping while their charges fed around them. It was an idyllic sight. When there was a seminar the girls would pop the goslings inside their shirts so that they could come into the seminar room to listen. After about 20 minutes the goslings would get restless and start cheeping for food. Lorenz would only tolerate this for a few minutes and then the girls were sent outside to let their charges feed. They would file out of the glass doors and flop down onto the grass opening their shirts to disgorge their goslings.
I wanted to speak to Lorenz about the work I was going to be doing in Iceland on pink-footed Geese. As usual he was fascinated asking if I would keep an eye open for Menage a Trois in the Geese. His theory was that adults were often seen in threes, the reason being that the third was a first year female who was not yet ready to breed but who was improving the chances of survival of her siblings by helping to care for them. These were very advanced ideas on socio-biology (altruism) which over the next few years were to become main-stream.
However, I was a little confused by the interview. For a start one whole wall of his office was a salt-water aquarium. It must have cost a fortune to install and to maintain. He explained to me that he had become very interested in Cichlid fish, an enormous group who have a pretty smart line in mimicry. He loved telling stories and hearing that I was English immediately started a story about Peter Scott the famous artist and naturalist. He explained that he was the first person to take Peter schnorkelling on a coral reef. It was a good reef and there were lots of fish numerically and many different species. If you have dived on a reef with lots of fish you will know what a cosmic but bewildering experience it is. Three dimensional ornithology in technicolor. However hard you try; by the time that you get ashore you have forgotten whether it was a blue fish with a yellow head or a yellow fish with a blue head. Anyhow Peter Scott was in the water for an hour or so, then sat down with his water-colours and from memory painted over ten species. Lorenz was entranced at this extraordinary demonstration of an artist’s memory. However, within the ten there were apparently two Cichlids which were in fact mimicking poisonous fish from another genus. Tentatively Lorenz asked if Peter could spot which these were. At this point Lorenz slapped his leather coated breeches with glee and said that Peter accurately spotted both. He was just launching into his ideas about ‘trained eyes’ and what was later to become called ‘search images’ in animals when his eye was caught by something going on in the aquarium. Without any hesitation, he turned to me and asked in English “Have you ever seen a fish masturbating?” I was slightly taken aback by the directness and intimacy of the question and stuttered out that I had not. He took me over to the aquarium and explained what he was seeing. Two flat fish had been mating. They do this by leaving the sandy floor of the aquarium and wrap themselves around each other as much as they are able. The female fish was now spent but the male was still keen for more action. Each time he swam up in the middle of the tank cleaner fish which will not deign to touch a bottom dwelling fish started to nibble him all over. As a result he then ejaculated. I did not think this quite fitted the definition of masturbation but was intrigued by Lorenz’s powers of observation and interpretation. He, like Peter Scott, had an artist’s eye but in the domain of animal behavior not colour and shape.
My passion for bird song has remained with me. When I got back to Oxford I needed a research project to fill in time before I started year 2 of the Zoology degree. John Krebs was doing research on great tits in Wytham Wood. They were all ringed with individual colored rings, but what I found was that I could identify them individually by their call, just as we can distinguish one human voice from another. So, within a few days, I could plot their territories without even seeing them. The experiment was to load them with testosterone by mixing it into Helena Rubenstein’s rejuvenating cream and then spreading it on the bird’s feathers. It was supposed to be absorbed through their skin and then they would become super males and take bigger territories. In fact they just had wet feathers which made them miserable and they lost their territories. Lousy experimental design. No publication, but a realisation that I could not only distinguish bird species but also actual individual birds in a species. When I lived in North Oxford, I could recognize all of the Song Thrushes in the area.
Conferences
As a young biologist, I was desperate to attend conferences but the registration fees were far out of my reach. The big international conferences, where the best papers were read, were designed for Americans on big research grants or those who could set the cost off against tax. The first big conference for me was an International Ornithological conference in the Hague, where all the work that was being done at the Max Planck on bird migration was being presented. Helmut Klein (my boss) was reading a paper so his trip was paid for. He helped me to forge a badge and I was in business. I heard some completely wonderful papers, but the best moment for me was at the end of a paper by Pennycuik on vultures flying. He had taken some marvelous film from a glider and used this to analyze their aerodynamics. For his finishing sentence, he said that he thought that vultures and eagles were the only creatures that purely used natural forces (thermals) to provide energy for their locomotion. As the applause died away, there was a bellow from the back of the hall. At first no-one could hear what the heckler was saying as the acoustics were all wrong. But he stood up, vaulted over the seats in front of him, and bellowed ‘Gossamer spiders’. And of course, he was right. They too use thermals to be lifted right up into the stratosphere and then land on the other side of the world.
I also heard Emlen speak on bird navigation and very nearly signed up to do a PhD with him in Ontario. It felt so exhilarating to be at the cutting edge of science.
Gleneagles
The second time that I went to an International conference was the International Knee Society in the Gleneagles Hotel. This was a really expensive conference and the hotel rooms were a small fortune too.
At the time my friend and colleague Simon owned a wonderful Ford Zodiac with really comfortable front and back bench seats, so I borrowed it to live in.
I parked it in the furthest car park from the front door of the hotel and slept there for the five nights of the conference.
I managed to forge a nice name tag and then popped up for breakfast around 8.30 am when it was at its fullest. There was no check on guests; the hotel was so remote that they did not need to bother. There was a choice of breakfast, porridge & kippers, full English, and continental. Sometimes I had all three. The conference was interesting but there were only lectures in the mornings as the Americans all wanted to play golf in the afternoon. I got to meet many of the Americans all of whom wanted to be shown authentic Scotland and had no idea that an Englishman knew as little about Scotland as they did – probably less. Each evening I would take them out in Simon’s Zodiac which they thought was ‘quaint’ to another pub hotel where I would make up terrible stories about the area, and the malt whiskies. They listened spell-bound. Then what else could they do but pay for my dinner. On the final day the Maitre d’ beckoned me over and quietly told me that they were aware that I might be sleeping in the scruffy Zodiac in the car park. He asked if I could move it to the staff carpark where it would not be such an eyesore! I thought that was a pretty kind thing to say.
BORS (British Orthopaedic Research Society)
It takes a certain kind of balls to call your research society BORS. There can’t be many acronyms with worse connotations, but that is orthopaedics for you. The research being presented at these meetings was usually preliminary results by new research workers from weak research units. What we should have done was have round table discussions where we would do the work that the supervisor should have done. All the criticism was done in open plenary. I had not realised how hurtful my comments were until one meeting I found that every paper had removed their statistical analysis when they heard that I was going to be present. That was in one way a good thing, as the stats were dreadful, but in another, it was a real shame because what we really needed to do was show how stats can be used constructively to improve research. In a way I was being egged on to do other people’s dirty work for them. Most of the senior research workers did not know any stats at all, and they seemed to enjoy watching someone else’s work being torn to pieces – a sort of Schädenfreude. At the Journal of Bone and Joint Surgery editorial board the editor would ask me to read out one of my more vituperative reviews as a form of entertainment for the Board. The laughter accompanying these ‘readings’ was tinged with that frisson of fear that one day the spotlight would be turned onto one of their papers.
Eventually, I wrote a lecture on ‘Statistics for Orthopods’. The aim was to give Orthopaedic Trainees the minimum that they needed to pass their FRCS (Trauma and Orthopaedics) exam. But the only way that it would work would be to keep them laughing from start to finish. I was invited all over the country to give this lecture, but I am not sure that the orthopods actually learnt much about statistics.
At the FRCS Orth exam itself I was invariably asked to examine at the basic science table. My feelings about this were that the knowledge and understanding of statistics or indeed any other basic science subject did not discriminate between a clinically safe and unsafe surgeon. Therefore I never failed anyone at this exam, however bad they were. The best moment was when a typical no-neck rugby player orthopaedic registrar sat down at my table. He was terrified. There was sweat pouring down his face, and his eyes were popping. I thought I would start with something easy, and lobbed over to him the simple question “What is bias?”. A silence fell, and I could literally see the question enter his cranium, cross untouched to his occiput and then bounce back to his frontal cortex without a neurone firing. He had absolutely no idea. Then his face changed, and his jaw set. He had made a firm decision. If he was going to fail then he was going down ‘all guns firing’. “Professor Bulstrode,” he said, “Bias is a form of bad luck, like being allocated to your table for a basic science viva”. He passed – of course! And probably still dines out on the story.
When I myself was on the conference circuit as a speaker I learnt a few tricks. The first was that French conferences were always over-run, but the French will never be late for their lunch. So, it was not uncommon as you mounted the podium for the lecturer to ask you to shorten your talk, as the last person (usually French) had overrun. The solution is to be prepared and have a plan for removing up to 50% of your talk (usually the middle).
The second trick is a riskier one, and only to be used on special occasions. If you really want to grip your audience then you don’t use Powerpoint and you don’t have any prompt cards. You learn the talk off by heart. Then you just walk to the front of the stage as if you were Hamlet delivering his soliloquy, take a deep breath and give the whole talk off by heart. It has the audience eating out of your hand.
Cars and Motorbikes
Car driving licence
As soon as I could take my driving licence I did, and then I was free to drive my father’s mini, an 800cc yellow thing, which was really quite quick – up to 40mph. The speed limit on Guernsey was 35mph but of course we were immortal and broke the limit all the time. After a slight fracas with a stone wall, I tore the wall of a tire, so I turned it round so that the dangerous bulge was on the inside and my father would not be able to see. My sister very wisely/kindly told him what I had done and I was in real trouble. After a dressing down it was agreed that a bit more openness was in order and that I should tell him when I did something wrong. Some weeks later my father was in bed. He was allergic to mussels but loved them so much that once every five years he would try them again and was now recovering from the reaction.
The reservoir
I had borrowed his mini to go bird watching at the reservoir in Guernsey. I had stopped at the top of the long grass slope that curved down behind the dam. As I stopped I saw a Heron flying up the lake. I leapt out to see where it would go as they were rare in Guernsey then. I had jumped out of the car without putting the hand brake on. As I watched for the Heron, I heard a car creeping quietly up behind me. It was coming perilously close to the edge of the grass drop-off and I turned to see who would be taking such a risk. My father’s mini with the driver’s door still open was rolling steadily towards the edge. As it passed me I dived across the driver’s seat, pulled on the hand brake and turned the steering wheel. The car was already moving quite quickly and spun around. I then realized that anything that I did was too late and that I did not want to go with this car to the bottom of the dam. I rolled clear of the car and lay in the grass as the mini spun around one more time then skidded faster and faster down the 60-foot slope. The mini hit the flat grass at the bottom of the slope, bounced back into the air, and in one hop cleared the 6-inch high retaining wall of the carpark, skidding to a standstill. I could not believe what I was seeing. The car appeared undamaged. I made my way down the hill got into the car, started it, and drove away. They made minis tough then! The next day the headline in the local paper was “Who done it?” with a picture of the skid marks on the grass, and a comment from one of the waterworks employees, wondering how anyone could have survived this.
Working on the new principle of openness I went up to my father’s room where he was actually reading the paper and explained that the skid marks were from his car. He was very good about it when he had heard the whole story.
The double crash
He wasn’t so good the next time. During the Christmas holidays, I had a job loading crates for the local brewery who had all their Christmas and New Year’s orders to get out. Beer was free on the job! One morning it was pouring with rain and my mother took pity on me telling me to take the mini down instead of going by bicycle. But she insisted that the car must be back at lunchtime as she was using my father’s new car that morning but he would need it in the afternoon. By lunchtime, I had already drunk a skin-full of beer, and having just seen the film ‘The Italian Job’, I was driving home emulating the best of the Italian Job driving with second gear, full throttle, and judicious use of the hand brake. The lanes in Guernsey are very narrow with high grass banks on each side, so on the corners, there is no room to pass. My mother says she heard me coming in the car before she even reached the corner. She was already stationary when I came around the corner and hit her head-on. The bonnet of my father’s beautiful Triumph Herald flew off over the car and I was left facing my mother. I am afraid that my courage deserted me and I got out of the Mini and ran away! That evening, when I finally got home, my father invited me into his study. One of his cars was a write-off, the other badly damaged. He explained that as far as he was concerned I could buy a motorcycle or anything else for that matter, but I was never to sit behind the wheel of one of his cars ever again, and I never did!
The Velocette MAC
I did however go out and buy a motorcycle for £40, a giant black 1953 Velocette with a fishtail exhaust pipe. Its top speed was about 50mph although it felt like 150mph, and the vibration at that speed numbed your hands. I loved that bike and went everywhere with it, wearing a Barbour jacket with a hot water bottle tucked underneath to try to stay warm.
Coming back to Oxford one day I had it going flat-out when there was a terrible bang, and I felt a searing pain on the inside of my right leg, which led to my leg kicking out sideways. I thought the cylinder head had come off and that the piston was about to unman me. There was a garage just ahead so I free-wheeled in, with the engine making a terrible noise, my leg jerking everywhere. When I stopped and looked down it was to find that the spark plug had come loose and blown out. It was the plug that had been causing me such pain delivering a series of electric shocks to my inner thigh, making the muscles contract. The pump attendant at the garage had watched this performance with great interest. Seeing as the plug was out I decided to have it sandblasted, a technique used to improve the running. I handed the attendant the hot plug wrapped in a handkerchief, and he took it away. When he returned I screwed it back in and asked him how much he changed. “No charge” he replied, obviously very impressed by the presentation of the motorbike arriving with the plug already removed. The Velocette 350 was eventually replaced by an equally unreliably AJS named “By appointment to HLJC (His Lord Jesus Christ) Conveyance of Elijah”. It too broke down the whole time and leaked oil from the bottom of the engine straight onto the rear tyre making it completely lethal for road holding. My next motorbike as a medical student was a Jawa 50cc moped, a simply horrible creature with a top speed of 20mph. However, I managed to cut space in the helmet to fit headphones so could have listened to music on a Sony Walkman if the engine had not been so loud! Finally, I got a Triumph Speed Twin 500, the nearest I would ever get to my dream bike a Triumph Bonneville.
Post office vans
Just about that time I started buying and selling yellow GPO post office vans. I now knew quite a lot about how to repair Morris 1000 cars and the vans were simply based on them. Each term I would buy one or two at the regular car auctions used by the GPO to sell them. The average price was £40 and most of them were in reasonable condition. I would paint them psychedelic colors, put some foam in the back, and explain to fellow students that these were either passion wagons or great expedition vehicles. If their parents were paying, I would explain to the parents that the engines had a speed limiter so they could not go too fast, and would therefore be a safe buy for their beloved son. I would then promise the student buying the van, that the moment he owned it, I would show him how to remove the speed governor and then they could go much faster. Using this sales pitch I could sell as many as I could prepare for £120 each, netting me a nice bit of profit. For several months I lived in one of them.
My parents had paid for my first degree as Guernsey did not give student grants but when I turned around and said I wanted to start medicine again, my father wrote saying that they thought that they had contributed enough and that if I wanted to study medicine they were delighted, but I would have to find my own living costs. I was very cross at the time but looking back now it seems a very reasonable decision. So, I had to fund two years at Cambridge, and for the second year, I effectively lived in the back of a van and scrounged meals where I could.
Santa Pod
My friend, Root, had always been interested in things mechanical and persuaded me to come with him to Santa Pod in Northamptonshire to watch the drag racing. We could not possibly afford the entrance fee so crept round the back through some woodland and climbed a fence. The noise and smell were indescribable. All the racing was over a short straight distance and most of the vehicles were running on Nitro. The drag racers were superb but my absolute favorite was a character called Snake Eye Priddle who had somehow got hold of a silver asbestos suit for himself. He was riding a quite enormous Vincent 1000 cc Black Shadow, a very old design of the bike, but with the huge advantage that its engine block was cast iron and so was strong enough to tolerate nitro. His first race was against another lunatic who had put two Triumph Bonneville Engines one behind the other into an elongated frame. He had then connected them both to a big lorry clutch which he was going to slip as he accelerated. There was a wonderful build-up by the commentator to the start and then off they went. The double Triumph Bonneville got into bother right away, spun round twice, and fell over, but Snake Eye stormed off and won with a record time. However, he was not finished. He decided to do another run alone with a higher ratio of Nitro. Again the suspense was racked up and off he went in a cloud of burning rubber. Halfway down the track his chain snapped and went sailing into the crowd and Snake eye freewheeled into the pits. But again Snake Eye was not finished. Clearly, the adrenaline had got to him. He rushed over to a spare microphone and asked if anyone had a spare chain because if they did, he was going to put in more and more nitro until he blew up. This was the kind of talk that the crowd and come to hear and they roared him on. Someone did have a chain and after a short delay, he was lining up for another run. This time he had 40% nitro, a very high amount. Away he went again, the crowd roaring in support. This time half way up the straight the engine exploded and the bike spun along the track pieces falling off (including Snake eye himself) pursued by fire engines and an ambulance. He was unceremoniously dumped onto a stretcher and carried to the side of the track where surprise, surprise there was a microphone waiting. With a smoke-filled voice, he enquired whether anyone had a spare Vincent 1000 because he was going to put more nitro in until that one burst. The crowd could not have asked for more. This was the kind of hero they needed.
Into the river
One evening after a celebratory dinner, goodness knows for what, I set off for Kennington well after midnight and far too drunk to control a bicycle. As I turned south down St.Aldates a policeman stepped out to stop me but I swerved past him (quite by accident, it was the way the bike was going) and carried on down to Folly Bridge. I was sober enough to know that evading arrest was not a good idea, so decided on the spur of the moment to cycle down the tow-path beside the river rather than along the Abingdon road. The start of the tow-path at Folly Bridge is three steps down, then a long slope. For reasons that are unclear to me, I did not dismount, but tried to ride down the steps. I succeeded, but lost control on the slope beyond and flew straight into the river. It was January and I sobered up very quickly indeed. I had a heavy overcoat on (an expensive Christmas present from my mother) and was going to drown unless I did something quickly. I slipped out of the coat and swam for the shore. By this time I was sober and it was a long way home so I dived back in to try to rescue my bike. I failed! My next memory is being wakened in a cold bath the following midday by my house-mates who were worried that I was dead. I nearly was. I was still in my dinner jacket but was very cold. I must have got into a hot bath when I got home, and then fallen asleep. The next day I went to see my sister as I was in real trouble without a bicycle. She was quite clear that we should go to the police and see if they had a grappling iron for getting it back out of the river. I was not at all keen. However, we concocted a story that I had been set upon, my bike stolen and thrown off Folly Bridge. When we arrived at the police station, a kindly police officer listened attentively and then asked the colour of the bicycle. I told him it was yellow. He sighed and then said “We saw you turn down the tow path at Folly Bridge and we waited for you with a squad car at the other end but you never came out”. I blustered. He continued “But you have come to right person as I have the police grappling iron ever since I got a body out first cast” We set off to Folly Bridge and I showed him where I thought the bicycle was. He looked up at the Bridge and then down at the place where I was pointing and muttered “Big throw. Big yobs, they must have been”. We got the bicycle third cast. He looked at me and said softly “You are lucky to be alive. That river is flowing really fast”. Nothing more was said but a few weeks later I saw him directing traffic at St Aldates. I stopped to say hello and thank him. He looked at me and then at my yellow bicycle and said “Ah it’s our little water baby. Had any more good swims lately?”
Climbing
I have always been terrified of heights, so I had to go climbing. I know that seems illogical, but I have always had a fatal fascination for those things which scare me most, and certainly if you are climbing regularly vertigo becomes less of a problem. However there is always the situation where the view is so huge or the footholds so small, that the fear comes back and it will then ‘grip’ you. That is why I have very rarely climbed solo and when I have, I have frightened myself witless.
As a child I was no good at climbing trees. Some of my school mates were utterly fearless. I was frozen with fear before I was six feet from the ground. Later at Radley we would go rock-climbing, and as soon as I was roped on, I would try anything. It now simply became a gymnastic exercise, and the rope gave me completely unwarranted faith in my safety. I did try to lead some climbs but as soon as I was stretched out on that lead rope, I would grip up. My friend Root was the only person I knew who also climbed and who was as frghtened as me.
On one rather simple climb under the Clifton suspension bridge on Avon Gorge he became gripped, following me up on the rope. As a result he left the described route and traversed sideways into a wall of ivy and vanished into it. The deeper and higher he went, the more rope I had to pay out, as I was belaying him from the lead position above him. Being buried in ivy is very reassuring because you can no longer see the drop below you. However it is very dangerous because it loosens the rock and it’s stems are tempting to use as hand and foot holds. As he ploughed his way through the ivy towards me we had a rather silly conversation as I tried to persuade him to go back so that we could take the ever lengthening loop out of the rope. He got higher, and the Ivy thickened so he felt more secure, when actually his position was more and more perilous. We had just come to an impasse where he was level with me but twenty feet away and with a 60 foot loop of rope between us, when a local student came swiftly past me, climbing solo without any rope or protection at all. Very embarrassing. At least I take some consolation in thinking that the whole situation must have given the solo climber huge pleasure. Root’s sense of humour was all pervasive. When he climbed with me he insisted on wearing a white T-shirt on which he had painted the following conversation:
“DON’T LET GO OF THE ROPE!”
“DON’T WHAT?”
“LET GO OF THE ROPE”
“OH!….. OK”
“Aaaaaaargggh!”
Brake failure
When climbing once in Wales we were driving in my old post-office van down a steep dirt track to the main road. The brakes failed and we started accelerating steadily toward the T junction with the main road. “Brakes have failed” I shouted as I tried for a lower gear – missed – and made the situation worse because we were now in neutral. Root reached across to the hand brake and pulled it up hard. It promptly broke off at the base. To my amazement, Root then shuffled back in his seat, crossed his arms, and said “Might as well die comfortable”. We literally flew across the main road, through the hedge on the other side, and into the field beyond.
Luckily there were no cars coming and after a couple of hours, we had managed to winch the van out and get on our way.
Night climbing
Night climbing in Cambridge was wildly exciting. There was a book describing the best climbs, and although you would be sent down if caught, the risk was low and the climbs short but classic. Rob Collister was a mature student who was doing teacher training and sometimes took part in Pentathlon. He had done all the climbs, but very kindly agreed to take me on a few. (He went on to become one of Britain’s greatest ice climbers). St John’s chapel was probably the best climb of them all.
http://www.insectnation.org/nightclimbing/camnightclimbing.html.
This is a classic vertical severe climb with every move you use in climbing following one after the other. Chimneys, laybacks, and swings. It was far too difficult for me to do without protection but Rob climbed swiftly up with a rope on his back and then lowered it to me. He had done King’s College Chapel, by tip-toeing up the iron grille outside the priceless stain glass windows and had performed the Senate house leap, a standing jump of six feet, sixty feet above the pavement.
http://www.insectnation.org/projects/nightclimbing/camnightclimbing/html/ch05.html
http://www.insectnation.org/projects/nightclimbing/camnightclimbing/html/ch08.html
I practiced standing jumps in the gym until I was certain that I could reliably do six feet and then set off to try it. However, there is a problem. The shelf from which you jump is quite narrow with a parapet behind it. The moment that you crouch to jump, your bottom hits the parapet and you will have to jump as you topple off balance. I tried to psych myself up to this, starting the maneuver again and again, but this was too much for me and I chickened out.
The Alps
I did one season in the Alps when I joined Rob and his friends at the Grand Saléve campsite just outside Geneva. Four of us had driven down in an old Morris Traveller. Petrol was expensive in France so we had loaded 25 gallons in jerry cans on the roof. I am sure that this was an illegal load both for weight and fire risk but the dockers probably thought it was water. Surely no one could be so stupid as to travel with petrol on the roof!
When the ferry docked in France, the starter motor jammed so we had to push the car off the ferry. There was great hilarity all round with the French dockers asking how far we were planning to go. When we told them that we were going to the Alps, they doubled up with laughter. We thought it was quite funny too, and bump-started the car, leapt in and off we went. Ahead of us was a roundabout and in the heat of the moment we forgot that we should now be driving on the right. We swept around it left-handed meeting a French 2CV rounding it the correct way. Luckily we were both leaving at the same exit so off we went neck and neck. From then on it became a bit of a race. Initially we were in the lead but then we had to stop to change a wheel. The chassis was so rusty that the jack just ripped out of the jacking point, so we had to unload the car by the road-side and then three of us bodily lifted it while the fourth changed the wheel. The students in the 2CV passed us again as we were standing there looking rather stupid holding up the car. I think they thought this was how the dumb British changed a wheel and nearly drove off the road laughing.
When we arrived at the Grand Saléve campsite they wanted to charge us camping fees, so we drove off up a forest track and parked the car there. This clearly annoyed some local foresters who the following day, when we were out, climbing felled a sapling across the roof of the car, denting the roof, breaking in the windscreen, and as we later discovered, breaking the chassis fixation point on one of the rear springs. This spring end then rose up through the floor pan of the car and quite literally buggered anyone sitting in the rear seat on that side every time we went over a bump.
We climbed hard on the Mere de Glace but we were cripplingly short of money. One solution was to buy tins of dog meat and then strip off the labels. When we arrived at a hut we would offer to pool our food to save fuel and then add our dreadful dog meat to the other climber’s prime Fray Bentos beef. Finally there came a day when Rob and I had no food at all, and there were no other climbers in the hut. The only thing that we could find were several large bulbs of garlic. Rob enquired whether I liked garlic and I said that I did, so we boiled the whole lot and ate it. This was a grave mistake.
Next morning we set off before dawn and were on the Milieu glacier by dawn. It is a Facile (easy) ice climb but I had never used front point crampons before. On top of that, the exposure was just horrendous. It was just a smooth sheet of ice dropping away for a thousand feet. At first Rob didn’t even want to rope up, he felt the climb was so easy, but even when we put on a rope we were not belayed so if one of us fell then he would probably pull off the other. I was utterly gripped and decided just to look at my iceaxes and at nothing else. My face was pressed against the ice and I was exhaling, sweating, burping and farting garlic. The smell was so strong that I could scarcely breathe, and ever since I have associated the smell of garlic with ice and terror.
Before I had arrived at Grand Saléve, there had been a miserable disaster for the climbers who had gone out before us. Two of them had gone to climb a tricky rock face close to Geneva. The weather was good so they left all their kit at the bottom of the cliff and tried to climb it fast in one day. This was a new fashion, championed by people like Rob Collister who felt that siege tactics were unsporting. You should travel light and fast. Unfortunately the weather changed suddenly and they were caught out in a thunderstorm. The face was soaked and then froze as the cold front came in. All they could do was tie themselves on where they were and wait for the following morning. One of them was out in the open in shirt sleeves and the other at least had a jacket and was tucked under an overhang. The next morning the face was still sheathed in ice and their colleagues who set out at dawn to look for them, realised that they were in big trouble and called a rescue. The helicopter came and by dint of some very courageous flying got the climber in shirt-sleeves off the face. But the climber under the overhang was going to be a real problem and what they did not realise was that he did not want to be rescued. He wanted to try to sort things out for himself. The winch man on the helicopter was swung in under the overhang and got a harness line around the climber, but the climber refused to cut himself free as he at least wanted to save all his kit. The helicopter had to start flying away as it was getting too close to the cliff and so the winch wire came tight. Something had to give and it was the climber’s shoulders which were wrenched out of joint by the rescue harness sliding up and over his shoulders. He was now helpless: both arms were out of action and he was merely held on by his belay. The winch man swung in again, re-attached a harness and cut him free. Both climbers were taken to hospital but neither had any insurance for the helicopter nor for hospital treatment. The following evening the other climbers in the party lowered them out of the hospital window and then set off back to the UK with them in a car, leaving some very large unpaid bills.
In the camp the argument raged to and fro as to whether this was ethical behaviour or not. Some felt that there should not be any helicopters or rescue in the Alps. It spoiled the purity of the climbing and consciously or subconsciously encouraged people to take poor risks, secure in the knowledge that rescue was always there. Others felt that insurance should be compulsory and that of course rescue should be undertaken if at all possible.
Time and time again the rescue issue has cropped up in my life and each time I have felt that it is a thorny issue. When I worked for the mountain rescue on Mt. Kenya, I felt that we provided an exceptional service. But it was also an excuse to move at high speed across wild parts of the mountain at strange times of day. In other words it was great fun, and to be truthful that was why we were doing it. On one rescue we were carrying a porter down on a stretcher in the dark through the forest just above the Met station on Mt Kenya. It was heavy work as the path was very narrow and rutted. I was at the back of the strecher and quite suddenly I receved a hard jag in my shoulder as the front of the stretcher was dropped. Before I could complain or move, a rifle fired right beside my ear. I looked up to see in the gloom an elephant standing in the path only metres away and clearly ready to charge. I dropped my end of the stretcher too. I muttered to the patient that everything was OK, and that he should stay where he was (not that he had any choice), and set off at a run back up the mountain in pursuit of my fellow rangers. The elephant didn’t charge. It must have realised that we were no threat, but from then on I made sure that when we travelled on the mountain at night, we would sing loudly all the time. My hours in church at Radley at last came in useful as I found that I could remember every verse of every hymn.
At a mountain rescue conference in the Lake District, I listened to yet another speaker grumbling about how many rescues they had to perform for improperly dressed, ill-prepared walkers in what they called some of the most dangerous mountains in the world. At this, I finally lost it, and stood up to say that the Lake District did not have any mountains. It had hills and pretty puny ones at that. I also pointed out that anyone who thought that they were dangerous was betraying their ignorance of the rest of the world because there were many hills and mountains in the world which were much more dangerous. I went on to say that when I went to the Lakes I usually went in running shoes, shorts and did not always take an anorak. I certainly did not bother with a space blanket, a whistle, food or water. I then compounded my crime by pointing out that if people did not enjoy mountain rescue then they should not do it. For me it was just a wonderful chance to do crazy things on a mountain. No one at the conference would speak to me after that!
Odd Jobs and Oxford
Christmas post
I don’t think you can work for your parents. I certainly could not, and watching the effort of some of our compatriots with their children it seems to be a source of friction and unhappiness. I’m not sure why. Is it that the children don’t share the goals of their parents or do parents inevitably give children unskilled jobs which the parents don’t want to do themselves? Who knows? However, I do believe that students should work if only to see how humdrum and boring some people’s working life can turn out to be. I did a lot of hedge cutting for my parents and learned how to use a hook and a stick, but it was brutal work and they never seemed very satisfied with the results especially since I never tidied up, nor put tools away after I used them!
My first job, as for many of my generation was delivering the Christmas mail. It was a slow job at first as I didn’t know the addresses or where mail boxes were on each house. The sorting office was down in St. Peter Port and the first slog up the hill to the central plateau of the island with a full bag of mail was real purgatory. Obviously, we hoped for Christmas tips, so there was a strategy for having an excuse to knock on the door in the hope that the subsequent meeting would stimulate generosity. One house that did not give me a tip was where on almost the first day I had to knock to deliver a parcel. The door opened but before I could do much a dog leapt out. I was at that time terrified of dogs and tried to spring backward and away to one side. Unfortunately, that involved me splitting my legs. The dog went straight between them, but not before it gave me a sharp nip on my inner thigh not far from my genitals. Leaving aside the shock and the fear, I was in a certain amount of pain. The lady owner was unapologetic and only wanted to take the parcel off me as quickly as possible. There was no mechanism in those days for postmen to deal with aggressive dogs, so after that I approached the house with great care. There was no letter box but there was a frosted window slightly open just beside the door. I knew exactly what that room was, and took great pleasure in delivering all that lady’s mail down her toilet for the rest of the season of good cheer. When she found the mail, she lodged a complaint. All I said to my supervisor was that I thought the whole thing was very unfortunate and then in passing mentioned ruminatively that this was the house where the dog had bitten me in the groin. I could see the Supervisor putting two and two, together and deciding not to make four out of it.
There were nice parts to the job. Spinning along country lanes with a nearly empty post bag was a very pleasant way of taking exercise. The following summer when I was up in Iceland, I felt something bulky in the inside pocket of my Barbour jacket. I reached inside to find a pile of Christmas cards. They must have been ones that I forgot to deliver! I did post them again when I got back to the UK and the recipients must have been very surprised to get them nine months late.
My second job was working in a brewery at Christmas. Actually, it was more than a brewery: it stocked wines and spirits too, and did wholesale deliveries to both pubs and hotels. The Christmas and New Year period were especially busy and my job was to help collect together the deliveries and then load the lorries. Beer was free on the job and so most people got through around 10 pints a day. I saw the effect of this when I returned the following Christmas. All the permanent staff looked ten years older. Some of them had also just tipped over that limit where they could no longer hold their drink. It was very sad to see. One person who impressed me very much was Cooper. The brewery still had a man who made and repaired barrels. He was very old when I was there and had served his apprenticeship just after the first world war. He only had a saw, an adze and a spokeshave, and could make a barrel to within 10% of the correct volume just by eye. Each stave had to have a curve and a taper so that it fitted its neighbor perfectly. He told me with great pride that he never had to put straw in the cracks between the staves, as his barrels were always watertight first time.
When I was a medical student I got a job as a pan washer in the kitchens at the Churchill Hospital. The manager did not want to give me the job as he said I was too bright and would make trouble. Well I wasn’t, and I didn’t, but it was truly the most dreadful job. There were two of us on pans, and each had a huge stainless steel sink. My co-worker was ESN (or so they told me) and was prone to terrible temper tantrums. The crew in the kitchen would bait him until he lost it, and then he would have to be sent home. However, he was bright enough to see that as fast as we washed pans, the chef dirtied them again, so he rapidly persuaded me to slow down. The chef used to rant and rave that there were no clean pans, but we would both of us try to ignore him. I had got one of the very first pocket radios with earplugs so could listen to Radio 4, which was much more interesting than the chef. I would fill one of my sinks with hot water and soap suds then imagine that the suds were icebergs. Now I would try to sail my saucepan ship through the ice pack, searching for leads, and pushing icebergs aside. Soon I was even slower than my colleague and peace reigned in the kitchen. Or, if it didn’t I couldn’t hear because I had headphones on. However, there was something soul destroying about deliberately working too slowly.
If things were really busy I would have to go out into the canteen and clear tables. We wore a paper junior chef’s hat and a boiler suit. I couldn’t help but notice that the nurses I might have been at a party with the night before as a medical student now looked straight through me. I was socially inferior to them now, and so I did not exist. I have always tried to learn the names of the blue-collar staff since then and try to greet them as human beings. Of course, lots of them have amazing stories to tell, of where they come from, how they got to Britain and what dreams and aspirations they have. One of the best senior registrars who ever worked with me, Martin Gargan, was a past master of this. He could walk the corridors of the John Radcliffe Hospital and greet by name every person he met and have a pertinent question for them about their health, their children, their family abroad or whatever. It is not a gift, nor is it a skill, it is something that all of us can and should do, especially if you have ever worked as a plongeur yourself.
My next post was as a research assistant for John Bonnar in Obstetrics taking bloods from women in the infertility clinic and radio-immuno assaying them. Infertile women have no veins. I know that from practical experience. I also know that women having babies are extraordinarily pleasant and reasonable while in labor and will let you take as many blood samples as you like, but the moment that they have delivered, they are wild lionesses protecting themselves and their babies as if their lives depended on it. In those days all radio-immuno assays had to be done individually. It was a mind-numbing job working to a fixed recipe. I don’t think I saw John Bonnar the whole of that summer and the job was not very fulfilling. However, I did discover that you can order boxes of Mars bars on the lab reagent budget and that if you put them in the deep freeze with the reagents they are wonderfully crisp to eat.
Despite doing all these jobs, it was a brutal shock starting my house jobs. I had become so used to 3 months off every summer vacation, that the prospect of no more long summer holidays for the rest of my life was pretty daunting.
Oxford
When I arrived in Oxford, I discovered that medicine was not for me. I found the dissection room terrible, and the physiology department antediluvian. They were teaching us how to smoke up kymograph drums!
Smoked drum kymographs – cutting edge in the 1920s!
These were metal drums that turned at a constant speed and were lined with paper which was then blackened with smoke. A stylus rested on the drum and this was attached to your measurement apparatus. As the drum turned the pen etched a trace through the soot to the white paper below.
Back at the Max Planck we were at least using proper ink pen recorders and were experimenting with Ballistic plotters for recording very rapid changes. The ballistic plotter was fitted with a blank .22 cartridge which was fired as the recording started. The pen quite literally shot up the paper and was deviated by the measurement being made. We were in awe of it because it could measure movements within one-tenth of a second! We also had the latest IBM computers.
IBM 360 computer 34,000 instructions per second!
These took up a whole room and required special cooling systems. On the front was an array of lights that showed the position of each diode gate (on or off) in the whole computer. There were only about 64 of those. Data was fed in by hand or using card readers. The cards were the size of a playing card and were punched with holes so that a light and sensor could read the instructions. The card reader was fast. It put nearly ten instructions through a second. However, it was prone to jam. If one card jammed the rest backed up and there was a wonderful explosion of paper dust in which was contained all your data. We were programming in a language called Fortran IV but frankly, it was easier to use machine code which simply told each gate in the computer what to do next.
For you computer junkies it operated at 0.0032 MIPS and had a massive 512 KB of central memory. This is about one two-thousandth of what is now available on a cheap memory stick, but at the time it was state of the art.
The Oxford Physiology department was back in its pre-war heyday, showing off what seemed to me to be gratuitously cruel experiments with frogs and smoked paper drums.
I also found the anatomy disturbing. We spent three whole mornings a week performing these ghastly dissections on formalin-soaked bodies. We simply could not find the structures that we were supposed to be seeking and if the practical was supposed to make the vast load of useful facts easier to remember then it failed. Everything stank of formalin. Our eyes watered and no matter how much we washed our hands we became pariahs in the dining room because of this all-pervading smell. I used to smoke a churchwarden pipe in the dissection room both to annoy the demonstrators and to remove the smell. It succeeded in the first aim but failed dismally in the second.
Zoology in Oxford
The department was small. There can only be 30 or 40 students in each year so everyone knows everyone else. Sir Alastair Hardy came and lectured. He had helped with the design of camouflage for gun barrels in the First World War (1914-18) and had now got all caught up in the supernatural.
Sir Alistair Hardy and Niko Tinbergen
Niko Tinbergen, another Nobel prize winner with Lorenz, also lectured in the department. His claim to fame was that he could roll a cigarette with one hand while writing on the board with chalk in the other. We also had Richard Dawkins so it was a dazzling line-up of talent. On the strength of this line up, I changed from Medicine to read Zoology. In my medical exams at Easter, I had done very badly indeed. My scholarship was removed and I suspect everyone on the faculty was relieved when I opted to change to study Zoology. The next term was complete heaven. The zoologists all had their first-year exams at the end of the summer but I had nothing. So I hand-reared a magpie in my mortar board and went on every field trip that I could. In the meantime, box after box of food and equipment started to accumulate until we had over one ton of stores to box up ready for the summer.
Iceland
Having never been on an expedition before I had no idea how important it was to pack the boxes logically and to label them properly. It is another one of those lessons in life where you learn just too late how important something is. Suddenly term ended and stores were still coming in. I had made no arrangements to get everything up to Leith, so we just did it on the hoof. When the train came into Oxford station we had a ton of stores stacked up on the platform. Before anyone could say anything seven of us had loaded the guards van. At Paddingon we commandeered some trolleys and got the stores down onto the underground. The circle line runs from Paddington to Kings Cross but we did not have enough money to ferry each packing case across. So two people who had bought tickets just went round and round the circle line. Each time they reached Paddington 2 people there would help them to load on as many cases as we could fit in with them. Then when they got to kings Cross two more people would be waiting on the platform to help unload and pile up the boxes. Round and round they went until all the boxes had been transferred. It wasn’t rush hour and the underground staff thought it was the funniest thing they had ever seen and even helped! So, we only paid our own tickets to transfer, over a day, ourselves and all our gear to Kings Cross. Then it was on to the overnight train to Edinburgh. No sleepers for us. We had no money at all. When we arrived in Edinburgh I had no idea that Leith docks were a couple of miles away from the station. Several large luggage trolleys were liberated and we set off for Leith. The trolleys had iron wheels and made an infernal row on the pavement and on the roads. By the evening we had moved everything to Leith and returned the trolleys. We decided to sleep on benches in a park in Edinburgh, so as darkness fell, we climbed over the railings and each found a bench in the park off Princes street. I was woken at dawn by a conversation just outside my sleeping bag which went as follows “What are yew duin’ here, Laddie” “I came to wake him up” “ What is he duin here?” “He was asleep”. When I stuck my head out of the sleeping bag it was to find a local policeman addressing one of my expedition colleagues. The policeman obviously decided that this short exchange was all he needed in terms of information and so said “It is breakfast you’ll be needing and there’s a café yonder that opens in half an hour”. With that he wandered off, his duty done.
The Gullfoss
Once we boarded the ship the adventure really began. The Gullfoss was a small tramp steamer. During the summer the forward hold was converted into tiers of bunks to hold all the expedition members. There were literally dozens of expeditions going north to study the aurora, to do geology and biology, and of course, we were all trying to look hardened arctic explorers when we were anything but. It was pretty rough on the way up and on the third day we caught our first sight of Iceland. It was blowing a gale with squalls of driving rain, but in the distance, we could see spikes of rock rising from the sea which were periodically coated in spray from the huge rollers crashing onto the shore. Behind the rocks, the ice of a glacier climbed to the horizon. The guys next to us on the rail were an expedition going to work on the Westmaneyr islands. Just at that moment, the captain walked past and one of their expedition pointed to the rocks and asked if those were indeed the Westmaneyr islands.
“Ya, ya” said the captain and carried on to the bridge. Our friends were devastated. They were committed to spending 3 months on these spray-laden rocks. Without further ado they pulled out their duty-free whisky and set out to get really drunk. Three or four hours later the storm had blown over and the sun came out just as we slipped up the channel between the Westmanyr Islands and the mainland. They were green moss-covered jewels, havens of peace with a little anchorage snugged away under the hills. We tried to revive our friends to show them the cruel joke the captain had played on them but to no avail.
The Pjorsarver
1969 was a bad year and even at the beginning of July roads were still blocked with snow. We had chartered a 4 wheel drive truck/bus to take us into the centre where we wanted to work on the geese. At first we made good progress but then the snow and permafrost made progress more and more difficult until quite suddenly with a great lurch the truck rolled onto its side tipping our supplies into the snow. The driver was furious and seemed to think that it was all our fault. Anyhow he insisted that we unload all our stores, and then using a winch he righted his truck. Without further ado he turned it round and informed us that this was as far as he was going and set off back for Reykjavik.
Fossrofulaika
In fact the place was a little ford across a stream with a mossy platform on one side, the perfect place for a camp. So the only thing for us to do was set up base-camp there and start looking for geese. The Lord of the Rings was all the rage at that time but we did not realise that Tolkein had visited and loved Iceland and had based his descriptions of Mordor on the country around where we were camped. The next weeks were spent walking, walking, walking, sometimes for 18 hours a day in every direction searching for Pink-footed Geese. The wildlife was spectacular. There was a Gyr Falcon near the camp and Golden plover everywhere. It never got dark so we never slept. When we reached the top of mountains we found boulders teetering on the edge of precipices. Clearly no-one had been here before, because if they had, they would have been unable to resist the temptation. Against our better judgement, we had a wonderful time tipping these boulders over the edge and watching them bound down onto the plains below. Every kind of volcanic geological feature was to be found here. Gigantic cave systems where lava had flowed over ice and then the ice melted away leaving jagged Troll caves, with gaping jaws facing the sky. We learnt how to cross the icy rivers linking arms and standing in a line down stream of the leader who was held up by the others as he took the brunt of the water pressure. Later in the expedition when we had to cross one particularly fierce and deep river, this soaking up to the chest morning and evening as we went to our work area became a real chore, but it had to be done. By then several of us were working in gumboots as our climbing boots had been destroyed by the sharp volcanic dust, that coated everything out in the central desert. Just before this cold river crossing to our work area, there was a shallow pond which must have had contact with a hot spring source, as it was pleasantly warm. Each morning Root, the joker of the team, would boldly wade into this pool and fill his gumboots with warm water. We would then link arms and side by side step into the Pjorsa river to cross.
The Pjorsa river
The Kerlingafjoll mountains
Each day as we got to the middle of the deepest channel and the water was right up to our chests, Root would shout “Stop! I need to tell you something.” We would have to stop anyhow because the whole party had to move together. “I just want to tell you something” he would shout over the roaring icy water “My feet are warm.” The joke went on day after day until it stopped being a joke and simply became part of the ritual of crossing the river.
We had very few books. The two I remember best were Lord of the Rings by Tolkien and The Voyage of the Beagle (the story of Darwin’s famous circumnavigation on which he based his Origin of Species). We were divided into three camps several miles apart and the books were in hot demand as there were long periods of sitting around when the weather was simply too bad to survey. Root’s solution was to tear each book into pieces and issue a few segments to each group. Whenever anyone crossed between camps they would take their ‘segments’ with them, and see if the camp they were visiting was prepared to swoop. The problem with this brilliant plan was that you had to read the book in the order in which you received the parts. This made the plot quite difficult to follow, but there was plenty of time and most of us went around the world with Darwin at least three times.
Drying out
Searching for new breeding grounds of the geese
A Whooper swan chick
It rained and snowed the whole of that summer in Iceland. I think that we only saw the sun twice in three months. On one of those occassions we were all of us right up under the tongue of the glacier, where there was a large ice cave out of which poured a melt-water river. Just to one side and presumably the cause of the huge cave, there was a hot spring spouting boiling water. By dint of a little damming and channelling we were able to create a pool with both a hot and cold water inlet so that the pond was bath temperature. We spent a couple of glorious hours there, warm at last. We were all naked and a competition started to see who could produce the best coiffeur of their pubic hairs. Photographs were taken of the results, but when we took the films to Boots for developing on our return to the UK, they refused to give them back to us, claiming that they were obscene. I wonder who was the obscenity judge at the Boots developing lab and how they did their work! Facebook have a lesson to learn from this.
Root and Harry Machin in a hot spring
We were bitterly cold the whole of that summer. I don’t think I ever managed to dry my clothes or my sleeping bag and the temperature hovered around freezing. Our craving for food changed, and soon all the chocolate of which we had tons, was finished. In the store tent there was a sack of sugar and large 4kg tins of margarine. The luxury snack for some of us involved cutting a cube of margarine, then rolling it in sugar and eating it. I cannot think of anything more disgusting now, but then it seemed the height of luxury.
The weather alternated between rain and snow but at one stage exceeded even its extreme standards and blew a full hurricane. Our two main sleeping tents were strong enough to tolerate the wind but the store tent simply exploded, and stores blew, rolled and tumbled away across the tundra. The wind was so strong that we could not safely stand so we retrieved what we could crawling along the ground and shouting ineffectually to each other.
Kerlingafjoll. Next day a Hurricane came and blew all our tents away
Root burns
On one of the trips searching for new Pink-footed Geese breeding sites, we decided to cross over the Kerlingafjoll mountain to a series of gorges beautifully named Meikyalikeyabotna. It was a long trip. We had over 40 miles to cover but decided to take no camping equipment – just travel with a rope and some food. The area we came into was barren and raw. Streaks of sulfur stained the rocks yellow and orange. Then quite unexpectedly we came across a large area of boiling mud springs, ponds, and little fountains. There was nothing on the map to suggest that this existed and we were very excited by the find. We jogged down the scree slope to the edge of one of the little boiling ponds. As I slowed to a stop in front of the pools, a camera flew over my head and started slithering toward the pool. I reached forward to grab it and turned to Root to expostulate that this was a really silly thing to do. He was standing just behind me, his mouth wide open, as he started to bellow with pain. His boots had broken through the mud crust and he was now up to his knees in boiling mud. We struggled out of the mud as quickly as we could but his legs were very burnt, the skin was already peeling, and he was in terrible pain. We were now faced with a six-hour march back to camp without medical care. Root was very good and hardly made a sound, but it was a dreadful journey.
Later the burns all scabbed up. When we returned to Reykjavik, Root’s legs were still in a bad state. At the campsite where we waited for the ship, there was an open-air naturally heated swimming pool with lovely hot tubs around the edge where Icelanders would meet to talk business all sitting around on the underwater seats. Root got into one of the tubs and with the rest of us and some Icelanders. After ten minutes one of the larger scabs on his leg peeled off and floated to the surface of the tub. There was a horrified silence and then the Icelanders (swiftly followed by us) left Root in the tub to retrieve the bits of his leg.
On the way to Mikyalikyabotnar. Sulphur springs just before Root sank through the crust and was burnt
In the days before the Gullfoss arrived, the camp filled with all the expeditions we had met on the way out. Next door to us were an expedition from Southampton University who had wanted to study the Aurora Borealis. They had a disastrous summer. The bad weather meant that they had seen no aurora at all and the trip had been useless. On this last night, the sky was clear and slowly the Aurora started to appear rippling across the sky. It got brighter and brighter, so I went over to their tent where they were already in their sleeping bags. I told them what was going on, and they told me to go away and stop playing silly practical jokes. I insisted that I was serious, but they would not come out, so two of us undid the door of their tent grabbed their sleeping mattresses and forcibly towed them out of their tent into the open. They lay there admiring the Aurora softly cursing under their breaths. All their equipment was crated up, so they just had to lie there in their sleeping bags and enjoy the view.
Orangesjokull
Our transport insisted on us coming out of Central Iceland over a week before the ship arrived, in case the road again became impassable. So for our last week, Simon and I traveled right up to the far northwest corner of Iceland and went camping. The midges were gone and this was truly the most beautiful corner of one of the remotest places in the world. We found an island on a fjord which was about 5 metres from the shore and was just big enough for us to pitch our tent. An inquisitive seal came by so we sang to him, and then a Loon started its haunting song which is so evocative of the empty Arctic, yodeling across the mirror-calm water. It was an idyllic end to an extraordinary expedition. We needed food so we walked up to the nearest farmhouse and asked if we could buy some meat and perhaps even some fish if they had any. “No,” said the lady of the house very firmly “ You cannot buy. We will give you fish and milk, but you cannot buy” She went on to explain that anyone who did not have their own milk and fish in a place like this was clearly in big trouble and needed all the help that they could get. We walked away quite humbled by her kindness. We cooked the fish with rice, but we didn’t have any fresh water, so I stupidly suggested that we cook using seawater. That was a big mistake. We spent the rest of the night face down on the ground, trying to suck fresh water out of the moss as we could not find a fresh-water stream in the dark.
Hekla
When we were in Reykjavik we met a delightful Icelander who helped us with all sorts of problems moving stores and organising paperwork. He was clearly a bit of a hell-raiser. Some months after we got back we received a letter from him. Well, it was not actually a letter it was a cassette tape and a piece of rock.
I put the tape on and Hreins familiar voice boomed out. “Hey, Chris. I tried to write you a letter, but my English, he is no good, so I am sending you the tape. I am standing on Mt Hekla. It is erupting! (background noises of booming and crashes). In the letter, you find the youngest stone in the world. How do I know it the youngest? Because it just landed on my head out of the volcano. Now I think I must go as the tyres on my jeep are melting”. It was a lovely farewell to a strange, strange place.
The plan for expeditions was that the following year we would go to Greenland to study the Pink-footed Geese there and then the third year to Spitsbergen. Greenland was cancelled because that year the Danes banned all British University Expeditions after several had to be rescued the year before, following some pretty irresponsible behaviour. Root and I set out to buy a surplus lifeboat to sail up to Spitsbergen. The dealer gave us some sobering advice when we asked him about the seaworthiness of the boat we were planning to buy. “Oh the boat will get there alright” he said “But you probably won’t survive the journey.” I am not sure that he was right but certainly, we would have needed to be lucky.
Colombia
With all plans at a standstill I joined an expedition going to do marine biology in Colombia, South America. One of the members had a father who was an executive in Shell and wangled a free passage for us in an oil tanker. The only problem the expedition had was that none of them was a qualified diver. I had my sub-aqua qualifications from school, so I claimed that I would be able to do any of the diving needed.
The next two years of Zoology were a riot. I was keen to continue with a PhD in zoology but realized that there was a real danger in making a career out of what is your favorite hobby. The backbone of Zoology is knowledge of the animal kingdom and all its ramifications. The standard set of books in the Radcliffe Science Library on the animal kingdom was 13 volumes. Six months before finals, I had not opened one. I wasn’t much interested in Insects and there had not been many questions on them for several years so I decided to give the whole insect world a miss (all six volumes of it). That was a grave mistake. The year that I took finals was the year of the Arthropods. Most of the questions were on beetles, crustaceans or some other member of that huge group and my results suffered accordingly.
I decided not to continue with Zoology but applied to Cambridge to read Medicine at Pembroke, a College that our family had endowed when it was first founded. At Interview I was asked, “ Why do you want to read Medicine AGAIN?” I have no memory whatsoever of my answer, but I got a place.
In the meantime, there was one more summer vacation, and so I was joined an expedition to Colombia. I did not have to do any of the organization, which was good as I had to work for finals. They had negotiated a free passage on a Shell tanker going to Venezuela and a free trip back, plus an invitation to base ourselves at a German Marine Biology station in Santa Marta in Colombia.
The passage out to South America started from the Rotterdam Europort where we boarded quite an elderly general-purpose tanker which was small by tanker standards (only 20,000 tons). As we set off down the Channel there was thick fog, so thick that we could not easily see the bow of the ship. As we crept passed the Straits of Dover the radar failed. The captain was called to the bridge and on discovering that no repair was likely in the near future he ordered the ship up to full speed. His argument was the sooner we got through the fog the better and as we could see nothing the chances of a collision were just the same whatever speed we did.
Then followed ten days rolling across the Atlantic. As soon as we were out of sight of land a huge oil slick appeared astern of us. The captain explained that it was forbidden to discharge oil at sea but the wash-out tanks at our destination were full so the owners had ordered us to wait until we were out of sight of everyone and then wash our tanks!
There was very little to do on the ship. The ordinary sailors chipped off the rust and then repainted the ship all day, every day. The officers just seemed to get drunk but were a very pleasant lot. When we arrived at Punta Cadon the oil terminal in Venezuela, we traveled by bus to Santa Martha in Colombia where the Germans had a marine biology research station. This was going to be our base. To our surprise, there was very little marine biology research going on but there was a major black market in corals, shells, and archaeological artifacts. In the hills behind Santa Martha were the remains of an ancient pre-Colombian culture called the Tairona. They had a stable agricultural system, beautiful gold and bead work, and fatally were monotheistic. Fatal because when the Spaniards arrived, the Tairona’s worship of just one god, proved to the Spaniards that they were worshipping the devil as it could not possibly be God (as they had not yet had the opportunity to be converted), so they set to and wiped them out, helped by the vile diseases that they brought with them.
Now, grave robbers worked the hills. As the forest was cleared for slash-and-burn agriculture the farmers would find sites of old villages. Word would be sent, and the grave robbers would come and search for treasure. Each house was a stone ring and under the doorstep, treasure was buried to bring luck to the house. So, these were lifted, and then a search was made for the graveyard, where the funereal goods were then looted. There were exquisite clay pots, little whistles, beads, and sometimes gold ornaments. The highest quality pieces were sold directly to USA museums who had buyers all along the coast, but the damaged and less beautiful stuff was sold by Sail (our guide) to the Institute where they were sent back to Germany and sold on the black market. The USA museums protested loudly about the looting of these sites but were still secretly buying the results of the looting.
Tairona pots
The diving that I had to do at the Institute was dangerous. The equipment was not properly maintained and the compressor had oil leaks, so although the other members of the expedition hoped that I would teach them to dive, I did most of the work with a snorkel, and was certainly not prepared to teach them using such lethal gear. One of the German marine biologists at the Institute showed me how to exhale before diving deep. This allows you to sink very fast and make free dives down to sixty feet. He could get even deeper! Pretty quickly all the diving work was finished and I had become seriously interested in the artefacts being sold. Finally Sail (a local Colombian artefact dealer) agreed to take me with him on one of his grave-robbing trips, and we travelled up into the Sierra Nevada to a new find. The forest there is the densest I have ever experienced. There is no forest floor, just a tangled mat of fallen branches and creepers. Everything you touch seems to be poisonous and the temperature and humidity made working with a machete impossible for more than a few minutes at a time. We didn’t find much at the new forest clearing but it was an extra-ordinary opportunity to see the hinterland of Colombia.
Humbert Threepulton
One thing I did buy from Sail was a Boa Constrictor which was about eight feet long. I called it Humbert Threepulton and it came back to the UK with me with three crates of pottery, beads, and shells. The captain of the ship that we came back on was not amused to have a snake on board but said nothing when we went through customs at Liverpool. Humbert accompanied me to Cambridge where he lived in a heated aquarium tank.
On one summer’s day, I let him loose on the lawn at King’s College where a dozen families were having picnics. It was not a kind thing to do. He didn’t like being out in the open and the picnickers were not expecting to be joined by a snake. After raising his head four feet in the air to look for cover, he headed for the nearest flower bed pursued by me, through the groups of picnickers, who literally ran for it. Later that summer I took him on the bus with me to Oxford wrapped in a sac. He had just shed his skin and so was very lively. As I left the bus the driver stopped me and told me that live chickens were not allowed on the bus “It was against regulations” he said. I explained that I didn’t have a chicken. “So what is it?” he asked. I opened the sack and hoisted Humbert out. The discussion ended there and then, with the driver simply asking that I leave his bus as soon as possible.
In Oxford I was sleeping on the living room floor of the house my sister was renting with a group of students. Humbert had his tank but had been joined by a white rat called ‘Crapper’ who slept in his coils. Humbert seemed genuinely frightened of live animals and would only eat dead day-old chicks, so surprisingly Crapper was quite safe. One night someone left the lid off the tank. The first I knew of this was a shriek from my sister. She had gone to the toilet in the dark and on sitting down had found the bowl was not the right shape or texture. She had turned on the light to find that she had been sitting on Humbert who had coiled himself around the bowl. I was required to remove myself and the snake first thing the following morning.
Accommodation, Night climbing
Living in College
You learn a lot about accommodation as a student. I started in very nice modern rooms at University College with a separate bedroom. Rooms were arranged on Staircases and there was a servant for each staircase. The scouts (as they were called) were lovely people and very fond of ‘their’ students. Mine always used to come in early in the morning to make sure I was awake. His opening gambit was always the weather. “Pretty stormy outside, sir, and looks as if it got in here too!” was a favourite.
University college
Digs
My second and third year were out in ‘digs’ a 5 mile ride to a Bed and Breakfast in Bagley Wood. Mrs Butterfield had married Basil the butcher and felt strongly that she had married below her station in life. She never hesitated to remind us of this. Poor Basil wasn’t hen pecked, he was flenced by Mrs. B whose clarion call on a rising note “Basil” had him scurrying to her side.
Cambridge
My accomodation in Cambridge again started in College but this time in very old rooms high in the garrets. The heating was on an electricity meter into which you put sixpences (2 ½ p) . That was a lot of money and didn’t last long. Who needed to heat the whole room anyway, so I lived and worked in a sleeping bag with a hot water bottle for my feet. In order to keep awake at night to finish those interminable essays, I used to chew on coffee beans.
Pembroke College Cambridge
My room was in one of the garret rooms in the back-ground
The Red House Hinksey Hill
During the vacation, I would try to sleep on the floor of the house that Jane was renting on Hinksey Hill. The house in Oxford was a posh one in a very smart area but having been let to students it was not in good repair. One of the medical students was planning to take his elective in Kenya and was going to try to drive out there to save money. He had bought an old motorcycle and dismantled it on the dining room table but somehow never got it back together again. The music system in the house had speakers fitted inside concrete pipes ‘borrowed’ from the road-side. ‘Boris the Spider’ at full volume sounded terrific.
The GPO van (Rabscuttle)
My time living in a GPO van was not good. Everyting was damp and cold. I parked on Selwyn Road in Cambridge and then for dinner I would pop into one of the nearby colleges and pretend to be one of their undergraduates. I was also sharing the van with my Boa constirctor Humbert Threepulton. When the winter got very cold, Pad Collister (Rob’s younger brother) took pity on me and I slept behind his sofa in his palatial rooms in Selwyn College. The only problem with this lovely arrangement was that he was in the process of breaking up with his girl-friend, so every evening I could hear them in the bed-room having interminable arguments.
The Radley Boat House
When I started my clinicals in Oxford I had joined the Navy and for the first time had some money. The old Boat House at Radley was for let and I persuaded the army officers who rented it to let me have a small room at the back. The location was incomparable, but the noise from the loudspeakers of the coaching boats ruined the peace of the afternoon while motor cruisers blaring music bumped and scraped past each other in what was a very narrow twisted part of the river. It was not a good idea to live there. I had nothing in common with Guards Officers from Eton, and it was a long drive into Oxford.
Walton Well Rd
For my second clinical year, four of us clinical students rented a house in Jerico belonging to the Lucy Iron Works. Richard McCubbin was a quiet kind person who emigrated to New Zealand and became a GP. Rhys Hamilton was a wonderfully extrovert character always with a new song on the tip of his tongue. His family had a cottage in Plockton looking over to Skye and he was very liberal in allowing us to use it. He became a GP in Henley. Simon Kay was from Guernsey like me, arrogant, ambitious, and for reasons that are unclear to me, very attractive to women. He became a Professor of Plastic Surgery at Leeds and I believe was the first to successfully replant a whole hand. For reasons that I was never clear about, he did not like me. I suppose I was pretty repellant but I suspect he was also jealous about something.
The beauty of the house was that it had a cellar, made up of two rooms separated by a brick wall. I will never know if that wall was structural, but we removed it anyway and now had a huge room for parties. The house next door was occupied by nurses who were always keen to party.
Hang gliding
Grasshopper
The moment I heard of the first hang glider in the early 1970’s, I wanted one. You could buy a Grasshopper kit for £60, a primitive Rogallo kite that rattled along with a glide ratio of 1:3 (three feet along for one foot down). We none of us knew anything about hang-gliders or flying, so assembling and flying these first ones was a real adventure. First, we had to find steep hills facing the wind. Then we had to learn that barbed wire fences hurt and that power lines kill. But the main thing we learnt about was the stall. It was clear that we had to run like hell downhill to get flying speed, and then if we pushed the control bar away from ourselves, the kite would soar away from the hill. It was what happened next that puzzled and hurt us. Quite suddenly the kite’s nose would dip and turn and we would crash back into the hill-side, no matter what we did. We got bruised and the kite got bent. I rapidly learnt how to repair kites and, from there, how to build my own from aluminium tubes, rigging wire and sail materials. California was the home of hang-gliding and a small non-glossy magazine produced there gave us information on what their newer kites looked like. From the pictures, we could guess what they had done and then build a copy. Very rapidly the aspect ratio (the width of the kite compared to its length) changed, and battens were fitted to control the shape of the sail. Then we flew in harnesses that hung down prone below the kite rather than sitting. The commitment to running off the top of a hill and tilting forward into a prone position was the ultimate adrenaline buzz.
Mick the mad ceiling erector
I linked up with Mick, a mad ceiling panel erector, who could somehow nail panels on to the joists while holding the panel itself up one-handed. The result was that he did not need a mate so earned twice as much as anyone else in the building trade. I realise now that he was a little mad, because every time he saw bollards marking off road works he would insist on driving along trying to clip every one without doing too much damage to the wing of his car. He loved the sight in his rear view mirror of all the bollards spinning and rolling away from the road, as he hit them one by one at speed. He and I pored over the American plans for the hang gliders and then built copies. He would then raise the kite up on a hill top and see if it balanced on the control bar. If it did, he would always ask me to do the first flight. We decided that to do this, we wanted the biggest, the steepest and the most open hill that we could find. The theory was that having got airbourne there would be the maximum amount of time to work out what was going on before I hit the ground. The problem was that crashes, when they occurred, were from a considerable height. However that moment of take-off in a newly built kite was incomparably exciting. I have never done anything quite like it in my life, before or since. There was one hill near the A4 by Marlborough where you could actually fly along the main road. If you were below 100 feet then every articulated lorry which came thundering towards you, sent up a jet of air which lifted you enough to catch another lorry. If no lorry came in time, then you could duck sideways and land in the field beside the road. We flew under thunderstorms sublimely unaware of the danger of being sucked into the centre of the storm.
Flying without instruments
We also flew in the cloud without instruments because we had designed the kites to be intrinsically stable so they should fly straight and level if you did not touch the controls. Some summer nights I would sleep out on the top of the downs with the kite rigged ready to fly at dawn. Often the valleys below would be cloaked in mist so we flew above the cloud and then dropped into it. One morning there was a rolling cloud on the front of the ridge (I think it is called an orographic cloud). The wind was moderate, smooth, and blowing straight up the ridge, but on the top, I was enveloped in mist. I had a brand new high-aspect-ratio kite with fully battened tips and was itching to fly it. So, I took off into the cloud climbing steadily away from the hilltop until it vanished behind me and I was buried deep in a silent white cloud flying smoothly forward. I kept my hands very light on the controls so that I did not disturb the balance of the kite, and within seconds the sky around me started to lighten as I climbed out of the cloud into the clear blue sky above. At that moment a loud clatter started. I was convinced that a batten had come loose from a sail pocket and gently tried to look over my shoulder to see which wing was a problem. I did not want to do anything sudden because I didn’t want to cause the kite to turn as it would then fly back into the invisible hill behind me. The kites were controlled completely by moving your body and were very sensitive to the slightest change in weight. The wing tips both looked fine, but as I turned to look forward again, I found myself face to face with a helicopter pilot flying along the edge of the hill just outside the cloud at about 500 feet. I think he was checking a pipeline. I don’t know who was more shocked. I could see his face clearly and we were both clearly very surprised by the sight of the other. The turbulence from his rotor blades would destroy a hang-glider instantly. I signaled for him to move away but he seemed frozen in fascination. It must have been quite a sight, this white kite materializing out of the cloud. I had no choice, so without further ado, I threw my weight left and forward tilting the kite into a savage turn back into the cloud and the hidden hill-side. I obviously did not shift my weight forward fast enough or the design was inadequate, because within seconds I was in a full spin, and thrown outwards by centrifugal force. In fact the design spun fairly flat like a sycamore seed dropping from a tree so I gyrated down hitting the ground fast but not fatally so. The kite was a wreck, but I was relatively unhurt having landed on the downhill side of the spin in a field of corn. Another lesson learned, although it all came back to haunt me when I started to learn to fly a proper glider.
Baiting the officials
We flew anywhere and everywhere. Duties in the hospital as a house officer were combined with gazing out of the window checking wind direction and speed, and dreaming of where there would be good flying and what it would be like.
I was immortal. Mick and I could design hangliders and fly where no one else could. A British Hang Gliding Association was formed which promptly started setting rules and controlling flying sites that we had privately personally negotiated with farmers. To us this was a red rag to a bull, so we would arrive early and be airborne before the marshalls arrived. Then we would jeer at them while soaring over their heads. Lots of pilots were getting killed but we always managed to find a reason why it was incompetence, not bad luck, that got them, then we could continue with our invincibility.
My house job in Bath was hard. I knew I wanted to do surgery but also knew that I lacked the commitment to make it through the highly competitive junior grades. I was just married, drinking hard, and bewildered by the new world that I was entering.
Breaking my neck
One winter’s day I was supposed to have the afternoon off and the wind was blowing hard and steady from the West with low rain-boden clouds scudding across the sky. When I finally got away it was already nearly dusk. My hang-glider was loaded on the roof of my trusty Renault 4 and I raced away from Bath to Milk Hill where I knew that the flying would be good. By the time I got to the hill and rigged up it was starting to snow, and the airstream up and over the hill was etched in snowflakes. You should never fly alone and certainly never take off alone. You need someone to control the nose of the kite as it first lifts into the wind. Otherwise, the wind can catch the nose and tip you upside down before you can get control. I lifted the nose alone, dithering with it until I could slip back into the correct position in the harness. There was a thud as the sail filled. I threw myself forward in the harness, and the kite hesitated, almost tipped back into a stall, then started climbing forward and up away from the hill. It was thick cold air loaded with snowflakes and the machine was now flying beautifully at around 20 knots. Now I could start banking sideways and skim along the ridge, leaping over the gulleys cut into the hill. For nearly two miles I ducked and weaved along the downs with the snowflakes swirling over the wing tips showing how the aerofoil was working. It was the longest flight I had ever done. Finally, I turned back, as I was bitterly cold. The wind had veered a little and was now coming up the front of the hill obliquely. There was not nearly so much lift and indeed there was a little rotor and down-draught over the gulleys. Nevertheless, I negotiated them one by one until I was close to my take-off point, and I was stuck. I simply could not get high enough to escape the clutches of a rotor in this last gully. It was getting dark. I was so cold that I could not feel my fingers, and I was tired.I decided to top-land, a dangerous maneuver which would enable me to walk the kite across the top of the cym and then fly on to my take-off point. I turned back behind the hill out of the updraught and started my approach to landing. Hill-top landing is tricky. If you go too far back the rotor on the back of the hill smashes you into the hill. Too far forward and just as your feet get close to the ground the glider slips over the front of the ridge and climbs again. I just managed to force the kite down before I flew over the lip of the hill, and jumping forward caught the nose, holding it under control like a lively horse. Then, holding the front wires like lunging reins I led the bucking kite around the cym to the smooth fronted hill on the other side. The wind was now gusty and stronger than before and I knew that I was taking a chance trying to take off. I could have walked the last bit, but I didn’t. I was tired, cold, and careless. As the nose of the kite lifted I couldn’t get my weight forward fast enough to control it. The kite tilted back into a stall and then lifted 100 feet. Finally, it tipped upside down. I don’t remember much of the next bit except that I think I was screaming in rage all the way down into the hillside. When I awoke it was pitch dark and I was covered in a light mantle of snow. I was tangled in the broken remains of the glider and my helmet was hanging down the side of my face broken into two parts. More importantly, my neck hurt and I could not seem to feel or move my left side. Funnily enough, I wasn’t especially cold. The snow mantle protected me from the wind and I had warm clothes on. However, I realized that I was not going to survive up there until the morning. If I concentrated I could get some movement in my left arm and managed to unclip myself from my harness. Then, I found that I could row myself with my good right arm down the hill, tobogganing down the snow. At the bottom of the hill, there was a hedge and then a road. Eventually, I managed to slide through the hedge and into the road, where I lay exhausted. Minutes later, or so it felt, a farmer in his LandRover came along checking for buried sheep. As far as I know he was the only vehicle to come along the road that night, as later it was completely blocked by snow. He took me to the hospital. Over the next days, my arm and leg recovered steadily as the tweaked nerves came back to life, and when I returned some days later the kite (which was white) was still perfectly camouflaged in the snow. No one had known where I was flying and I doubt that I would have been found had I not been able to slide down to the road. From that day on, I was frightened of hang-gliding. I was no longer immortal and the joy of take-off was replaced with dread. On Mt.Kenya, Phil Snyder (the park warden) and I had tried to make a hang-glider out of bamboo poles (there were plenty growing there) and deck chair canvas. No luck. But later I went out and tried to fly down the Rift Valley with a professionally built high aspect ratio hang-glider. The thermal activity was ferocious so flying after around 10 am was downright dangerous, but drifting over the African savannah side by side with a vulture was absolute heaven even if I was terrified throughout. Every kick of turbulence brought my heart into my mouth as I was convinced that I was about to invert. An old RAF pilot out there (Danny Probin) who had built his own single-seater plane and often flew along the rift valley said firmly that no one should ever fly in Africa without control surfaces (a rudder and flaps) as he had been inverted several times in a conventional aircraft and only saved from crashing by the use of his controls.
Gliding
Later when I was learning to glide I kept very quiet about my hang-gliding as glider pilots despise hang-glider pilots. However when high over Loch Leven, my instructor reversed the controls and put us into a spin, I immediately corrected the situation and begged him not to do that again. Intrigued, he asked why. I explained that I had spun several times in a hang glider and that every time it had hurt a lot when I hit the ground. I can remember even now his awe-struck voice just behind me in the instructor’s seat when he repeated “You have spun, hit the ground, and survived!” He was actually quite intrigued, but when I explained that we also flew in a cloud without instruments he was horrified. I don’t know who suggested it but we had a discussion as to whether I could fly a glider in the cloud without an instrument rating. I thought that I probably could. The next morning there was a low cloud and flying was cancelled because the winch launch was going to take us straight into the cloud. The instructor explained why there was to be no flying until the cloud rose but then went on to say that he would in fact be flying with me. We prepared the glider, did our pre-flight check, hooked up and the winch whipped us 1000 feet up into the air. Winch launch is only one way of launching a glider and it is cheap and relatively easy. It does not give you much height compared with an aero tow launch, but we were flying at Loch Leven in Scotland where there is a mountain ridge close by which you can hop over to, and then use ridge lift to stay up. I had flown that ridge many times in a hang glider twisting and turning between the crags hugging the mountain side looking for lift. However today the Bishop Rock was not even visible because of the low cloud. As soon as you are off the ground with a winch lift, you pull the stick back, and the nose goes up: the glider shudders as it climbs steeply. If you pull the stick back too much the load becomes too great and the cable breaks off, and you have to make an emergency landing. If you don’t climb steeply enough then you don’t get as much height as you should. That day we soared up at the correct gradient and two-thirds of the way up we went into the cloud. That didn’t matter much as you are feeling the load on the wire more than anything else. However, as you come to the top of the wire there comes a moment when you are almost over the winch and if you don’t pull the release then the wire will start to pull you back down again. At that moment you have to push the stick forward to put the glider into a little dive, slacken the cable, then pull sharply on the release lever, and away you fly. This was the moment of truth. I had no external landmarks and was determined not to let the nose of the glider creep up into a stall. So I firmly pushed the stick forward, pulled the release, and off we went into cotton wool. There was no time to look at the instruments. I was flying quite literally by the seat of my pants. Determined not to stall, I pushed the joystick even further forward. Now I could hear the wind around the glider rising. We certainly had airspeed. Seconds later the wind around the glider rose to a howl. What on earth was going on? Before I could think what to do next the cloud around us started to clear and the ground appeared – above my head! Behind me, the quiet voice of my instructor chanted the time-worn phrase “I have control’. In other words, you are out of control and I now need to sort things out. We were completely inverted. I had pushed the nose so far forward that we had gone beyond a vertical dive. We had been in the cloud for less than ten seconds. I was both impressed and apologetic. Hang gliders might fly uncontrolled in the cloud but gliders did not. I had learned my lesson. However, the instructor remained intrigued and kept questioning me about hang-gliding. Later that day as we soared along the ridge of Bishop Rock, I mentioned that of course a hang glider would be much closer to the ridge and would be working in and out of every gully, and that would be much more interesting. Without any further comment, the instructor behind me gave that well-worn phrase “I have control” then added, “tighten your straps please”. He then turned the glider down and into the ridge. We flew along at 60mph hugging the hillside sending sheep running in panic in front of us. We were so close to the poor animals that you could actually see the sheep’s eyes rolled back in terror. At the end of the traverse, he tilted the glider into a vertical climb until we stalled, tipped it over onto its side, turned down again and did another ground-hugging traverse of the ridge as I was thrown all over the place by the positive and negative G forces that the glider was pulling. I was used to skimming along at 20mph. Doing the same thing at 60 mph was incredibly exciting, and I had to admit that this beat hang-gliding into a cocked hat. “I decided to sign up for another week of gliding despite the fact that I was on night duty in the Casualty department of the Royal Infirmary in Edinburgh, so the next week was pretty sleep-deprived. On the last day of the second week of my glider pilot course, they finally announced that I could go solo.
My first solo flight.
The glider they gave me was no hot-ship but it was a pretty natty machine compared with a hang glider. The weather was lovely, a stiff breeze from the West would provide a lovely ridge lift on Bishop Rock and there were some fluffy clouds looking very much like the top of thermals. Before I could fly, one of the hot ships went out. These are super high-performance gliders with long thin wings, waspish fuselages, and a cockpit made completely of perspex. So it must feel as if you are sitting in the open sky with just a joystick and a couple of instruments between your knees. I watched him carefully. Straight off the winch, he headed to the ridge and in a couple of sweeps had gained another thousand feet. Then he turned forward into the eye of the wind. He seemed to be going quite slowly because I suppose he was working his way West against the wind. Then under one of the clouds he tilted into tight circles and rose up like a lift until he vanished in the cloud sitting on the top of the thermal. When he next appeared he was a dot. Then he came on the radio to say that he had caught a ‘wave’ lift and was putting on oxygen. Wave lift occurs very high when the wind starts oscillating over mountain ranges and produces long lines of lift and sink like giant rollers in the sea. If you can get into the front part of the wave and traverse along its length you go up and up, and up, in the smoothest of lift. Within minutes he was back on the radio to say that ice was accumulating on his wings and he would have to come back down. He must have dived very steeply because minutes later he appeared over the clubhouse at 100 feet going very fast indeed jerking his joy stick to and fro to shake his wings and throw off the ice. Using this speed he turned and climbed back up Bishop Rock, then into a thermal and back up into wave lift. I was mesmerized. These hot ships do well over 100mph and only sink one foot for every thirty feet they fly along horizontally. Once you are at altitude you can fly fast for miles and miles.
Then it was my turn on the winch. The instructor suggested I went up and then if I felt confident go across to the Bishop Rock and see if I could fly the ridge a couple of times. So, as soon as I was off the winch I headed for the ridge and quickly picked up some lift. After four traverses I too was a thousand feet above the ridge, and looking upwind across Loch Leven I saw what could only be a thermal cloud. I couldn’t resist it, and although I wasn’t really cleared for it I set off up-wind, secure in the knowledge that if I didn’t find a thermal I would still have plenty of height to fly back down-wind to the airfield. Quite suddenly the glider started bucking about and looking down at the variometer I saw that I was climbing fast. Wow! I was in a thermal. I kicked the rudder and started circling as fast as I could, hoping to stay in the thermal. The vario continued to report that I was climbing fast and suddenly the sky went dark. I was right up at the cloud base. The altimeter was recording nearly 10,000 feet. I knew that I must not go into the cloud so I straightened up pushed the stick forward and headed even further West. As soon as I cleared the cloud I realized that I was so high that I could see right across to the West coast of Scotland, so off I went. A quick calculation told me that, at this altitude, I could go more than 30 miles upwind and still be able to glide home to the airfield. For the next couple of hours, I worked my way further and further West. The Gods were with me. Every time I lost altitude and worried that I should turn for home, I caught another thermal, and up I went. When I finally got back to the airfield, thinking that I had been out for half an hour, a very thin-lipped instructor pointed out that I had been away for 2 ½ hours and that they had been very worried about me. I was too happy to feel very guilty.
Falling asleep
As I drove back to Edinburgh in the warm evening sun, I felt very content and unworried that I now had 12 hours of night duty to do. Moments later, I woke up to the most terrible noise. I had fallen asleep on the Forth Road Bridge bounced off the barriers and turned the car onto its side blocking the carriageway. I was shaken but unhurt. The police seemed to arrive in minutes and noted that my Hillman Avenger (what a preposterous name for a dog of a car) was not taxed and had Puff the Tragic Wagon etched in the mud on the back window. They started to take my details and direct the traffic. Then one of them said, “Arent you one of the doctors in the Casualty at the Royal Infirmary?” Sheepishly I admitted I was, and that I was due on duty for the night in one hour. There was a quick muffled conversation between the officers then one of them said “ Come on doc, lend us a hand” and the three of us rolled Puff back upright again. The engine started and they invited me to leave forthwith and get on duty at the hospital. Nothing more was said about the tax disc. The police are a lovely lot when they are on your side and in casualty we are definitely on the same side.
Clinical & House jobs
Clinical studies back in Oxford
Clinical studies were a brutal shock. I had blithely thought that once I was through pre-clinical everything would be plain sailing. I can’t remember what happened on that first day but I got a right roasting from a ward sister for opening a curtain or breaking some incomprehensible rule. Without further ado, I packed my rucksack and hitchhiked up to Scotland to go climbing while I considered my next move. I was sorely tempted to give up medicine altogether but had spent a lot of time and money getting my pre-clinical degree and was loathe to throw it all away now. I had to give myself a strong talking-to before I returned. I was getting a first glimpse of what a hard slog this was all going to be.
One of my first consultants was Joe Smith a delightful and astute urologist. He knew and liked Jane (that got me past many problems in the clinical school) but saw that I was going to be a challenge. At least he made the effort, bless him. He allocated me to a patient who had the same birthday as me. That was a cruel shock to start with, as he had a nasty tumor. Joe insisted that as it was ‘my’ patient I should scrub up in theatre with him. The tumor had already spread far through his body. There was nothing to be done. He would die in the next few weeks. I was horrified. I have always been bad about people dying and Joe had caught me on my rawest nerve. My arrogance and my facetious manner took a serious drubbing. I did not like my patient dying, but I could see the fascination of clinical medicine. However, I was still going to get into trouble.
Minimal change glomerulo-nephritis
We had a lecture from a delightful pathologist Mike Dunhill on Minimal Change Glomerulonephritis. It was clearly a subject dear to his heart but was rare. At the end of an interminable one hour lecture, I put up my hand to ask a question. He was delighted, as clearly questions on this abstruse condition were few and far between. I explained that I would probably be going in to General Practice (I thought that I was then) and wondered how often I would see this condition in an average practice. Poor kind man: he did not see the trap I had set. He pondered and then said “Once every three hundred and fifty years” “Well then” I replied quick as a flash “What the hell am I doing in this lecture then?” There was a roar of applause from my fellow students. I got to know Mike well during the clinical course and wished that I had not said that. He was such a kind gentle man.
Ward work
Patients were in hospital for a very long time then, ten days of bed rest after a heart attack, and two weeks after surgery for peptic ulcer. Robert Duthie brought his patients in two days before surgery just to give the medical students time to take a history from them and examine them properly. So, there were tons of patients with nothing to do but be seen by students. I just felt it was repetitive for the patients and pretty dull for the students who were the fourth or fifth to clerk that patient. We were divided into groups of eight in the second year and hunted in packs. You got to know your group very well during that year as we rotated through the specialties. I got into especial trouble with psychiatry. I was allocated to the Phoenix Unit at the Littlemore Hospital. This unit did not believe in drugs or ECT (good) but used silence to get people to talk out their problems. The professor (Mandlebrote) was famous for this technique which involved smiley beningly. whatever a patient said, and asking them why they had said whatever it was that they had said. Douglas Adams reproduces this beautifully in Hitchhiker’s Guide to the Galaxy. You can imagine that pretty quickly even the thickest patients learned to say nothing. So, we would sit for two hours in a circle, staff and patients mixed together, and wait for someone to say something. Whole summer afternoons were wasted in this tedious pursuit. One desperate afternoon I spent the whole meeting trying to work out if I could climb all the way around the room using architraves and window frames, but each time got stuck between one of the windows and the door. At the end of the meeting, the senior registrar strode over to me and said “There is no way between the door and the window. I have been looking for 20 bloody meetings!” and strode off.
The fashion at the time was videoing interviews and then analyzing the interaction in front of the other students. This was potentially desperately embarrassing, especially as it was the first time that most of us had seen ourselves on video, and because students can be pretty merciless. My patient to video turned out to be a rather sweet girl who I knew vaguely as she was one of the tellers at Barclays Bank in the High street where I went to collect my £5 per week allowance. I duly started taking a history and then had to get on to the sexual things. Quite suddenly she broke down in tears and explained that she had been gang raped by her brothers in the sand pit as a young girl. I was completely bowled over by this revelation and as she continued to talk, all I could do was say “Good…..Good…..Good” Our tutor thought this was marvelous and to this day I can remember him turning to my fellow medical students, as he played the clip for the third time. “Now watch here! See how this middle-class public schoolboy is completely blown away by what he is hearing“. As he played the clip again and again, the laughter of my fellow students was still ringing in my ears.
Medical student visits
As medical students, we were taken on public health visits. I found these fascinating. At Morris Cowley Works which had become British Leyland, we were taken to see the car production line by a young manager. At each workstation, there were boxes to sit on around a table. Three men would be playing cards while one (usually a foreigner) worked the line. Apparently, the unions insisted on that level of overstaffing. One of our party had a mini skirt on and as soon as the workers saw this, they started hitting the production line with spanners and hammers making as much noise as they could. The manager whispered to us. “Just ignore them. They are animals. If you pay attention to them it will only make them behave worse.” How they ever produced any cars there I do not know.
Another visit was to the mental hospital at Cholsey Fairmile. This was a huge institution housing a range of cases from those who were violent, through patients with Downs Syndrome, to girls who had illegitimate children and had been locked up for their ‘crime’ and never released. At the time that we visited, the Hospital still had its own farm worked by the inmates which actually made a profit. The plows were not drawn by tractors or by horses, they were drawn by teams of sub-normal men who were put into harness to reduce their excess of energy! This was still going on in the early 70s and there were still inmates who had been put there years before for having an illegitimate child. It is all closed now and the site is covered with very smart neo-Georgian family houses. If there were ever such things as ghosts, that is where they would be.
Skye and the Cuillins
One of my fellow medical student’s family had a house in Plockton opposite Skye. To drive there in those days was nearly 24 hours of driving but it was a sublime place. We went up one Easter when there was still snow on the Cuillins, and we climbed a massive snow field in front of Skur nan Gillean. I had an ice axe but no crampons, so I cut steps at the front in classic Victorian style. Richard McCubbin followed with his hands holding my boots and his boots then went into my step holes. Three more followed behind, using the same technique. It all started as a bit of a joke but pretty swiftly we got into the rhythm and overtook another party climbing conventionally with snow anchors. When we got to the top there was a tricky chimney to climb. It was clear that some of the parties were not up for this, as we had no rope. Just at that moment, a rope snaked down from above and with great relief, we tied ourselves on one by one and climbed onto the ridge where two elderly men were belaying us. They enquired astutely whether we were medical students. We admitted we were. “Ah” they said. “We thought so”. “We are local GPs and reckoned that only medical students would have tried to climb 1000 feet of ice face with no protection whatsoever”. What could we say except thank them and head on along the ridge and down the other side?
Len Mercurious
There were also problems in A&E. A year ahead of me was Len Mercurius Taylor the coolest spade on the block. He was now a senior medical student and we were, of course, in total awe of him and his ilk. One evening a rather lovely girl was brought in from Port Meadow stark naked and covered in cow dung. She appeared to have taken some illegal hallucinogens and was now high as a kite. The ambulance crew manhandled her into a special padded side room that we kept for disturbed and violent patients and slid the door to. Len heard of this case and strode over ordering us all to stand back. He would handle this case. He opened the sliding door stepped in and closed it behind him. However, we were not going to miss this, so a foot in the door prevented it from closing completely. The patient was sitting on the floor at the far end of the room and looked up as Len came in. He introduced himself but she was clearly not listening. As he walked towards her she murmured “You are black, and very beautiful” This was poetry to Len’s ears. As he got closer she reached up and grasped him by the waist. Then before he could react she pulled herself towards his groin and bit him on the balls. You have never heard such a scream in your life and Len threw himself backwards. He hit the door at speed which simply collapsed outwards as it was on slides, not hinges.
There Len lay clutching himself and crying that he had been castrated. We howled with laughter and tried not to wet ourselves.
It is strange to think that at that time in the early seventies, I met a patient who had fought in the Boer War (1899-1902), and another patient who claimed that his grandfather, whom he had met as a child, served at the Battle of Waterloo.
Tingewick
The high point of the student calendar was the Christmas pantomime called Tingewick, named after a village halfway between Oxford and Cambridge. There was a time to have some fun, but it was also a chance in humor to tell our teachers what we thought of them. There is a censor but almost anything goes. When the Professor of Pathology was at war with his whole department and to cap it all went blind, there was a delicate period of several years while the University eased him out of his post. In the middle of these delicate negotiations, he was portrayed in Tingewick as a pirate called ‘Rusty Gun’ When one of the other characters asks why he is called Rusty Gun the punch line was “Because he can’t be fired” The audience to a man groaned and buried their faces in their hands.
Our Tingewick was great fun except for the director Adrian who had to pull this show together. A local brewery provided free beer which we consumed con brio. I was a terrible singer and quite shy about it. My entrance as the new Professor of Paediatrics from London required me to walk straight to the front center of the stage and start my song. My entrance went fine but I was completely blinded by the footlights and went straight over the front into the orchestra. Alcohol may have played a part. Adrian thought I was playing the fool and took me by the throat and shook me. At least that sobered me up.
It was very hard to juggle all the fascinating things that were going on in life at the time. My motorbike broke down or lost its chain most days, so my hands were continuously covered in oil. One morning I was summoned from the back of my group to examine a pregnant ladies’ abdomen. I tried to duck out of this tactfully but the consultant was having none of it. I laid my hands on this enormous belly and there was a stunned silence, broken by the consultant leaning forward and lifting my hands up and away and saying “There is nothing like a pristine white gravid belly to show up a completely disgusting pair of student hands. Get out!” and I went.
Stokes-Adams in the Cornmarket
Finals were drawing near and my ignorance of medicine was palpable. Later when you are a fully registered doctor the situation is different; you know nothing but feel that you know everything. I was still in the double negative stage. I was walking along the Cornmarket in Central Oxford and saw a commotion beside a bus stopped in the middle of the street. It was clear that someone was collapsed on the steps of the bus. I decided that I ought to try to do something to help. “Excuse me” I said as I tried to work my way through the assembled crowd “I am a medical student.” No-one moved. “ Excuse me, I am a doctor!” Like the Red Sea, the crowd parted in front of me, and there I was ‘at the site of the incident’ as the police would say. Lying on the steps of the double-decker bus was an old man who was very blue. Standing over him was a policeman and another person who said he was an off-duty fireman. Clearly, cardio-pulmonary resuscitation was needed and I racked my brain to remember what had to be done. I had no desire to give this man the kiss of life, so asked the fireman if he was competent to do this. He was “Fine,” said I “I will do heart massage, you do Kiss of life” and we got started. The policeman standing beside me said that there was going to be an ambulance in around 20 minutes. Clearly, that was not going to do, so without thinking I suggested that we should commandeer the bus, as the Emergency Department at the Radcliffe Infirmary was only a few hundred yards up the road. The policeman clearly like that idea and turned to the driver of the bus who was hovering around and announced loudly that we were commandeering the bus and would he please clear the passengers. Obviously, they could not get past us blocking the steps, so the driver rushed to the back and opened the rear fire escape door, and all the passengers were escorted off the bus. The driver then ran to the front to climb into his seat and suddenly stopped, leant out of the bus and announced that there would be another number 14 bus along in a moment! Obviously not a man who takes his duties to the bus company lightly! Off we went with the policeman leaning out of the side of the bus waving his helmet crying “Stand back. This bus is commandeered”. What a wonderful word that is! We swept through the traffic lights at the Martyr’s memorial and headed up St. Giles. The entrance to the alleyway which led down to A&E at the old Radcliffe Infirmary was very narrow and the bus simply could not get in. So we reversed back out into the street and a trolley was brought for the patient. Lots of white coats gathered around so I decided to make myself scarce.
The following day I was summoned to the Dean’s office where he had the Oxford Mail open in front of him. The front page picture and the headline was ‘Mercy dash by bus saves patient’. There was the bus with the policeman waving his helmet and the driver crouched over his wheel. The Mail had clearly set the picture up afterwards. But the Dean’s finger was pointing at a sentence in the caption. ‘A doctor who helped with the rescue vanished immediately afterwards.’ The Dean was looking at me quizzically “Not quite a doctor yet, Bulstrode” He did not add that at the present rate of going I was not likely to be either! “ I wonder if that was you” he said knowing perfectly well that it was. “If so, the patient is the Professor of Russian at the University. He has been admitted to my ward on the take. He has had many Stokes-Adams attacks before (a brief episode when the heart stops and then starts again quite spontaneously) but never when a medical student is near. So he has never had someone jump on him and break four of his ribs giving him a cardiac massage which he did not need.” I had never heard of Stokes-Adams attacks but made a note to check it up before finals. Quietly I took some solace in the fact that some ribs were broken as we had been taught that to be effective in the elderly, cardiac massage had to be powerful enough to break the ribs. I trudged down to the wards to apologise. He was a delightful man and was quite prepared to forgive my over-exuberance: he was just so short of breath and in so much pain that he was having problems expressing himself!
Applying for House jobs
We had tried to do some night climbing in Oxford but the stone was in very poor repair. However, we did have a couple of jolly nights when all the colleges were flying their flags for some celebration or other and we managed to climb and swap them all around. Harmless fun, but it burnt up excess energy. The consultants all knew us by name. There weren’t many of them and there were even fewer of us. In the evening many of them would come to the student bar for a quick drink before going home. It was a very congenial environment. I was not a ‘good’ clinical student and so I was going to have to make do with a second rate house-job. The talk of the Student Club was about which jobs were good (prestigious) and which were not. One tea time I was sitting with the down-and-outs in one corner of the club room while the goody-goody-two-shoes were huddled in the other testing each other on abstruse conditions. I called across to them to tell us which jobs they were applying for, so that we didn’t need to bother. Not a word would they say. I decided that I would go abroad and found that I could do at least one job in Rhodesia. That sounded fun, so I applied and got a place. Then just months before the jobs were due to start, Rhodesia declared unilateral independence from GB and the house jobs were no longer recognised by the General Medical Council. I was in a pickle. I went to see the Dean, one of the few times I went to see him rather than being summoned, and he said he would see what he could do.
Nuffield Department of Medicine
When the jobs were announced a week later I found that I had a top job with the new Professor Weatherall in the Nuffield Department of Medicine. I enquired delicately what had happened and was told that all the best students were convinced that this was going to be the most hotly contested job, and so had not applied. On the other side, Professor Weatherall had said that he would take any student except Bulstrode, but as there were no other applicants he had little choice. So fate plays its games. It was also a terrible job, and I learned nothing, except how to certify death. On my first night on call, I was bleeped to the ward to see a patient who had died. I did not get a clue what to do. I had probably missed that lecture if there ever was one. I told the night sister that I was new and asked her what was I supposed to do. “Well”, she said “What the other doctors do is look to see if the patient has stopped breathing. If they have, they go away and have a cup of tea, and if they are still not breathing when they get back, why then they are dead? I’ll go and put the kettle on.” There, it was a simple as that.
That year was the hottest summer ever and we were in a rebellious mood, so we cast away white coats and then ties, long trousers, and then socks. Finally, David Weatherall said as he started his weekly ward round. “Well if the house officers have got no more clothes to put on, I suppose that we had better start the round.”
Bath
My second house job was in Bath. This was a busy job and I was completely out of my depth. Katherine and I were newly married and had a beautiful flat in the hospital grounds. It was a long glassed-in corridor from the wards. If you were called at night you put a white coat over your pajamas and headed down that corridor. I was not the only one who tried to walk it with his eyes shut. Only in my case, I broke my nose walking straight into a pillar. I had a wonderful senior house officer who was kind, competent, loyal, and hard-working. He saved me from a load of trouble, as I was drinking hard, flying hang gliders when I could, and planning to leave for Africa as soon as possible. As house officers, we got to do some surgery. My first operation was a circumcision on a young man going into the Army. The dorsal vein needs to be tied off carefully, and clearly, I did not do that; because in the middle of buying a celebratory round of drinks for my first successful operation, I was called by the staff nurse in charge of the ward to say that my patient was bleeding. I must say that I thought this was a practical joke but played along. “How much” I enquired solicitously “Two pints” she replied swiftly “Staff,” I expostulated “Do you know what two pints of blood looks like?” “Yes doctor” she replied “It fills the bed and runs onto the floor” I headed for the ward, and then with the patient to the emergency operating theatre where I applied a properly fixed ligature and arranged for the patient to receive a transfusion of blood overnight. The next morning when I arrived in the doctor’s mess for breakfast, the whole mess rose to their feet as one and gave me a standing ovation for being the first surgeon in Bath who had to transfuse a circumcision.
Trooper Evans
My favorite anaesthetist was Trooper Evans, who as his name implied had served in the military. He was a pretty experienced surgeon in his own right and when Simon (my immediate superior) found things difficult Trooper would put on a pair of gloves and join us. However, his great claim to fame was being banned for life from the local psychiatric hospital. He had been attending weekly for an Electroconvulsive Treatment list for depressed patients, where he would anaesthetize the patient, then the psychiatrist would apply the paddles and give the patient a mighty shock across the brain. It is a horrid treatment to have to witness, and Trooper hated it. One of the less experienced psychiatrists somehow got his fingers under the paddles when he pressed the ‘fire’ button. So, he got the shock instead of the patient. Trooper says he convulsed across the room until he hit the wall where he slid down onto the floor semi-comatose. Trooper trotted over to him and asked kindly “Are you feeling happier now?”. For that remark, he got a lifetime ban which suited him just fine.
The mess was a very important part of the doctor’s social life as our duty hours were so long. The mess parties, funded by signing cremation forms, were a splendid time but did get out of control at times. After one dinner we were battling for control of the corridor with fire extinguishers when the night matron came to complain about the noise. We kidnapped her and locked her in her own office from where she called the Duty Manager. He declined to come in and said that if anything this was a police matter. The police arrived, surveyed the carnage, and decided that things would be better sorted in the cold light of day. Wise decisions all around, but not something that would be tolerated today.
Ward sister Bath – Sister Poppett
The ward sister was my bete noir. She was old guard and before taking reports in the morning would go around switching off all the patient’s drips. I am not sure why she did that, control I suspect, but very irritating as sometimes the drips then clotted up and had to be changed. So Anna (my fellow house officer) and I would go around switching them back on again. Finally the inevitable happened and we met on our respective rounds. She switched the drip off. I turned it back on. “I just don’t understand…” she started, but I didn’t let her finish. “That is abundantly clear,” I said and continued on my way turning on the drips. She reported me to the consultant for insolence and he summoned me to his office. “I have only one thing to say,” he said “House Officers are expendable. Have I made myself quite clear?” And that was the end of it.
Practical jokes
The humor in many practical jokes is the result of humiliating or harming someone, and it is rare that a joke can be designed that is funny but harmless.
We had also climbed the Tower of the Winds (the centrepiece of the medical school then) and had stuck giant black paper footprints climbing one side and descending the other. This had also harmed no one, but had resulted in the poor Dean having to ask me in the most general terms whether I could arrange for them to be removed before they had to call in steeple jacks to do it!
A silly impulsive bet that I could not streak down the main corridor of the Radcliffe Infirmary naked with a cardboard box on my head was slightly marred by the night my sister recognized me (I know not how!) and reported me to the Dean. I fear that this was an early example of being set up by my colleagues, as why else would sister have been walking the corridor just then, and why did she know at once who I was. My mistake was to ask how on earth she knew who it was when I still had the box on my head! What a giveaway
Smile on a Pylon
Each morning as I rode to work on my beastly Jawa moped I passed a monster new pylon on the Southern Bypass. Eventually it all was too much for me and I liberated a bed-sheet from the hospital and stenciled a large Smiley face on it. That night I climbed the pylon to the very top. It was an eerie feeling as there is electricity arcing across from the wires onto the main struts of the pylon. So I was a bit live too! At the very top it was windy and the pylon rocked in the wind. Luckily it was the middle of the night so I didn’t suffer from any vertigo as I could not see the ground below me. The flag looked magnificent the next morning except that I had tied it on upside-down. The electricity board gave out wonderfully stern warnings about how dangerous this had been and claimed to have had to turn off the electricity to South Oxford in order to bring it down. It did start the kernel of an idea for the Oxford Dangerous Sports Society. The very topmost wire on an electricity pylon is a neutral wire so is not live. It would therefore be possible (if you could keep your balance) to bicycle along this wire if you removed the tyre from the bicycle wheels and cycled along on the concave rim. Just imagine swooping across the countryside on a bicycle following the lines of the pylons.
Standard electricity panel good for hanging flags.
The earth wire on the top would be great for cycling along
The Road Sign Scheme
On April 1st 1975 the Oxford City Council was introducing a completely new one way system in Oxford. The evening before, we were all in the student bar and Jeff Taylor suggested that it migh be fun to muck-up the signs for the following morning as it was April fools Day. Shortly after midnight we set to work. My plan was to try to create a closed loop, but it was not nearly so easy as we had hoped. The new signs were on different diameter posts, so it was not possible simply to move one to another. However, after about three hours we had done it and we had created a closed loop by moving only three signs. There seemed no point in going to bed, so we went to the covered market to have breakfast at George’s and then sat down outside Blackwell’s to see what would happen. We were actually sitting under one of the signs we had moved, and beside us was standing a young traffic policeman who was directing the traffic. Quite quickly the traffic built until the cars in the closed loop which ran down the Broad up St Giles and back down Parks Road were nose to tail and moving steadily. Finally a car stopped and the driver expostulated with the policeman that he had been round the loop three times and could neither get into Oxford nor out. The policeman calmly and politely told him to follow the new signs and set him on his way. By 8.00am it was clear to the police that there was something badly wrong, and hurriedly sacks were put over the new signs. But the damage was done and the national papers reported that queues of traffic over 8 miles long had formed on all the entry roads to Oxford.
That afternoon I was again summoned to the Dean’s office. When I came in he did not invite me to sit, but did ask me not to say a word. He then went on to explain that he had been one of the unfortunates caught in the traffic that morning. Each time I tried to intervene he simply asked me not to say a word, so that I would not incriminate myself. As the discussion (monologue) moved to what had happened and who might have done this, there was some noise in the ante-room and his secretary came in to say that the police were there to see him. He took a deep breath and looked at me and then said very quietly. “ behind me there is a door, which leads into a lavatory. There is a window in that room. May I suggest that you avail yourself of that window, and go climbing in Scotland until the dust has settled on this matter”. So I did.
The Shark
Swimming on Croyde Bay in Devon was dangerous. We had an arrangement that all the young children would wear a pink beach cap and that each child in the water would have one adult allocated to it, who would do nothing else other than watch that child. In the centre of the beach, there were lifeguards, idle Australians, who spent the day lounging on the top of their Land Rovers. They set flags on the beach about 100 feet apart and insisted that no one was allowed to swim outside these flags. Well, this was quite unacceptable to us. We were certainly not going to be packed in like sardines for their convenience. Each year there was a bit of an argument. They would tell us we were not allowed. We would tell them that no one, least of all them, could tell us where we could and could not swim.
It became an annual irritation so we decided to do something about it. We made a great white shark. Well, not exactly; we created a giant dorsal fin out of expanded polyurethane covered in black bin liner material. It was very difficult to get this fin to stand up in the water, but eventually, we found some scaffolding poles which were heavy enough to ballast the fin. Design, manufacture and sea trials were all carried out far from the beach in the estuary where we went sailing. It took much longer than I expected to create something that really looked quite realistic from afar. It stood about four feet high and flopped to and fro in the waves most convincingly. The day came for the launch. It was a Saturday and the beach was packed with people. The sea was quite calm and quietly we moved the parts down to the sea just around the headland of the bay, in a rocky gulley. We had a canoe and a roll of fishing line. The plan was to assemble the shark and launch it. Then the canoe would tow it out and across the bay on the end of a 1000-foot line. We gambled that the canoe would be so far away from the ‘Shark’ that no one would realise that the two were connected. The shark model was very heavy indeed and devilishly difficult to manoeuvre over the rocks. By the time we got to the water’s edge a low swell had built up which was crashing up the gullies in the rocks. As we launched a large wave came and bowled me over as I tried to prevent the shark from being damaged. My back was cut open from end to end but this was no time to stop for First Aid. Simon was paddling the canoe. He felt that as a psychiatrist he might be better at calming things down if the lifeguards got cross. When he was about one quarter of the way across the bay the line came tight and the shark started to follow him out. It looked magnificent. For what seemed like an age Simon paddled serenely on and the shark fin started to cross the bay about 100 yards outside the surf. Then people started to notice and to point. Rather strangely fathers could be seen running out of the shallow water onto the beach. They were running to get their cameras. Then you could see mothers running down the beach to gather up their children. Finally, the life guards saw the fin. There was pandemonium. They all leapt off their Landrover and started strapping diving knives to their legs. Then they launched their surf canoes. One paddled straight out to Simon to warn him to get clear, there was a shark behind him. Simon sweetly pointed out that the shark was his and that he was taking it for a walk. Slowly it began to sink in to the Australians that they had been taken for a ride. At first, they were very cross. One took his knife to the long polythene-covered fin and started stabbing and ripping it, and then they pulled it ashore. Later they came over to us as a group and grudgingly admitted that it had been a good practical joke.
Loch Ness Monster
The one that I have never done but would have loved to was create a Loch Ness Monster. The key to this one must be that people, preferably God-fearing American tourists would see something huge but only briefly and in poor light, and then it should vanish completely. This would not be impossible to achieve. A gas cylinder sunk to the floor of the loch fitted beneath a black parachute canopy would do the trick. When the cylinder was activated, the canopy would rise to the surface as the gas gathered beneath it, and appear as the back of some large animal. The key would then be to have a mechanism that automatically vented the gas quite quickly so that the large black shape sank beneath the waves and back to the bottom of the loch within minutes. The whole system would need to be under remote control so that an evening could be chosen when it was calm with a light breeze blowing ashore. The light should be low so that any film obtained would be tricky to enlarge and interpret. There would need to be witnesses, preferably several, on the balcony of a hotel, with the object surfacing close enough to be witnessed but not so close as to be correctly identified. The final clincher would be to have the gas in the cylinder mixed with hydrogen sulfide so that the sinking monster would leave a lasting smell of age and rot.
Leaving the Navy
I joined the Navy to pay for my clinical studies. Tim and Robert my brothers-in-law were already serving naval officers and the Medical Director General of the Navy was the father of one of my colleagues at University College. The Navy were desperate for doctors. Most of those joining the medical branch were incipient alcoholics or already well on the way. The Navy needed doctors to put on their nuclear submarines as, without a doctor, they could not go to sea. The deal was that you would get your three years of your clinical studies paid, but then for that you had to serve for five years. What a Faustian pact!
The clinical years were great. For the first time in my life I was earning. The Navy paid for me to go on my elective to Kenya where I ran an experiment on High Altitude Oedema. I don’t think that I could have got further from the sea anywhere in the world or chosen a subject to study more removed from the Navy, but in many ways this reflected their total lack of ‘grip’ on the organization they were supposed to be running. I managed to do a diving course with them too, but when it came to clinical medicine they were worse than hopeless. They took me down to the Institute of Naval Medicine as I think they hoped that I would join their sleepy research team there. They put us into their high-altitude tank. Each of us cadets was fitted with an oxygen mask, and the instructor pointed out that I might find it easier than the others because I had been to high altitude before. We all sat on the benches on the side of the tank. At 20,000 feet I felt decidedly odd but didn’t want to say anything because everyone else said they felt fine. We reached 29,000 feet (the top of Everest) and that is the last thing that I remember as I passed out on the floor. As I came to the instructor was saying to others “So you see, even though we did not give him any oxygen, he did not say anything before he passed out. That is the danger of hypoxia.” He leaned over me and asked if I felt OK as I was now getting supplementary oxygen like everyone else. Without thinking I punched him straight on the jaw. He rocked back and said in a slightly philospohical tone while stroking his bruised chin. “That is the other thing to note. They become very aggressive when hypoxic”.
When I started my pre-registration house jobs (what are now called FY1) the Navy put me on a lieutenant salary which was a junior doctor salary plus a small percentage (the X factor) to allow for the fact that you were on duty 24/7 for your Queen and country. That was the year that overtime was first paid to civilian doctors, and although it was at a paltry rate (1/4 of normal hours) we were doing such long hours that civilian salaries had nearly doubled. All house jobs were a one in two which meant 36 hours duty in 48 hours. That meant a working week of over 120 hours. When I pointed out to the Navy that I was being paid less than my civilian counterparts they told me that I was talking rubbish, but then when questioned, they knew nothing about the new overtime rules. It became clear that as soon as I finished house-jobs I was to be sentenced to nuclear submarines. I talked with one of the docs doing this job and he said that all you did was try to share out the psychological problems with the padre. I did not fancy that at all. The alternative was to go and work at Porton Down on chemical and bacterial warfare. Katherine put her foot down over this. One of the very few times in our marriage when she did, and she was absolutely right.
Eventually, things came to a head and I was summoned to see the Admiral at Earls’s court. I was ushered into a very posh office and we went over the various issues that were troubling me. It was clear that they still did not know anything about junior doctors salaries and that now that I had sold my soul to the devil, I was to do as I was told, or I would be court-martialled. With my heart in my mouth, I challenged him to court-martial me, as I pointed out that the adverse publicity would ruin their recruitment plans completely. The argument ran round and round and eventually, I got to my feet to leave and stormed off towards the nearest door. It opened into an enormous drinks cabinet! The admiral pointed out wryly that the exit was the door to my left. Having thanked him for the only piece of useful advice I had ever had from the Navy, I stormed out, quaking in my boots over what would happen next. I got my discharge papers the following week and a request to inform them of my salary as soon as I had one so that they could calculate repayments. My first salary was from Oxfam and was one hundred pounds a month. I duly informed them and my repayment was set at £10 per month. At that rate I would still have been paying them back in the years 2300. The repayment rose once I had a better salary and after five years the whole debt was paid off. No interest had been charged. I had escaped very lightly both professionally and financially.
Kilimanjaro 1
My first brush with High Altitude Oedema was when I was still a zoologist and decided with Steve Cobb to try to climb Mt Kilimanjaro, a magnificent 18,000 foot volcano rising out to the central African plains and dominating the view from Steve’s house in the middle of Tsavo Park. At that time Tanzania was being especially difficult so the normal route up the mountain was closed to visitors. However Steve knew the people at Mweka, a park warden training college in the foothills of Kili, and thought that we could probably sneak up from there. We were both very, very fit. Steve had just rowed for Isis and I was just finishing with Pentathlon, so we set off in his jeep, slipped across the border into Tanzania along one of the back roads and were in Mweka early in the afternoon. We did not want anyone to have a chance to forbid us to do anything, so we literally jumped out of the car and set off through the forest up a narrow track which led up the mountain. We made fine progress, almost running along the path with our light packs, and by the time that evening fell we had arrived at an aluminium rescue hut at 10,000 feet. We were very pleased with our progress indeed, found an old iron kettle inside the hut and set to making a brew. The tea tasted a little strange and I, bullshitting as usual, explained that I thought that this was probably something to do with the effect of altitude. Steve set off to refill the kettle as I was sure that hydration was important (it is not!). When he came back he had a long face. He lifted the lid of the kettle to show me a dead rat partially decomposed floating in the kettle. We had just drunk tea made from parboiled rotten rat. No wonder it had tasted strange. It was about then that I started to feel unwell. I was nauseated and had the makings of a deep pounding headache. Steve had the same so we put it down to drinking rat, and settled down to sleep. The next morning I was much worse and so was Steve, but putting a brave face on things I brewed up some porridge to give us strength. Somehow neither of us could face it, so we emptied our mess tins onto the roof of the hut to discourage rats, and set off up the path. As we worked our way up the mountain far below we could hear the tac-tac of the ravens pecking our porridge off the roof of the hut. As we went rapidly higher I felt worse and worse. Steve was also not right as he was not saying a word and although we had moved fast we were going slower and slower. Eventually we reached the first snow so I suppose we must have been somewhere over 16,000 feet. I could hardly see straight and my head was pounding. I sat down to rest, the first time on the walk that I had done so, and felt exhausted. I noticed that Steve was sitting down too. Next minute I was awake and very cold but something had happened. It was now late afternoon and we had stopped to rest mid-morning. Clouds were rolling in and there was a spattering of a mixture of snow and rain. The moment that I moved the horrible headache returned. I shook Steve awake. He looked terrible. His face was puffy and he didn’t seem to be seeing or thinking straight. I uttered the fateful words. “I think we should go down”. Steve didn’t argue and we started stumbling back down the track. As we descended the headache started to lift. By the time we reached the tree-line I almost felt well again. That was my first experience of high altitude oedema and in retrospect we were probably lucky that it had not been worse. My research on Mt. Kenya is that it commonly strikes the fittest and the strongest probably because they push their cardio-pulmonary system harder. If you are going to row for Oxford University you are well used to pushing yourself to the absolute limit and that is when High Altitude Oedema gets you.
I climbed Kilimanjaro again several years later. This time we took porters and went up very slowly enjoying the wild-life, the flora, and the views. By the time we got to the top hut we we almost all of us in good trim. The final ascent to the crater rim is made before dawn because it is loose scree and much easier to climb when it is frozen. We reached the crater rim at dawn. What a view it is. Then we circled round the rim to Uhuru the actual summit. At that point all the others wanted to go back down but I was intrigued by the snow filled crater with the great black smoking hole in the centre. So, I set off alone into the crater. The descent was easy although the snow was waist deep, but when I turned to climb back up to the edge I found myself exhausted. Every step left me desperately breathless and for a while I was not sure that I would ever reach the rim. Finally I did and started the glorious run down the scree where every stride takes you twenty feet. When I reached the top hut my party had simply gone on ahead and it was some hours before I caught up with them. I didn’t say anything about how much danger I had been in.
Mt Kenya
After this brutal introduction to high altitude oedema on Kili, I was intrigued by this strange disease which had only recently been described but which had clearly been affecting miners in the high Andes for hundreds of years and which was killing people on Mt Kenya and Mt Kilimanjaro.
Mt Kenya has had a mountain rescue team for some years after a notable tragedy involving an Austrian climber who fell and was left hanging from a rope high on the mountain. The Austrians flew out a rescue team and a helicopter only to have it crash into the rock just below him. He had the appalling experience of surviving having seen his rescuers killed trying to save him. The final rescue was carried out by Bill Woodley a legendary park warden flying his little supercub aircraft between the twin peaks of Mt Kenya Nelion and Bation. This is absolutely at the altitude limit of this aircraft and the winds are very turbulent there. Nevertheless, he managed to trail a 1500-foot rope and drop it so that it straddled the col between the peaks. The Kenya mountain rescue team was then able to use this rope to reach the injured climber and lower him to safety.
After that, the Austrians helped the Kenyans to set up a permanent and professional mountain rescue team that also acted as rangers on the mountain. They were led by an ex-hippy lawyer from the USA called Phil Snyder who was an outstanding climber in his own right and put up some classic routes on Mt Kenya. I liked Bill Woodley a lot and Phil Snyder too, and they kindly let me come and work and do some research on high altitude edema. I had a tent a 8,500 feet just across from the main gate to the park and three hundred yards from Phil’s house. At night the grass around the gate was grazed by a herd of buffalo. They, of all animals, frighten the hell out of me. Perhaps it is a throwback to Guernsey bulls, but they are unpredictable and very fast and have a bad reputation for killing people. Each evening I would have a beer with Phil and then walk the hundred yards across the sward to my tent, past the grazing buffalo. Phil knew that they made me nervous so one evening he crept along behind me and just as I got to the critical point of no return, stamped his feet and snorted. I have never run so fast in my life and dived head first through the tent door, although what protection I thought that a tent would give me I do not know. Behind me Phil was literally rolling in the grass weeping with laughter while the buffalo gazed on, chewing the cud mournfully. Not much later the laughs were off.
On New Year’s Eve some of the young rangers got a lift down to Naro Moru township 10km down the road. When they had finished celebrating they drove back up the hill to the camp. But one of them was left behind and he walked up alone. As he walked through the herd of buffalo one of them charged and killed him. In the morning his body was sprawled in the middle of the track, his neck broken. Off to one side the herd of buffalo continued grazing as if nothing at all had happened. Within minutes of the body being found the rangers were on their hands and knees chattering away in Kikuyu. They were piecing the story together from the tracks on the ground. Here was where the buffalo had started his charge. Here was where the ranger had run and then stumbled, risen up, and been hit. Clearly something had to be done, and Phil went to fetch his heavy-duty game rifle. He asked the rangers which buffalo they thought had done it. They picked out the old male who had a twisted foot although there was no sign of a twisted foot on the tracks of the buffalo who had charged. Phil thought about this and decided that a buffalo with a twisted foot was probably in pain and therefore was more likely to be the one that had committed murder. Charged, judged, and found guilty. Phil loaded his gun and walked slowly up to herd of buffalo who took absolutely no notice of him as they were used to people moving around the camp. He singled out the ‘guilty’ bull and as that animal gazed at him chewing the cud, shot him dead from thirty yards. It was a clean shot and he dropped where he stood without even a change in his facial expression. The rest of the herd dived into the forest. A lesson had been taught. The rangers sharpened their knives and prepared to divide up the meat.
The mountain was a strange place, a mixture of conflicting ideals. Bill Woodley was an old-fashioned colonial and wanted to build and maintain roads. I wanted the road up the mountain closed because it made it too easy for people to get to high altitude before they had time to acclimatize, and the walk through the forest is one of the most beautiful parts of the mountain. Black and white colobus monkeys bounce through the trees while at night the eerie howling of the tree hyrax is one of the most spine-chilling sounds I know. It sounds as if an old witch is being slowly strangled and is gasping for her last breaths. Phil wanted the mountain for climbing, while the conservationists would have gladly closed the mountain to everyone.
One of the problems was its proximity to civilization. Visitors could fly into Nairobi from some western city at sea level and be at the Met station (at 10,000 feet) on the evening after their arrival. The following day they could be up in the heathland and the day after on the top of Point Lenana at 16,000 feet. If that is not a recipe for a miserable time with headaches and vomiting and the risk of death from High Altitude Oedema I don’t know what is. In our haste to tick things off we sometimes miss the whole point of the experience.
When Bill Woodley had become a park warden at the end of the Mau Mau uprising he had done a very clever thing. He employed all the senior officers of the Mau Mau in National Parks: so he recruited some of the cleverest and most highly motivated Kenyans in the area. His driver had a huge silver mustache and was called General Durango. When I could speak Swahili he would tease me and tell me that behind that rock there beside the road was where the Mau Mau had set up their ambushes. One day he looked very thoughtful and said how much he wished the British were back ruling the country. I laughed and told him not to talk such rubbish. Flannel like that cut no ice with me. “No” he said. “There are only very few things that a man wants to be able to live. One is roads which are free for anyone to pass along. The second is a legal right to your land, and the third is markets where a fair price will be paid for your produce. Under the British, we had those three things. Now we do not.” I had never heard freedom described in such simple terms before.
I wanted to go climbing with Phil and eventually, he agreed to climb Point John with me, one of the subsidiary peaks which has a classic route on it. The climb was great. Following a really good climber is a real pleasure. The only slightly daunting part was points on the climb where I knew from the mountain rescue records that climbers had fallen. I knew exactly where they had slipped, where their bodies had landed and what they looked like when found. All a little too close to the bone. When we reached the top Phil pulled out a small joint and we smoked it in celebration. It was a stupid thing to do as the altitude amplified its effect. We set off down and I started abseiling. As I got to the end of the rope I realized that I was swinging in space with no ledge to land on. There was also no stop on the end of the rope. I sobered up pretty smartly and started climbing back up the rope. I had very nearly committed the oldest and most stupid mistake of them all and abseiled off the end of a rope.
Leaving Britain
Jonty Boyce
I found a soul mate in a fellow medical student, Jonty Boyce. Neither of us were ready to be sucked into the career mincing machine which was the fate of a junior doctor in the NHS. While grumbling away in the student bar at the Medical school, an elderly and eccentric consultant appropriately called Bent Juel-Jensen sidled up to us and asked if we wanted to do something very worthwhile but very dangerous. Our ears pricked up. Somehow he had got connections with the Ethiopian royal family whose head Haile Selassie had been deposed by a wicked military dictatorship called the Dergue. One of Selassie’s nephews Ras Mangesha Seyoum was leading a resistance force of Tigrinyan fighters against these wicked oppressors. They needed doctors to help in the refugee camps. Would we volunteer to go? This was real-time John Buchan stuff and we were hooked at once. We decided to drive out to Africa, so we bought an old Volkswagen van which for obvious reasons we named Ludwig (van Beethoven). We stripped the engine, built a giant roof rack for it and then liberated all the drugs that we thought we would need from the hospital pharmacy. It seemed like a Robin Hood gesture then. I am not so sure now!
Ludwig Van
The Volkswagen bus was an ex-dutch GPO van. No back windows and an empty interior. Plenty of room for equipment, we reasoned. We were worried about the engine overheating in the desert, so we fitted an oil temperature gauge. But when we asked VW what was the the highest temperature that we should allow, they didn’t know! We also decided to fit big bat ears on the outside to force extra air into the engine compartment. They were made from plastic washing-up bowls cut longways. They looked very impressive, but I doubt that they made much difference.
Finally, we were ready to go! We passed through Switzerland where Katherine’s family took us skiing, an extraordinary contrast in every way to what we were about to do. The cold glistening snow and wealthy complacency of the Swiss certainly jarred for me.
Geneva
While in Geneva we visited the various aid headquarters. Bent Juel-Jensen had been to medical school with the head of the WHO. He refused to see us, and Bent threatened to go and beat him up muttering in his swarthy Danish accent that the man had been a pompous prick as a student and doubtless was one still.
Each organization we visited had Headquarters which looked out over Lake Geneva and each had a large redwood planted in the forecourt. We speculated that the size of the tree related both to the age or wealth of the organization, as some of the newer ones had clearly spent vast sums of money purchasing enormous trees to give a spurious impression of a long-established presence.
The World Council of Churches were interested in what we were doing and agreed to support us. As we entered Walter Mitte’s office (I am sure that was his name) the man himself was standing at a Reuter ticker-tape, which was pouring out the latest news from Africa. With a gesture that I will never forget, Walter ripped off the latest piece of tape and handed it to us. “Looks like you boys are heading into trouble,” he said “ Another 100,000 Ethiopian refugees have just crossed the border into the Sudan.” Around the walls of his office were boards with headlines plastered on them like “Peru Quakes”, “Indonesia burns”, and “Congo revolts”. Underneath were terse notes saying how many people were involved and how much aid had been sent. I could not help noticing that the final common “Follow-up” had the same comment every time. “As soon as further information is received, the extra money will be sent!” Against the melodramatic backdrop of the news boards, a plate glass window looked out over the placid Lake Geneva with its huge fountain pouring the aqueous equivalent of Swiss francs high over the banking center of the world.
The ‘no feedback’ message was to come back to me later in the field. After one especially dismal report to the World Council of Churches explaining that half of the money they had donated to us had been stolen, they wrote a kind letter back to me, explaining that ours was the first project that had provided feedback on the money that they donated. They went on to say that we should not bother to send any more reports as their donors simply did not want to know – they just wanted to give their money. OXFAM asked if we could send some photographs of starving children to use for fundraising. We didn’t carry cameras on principle as they represented so much wealth dangling around your neck. But as we pointed out to OXFAM we could get more pictures of miserable people if we spent five minutes on the underground during rush hour in London than we ever could in the camps, where people might be starving but nevertheless, the main sound was laughter.
Athens
It was a long drive down to Greece lengthened by a 500-mile return to collect papers that we had left at the Yugoslavian border.
When we arrived in Greece there was snow on the hills and frost on the ground but we still slept on the roof rack as there was nowhere else to put our sleeping bags as the van was full of drugs. This meant that at Delphi we woke very early indeed. The ruins were not due to open for some time so we climbed the fence and had the whole site to ourselves. The running track is in very good condition with the plinths for the winners still intact. It was irresistible. Running was done naked in ancient Greece, hence the word gymnastics, so we ran a circuit naked and then posed for photographs in marvelous stances on the winning podia. Just at that moment, the gates opened and the first coach load of visitors for the day poured in through the main gate. We dived for cover and then struggled back into our clothes sheltering behind the podia that we had so proudly been crowning seconds before.
The ferry from Athens to Alexandria was uneventful but our arrival in Africa was not. There are agents on the ship (alias pimps) who for a price will shepherd you through Alexandria customs. We spurned their help and for the next eight hours paid the price as customs officers looted our vehicle. The only reason that we did not lose all our medicines was that they clearly did not know what some were for and therefore felt that they probably could not sell them.
The Journey up the Nile
We worked our way slowly up the Nile sometimes riding on the roof of the van and other times riding the two bicycles we had with us Fluke and Flukette. Despite the risk of Bilharzia we were determined to swim in every cataract of the Nile, on the grounds that Bilharzia is only found in the snails that live in still water.
At Gaza, we climbed the giant pyramid pursued by guides determined to try to get Baksheesh off us.
At Luxor, the frenetic pace of lower Egypt started to change to the slow pace of Africa. While we were in Luxor it rained for the first time in ten years. The children stood around gazing in awe at the sky. They had never seen rain before.
The Nubian Desert
As soon as we started across the desert we got bogged down in the sand and had to use the sand mats. Perhaps it was lucky the Alexandria customs stole so many of our drugs as we were still heavily laden with fuel and water. Two of us sat up on the roof ostensibly to look for the safe way forward, but actually, because it was a wonderful feeling up there. The engine in the rear meant that we could not hear it at all, and the breeze blowing over us kept us cool, while the desert rolled by. Speed was critical. If we went too slowly then we got bogged down in the patches of soft sand. If we went too fast then the steep wadis crossing the desert might tear out the suspension.
The desert was crisscrossed with tracks as there was no formal road. The problem was that the central tracks were so rutted that the VW just bottomed out and had to be dug out. However, if we went too far out into the desert onto clean sand and gravel there was a danger that we would miss the road altogether. Now and then we met young men driving stripped-out Peugeot 505s fast across the desert, the back and roof loaded with petrol jerry cans. These were young wanna-be taxi drivers who had bought a cheap old car in Europe and were now trying to smuggle them into East Africa without paying the prohibitive import duty. In the evening we could pick up the World Service on the radio. It was a poignant memory of the struggling world that we had left behind.
Eventually, our route paralleled the single railway track, which crosses the desert. It was impossible to drive beside the rails because the sand was too soft, so we actually drove on the tracks. I believe that Volkswagens were initially designed to fit the tracks of German railways so that they could run on the tracks if the tires were removed. Whatever the truth of that story, the gauge of the Nubian railway certainly did not suit the VW and we bumped along the sleepers keeping an anxious look-out for approaching trains. Apparently, there was only one train per week, but with mirages blurring our view of the distance we remained very anxious. Every twenty miles or so we came across a solitary hut occupied by a Sudanese Rail company employee whose only job appeared to be to keep his section of rail track clear of sand. One of them demonstrated his daily tasks. At dawn he set off up the track with his big toe hooked over a rail, sliding it along displacing the sand, which had gathered in the night. He cleared a groove a mere inch wide beside the rail so that the train wheel flanges could bed down beside the rail. Then at midday, he turned round hooked his toe over the other rail and set off back to his hut. The following day he set off in the opposite direction!
There was little time to savor the landscape and the history of this extraordinary area. We were so anxious about what the next day of the journey would hold that foolishly we raced on covering as many miles as we could each day.
Khartoum
Khartoum was a rich mix of old colonial, crumbling sub-Sahara, Arab, African, and UN buildings. It was clear that our ’employers’ the Sudan Council of Churches were a hopeless bunch of administrators struggling to stay afloat in a deeply Muslim country, and that despite magnanimous promises, little help could be expected from them.
In the middle of town there was a wonderful compound called the Sudan Club. It was an oasis for ex-patriates, with a bar and a swimming pool and lots of information on how to survive in this peculiar country. Government offices were supposed to open early in the morning (but often didn’t). However, without fail they all closed at midday, and instead of re-opening after a siesta, the officials all piled off to earn a second salary in the private sector. This meant that any government business was all over once the heat became quite unbearable. We would then return to the Sudan club to sit by the pool and drink local beer while we joined the throng of grumbling ex-patriates who were struggling to get out of the country. There were large numbers of English teachers who were on one-year contracts paid by the British government, but they could not leave at the end of the contract until all their papers were in order. In those days organisations seemed to take much less responsibility for their staff.
Near the bar was a large board of snakes and ladders drawn by some local wag. The ladders were the various permits needed to leave the country. But much bigger were the snakes which were named officials who simply would not issue passes on time. These made previously hard-earned permits obsolete and led to the collapse of your application. This board was always surrounded by a crowd of teachers, discussing how they were doing with the snakes, and how close they were to getting an exit permit.
Later when we were three days by road away from Khartoum, the Sudan Club became a haven of sanity and the swimming pool a wonderful release from the frustrations of the government offices, which we all had to visit with monotonous regularity.
The Sudan Club
The pool held a near-fatal fascination for me: my particular passion was to see how long I could stay underwater where it was cool and quiet. This developed into a more sophisticated game. I had learned from diving in Colombia that you can stay underwater nearly as long when you breathe out as you can with a lung full of air. It is only a mindset. If you breathe out, you sink to the bottom and if you are very slow and careful you can use your weight to create enough friction to walk along the bottom. It requires lots of practice. You have to tilt your body forward, and then push very gently with your feet. Too hard a push and you fly up off the bottom and cannot move forward until you have sunk again. Or you slip and fall gently forward onto your nose. The task that I had set myself was to walk from the shallow end, where my head was above the water, down the slippery slope into the deep end, on to the end of the pool, turn round and then walk back across the deep end, up the slope and into the shallow end. Even with practice, the underwater part of the walk took over two minutes. Well, I could very nearly do it with lots of practice but I needed another 10 -15 seconds of breath-holding. So I started over-breathing before I started. I knew that this was dangerous as hyperventilation only gets rid of carbon dioxide from your blood; it cannot increase the oxygen (which is already at 100%). The result is that the carbon dioxide (which controls the drive to breathe) rises steadily from a very low level, so does not reach a level that forces breathing for some time. During that time oxygen levels are falling steadily but the body has no sensors for that. Oxygen is what keeps the brain conscious so hyperventilation can lead to a drift into coma without any stimulus to breathe. And of course that is exactly what happened to me. One of the other expats was watching my futile efforts to complete my walk and saw me surface just short of two minutes after I went under. To his surprise I did not lift may face and take a breath, I just sank back down into the turbulent green soup, which was as clean as the pool ever got. After thirty seconds it suddenly dawned on him that I was drowning and with a yell he sprung from his deck chair and dived into the pool where he saw me go down. Feeling blindly along the bottom he found me and dragged me to the surface. Having summoned help they started to drag me up onto the side of the pool right in front of my horrified wife. She says I was deep blue and to her (and later my) embarrassment I had an erection (caused by hypoxia) which now caught on the side of the pool as they pulled me onto the bank. The pain was a strong stimulus to breathe and I woke spluttering and choking with an appalling pain in my penis, surrounded by a crowd of very curious people. Strangely I had no desire to go back to the Sudan Club for some days after that. We had no money so we sold our van but we had met up with an unusual English couple travelling round the world in a beautifully fitted out Land Rover. They were years ahead of their time and were looking for adventure, so they helped us hugely with transport down to our work area in the very East of Sudan on the Ethiopian border. We had been asked to look after Ethiopian (Tigrinean) refugees. But we were now beginning to learn that things were a little more complicated than just getting there. The British Military attaché called us in, to find out what we were doing and ‘how could they help’. What a euphemism that was. All they wanted to know was as much as possible about what was going on down there, and when it came to us needing help we might as well have been carrying Chinese passports.
The chief of the secret police also wanted to see us. Khalifa Karrar seemed an amiable man and wrote several letters of introduction for us. The only slightly disturbing thing was that whenever we showed these letters to people in the Sudan, people blanched and literally leapt to provide us with what we wanted. Anyone who engenders that kind of terror cannot be quite as pleasant as he appeared to us.
Sudan
My house jobs had been a huge disappointment to me. I had thought that, at last, I was going to be starting work as a ‘real’ doctor after six years of ‘training’. As it was, 90% of my time was spent filling in forms, the other 10% being reprimanded for not being in the operating theatre hanging on to a retractor and massaging the ego of a surgeon. On the medical side patients grossly disabled by strokes were left in suspended misery. One consultant explained to me that they were weeping because the stroke made them emotionally labile. A simpler explanation was that they were in a horror of living death, and many of us medicated them to make them comfortable aware that the doses we were giving were speeding their passing.
OXFAM offered us a salary of £ 20 pm to go to Sudan, and various other organizations offered cash we could use to buy drugs and fuel. We put on a huge roof rack for sleeping (the van was full of kit) and set off for Athens. When we got to the Ethiopian border, Jon Boyce and I separated to look after separate camps. For my clinic, we built a huge grass hut (Tukul). Clinic started at 5 am and finished at 12 when it was too hot to work any longer The United Nations visited by helicopter about once a month. I couldn’t understand why they came so often until I discovered it was actually to buy Marijuana to ship out in the diplomatic bag to Geneva. Wealthy businessmen also visited from Khartoum wanting medicals done on young refugee girls. I found that they were being bought for use as house slaves and whatever. I thought the whole thing obscene but perhaps that was a better life than the camp.
For each murder in the village (there were lots) Sharia law required that there had to be a retribution execution of one member of the family involved in the killing (not necessarily the guilty one). These executions required a medical signature that they were ‘fit for execution’. I drew the line at this and was told firmly by the very nasty chief of police that if I did not sign, they were going to execute them anyhow. It would just create a problem with the paperwork for him, so he would create problems for me. I certainly found these sort of questions more challenging moral issues than the ones we were presented with as medical students in the ethics teaching sessions.
It was also pretty clear that I was not working in a refugee camp: this was a military base, so we were not really refugee doctors at all. Eventually, the TPLF told me that they had beaten the Dergue and asked me whether I would move into Ethiopia itself to set up clinics etc. This was important to them as the transition from being guerillas to being the legitimate government is a tricky one. You have to set up schools, clinics and administration before you can collect taxes and legitimize yourself as the ruler of the land.
The trip was a disaster. As soon as we got into Ethiopia, we found that there had been a battle in the border town of Gallabat. There were bodies everywhere, some parts eaten by dogs, others just rotting. The TPLF certainly did not control the area. We abandoned our plans and set off back for the Sudanese border as soon as we could. But by then it was dark, and the border guards were very jumpy. We were arrested and I spent the rest of a long night face down on a concrete cell floor with a Kalashnikov pressed into the back of my head. At the other end of the gun was a psychopathic young soldier who thought it was amusing to keep cocking the gun. If you do that often enough the gun fires spontaneously. By the morning my attitude to Sudan, my presence there, and the project had changed radically.
Shortly afterward I fell ill with fevers, hepatic-splenomegaly and lymphadenopathy. My six months on the Nuffield Department of Medicine had trained me well and I was diagnosed with terminal Hodgkin’s disease and lay down to die. The fact that I was surrounded by cases of typhoid every day did not register. I eventually had a ‘typhoid crisis’ and recovered but weighed 8 stone and could scarcely walk.
Before this all happened, I had trained 5 bare-foot doctors to help in the clinics. To my slightly unwarranted irritation, they were running the clinic beautifully, without me, seeing 100 patients a day. They spoke Tigrynean and worked with only five diagnoses. The clinic had been transformed, whereas, with a translator, I could only see, at most, ten and was making lousy diagnoses.
By now it was the dry season and there was no food. You can’t treat patients who are starving (a pretty basic truism) so our work was a waste of time. A wave of cholera was headed our way and the Army had requisitioned all our drip sets. By then I weighed even less and one of the health assistants took me to one side and told me it was time to go. He explained that some of the Sudanese and a few of the refugees would survive the cholera but I certainly would not in my present state. I had always wondered who the cowardly doctors were who fled London in the Great Plague. And now I found myself behaving like one of them, as we set off South for Kenya. It is a truism that you don’t die of starvation, you die of intercurrent illness. We were treating the illness so the refugees were dying once, twice, three times. I fear that overall we had done more harm than good, and learned some hard lessons.
Escape from Sudan
The End of our time in the camps
The final stimulus to pack and leave was the approach of a typhoid epidemic. The news broke while I was in Khartoum trying to sort of food supplies. When I got back I found that the Sudanese army had visited my clinic, and removed (stolen) all my iv fluids and all my antibiotics. One of the old clinical assistants from a nearby village was visiting when I heard the news. He looked at me quietly from head to toe, and then said “Hawadja, it is time for you to go. You have no medicines for yourself never mind your refugees. You will simply be one of the first to die.” As a child, in history lessons, I had always wondered how those doctors felt in the Black Death who fled London rather than staying to help their patients. Well now I knew because this old clinical assistant was quite right. I now weighed around 110 lbs. We had no food, no medicines, and we were tangled up in a complex political/military situation where we had no idea of the rights and wrongs, and where we now knew our lives counted for very little.
Down to Kenya
We decided to go to Kenya and the most interesting way to go would be to travel South through the Sudd to Juba. There was a paddle steamer, which left once a week from just outside Khartoum and we booked to go 1st class. This only meant that you got a bunk in a four-bed cabin. Second class, you were on a barge with a roof to keep off the sun. Third class was simply out in the open on top of the cargo barges. The ferry was not one boat. It was a paddle steamer that had extra barges strapped on each side and was then pushing another barge and towing two more. It was an armada. Of course, it didn’t leave on time so we had a chance to get a feel for our surroundings.
The steamer we were on was an old colonial design looking a bit like a College barge. Lovely old wood work but everything is broken. There were stewards on board who would cook for you at an exorbitant price and clearly made a good living from producing quite disgusting food. They were very anxious that we should not keep livestock or cook in our cabins. This was nothing to do with hygiene or safety, it was to enable them to keep their monopoly. By the time we finally left, the barges were absolutely heaving with people. It is a fascinating question why so many people are prepared to travel such enormous distances in such discomfort. Are they visiting relations, starting a new job, or even looking for work? It is just so uncomfortable and dangerous traveling through these regions.
The Armada made serene progress up river curving left and right around the meanders. For many days the papyrus grass was so high that it was the only thing that could be seen. Every now and then a narrow water creek would vanish into the reeds, leading, I suspect, to yet another isolated village buried deep in the huge swamp which is the Sudd. The ten-day journey became more and more of a nightmare. There was little or no food and John who we were traveling with developed renal colic. Luckily I was carrying Pethidine in my medical bag. Then on one of the second class barges a young teacher slipped on the stairs and broke his neck. Now we were carrying a cadaver on top of everything else.
Arrested again
We finally arrived in Juba just after sunset, to be met by a line of soldiers and police. Apparently, there had been some uprising and it was suspected that there might be insurgents on board. We were all forced to lie face down in the mud on the river bank. One policeman opened my medical bag and just emptied the contents into the mud. I was furious but there was nothing that I could do or say. He was just inquisitive and a little bored. Our passports were removed from us, a thing that I never normally allow, and we were stuck in Juba.
The following day we made our way to the airport and found there an Italian pilot who was due to fly his light aircraft down to Nairobi the following morning. Yes he had two seats, and yes he would take us for $100 each in cash. He asked if there were any difficulties with immigration and we admitted that we were. He didn’t bat an eyelid. He just said that in that case, he would be taxiing up to the end of the runway and would be turning to take off at exactly five to ten. As he turned he would open the door of the aircraft and if we happened to be there and jumped in, why then he would take off! So all we had to do was somehow get hold of our passports. I went to the police station and explained that we had to have our passports to see the British Consul so that we could tell him that we were being held in Juba. This was partly true. If there is one thing that I have learned on my travels and that is ‘Never lose your passport’ because if you do, the British Government may use this as an excuse to deny your existence and refuse to help you. And just in case you do have your passport removed from you, a couple of photocopies hidden in different places may be the difference between help and total indifference. I had no idea if there was a consul in Juba (probably not at that time) but the story that we needed our passports was plausible. After a minute of heart-stopping delay, we were given our passports and told to return them as soon as we had seen the Consul. Sure enough, the aircraft was there turning onto the runway at 9:55 and we leapt in the open door. The inside of this old 4-seater Cessna was not at all what I was expecting. I had to sit next to the pilot and Katherine squeezed into one of the rear seats, which were blocked by a large piece of equipment. When I looked back to what was the problem, I noticed to my horror that the piece he was carrying was part of the tail-plane of an aircraft. Over the noise of the engines, he admitted that he had landed at Juba a few months ago, having forgotten to put down the wheels. He was now taking the remains of the aircraft back bit by bit to Nairobi for repair.
His current aircraft was not much better. As we bumped down the runway under full power the knobs on the control panel all started vibrating loose. He was spending as much time on holding knobs on their shafts as he was controlling the aircraft. The flight out of Sudan into Kenya was uneventful, apart from a whoop of joy as we crossed the border.
Nairobi
When we landed in Nairobi, everything was proceeding in its gentle civilised colonial way. Sudan was another world. We hitched in from the airport and went to see our friend Steve who was working as a lecturer in the University. He looked up as we came in, smiled his friendly smile as if he had just seen us yesterday and suggested that we pop down to the supermarket to get some food for supper. I have to admit that I was beginning to feel deeply disorientated. It is difficult to come from what we had just seen and done to this haven of peace. I finally broke when we started walking down the aisles of the supermarket surrounded by all the things that we had been missing for so long. There was bread on the shelves, sugar, meat, vegetables: but worse there was choice. From nothing to choice was too much. It was toothpaste, which was the final straw. I simply could not decide which brand to buy. I found myself with tears rolling down my face and had to go and sit outside on the steps while Katherine finished the shopping. The sudden contrast of struggling to find anything in shops to the full Western Monty of a range of choice is something everyone should experience at least once in their lives.
Closure
When we left Sudan I weighed a little over eight stone and emotionally I was shattered by what had happened in the camps. Basically, the refugees had to die. They were in the wrong place at the wrong time, and Africa shows no mercy. We were not in fact treating refugees. Our camp was a guerilla base camp. It was also a center for drug dealing, child slavery and arbitrary executions. Really we were all so idealistic! What on earth did we expect?
Kenya and Tanzania
When Katherine and I landed in Nairobi we were completely dissociated from normal Western life. We had nearly starved and been pretty ill. I needed a job, as we had absolutely no money, so spoke to one of the local GPs who said he would put the word out.
24 hours later I had an offer of a job in Mombasa hundreds of miles away on the coast. I accepted by telegram (they seem so strange now) and received back a first-class ticket on the overnight train. It was still as steam train with waiter service, linen napkins and proper cutlery. Meanwhile, the train made its way East through the barren Tsavo park. I was terrified. I had never worked as a ‘real’ doctor, only a house officer and a refugee camp doctor. I tried to imagine what on earth a normal Western patient might present with and how I would treat it. I didn’t sleep a wink tossing and turning trying to think what I would do. When we arrived in Mombasa I was met by a very good-looking and efficient practice manager who took me straight to my ‘house’ a lovely 2-bedroom cottage in an acre of garden within ear-shot of the Indian Ocean, where waves were breaking on a sandy shore. Standing to attention in front of my house were my staff. I had a cook with an assistant, a gardener with an assistant, a car cleaner, and an askari ‘night guard’. There was also a car. I stammered that I had no money, and the practice manager waved her hand and explained that the practice paid for all of this and that I would have an advance of one month’s salary of £400, a King’s ransom as far as I was concerned. The contrast from Sudan could not have been greater. The manager wanted to leave me there to unpack, but I had nothing to unpack so dumped my rucksack and headed off with her into the practice in town. I was desperate to see what kind of patients there were and how the other doctors treated them. I was ushered in to meet the senior partner who seemed almost frightened of me. When I suggested that I might sit in with him for the rest of the day to learn how things were done he absolutely refused. I later learned that he had heard that I had trained in Oxford and was terrified that I would be critical of his standard of medicine.
The practice manager saved him by saying that there were a shipload of Greek sailors waiting, all of whom had gonorrhea. His face lit up “Why don’t you start with them?” and I was ushered through by the nurse to my own personal air-conditioned office. I don’t speak Greek and didn’t know how to treat gonorrhea. At my side was a very stern-looking nurse, but I took courage in both hands and asked her what was the Practice Policy. She visibly relaxed (here was a new doctor who was going to do as he was told). “One gram of penicillin into the buttock” she immediately answered and offered to take them away for their punishment. Within minutes my surgery was empty and I had treated my first eight patients. I was jubilant. Clearly, all I had to do was ask the practice nurse, and everything was sorted.
Actually, I spent very little time in my office. Most days I was in my car driving up and down the coast doing clinics for the staff and families of the luxury hotels or now and then seeing a tourist who was sunburnt or stung by scorpion fish. When I did a clinic I would stay for lunch courtesy of the hotel, so it was not a hard life. In the evening I would often have colleagues for supper. The form would be for me to tell the chef that morning how many guests there would be and what we would eat. In the evening I would head off to the sea for a quick swim and by the time I got back a freshly ironed set of whites was laid out ready for me. I was supposed to keep all doors of the house locked while the askari patrolled the garden, but I have to admit that when it rained I left the back door unlocked so that the askari could take shelter. It was heaven and I seriously thought about staying permanently. My fellow junior partner concentrated on psychiatry but was also a very knowledgeable doctor on skin rashes, which were common, so I frequently popped through into his office to ask his advice. Invariably he was in consultation with a young woman in floods of tears, pouring out her woes to him. To my horror he would nod and commiserate but under his desk was a novel which he was reading. He explained that all these patients needed was a ‘good listening to’ and that he might a well read a book as they poured out their woes.
Katherine was just up the coast on the Tana River continuing with her research and after a couple of months came down to stay with me in Mombasa. We decided to drive out to a hotel for lunch and as we went up the coast Katherine asked me to slow down as she felt I was driving too fast. As we passed a bus parked at a stop by the road there was a thump. A young boy had run out across the road from in front of the bus straight into the rear door of my car. He had broken his leg so we lifted him into the car and set off for the nearest hospital. It was run by two Indian doctors who said they would set it under anesthetic. I left the child there and we carried on our journey. The next morning halfway through clinic the Chief of Police came in and ordered me to put out my hands. As soon as I did so, I was handcuffed and charged with death by dangerous driving. The child had not woken up from the anesthetic. We called the practicing lawyer who got me released on bail, but explained that if a single African said that I had caused the accident, I would be found guilty and receive 5 years of hard labor. I was devastated.
A couple of months later the Chief of Police came again with a nasty chest infection and a document dropping the charges. He explained that he was worried that I would not treat him if he did not first drop the charges. I was very shaken by the whole affair. It had taken the gloss off living in Mombasa. Some weeks later I was driving back in the evening from a hotel clinic. I saw a BMW Coming fast the other way and there was a villager crossing the road. I slowed down but he continued into the path of the car coming the other way which must have been doing over 80mph. By the time he hit the pedestrian, I was stationary but his body flew right over my car. I ran back to him, certain that he would be dead but he wasn’t. The atmosphere was tense. It was getting dark and the BMW was lying on its side by the road. The occupants, an Indian family had all climbed out of their car and run away, terrified that they would be lynched. The patient had broken both femurs and needed to go to the hospital right away. The only way that I could get him into my small car was to fold him over his femur. The nearest hospital was a private one and I took him to the Resus room and started treatment. The only doctor there was not helping, he was just taking notes. He then asked me who was paying the bill, as it was already several hundred pounds and the patient certainly could not afford this treatment. He suggested that I take him to the Mombasa General Hospital which was free. When I arrived at this huge hospital, there was no doctor to be found and so I left him to the tender mercy of the nurses, who had told me to “get out Mzungu (white man). This is a black man’s hospital.” He died that night. Enough- it might be a land of milk and honey but there was a darker side too.
Tanzania
Katherine had got a job as a lecturer in the university of Dar es Salaam in Tanzania so I followed her down, and started on the books I would need to know to pass my surgical exams when I returned to the UK.
Edinburgh
My first job was as a casualty officer in the Royal Infirmary. It was a tremendous experience but the last six weeks were neuro-surgery where you slept on the ward with the patients. Sister had a phone booth in the middle of the ward where she could speak to Matron out of hearing of patients or their visitors. It was a terrible ward with no senior support and a high proportion of patients for whom nothing could be done. My co-worker was a West Indian, and if a seriously injured white patient was admitted, he would say “This patient is a honky. You are a honky. Honky treats Honky” and would leave me to it, even though he was senior and more experienced than me.
Edinburgh and The London
Edinburgh Accident and Emergency was a delight. We had a keen young consultant who supported his juniors, and he had a one-hour rule. As soon as the patient had been in the department for one hour they were sent to the most appropriate ward. I will never forget the glorious sight of a senior orthopedic consultant storming down followed by his acolytes having been disturbed during his tedious ward round by the arrival of six patients from A&E. He blustered and roared then retired defeated. I don’t know why we don’t still do it today.
The only problem with the job was a 6-week secondment to Neurosurgery, as they had no junior doctors. The registrar was a delightful West Indian general surgeon who knew no neurosurgery either, so whenever a severe head injury came in, he locked himself in his office and refused to come out, saying “This is a Honky head. You are a Honky. You deal with it.” There was no clerk to file lab results so they were just dropped onto the sofa in the registrar’s office, where they piled up until they avalanched onto the floor. Our worst moment was an order to admit a young farm laborer who had gone into the local pub with a pitch-fork to sort out a colleague who had appropriated his girlfriend. He was chased out of the pub and decided to escape by climbing an electricity pylon. He then tried to jump across onto one of the high-tension wires, shorted out, caught fire, and fell to the ground in flames hitting his head and knocking himself out for a couple of minutes. There was a huge argument as to which specialty was to take him, burns, general surgery or psychiatry. It was finally agreed by the others that he was to come to neuro-surgery as he had been knocked out. There was no anaesthetist on the ward so you had to ventilate your own patients. That meant that you had to sleep on a bed in the ward (when you got any sleep). A very strange elderly spinster anaesthetist would visit every evening ang bring dolls to ‘stimulate’ the patients. One of the ‘toys’ squeaked each time it was squeezed and she gave this to a patient who was having regular epileptic fits. When she had one of these fits she squeezed the toy and it squeaked. In those days the treatment for an epileptic fit was 5ml. Paraldehyde, a foul substance which had to be given in a glass syringe as it melted plastic. Finally, I could take no more and asked my sister for 10ml paraldehyde in two syringes. “Oh no doctor,” said she, “ we only give 5 ml in Edinburgh”. I repeated my order for 10ml, then gave 5ml to the patient and injected the other 5ml into the doll, which gently dissolved. For me, this was therapeutics at its best.
The bulk of the neuro-surgery was done at a different hospital where they only did planned operations and where all the consultants worked. One of them came once a week to the Royal Infirmary to do a ward round of the trauma cases. The week after the paraldehyde case the round was taken by the President of the Royal College of Surgeons. As we came to the end of the round I asked him, in front of the ward round, if I could see him in ‘my’ office. You could have heard a pin drop, but I had just come from the Sudan and had seen things much more terrifying than a President, He duly came to the office. l I did not invite him to sit. There was nowhere to sit anyway. I showed him the office with the lab results scattered over the sofa and told him I in no uncertain terms that two junior doctors with no neuro-surgical training were not satisfactory. His response was to say that he thought I was probably tired and a bit overwrought and should take the rest of the day off.
There was no change in the ‘Cabbage patch’ (as the ward was described). On the final night I really was exhausted (you were on duty non-stop). As a practical joke the nurses hid my bed so when I finally came to lie down I could find no bed. They thought this was a fine revenge for the last six weeks, but I was not finished with them. The phone on the ward was in a sort of phone box in the middle of the ward (partially sound-proofed so as not to disturb the patients). The night sister would phone the matron from this box when reporting. Just as she was finishing one of her reports, I opened the door of the phone box a crack and inserted a CO2 fire extinguisher and up her skirt. She just had time to say to Matron “I’ll have to go now” when I opened fire. The scream as her knickers froze could be hear right down the corridor. Revenge was mine after 6 weeks of hell.
The following week I left Edinburgh and went to the Westminster Hospital in the Centre of London. If I thought things would be better, I was mistaken. The SHOs there worked 7 days a week for 6 months. There was no need for off-duty. It wasn’t necessary. There wasn’t enough work to need both SHOs on duty but pride demanded that it should be so. I pointed this out and demanded that if I had to work 24/7 then I should be paid accordingly. The hospital refused so I took them to court and won. The following day I got a tap on the shoulder from the senior registrar. “The Professor congratulates you on your win but you have one week to leave”. I quickly grabbed the British Medical Journal to find that there was a job advertised at the London Hospital Whitechapel, starting immediately. I applied and was summoned for an interview with the Professor of Surgery. Before I had even sat down he said “I hear you have been sacked by Professor Elllis”. “Well, said I, it is a bit more complicated ….” But I got no further. Prof broke in and said, “I hate Professor Ellis so I am giving you the job, but you fuck with me and you won’t even get one week’s notice”.
I started at the August London Hospital, Whitechapel, which prided itself on the vile behavior of its consultants. My first post there was orthopedics. I had never done an orthopedic job before. My first night on duty involved operating on a fractured neck of the femur. I rang my senior registrar on call to tell him the situation. He was clearly furious as he only just got home to Surrey. He ordered me to get the patient on the operating table ready for his arrival. I assumed that he lived 15 minutes away and raced to get the patient ready ably helped by the nurses who actually knew what needed doing. Over an hour later the patient was ready and at that very moment, the registrar (he was not even a consultant) swept through the door. He did not scrub up or even put on a mask and surgical gown. He simply rolled up his sleeves and put on some surgical gloves. Without further ado, he cut open the patient’s hip removing the broken piece of bone and dropping it on the floor. He then took the implant and with a mallet drove it into position in the femur. He then relocated the hip joint, turned and started to remove his blood-covered gloves. As he removed them he flicked them into my face saying “and don’t you ****ing ever call me in at night again’’. He put on his jacket and headed for home in Sussex! Sister quietly showed me how to close the wound, and explained to me what he had done, so that I could write an operation note.
Hoppy
The night sister was a marvel, as we juniors had no training and she had been there years. Sister Hoppy would clip-clop up and down the theatres giving advice and encouragement to all the juniors working unsupervised on the evening and night shifts I remember one evening trying to remove an appendix, but I was hampered by the fact that I could not find it. “Get Hoppy,” I said to the anesthetist who put out the call down the corridor. Sure enough, clip-clop came Hoppie’s clogs “Now then, what’s the problem?”. “This patient hasn’t got an appendix” I moaned. “ Nonsense,” said she “Where have you looked?” . “Everywhere” I replied. ”Right” said she. “Let’s start at the top, – nothing? – now the side. There we are. On you go”. Just then there was a call from the other end of the corridor “Hoppy you are needed in gynae, they can’t get the baby out” and so it went on. I never had to call and be insulted by a senior doctor again.
A gunfight in the hospital
Some months later there was a call to theatres at 10.30 am. “Clear two theatres! We have two policemen who have been shot.” The story was that the banks opened at 10.30 am. There was a shortcut between Whitechapel Road and Commercial Road which involved walking through the casualty department of the Hospital. Two young policemen were in Casualty chatting up some nurses when two armed robbers in hoods came running through casualty taking the standard shortcut to Commercial Road having robbed a bank in Whitechapel. The policemen guessed from the masks that they were up to no good and invited them to stop. The police were both promptly shot (not badly). The senior surgeon was in Emergency Theatre 1 doing a major operation. I explained the situation to him, and without looking up, he told me to order one of the more junior surgeons to clear. I made my way down to the second most senior surgeon’s theatre and passed the message to him. His response was unprintable but was in summary “No!” I relayed an edited version back to Mr Eadie and witnessed the most extraordinary confrontation. The two surgeons in gowns masks and gloves swopped insults in the main corridor of the theatres both refusing to stop their operations and insisting that they were more important than the other. This shouting match went on for some time, providing great entertainment to the staff in the other ten operating theatres. By the time the situation had been resolved, it would frankly have been quicker to have taken the two policemen by ambulance to the other end of London for treatment.
A Coroner’s Case
One evening a patient came in on a blue light who had set fire to himself. In fact his clothes were still smouldering when he arrived. The result was that the canvas stretcher burnt through as he came through the casualty door and he slipped to the floor, where he had to be treated first with a fire extinguisher. He was moved rapidly into the resuscitation room but was clearly not long for this world. He obviously needed a CAT scan of his head. In those days very few hospitals had these scanners so he had to go several miles to the West Middlesex Hospital. I arranged this and off he went with a police escort, and an Australian junior anaesthetist ventilating him as he was not breathing on his own. After about an hour I got a phone call from the anaesthetist holding a ventilation bag in one hand and a wall phone in the other. He said that he simply could not find anyone to take the patient from him. Obviously, he was being too polite for London, so without thinking, I said “Make a fuss. Break a window”. “OK” came back the reply, and next minute I heard the tinkling of glass. I love the Australians, they are so literal. The patient arrived back some time later having had the scan but there was no scan and no report, so that was no help. I was still young and eager and forward thinking and decided that if we could not save the patient we could at least donate his kidneys. The only problem was that we did not have a name so I asked the police for help to identify him. They love doing that sort of thing and set to work. They had already had a ‘blue light’ run across London with outrider escorts and now had a real challenge which was not as hard as it sounded as he was a regular vagrant who lived in the street near the hospital. Meanwhile, I tried to find out how to donate kidneys. Apart from permission of next of kin, we needed all sorts of blood tests which I duly organised while he hovered close to death on the Intensive Care Unit.
The police came back in triumph having got his name and next of kin who was a farmer in the depths of Southern Ireland. They had even got a phone link patched through the police switchboard (this was like a thriller novel). Very gently I explained that he was not going to survive and that we could at least do one thing good and save a life for a life by donating his kidneys. For a very long time there was no answer, then with a soft Irish Burr, his brother asked if it was his kidneys we were wanting. I said that was the plan. Again there was a long long silence. “It is strange” he said “Only last month he was told he needed new kidneys and was put on a waiting list for a transplant. One month you want to give him kidneys, the next you want to take them away. Sure, you must know what you are doing. You do whatever you have to do”. I gently put down the phone and looked at the blood results which had just come in. They showed severe renal failure. We turned off the ventilator and he passed away quietly.
But that was not the end of the matter. This was a Coroner’s case. I didn’t really know what it meant (except that it was a bad thing) but decided I would go to the post-mortem as a learning experience. Apparently, the coroner’s pathologist was a knight of the realm and famed for his ferocity, so I was interested to see this mythical creature. I was good and early so was standing ready when he swept in wearing a tailcoat. He removed this and handed it to his assistant, in what was a well-practised routine, then gloved up. It was the first time that I had seen gloves opened, stretched, and held for the surgeon to insert his hands. I thought that looked very cool and wondered whether I could teach the nurses to do it for me when I was operating. While he was doing this, I introduced myself and explained that I had come to learn. He gave me a very old-fashioned look over his bifocals and asked me to summarise the case. I decided to leave out the kidney donation debacle. As soon as we started it was clear that, on top of the kidney failure, he had fulminating broncho-pneumonia. He asked me what antibiotic i had used. I had forgotten to prescribe antibiotics and I stumbled to explain, unsuccessfully, that in the heat of the action, I had not given any antibiotics because I was focused on the head injury. He didn’t look happy and took a specimen of lung and dropped it into a specimen pot his assistant was already holding out. He then took a second specimen and handed it to the assistant saying “This is for the doctor here. (There was considerable emphasis on the word ‘doctor’) He will want it to be analysed independently. After some cutting comments about the kidneys he swept out leaving me shaking in my boots.
I was pleasantly surprised to be phoned by the Coroner, who it transpired I had met when I was working in Mombasa. His father had been disembarked from a cruise ship with cardiac problems so I had treated him. He had used his father’s illness as an excuse to fly out for a week living it up on the coast in a luxury hotel. He had also insisted that I should sign that the trip was necessary so that he could claim all expenses (including beach clothes) on the insurance. When the cruise ship docked she had to turn around. There was very limited space in the small harbour so there were junior officers stationed on the bow and stern reporting to the bridge on how close they were to the dock-side. They were very smartly turned out in whites with tight shorts. Beside me on the dock were the shipping agents, two Indian ladies in Saris chattering away in Gudgerati. Just to make conversation, I mentioned that their uniforms were very smart and the shorts very close-fitting. “My God,” said one of them “What do you think we have been talking about for the last ten minutes?” Luckily the patient recovered so we all parted on good terms. The coroner obviously remembered (especially the reimbursement on his insurance) so he invited me to lunch in his very nice house before the afternoon hearing. All went well until we set off for the coroner’s court when he said “You have got the hospital notes haven’t you?” I hadn’t and he looked a bit worried. “Look out” he said “this pathologist is a bit fierce. Just let me lead you through the cross-examination and answer as briefly as you can”.
The coroners court is dark and very imposing. I was called first and the questions are engraved on my memory. “ Dr. Bulstrode when you first saw this patient was he very sick indeed?” I duly replied “Very sick indeed” . Next question “When he returned to your care, would you have said that “There was no hope at all?” “No hope at all” I responded. Now it was the turn of the pathologist. “Could you give the cause of death?”. “Bronchopneumonia” he replied making no mention of the kidney failure and head injury. Then came the key question. “What difference would antibiotics have made to his chances of survival?” There was a long silence while the pathologist looked me up and down, and then he replied. “None at all, and if you have no further questions I will get back to my other duties”. Then he stepped down and swept out of the court. As he passed me, he winked. I was told afterwards, if you went to the post-mortem he would let you get away with anything. If you didn’t, then God help you.
Ward Rounds
Ward rounds were a tense time. Most of the consultants only came around once aa week if at all so they didn’t know their patients and the patients didn’t know them despite the fact that they were in their care. The consultant was followed by a train of junior doctors, nurses, physiotherapists and Occupational Therapists making a fine show. On one round we had a very fat lady with a buttock abscess. This had been drained by the most junior doctor who had clearly formed a good trusting relationship with the patient and her large family who were all grouped around her bed. As soon as the patient saw the junior doctor she called out in praise and welcome, showering him with chocolates and enfolding him into her visiting family, ignoring the consultant completely. The consultant, charmingly known as ‘sid-vicious’ carried on to the other patients as if he didn’t have a care in the world. As he got to the door of the ward the house officer finally managed to extricate himself and re-joined the round, apologizing to the consultant saying “ I am so sorry!, I was caught up”. “Caught up” said the consultant grabbing him by the lapels and hoisting him into the air, and slamming him against the wall. He then head-butted him in the stomach and dropped the winded house officer who to the floor. The consultant then turned to the ward and said “That is what I call caught-up” and swept out of the ward.
Doctor’s dinner
Before a major operation, patients with medical problems were normally referred to physicians for advice on the safe management of their problems.
In this case, the lady was diabetic and I wrote, as usual, to the physicians asking them to review her. My new house officer was red-hot good, always reading the latest papers and clearly cut out for high office. He had just read the latest paper on the management of diabetes and had applied the relevant drug regime to this lady’s notes and drug chart.
The medical ward round team duly arrived later in the day to find that everything they were going to set up for this poor patient by an ignorant surgical team had already been done. The consultant physician had lost face, and duly lost his temper with this junior house officer, demanding to know why his and his team’s time were being wasted, when all that was needed had already been done by poor benighted surgeons without any authority. He then stomped off the ward. It was a busy day and I heard subsequently that the officer had not had time for breakfast or lunch. That evening it was the doctor’s dinner and, after pre-dinner drinks of strong cocktails, I found myself seated between the angry consultant and the over-wise house officer who was late arriving because he still had work to do on the wards. I understand that when he first arrived he knocked back two cocktails before coming in to the hall and taking his seat. The consultant recognized him and leaning across me gracefully apologized for his behavior that morning. The house officer was just taking his first mouthful of soup, but instead of responding, he looked blankly at the consultant, poured all his soup down his front and slid off his chair under the table, where he lay unconscious. The consultant looked at me, shrugged his shoulders, and said “There you are. That is gratitude for you in the younger generation”. The houseman was actually in a hypo-glycaemic coma (low blood sugar) because he had taken a wallop of alcohol on a completely empty stomach. He stayed there for the rest of the dinner, as everyone else was too busy enjoying the dinner to think what might have happened. He was quite easy to treat after dinner but had no memory of the day at all never mind the dinner.
Mr van Dyne
For the next four years, there was no training as such, just a rotation through a series of hospitals all of which were about to close, Albert Dock, Eastham Memorial, St. Andrews Bow, Bethnal Green.
One call was at least amusing. I was called one dark November evening to Bethnal Green Hospital to see a Mr van Dyne. He had a gangrenous toe and when I arrived at the Porter’s Lodge I announced that I was Mr Bulstrode to see Mr van Dyne. (You became Mr. when you passed your surgical exams. I had just got my FRCS exam so was very touchy about my title.
“I hope you are not going to cut anything off” replied the porter. Quite sharply, I pointed out that I would decide what was to be done not the night porter, and stomped off down the labyrinth that is Bethnal Green. When I arrived on the ward I found an elderly man stark naked in a wheelchair. Every inch of his body was covered in tattoos. I made the arrangements for amputation of toe, and set off back to the front door. I decided that I was not going to let sleeping dogs lie, and rapped on the porter’s door. When he came out and saw who it was, he was very apologetic but then went on to ask me if I knew who Mr van Dyne was. When I said ‘no’ he asked if I had heard of Al Capone. I had. “Well van Dyne was AL Capone’s bodyguard and so never paid for his tattoos. However, they say that when he dies they are going to come and get all the skin they are owed. I just didn’t want you involved in owing skin” I laughed heartily at such a typical East End story. But a few days later I went and checked in the library. Van Dyne was Al Capone’s bodyguard. He was tattooed from head to toe and moved to London after serving his jail sentence. So I may have operated on Al Capone’s bodyguard.
The Hospitals in and around London were divided into those where Jews predominated and those which were very anti-semitic. One of my colleagues on the surgical training program was a small Lithuanian Jew, a very good surgeon and a very nice man but quite unable to get a job because he was Jewish, and no jobs had come up in Jewish hospitals. He had to sit through job interviews where he was patently the best candidate but the local consultant on the appointment board simply refused to appoint a Jew. I had once mistakenly told him that I was descended from aristocracy, and from then on, he insisted on addressing me as ‘Baron’. One day I received a letter from him starting with “Dear Baron” It went on to say in very flowery English (he liked flowery English) that he had reviewed a patient on whom I had operated and congratulated me on the result and the patient’s satisfaction. I was puzzled because letters between fellow doctors were usually reserved for criticism of some aspect of the patient’s care. After a few of these letters I caught on to the strategy. Each time I saw one of his post-operative cases in clinic, I wrote to him expressing my amazement at seeing such a good result in such a difficult case. The following week I happened to see him strutting down the corridor six-foot tall, head up and shoulders back, like I had never seen him before. I could see my letter to him poking out of his white coat pocket. From then on, about once a week, we each of us wrote a letter to the other praising the result of their surgery. It was a silly game but was a huge morale booster for both of us.
While I was one of the registrars, one of my consultants hosted a meeting of the International Hand Society. My consultant asked me if I would take the visitors on a tour of the hospital, while they held their executive meeting. What could I show them that they did not have better in their own hospitals? Eventually, I had an idea. First, I took them to the basement which housed nearly one million sets of hospital notes. The week before it had flooded as a result of a burst water main. When I turned on the lights it could be seen that most were under water but a few remained floating on the top. Then I took them to the basement corridor, which led to the ‘state of the art’ CT scanner. The floor was seething with cockroaches. I explained that when we were bringing a patient on a stretcher, we sprinted to see how many cockroaches we could squash with the wheels. We then went to the operating rooms and I showed him the pipe ends where rats came out at night and we tried to cosh them with a baseball bat. Finally, I took them to the top floor where the secretaries worked in an open-plan office. The roof and ceiling were in part a canvas tarpaulin used to cover a hole made by a V-bomb that had come in through the roof during the Second World War and failed to detonate. That had happened over 25 years before.
When we got back to my consultant, he asked the visitors if I had given them an interesting tour. The Swedish professor said it was absolutely incredible. He would never ever forget it. My consultant looked pleased but bewildered that anyone could find anything so interesting in the London Hospital!
One of my attachments during ‘training’ was six months doing pediatric surgery. You have very frightened children and, if possible, even more frightened parents. One trick which seemed to help was to get to get the children to laugh, then if possible, get the parents to laugh too. I had a series of tricks and if they worked it made a huge difference.
One evening I was in a tearing hurry but there was only one child for surgery the following day. So, when I came into the children’s ward there was just this little seven-year-old and some anxious-looking parents. Without thinking I swung up onto the curtain rails, made my monkey face and started swinging down the ward. When I reached the child’s bed I dropped down onto my knuckles and introduced myself as the surgeon for tomorrow. Things had gone badly wrong. The child was screaming in terror and the parents said that they were not having an ape operating on their beloved and only child. Nothing I could do would change their minds, so I had to phone the consultant and ask him to come in and do the case. He was supposed to do it anyway but traditionally it was left to me. It was not my finest moment.
Research, Inventions & the Cutlers’ prize
Research
I was becoming increasingly disenchanted with research. My thesis had been very weak. I had absolutely no supervision and struggled with the methodology and the write-up, but at least I now had a basic understanding of the real statistics that you could use in clinical medicine. I had chosen to study leg ulcers. The beauty of the subject was that it is a very common problem so there was no shortage of patients to study. It is also a very unsexy subject, and very little science has been done on it. It was a terrible subject because I had no one competent to supervise me and I was going to try to use some complex new technology that was unproven. I had no time off clinical work to do my thesis, so all the work had to be done in my spare time or at night. Luckily I had a co-registrar at the Royal National Orthopaedic Hospital, a delightful Sri Lankan, Sam Sundaram, who was happy to cover all the clinical work.
We were a strange team at the Royal National. Registrars from all the London Teaching Hospitals rotated there. One of them was JPR Williams one of the most famous Welsh International Rugby players of all time, a beautiful pianist but not a strong orthopaedic surgeon. He was a very humble man but had the misfortune to be worshipped like a God in Wales. One morning an exceptionally pompous registrar from our training program was giving a presentation of a brand new idea, a double-slide presentation. Unfortunately, he hadn’t quite understood the merit of the technique and so had decided to present the slides on his technical topic on one side and pictures of French Chateaux that he had visited that summer on the other. I didn’t think much of this and started heckling, and was just getting well stuck in, when I heard JPR’s soft welsh lilt behind me “Jesus Chris Almighty I would rather face a massed onslaught of the All Blacks chasing a loose ball than Chris Bulstrode in full tune.” I felt honored.
Leg ulcers
I needed large numbers of patients to study under controlled conditions for my thesis and to achieve that I needed hospital beds. There was absolutely no chance of a single bed at the London, but I was working at Eastham Memorial and the Albert Dock at that time. During a porter’s strike, the Albert Dock was closed for surgery, so I commandeered all twenty beds in the hospital for my study patients and admitted twenty leg ulcers for intensive treatment. Day by day I prayed that the strike would not end, and finally, I achieved two whole weeks of treatment, nearly enough material to finish my study. From then on, I visited each of my old ladies weekly, riding out into the East End on my bicycle with my special stereo camera lashed on the back. Then at night I would measure the films taken, with the special three-dimensional analyzer. My old ladies had been deserted by their families who had emigrated out into the new towns, Basildon and Harlow when the docks closed. They were lovely but lonely. As I dressed their ulcers for them, they would make me blush to the roots of my hair telling me stories of what they got up to during the blitz in the second world war. They were very rewarding to treat. They were so grateful and healed well. My bubble of self-esteem was firmly burst by a district nurse who was rather annoyed at me barging into her territory. Her comment was a question, “You do know what happens to these ladies when their ulcers are healed?” I answered that I did not. She then said “They die because there is no-one to come and see them anymore. Their leg ulcer was their only contact with the outside world.” It was a cruel comment, but probably had a lot of truth in it.
Eastham Memorial
I had a senior registrar job at Eastham Memorial Hospital at last and felt very proud. John King my boss had lost interest in clinical work although he was teaching himself arthroscopy. This meant that I spent long hours standing around while he struggled with the scope as we had no television in those days. However I did arrange to have some new arthroscopic knives made for him by the instrument maker who lived in the basement of the London hospital. I got to like him a lot and eventually he made the instrument for me that won the Cutler’s prize.
On my first day at Eastham Hospital I met Bruce Jaja, a middle aged Nigerian who was the permanent SHO there and obviously had no intention of ever taking his fellowship. He was much older and more experienced than me, and we eyed each other warily. On the first evening before going home I went into the ward just to check that everything was settled. To my surprise all the bed curtains were shut and there was wailing coming from one bed. I stuck my head around the curtain to find Jaja standing astride a little lady pulling on her leg. I asked him what on earth he was doing. He explained that her hip replacement had dislocated and he was putting it back. He had three more patients to do! There simply should not have been that many dislocations and putting them back using brute force and no anaesthetic was frankly barbaric. I waited until he had finished and then had a word with him. His response was forthright “You are the boss. The day time is yours, but the night-time is mine”. I was being firmly given my marching orders.
After some months I noticed that we only ever had a junior anaesthetist for the operating list. That junior was a delightful man called Archie Brain who was forever inventing things. If it was not a cow-catcher set of bars to move anaesthetic tubes out of the way when moving the anaesthetic trolley, it was a new invention called the laryngeal mask which went on to take the world of anaesthetics by storm and must have made him a millionaire. I just spent my time begging him to stop fiddling around and get on with the anaesthetic! However, I was troubled that I never met the consultant, so eventually I asked switch board to phone him. He answered almost at once. I asked if he was consultant in charge of the list and he agreed that he was. I then asked him where he was, and he said he was at home. I asked him why, and he explained everything to me. Apparently they were very short of consultant anaesthetists in the East End of London and he had therefore agreed to cover more than one list. In fact he was covering up to four lists at a time, five days a week and earning a salary to match. He explained that the safest place for him to be was at home which is where everyone knew he was. I was amazed and said something fatuous like “You will get sued for this”. His answer was a weary one “I will be dead before they do” and he was right. He was dead within six months, leaving, I assume, a very wealthy widow.
The Cutler’s prize
The instrument for which I won the Cutler’s prize was very simple indeed. It merely rolled up a plastic sheet so that we could close a gaping wound. After we performed a fasciotomy for a swollen limb, we left the wound open until the swelling had settled. By then the skin had shrunk so the patient usually needed an unsightly split skin graft to cover the gap. However if you placed a sticky plastic sheet over the wound (called an Opsite) and made sure that it spanned from healthy skin on one side to healthy skin on the other, then the skin edges could be pulled together slowly, day-by-day, by reefing in this plastic sheet. My device was merely a roller that fitted into a rack with a simple ratchet on it. Each day the roller could be taken in one click and the wound slowly closed. When it won the Cutler’s Prize I was invited to dinner at the Cutlers Hall and presented with a lovely old solid silver medal. The joy of the occasion was slightly marred by the Chief Cutler quietly enquiring whether I could arrange for them to have it back when I died as they did not have an unlimited stock. I gather that the fasciotomy device was used with great effect in the South African war against the guerillas but otherwise like many good ideas it died an early death.
Other Inventions
You need to be a very special person to be an inventor. Many of us try but only a few like Dyson and Archie Brain succeed.
For a start you clearly have to be as observant as an artist of everything going on around you, but your eye should be at how things work, not how they look. Then you need to have an encyclopaedic brain to know about the options available. When the first iPod came out with its scrolling wheel, I recognised at once the dial on a top-of-the-range ship’s radio receiver. Someone in Apple must have had that image in the back of their mind and were able to link it to a completely different area. But even that is not enough. You have to have the dexterity to build and refine a prototype. Finally and most difficult of all you have to have the tenacity to get it to market.
My fasciotomy closure device which won the Cutler’s Prize was a good idea but I didn’t have the attention span and tenacity needed to bring it to market. I still have a lovely design for a machine that would mobilise a swollen damaged hand, but I am far away from that field now. The idea that came closest to making money was my surgical gloves.
It is critically important in surgery that we do not continue to work with gloves that have a hole in them. We may get infected by the patient and bacteria from our hands may get into the patient’s wound. In orthopaedics we wear double gloves to reduce the risk of a full thickness perforation, but even then a bone spike that penetrates the outer glove is pretty likely to penetrate the inner glove too. My idea was to put a coloured powder between the two gloves which in powder form was not especially bright. But as soon as the outer glove is perforated and fluid runs between the two layers, the dye lights up and shows the surgeon that he needs to change his gloves. We patented the idea and then went to a major glove manufacturer who seemed very reticent about the idea. What I subsequently found out was that someone else had developed an even simpler way of doing this, which Regent were busy developing. They simply had the inner glove a different colour and as soon as water got between the layers, the colour of the inner glove became more obvious. They are now in regular use.
However the development phase was fun. The University Invention Development Office, who were pretty ineffectual, invited me down to Trinity College to meet the Minister of Education to demonstrate my idea, as it was felt to be simple and clear enough for him to understand. After a pleasant lunch, the beautiful mahogany table was cleared and a crystal bowl of water placed in its centre. What a setting for demonstrating a new invention. I put on the gloves and dipped them in the water. No colour change. Then I pricked the outer glove and immersed them again. A bright green stain spread across the glove. The Minister clapped; the Master of Trinity looked faintly amused. Then the minister said to me “What do you need to think up something so clever, yet so simple?” Without thinking I replied “A renaissance mind”. I saw the Master of Trinity actually sneer. His high falutin’ idea of the Renaissance bore no resemblance to the crude but practical world of ‘real’ inventions. I am sure that I was closer to the Renaissance concept as it had been for Caxton and Da Vinci than he was.
The Nuffield Knee
The only patent that made the University a lot of money (£1M) was the design of a new knee. I was at the Nuffield Orthopaedic Centre (NOC) and wanted to call it the NOC knee but that idea was firmly scotched. The real designer was a lovely engineer called Mike Tuke and it was developed by an aggressive company called Corin, whose boss had once been a junior manager at the infamous Ford Dagenham car plant, the centre of militant Trades Unions in the 1960s. I contributed nothing to the design but I think they were gambling that as a rising star I would help marketing. I didn’t but the University let me use as much of the funds as I wished and this gave me the opportunity to do some really interesting projects. When the prototype knee was ready we needed to put it into a cadaver to see if it fitted. A notable clergyman has just committed suicide over an editorial he had written in a church magazine and he was the first recipient, as soon as the post-mortem was completed. He was a very large man and rigor mortis made it very difficult to bend the knee to get the implant in. Having satisfied ourselves that it worked on one cadaver we started implanting into living patients. You would never be allowed to do that now, but all I had to do was tell the patients that it was a really good design (I hoped) and off we went.
Hi-neck hip
I was also involved in the design of the Hi-Neck hip, a sort of District General version of Michael Freeman’s expensive and difficult to use hips. It was cheap and cheerful and seemed to work well, but like all these things was swallowed up in the next fashion change.
What happens to bones?
I suppose that the research I am most proud of is the paper I did on ‘What happens to wild animals that break their bones?’ I had been called to casualty to deal with a fracture and must have annoyed a casualty officer because he said “I don’t know why we bother to call you orthopaedic surgeons, because we know that in the wild, animals heal their fractures on their own.” It was quite a challenging remark to me as an orthopaedic surgeon because I had studied zoology before I did medicine and had sort of heard that remark in passing but never really chased it up. I decided that I would get to the bottom of it, and set off to the library to try to chase it down. There was no internet in those days, so it was really a matter of pulling down reference books, and then finding whether it was mentioned, and if so, whether it was referenced. Of course, as usual, some of the references were wrong, and others just referenced someone who had referenced someone else, but finally I got to the source which was by a Swiss primatologist called Schultz in the 1930s whose love for his fellow animals consisted of a passion for shooting them, dissecting them, and preserving their skeletons. He had descriptions of skeletons of Orang Utangs, Gibbons and other primates where there was clear evidence of a healed fracture. He had therefore deduced that these animals had managed to heal their own fractures. His immortality, such as it was, all seemed to boil down to this finding. To my amazement there was a Schultz Museum in Zurich where all these skeletons were stored and catalogued, so I made a visit there. The curators were clearly quite excited that someone wanted to visit their macabre collection, and I spent a couple of days working through each skeleton, noting and photographing any fractures that I found. There were not many, but he was right: there were several healed fractures and a couple of unhealed ones. However, there was something strange about the fractures which made me go back over them a couple of times. I noticed that many of the fractures had healed with the bone ends considerably overlapped but the bone overall was not much shorter than the other side. So, after the fracture had healed up, the bone must have grown and it had done so faster than on the other side.
At the London Hospital in the 1970s we were forbidden by the senior orthopaedic surgeon from fixing fractures with nails and indeed children were not treated this way anyhow because inserting the nail damaged the growth plate of the bone. We treated most long bone fractures on traction with weights and strings. Once we had got the patient comfortable on traction we would take an X-Ray to check the position of the fracture. In adults we tried to get the bone out to full length, but in children we were taught to let the fracture shorten a bit because it was known that in children the fractured bone overgrows and the limb can then become too long.
These primate fractures all showed exactly this feature. They were longer than they should have been when compared with the normal bone on the other side. What fun! Schultz had assumed that just because he had shot these primates when adult the fractures had also occurred in adults, but actually none of them had. Of course that made sense. Young primates would be more likely to sustain a fracture because they would be more likely to fall, and when they did break a bone they could be carried and protected by their mother until the fracture healed. Well that had scotched the well accepted dogma that adult animals could heal their fractures, but just because we had not found an example did not mean that it did not happen.
I thought I would write to as many colleagues and friends who had observed wild animals for long periods. All of them kindly wrote back and confirmed my suspicion that not only could wild adult animals not survive a fracture, the fractures were also extremely rare. This suggested that natural selection had ensured that adult wild animal’s bones were stronger than they needed to be for normal use. This was to avoid them ever fracturing. Indeed the figure that came out of all the observations of hundreds of animals over decades was one major long bone fracture every ten thousand animal years, a very rare event indeed. We then took the experiment a little further. I knew the population of East London and I had records of all the long bone fractures admitted to East London hospitals, so I was able to calculate the incidence of long bone fractures in this population. If I removed those fractures caused by the high energies produced by the equipment of modern society such as motorcycles, cars and studded football boots (which of course give extra grip) then surprise, surprise the incidence again came out at one per ten thousand years!
This data all fitted very nicely with some research done by a zoologist who had looked at the strength of skeletons in birds and snails. His argument was that a crack in a snail shell was not fatal (it could function and repair it quickly). Therefore from a natural selection point of view, there was not a very high pressure to have a skeleton strong enough not to break. As there was obviously a metabolic cost to a producing a stronger skeleton, the balance would come out in favour of a weaker skeleton. He also looked at seagull wings. Here a break is fatal and he found that the wing bones are engineered way over strength. So here the metabolic cost of heavier, stronger wing bones was overwhelmed by the selective cost of a fracture. Humans were obviously closer to seagulls than to snails!
That research was fun. It challenged a piece of well entrenched dogma and came up with some interesting stuff in the process. The leg ulcer work was simply hard graft. All it really showed was that it didn’t matter what you did with leg ulcers. If you cared for the patient then they got better, but when they did get better they lost human contact and so paradoxically were worse off.
Vice versa
I was becoming increasingly interested in medical politics. When I left The London I had metaphorically written on my shaving mirror “You will not forget” because my training there had been so poor and I was determined to try to improve things for others following me. I also did not agree with the long hours that junior doctors were compelled to work. It was ruinous for home life, and really was not very productive for the service either. If you have a service planned by one sub-group (the consultants) on behalf of everyone, it should be no surprise if they change the service surreptitiously and without malice to ensure that they only do the interesting work. The rest is left to the Hod carriers (the junior staff) who do not rebel because they know that if they don’t rock the boat, they will be in that privileged position in a few years’ time too, and then they can forget the misery they suffered on the way up.
I got heavily involved in planning the reduction of junior doctors’ hours and improvement in their pay and living conditions. In retrospect, I fear that I did not do much good. One of the simplest ways of selecting good successors in a profession is to look at their motivation. A junior who is in the hospital all the time and especially every time that you are there, looks much more motivated than a junior who never seems to be there when you need them. We had this down to a fine art in Bath where I did my surgical house-job. I knew the ladies in the switch-board well and provided you involved them in the plot they would cover wonderfully. If I was hang-gliding, I was caught up with a patient in the ITU. If I was out running, I was scrubbed in theatres. They also rang us when our consultants were coming in for any reason, so that we had the choice of being there before them. One evening we had gone across the cricket pitch (yes the hospital had its own pitch) to the pub for a quick beer. The bleeps reached there, but that evening I was being difficult and had not answered. The call was urgent so switch board triple bleeped me, a signal really reserved for a cardiac arrest. It was a lovely summer’s evening and I sprinted across the cricket pitch back to the hospital. I thought the window of the telephone exchange was open, so decided that I would do an entry fit for a triple bleep. Without slowing stride I vaulted through the window of the exchange. It was not open. I had just failed to see the reflection of the glass in the falling light. The result was that I brought the whole Georgian window and its frame down in the exchange. The girls were very good about it, and years later when I rang the Royal United and gave my name to the switch-board ladies, they greeted me as a long lost friend, and asked if I had taken out any other windows.
The situation was dire with junior doctor’s training. The majority were from the Indian sub-continent coming to the UK to get a BTE (Been to England). They did not dare complain about conditions and were abused roundly. If they had any sense they would go back home after a few years and claim that they had received a magnificent training! Many of the good ones stayed and promptly started to abuse the system just like their British bosses had. I wrote papers on how duty rotas could be organised and how ‘Hand over’ could and should be a learning experience but there was little change. Looking back now from the perspective of several years later, there was a revolution, but it did not feel like it at the time. As fast as we made one step forward we seemed to slip two steps back, and at the end of the day Duthie was right, I lacked the courage of my convictions: I could always see the other side’s argument and was frequently paralysed with doubt about what we were doing.
I suppose things came to a head at Kettering where we went for an inspection. We were supposed to meet the junior doctors but only two turned up. I suspect that the rest had been warned off. Both of them had been on duty the night before and looked like death warmed up. One of them would not speak at all but the other was a feisty Russian lady. I asked her about her training. She thought and rolled the word around her mouth a couple of times “Training” she said “ You know, I have worked in UK now for two years and I think I speak good English but ‘training’ that is not a word that I have ever heard!” I think she made her point very well.
One area that especially interested me was the house-job year (pre-registration), or as it is now called Foundation Year (FY)1. I remember being tired, frightened and quite angry during that year, but my colleagues in the consultant dining room at the Nuffield Orthopaedic Centre eulogised about it, claiming that it was the best and most formative time of their lives. I decided to try to go back to being a house-officer offering myself as an unpaid locum. It was actually surprisingly difficult to find a job because locum cover for house-officers was not available, they just had to cover amongst themselves (making even more work for no pay). Finally I found a cardiology job for one week in the Bristol Royal Infirmary. I have never been good at cardiology but decided that this was appropriate, as most F1s are hopeless at cardiology too. Even so, in panic, I did buy one of those small ‘Teach yourself ECGs’ books the day before starting and of course never opened it! The consultant was a delightful if slightly scatter-brained man. He knew who I was (although I think he forgot during the week) but none of the rest of the team did. Each asked me where I was from. I answered that I had been abroad for a while. Then you could see them thinking ‘Something is not right here. He must have been struck off by the GMC to be doing an FY1 locum. Keep clear!’. A brief hooding of their eyes would be the only clue that they were thinking unchristian thoughts. The job was an absolute mêlée. I had forgotten how exciting it was as a house-office. You are in the centre of everything. A nurse, a patient, a relative, a consultant wants something done. It is you that they come to. Back in my own hospital, as a consultant, I found that every time I came on the ward I would be met by sister who would ask how she could help. What she was really saying was “What on earth are you doing here? There are things going on that we don’t want you to know about so I am going to try to stop you right there.
The job was far, far busier than I remember. Far more paper-work. Many more tests to be done. You literally did not sit down. Not that I was invited to. I was only a locum after all. We had a take-day once a week and everything moved up one gear. No sign of the consultant but now there were a steady stream of calls from the Emergency Department wanting patients clerked. The day flew by and at 11pm I was bleeped by the consultant from home to find out how I was getting on. I was rather touched by his concern. I explained that we had admitted twelve but that there were eight in casualty waiting to be clerked. “Fine” said he “Have a good evening” and put the phone down. I turned to the SHO in amazement and asked “How many would I have to say were waiting before he did something?” She looked at me a little surprised at my question, then said “Oh we think that he puts on his pyjamas, brushes his teeth says his prayers ,rings the house officer and then tucks himself up into bed”. So the question about ‘how it was going’ was a completely rhetorical one.
The next morning was flat out getting ready for the ward round at 9 am. I now had not slept for 26 hours and to say that I was tired was an understatement. However before the round started there was one extra bit of excitement. We had admitted a rather sad middle aged lady with a paracetamol overdose in the middle of the night. She needed blood levels checking and a guard on her in her room. At eight am the consultant psychiatrist arrived to assess her, which he duly did, but then left her unguarded. She promptly jumped out of the window (luckily ground floor) and vanished up the main street in her nighty. One of the nurses saw her going past the window and raised the alarm. The psychiatrist turned to me and in a bored way enquired if I was the house officer, and then requested that I call the police to get her brought back. For just one moment I broke a little of my cover. “No” said I, “You will call the police. I will just make some contemporaneous notes of a crass piece of clinical mismanagement”. “Who are you?” he demanded petulantly. “You don’t need to know” said I. “You just need to get on and do your job properly”. Gosh, I felt better after saying that.
The ward round was starting and off we went with that extraordinary shuffling of notes that goes on as you frantically search for the serum rhubarb that you are sure you ordered but can’t remember if you got back. Medical ward rounds are slow, incredibly slow. We finally saw the last patient around 2pm. I was tired but each time I tried to take a break by sitting on the side of the patient’s bed, sister would actually cuff me and tell me “We don’t sit on patient’s beds in this hospital, doctor”. I swear that if she had done it one more time I would have given her a full frontal Glasgow kiss. As it was, I was having difficulty seeing straight. However Gabriel the consultant was in full flow. I remember that he must have spent the best part of an hour discussing his innermost feelings about Nifedepine, a drug that I had not even heard of at that time, and now cared about even less. I think he must have forgotten who I was, as it was clear that all the others in the team had heard this soliloquy before. However, at the end of this marathon round he did turn to me and say “Chris, it is Chris isn’t it? You are probably quite tired so as soon as you have everything tidied away, do get yourself home early and get some rest.” I simply could not believe what I was hearing. For the last two hours of the round my bleep had been going continuously, a sort of status bleepicus, and on top of that there was a ton of paperwork to be done. In fact I finally got clear of the ward at 10pm that evening 44 hours after I came on duty. Sure, I was slow but not that slow. No one would have got away before 5pm.
On the last day Gabriel popped in to say good-bye. He explained that he was off to the merit award committee. He knew that I knew this was a critical meeting where vast bonuses in salary were doled out by the consultants to each other. It is a committee that I especially dislike because at that time it was top secret and almost certainly corrupt. I replied thanking him for allowing me to do this experiment then went on “You go on to the merit awards, I’ll tidy up the mess on the ward”. He left, and then stuck his head back in the door “What did you just say?” I repeated my last sentence. He let out a slow sigh. “It looks as if I am not going to the merit award committee, doesn’t it?” came back into the room and drew up a chair. I asked him about the phone call at 11pm. He seemed quite aggrieved. “But I rang to find out how you were”. “Yes” said I “But do you remember how many patients I said there were to be clerked?” He didn’t. “What would you have done if I had said forty patients?” “What would you expect me to do?” he asked in an aggrieved voice” “Come in and lend a hand” said I firmly. “But, but, a consultant could not, would not, do that” he cried. It was pointless. Here was a delightful kind man who was simply not encultured to what I was proposing.
And it continues to this day. Here I am writing this in Invercargill in 2013 and we have five consultant physicians here who share the on-call. Each has an average of three inpatients to look after and one duty day a week. When a medical patient comes in s/he may be seen by the GP who evaluates them. Then the ambulance crew do a very full assessment. When they arrive in hospital they are again assessed and prioritised by the triage nurse, and then by the junior ED on duty who may then ask the senior ED doctor to see. Then they are referred to the medical registrar who assesses them fully and if they need admitting they are then clerked by the medical house officer. Then and only then will the consultant be involved. This ridiculous fandango would leave even the print unions at their worst, speechless at the level of over staffing and demarcation. As it is, the process takes so long that the patient has to be admitted in the end, whether they needed it or not, because darkness has fallen and it is not safe for them to go home alone. If the consultant physicians saw them straight after the triage nurse and made a care plan then I guess that one third of the current admissions would not happen, and the ED would not be crammed with patients waiting to be seen by the next person in the chain of command.
Having talked to Gabriel and spoiled his chances of putting his oar in for the merit award committee I went back to the doctor’s mess to collect my gear. There was an impromptu mess meeting going on, so I stopped to listen. In the middle of this noisy meeting was the house-officer who had been on duty last night. He was fast asleep. Around him a passionate debate was going on. There was no house-officer to cover the wards at the weekend for medicine in the whole of the Bristol Royal Infirmary. In other words there was no locum to replace me. Some of the doctors felt that this was the hospital’s problem and wanted to go. Others felt that it broke the Hippocratic oath to leave patients unprotected and that someone should stay but preferably not them. Slowly the focus fell on the sleeping house man and after a short whispered debate, each doctor wrote out a list of their problem patients on post-it notes, and stuck them in a line down his tie. Then they tip-toed out, giggling to each other. So, having done Thursday night take, he was now going to cover Friday, Saturday and Sunday night. During that time no consultant would know or care about the situation he found himself in and would probably abuse him for not doing a good job. I thought of staying and helping him, but then thought ‘This is going on all over the country. What will you achieve by staying, apart from justifying your own conscience’. The saddest part of the whole episode was that when I got back to Oxford I found that lots of the same things were going on there in my own unit. The BMJ published the article as ‘vice versa’ but it changed nothing.
Moving to the JR2
The Trauma Service
The specialties of Orthopaedics and Trauma were slowly separating in Oxford. The Emergency Department at the John Radcliffe had been run remotely from the NOC as an annexe of the orthopaedic department. Some of the consultants had part-time contracts there and went across one day a week to do a clinic, a ward round and an operating list, but the service was really run by the registrars. They had the resilience to operate all night and this was their chance to spread their wings and operate without supervision. This was called ‘cutting yourself silly’.This arrangement suited the consultants well too, as they didn’t want to come in at night and were anyhow becoming de-skilled.
When I moved back there, the Emergency Department had a proper ED consultant in charge, and three new consultants had arrived who only wanted to do trauma. If a fourth person could be roped in, then there was a critical mass to set up a separate consultant led trauma service. I wanted to get out of the Nuffield Orthopaedic Centre and was intrigued by the idealism of Peter Worlock, Bob Handley and Keith Willett. They wanted a consultant based service, not a consultant led one. We would stay in the hospital for 24 hours at a time, and see to every aspect of patient care, admission, operating, ward care and discharge. The registrars would help us but would no longer run feral. They did not like this at all. Peter Worlock became the self-appointed leader and started to run the service along almost military lines. I was without doubt a weak link. My trauma training at the London had been minimal and was very out of date. Peter came from Nottingham which was at the forefront of new aggressive techniques. I also had not done any trauma for ten years, having worked mainly at the Nuffield Orthopaedic Centre doing joint replacement. No quarter was asked for and none was given.
Each of us did one 24 hour duty then supposedly had a day of rest followed by normal duties until the next duty day came. As I was an academic I was only required to do one day a week, and soon became isolated from the rest of the unit. At 8am the consultant from the day before would hand over all the cases in the unit to the incoming consultant in front of an X-Ray screen (not the patients!) then finish all his paper work and go home to sleep. My experience was that the tidying up after a 24 hour duty took four or five hours so the duty was 28 hours non-stop. In order to cope with the high work load brought on by choosing to surgically fix all fractures, we were obliged to operate all night. The anaesthetists hated this and tried every trick they could to block us, so tempers became shredded. The service we provided was superb but it created tremendous anger in other units who were relying on unsupervised juniors to provide an indifferent service.
We had psychologists interviewing both us and our wives every six months to see how we were coping with the strain of working on this service. The last time that the psychologist visited Katherine she ushered her into the living room and showed her the collapsed ceiling where I had fallen asleep in the bath with the taps running. Then in her inimicable way she pointed out that I was completely psychotic after 28 hours of non-stop high pressure duty and that she therefore removed three things from my presence, my Visa card, my car keys and the children, as she claimed that I was not safe with any of them. I think she made her point clearly. The experiment certainly contributed to the break down of three of our marriages, all of which ended at around the same time.
The principle of the experiment was, and still is, admirable. However, we did not handle it very well. If we had managed to stick together and work as a team we might have made it. As it was, alpha egos clashed and for a year we chose not to communicate at all to avoid any rows. The explosion when it came was terminal, and I left the trauma service. Since then the original experiment has been diluted back to a consultant led service but I learnt some interesting lessons. The first was that after a certain age you cannot go on operating through the night. You cannot see straight. Interestingly even in a big busy Trauma service there is almost no work to be done between midnight and seven am unless you choose to create work by leaving a backlog from more sociable hours. The other thing I found was that when I did a ward-round in the evening to check that the wards were settled I could ensure that there were no bleeps to the junior doctors in the night by taking their bleeps off them and warning the ward staff that if they activated any of the bleeps they would get me. I then suggested that it might be best to check all drug charts and fluid charts there and then. I also went round all the frail patients and asked them what their wishes were about resuscitation. I was very embarassed to do this and, was surprised that they all seemed relieved to be asked. Clearly it was something well forward in their minds, but they too had been too embarrassed to discuss it. The second surprise was that they all wanted resuscitating, however ill they were. The problem of finding out their wishes was purely mine. Another life lesson learnt.
Personal chair
I was given a personal chair in Oxford very shortly after the scheme was introduced. Somebody must have pushed for that. I wonder who. Up until then there were world famous scientists who were still just lecturers. Now, I suspect it has gone a little far the other way, and every Tom, Dick and Harry (including me!) is a Professor. Up until then my career had been dominated by very powerful bosses who needed careful handling or confronting head-on. Now it appeared that I was in charge of my own destiny. To clarify this, I made an appointment to see the University Registrar, the most senior administrator in Oxford University. He duly sent me an appointment. I explained my predicament. What were my duties as a Professor? He explained that technically I worked under the direction of my head of department but after what had happened with my previous head he doubted if there would ever be an attempt to make me do anything. He allowed a winsome smile to cross his face. Clearly he had watched the battle royal from afar. “Therefore” he said “You have no duties”. This really was not good enough for me, and I asked if he could be more specific. He sighed and said “Yes I suppose so. You are an orthopaedic surgeon after all.” He then thought for a moment and said “If you were to go sailing until you were 65 we would support you, but not approve. Has that made it quite clear?” It had. I left his office and danced down Little Clarendon Street singing “I’m free!”. But of course I wasn’t free. My puritanical upbringing merely drove me to greater excesses of work driven by my guilt for being in such a privileged position. Since I was given that unqualified freedom by the University of Oxford I have never worked so hard in my life.
ABC
The ABC fellowship was a biennial event where six surgeons from Britain Australia and South Africa travelled for 6 weeks around the major centres of the USA being lectured to and hosted by the best of America’s orthopaedic surgeons. The following year they would come to us. The whole idea had been set up after the second world war when I suspect Britain had more to offer than it does now. It certainly exposed the widening gap between our own and their medicine. It was also an opportunity to get to know five other orthopaedic sugeons very well as we lived, ate and travelled for six weeks together, and had to get on as a team. All of us had to be under 40 and were chosen by a committee. I very nearly did not get a place as at the interview I was asked what I had learned during my previous European Fellowship. Without thinking I answered “How to handle an overdraft, as I have still not been re-imbursed for it”. The secretary of the British Orthopaedic Association who was a consultant at Barts and therefore viscerally disliked London Hospital trainees immediately protested that I had been paid. I said that I had not. He said I had. He was very powerful in London orthopaedic politics and frequently boasted of how he controlled all the jobs in London, so I acidly asked him whether he now had control over our bank accounts as well as our careers. Several of the panel giggled with glee at this dig, but I fear that we cemented our relationship there and then.
The team arrived in New York to be met on a Sunday by a charming but harrssed looking surgeon who was our host. The story was that he had hosted the last group two years before when one of our party was found in bed with his teenage daughter instead of at the dinner on the second night. We were hosted at Colombia Presbyterian right at the north end of New York in a very rough area indeed. We were asked not to go running in case we got shot. I went running anyway but was saddened by the thought of these doctors working in an environment which they perceived to be so dangerous. There was a siege mentality, with doctors coming to work early so that they could park close to the doors of the hospital. Every second day we travelled by train or plane to a new city where we were dined and subjected to death by lecture. The science was poor, and none of the talks inspired me. However, everything was bigger, newer and more expensive than anything that we had, and quite clearly they thought that the British NHS was a joke. I was hugely impressed by the Niagara Falls that we visited when we were in Toronto. I have always been intrigued by what it must feel like going over the edge in a barrel. As the tour boat inched closer to the Falls I had the guide open and was reading excerts from it in a plum BBC voice just to tease the others.. When I stopped a local couple begged me to continue as they just Luuuuved the accent. My travelling fellows all moved away in disgust. In Memphis we visited the famous Campbell Clinic where the standard textbook of orthopaedic surgery is produced. I badly wanted a copy and paid a lot of money to buy one at a book fair the day before we arrived in Memphis. As a practical joke the other fellows arranged for me to be presented with a copy at the Campbell clinic by the senior author at a Gala dinner. They hoped that this would upset me as I had just spent several hundred pounds buying my own copy. I should have known that this was a spoof as the award was for the best paper and mine had been very weak. When I was presented with the book I had to give a short speech of thanks. I could not think what to say but could see my colleagues doubled up with laughter at the confusion on my face. I started with the truth, which was that I had just bought a copy of the book, but then went on the explain that just before I left the UK, I had tried to get the NOC library to buy a copy, but that Professor Duthie had vetoed the idea because he claimed there was nothing new in the most recent edition. Now I could see that I had everyone’s attention. This was a direct challenge to the Campbell clinic. I asked if instead of accepting the book for myself, I could take it back to Oxford and donate it to the library to show how far things had advanced in the last few years at the Campbell clinic. There was a hurried discussion amongst the senior Campbell clinic staff and then Crenshaw himself (the senior editor) stepped forward to personally sign the book. I subsequently discovered that my colleagues were planning to give the book back as soon as the presentation was over but that after my speech, the senior doctors at the Campbell had been obliged to pool together and pay for the book to be presented.
That night we went on to some blues clubs and listened to Jerry Lee Lewis Jr. and many others playing all through the night. Lectures started again at 8am the next morning and we were exhausted. We had a rota to decide whose turn it was to ask questions and Jeremy Fairbank was ‘it’. When I looked across at him half way through the first lecture he was sitting immediately in front of the speaker and had slumped over sideways fast asleep. Just at that moment he sighed, shifted himself, farted loudly and slumped over asleep facing the other way. The Americans pretended not to notice.
The South African with us was a delight. He was a children’s orthopaedic surgeon who specialised mainly in club foot surgery, a rare condition. In Iowa a delightful old orthopaedic surgeon was rolled out to present his life-time experience of 200 club-foot operations. Thays had spoken very little up until then but now became very interested. At the end of the talk he wanted to make a comment but prefaced in with some self-denigratory remarks. He pointed out that although he had done over two thousand club foot operations his experience was limited to the left foot only as his African assistant did all the right feet. The Americans simply could not decide if he was taking the piss or being quite serious. Nor could we.
At the dinners we were expected to dance, but Americans dance between courses instead of at the end. Thays consistently refused to dance claiming in his thick Afrikaans accent that it was disgusting “Eet ees loike making love to someone elses wiffe in public” he grumbled.
Towards the end of six weeks wining, dining, and being lectured to we were all tired. One of our final events was in Boston and we were taken to a farewell dinner at the Harvard Club, a sort of cross between an Oxford College senior common room and an old style golf club. Throughout the tour I had been pretty rude to my colleagues about the American’s preoccupation with what I would call trivial history, very rude about their total disregard for scientific methodology, and astoundingly rude about their ignorance of what was happening politically in the rest of the world, and it was my turn to make the thank you speech. I decided to try a little irony, as a way of venting some of my spleen without being too obnoxious. I started off thanking them for doing us the honour of entertaining us in this building so redolent of the history of their country and went on to say how touched we were to be shown glimpses of their history every where we had gone. I continued by congratulating them on the great science they were doing, which would surely prove to be such a benefit to mankind. And finally I congratulated them of being such inspired leaders in the present world, helping other countries less fortunate than themselves, and standing up as a beacon of democracy. By the end of my little tirade poor Jeremy had his head buried in his hands with embarrassment. Then damn me if their President didn’t come across and shake my hand and say “Goddamit, that is one of the best speeches I have ever heard in this building”. Never try irony on Americans.
Houses
65 Cloudesley Road, London
For many months before Katherine returned from Africa I had been scouring London for a house which we could afford to buy. I was simply amazed at the variation in price depending on location, and struggled to learn which districts were going ‘up’ and which might be going ‘down’. But little by little, I got the ‘knowledge’ of London and roads started to connect up. Eventually we found a house we could just afford (£60,000) in Islington in North London. Islington is dark blue on the Monopoly board, the second cheapest after Whitechapel and Old Kent Road. Jim, Katherine’s father, gave us some money, my parents lent us some too. Some savings and a mortgage did the rest. In those days you had to save with a building society for at least one year before they would consider your mortgage application and then there were rapacious mortgage brokers who insisted that your mortgage had to be linked to a endowment life insurance policy. I was very suspicious that they were so eager to lend money and that the policy had to be with one company. Now in retrospect I know that these endowment policies paid huge commission fees to the brokers and subsequently failed to raise enough money to cover the mortgage. When we first took out the mortgage inflation was at its peak and we were paying 15% interest per annum!
The house was a very tall narrow terrace on a lovely quiet street which had a very broad pavement. Apparently as late as the 1920s it had been used to drive sheep down from Hertfordhsire to Smithfield Market for butchering. It had a lovely pub selling London Pride and a huge church which had been adopted by an African mission society so there was much singing and clapping every Sunday.
The basement of the house was half underground and had a kitchen connected to a dining area. Four steps led up into a tiny garden chock-a-block full of snails. The ground floor had the front door and was a living room, but also had to store the bicycles. On the first floor there were two tiny bedrooms and a bathroom at the back, and on the top floor there was a master bedroom. I fitted a shower into one corner and I glassed over the balcony at the front, so that with some artificial lighting we had flowers all the year round. I could take the polycarbonate panels off in the summer and then the tiered window boxes filled with snails which each morning I consigned to outer darkness, hurling them over the parapet onto the street two floors below.
When we sold it to move to Oxford, it had tripled in value and made us more money than either of our salaries. We had a delightful live-in au-pair to look after Harry as Katherine had landed a good job at University College setting up a Human Sciences course. The au-pair was the daughter of a doctor in Boston, New England and clearly had a taste for alcohol as she cleaned out all our duty free. Harry adored her. She wore long velvet dresses and reclined on a chaise longue in the living room reading Harry story after story in that soft Bostian accent. I suspect that provided she had access to alcohol, nothing else troubled her.
Black Notley
By now I was a senior registrar so my job rotated me around several hospital. The bike ride to the Royal National Orthopaedic Hospital at Stanmore was nearly 20 miles and went up some hard hills. The first was Highgate, a pig of a hill right at the start of my ride and crowded with traffic. It was a busy bus route so I would wait for a bus then pedal hard and catch the rear handrail which the old double deckers had for getting on and off. I could then be towed up the hill. One morning the West Indian lady ticket collector decided that this was not on, and told me to buy a ticket or let go. I tried to argue and good democrat that she was, she put the issue to the vote with the passengers on the bus. Should I be allowed a free ride to the top of the hill or not? The vote went against me – badly. I tried to argue again, but taking the law into her own hands she swotted my hand with her leather change bag and off I came. I had to grudgingly admit that she was right!
My second posting was to Colchester and Black Notley an elective hospital in Nissan huts deep in the fields of Essex. Gosh what a dismal county, flat corn fields, no hedges, no humanity. I hated it. The senior registrar ran the hospital from a house in the centre. Two of the SHOs from different tribes in Nigeria were trying to kill each other, but my boss Tudor Thomas was a gentle soul who always planned the first patient on each operating list to be a teaching case suitable for my needs at that time. What kindness and consideration. In outpatients he used to send sister through to call me to his office. “Mr Thomas wonders if you could join him in his office”. The first time, I padded through racking my brains for what could have gone wrong. “What do you think of this X-Ray” he asked pointing to a film on the screen. As soon as I saw the picture I started to relax. I had never seen this film before. This was not my patient. “Not me, I’m afraid, Mr Thomas” I said. ‘No, no” said he “I just want to know what you think”. At the third iteration of this futile conversation, I realised that he was not trying to trap me, he really wanted to know if I had any ideas. It was the first time anyone had shown the slightest interest in what I thought in orthopaedics, and I was very touched once my paranoia had settled.
To me the Essex coast was even more dismal than the inland. I was desperate to go windsurfing but it was always low tide and the mud stretched endlessly.
I was at Black Notley when the new Colchester General Hospital was opened, and it was there that we went to do our trauma. It was the first new hospital that I had seen. It was bright, light, and airy and it changed the morale of the staff immediately. However, there was some pretty seedy management behaviour. When the Queen came to open the hospital, turf was rented to cover the bare earth. Gold fish were put in the ponds, and bedding plants, in flower, in the flower beds. Lovely. The only problem was that they were all rented for the day, and the following day contractors arrived and removed them all. I thought that was a little cheap. But we had our revenge on those uncaring managers. The new accomodation block for on-call junior doctors was a cheap Industrial building with a corrugated asbestos roof. It did not even have proper rooms inside, just partitions that went just above head height. It might have been cheap but it was not fit for purpose. We wanted it improved; the management said they could not afford it. In other words it did not matter. Word had already got out about some of my climbing exploits and when the rumour got round that I and a group of friends were going to climb onto the roof the day before the Queen’s visit and paint ‘H block’ on the roof, management capitulated. H block was the other name for the notorious Maze prison in Northern Ireland used to house convicted paramilitaries: it was in the news daily at that time.
Wit’s End
I was so happy to leave London. It was dirty, aggressive, and overcrowded. Everyone should have to live and work in London for a few years. They will never complain about living anywhere else.
It took some time to find Wit’s End but it was in the country, had lots of land, a sunroom and an Aga. I admit that the build quality was not what it could have been but hell: it looked south and west, down a deep valley that was crying out to be turned into a lake. It was a bicycle ride over Shotover to work, but that ride separated work from play. For Katherine, it was much more difficult as hers was a commute into London, but at least the bus stopped close to University College, even if it stopped in traffic jams for a couple of hours before that. The garden was ideal for a children’s playground. It had a sand pit and two aerial runways – a small one for the youngsters and then a giant one that spanned the valley. Aerial runways are quite hard to design. The start has to be higher than the end otherwise they don’t run at all. But the sag in the middle is also crucial for building up speed at the beginning and then slowing it down at the other end. Poor Harry was the guinea pig for each of my designs. For the first attempt at the big valley crossing, I used a rope. Long ropes stretched and Harry swooped down into the valley. But he swooped too low and the valley was then full of nettles. I will never forget the look on his face when he finally came to a standstill, Breach of trust was written all over it.
Eventually, I was able to complete my greatest dream and build a lake in the middle of the valley with a little island on it. It was a mighty scheme made possible by a mad contractor who specialized in puddling clay to make lakes. I loved that lake. It had trout in it. It had children in it. It had racing radio-controlled yachts. It had newts. Every time I went down there, it made me happy. On the lawn, on one side I built a straw barn to keep the Flying Dutchman dry. After one season it started to fall down and then provided immense pleasure to the children who built dens in it. The house has been gutted and rebuilt now and looks much smarter but uglier, but the views are still to die for.
Operation Irma
I was just walking down the corridor in the old Emergency Department at the John Radcliffe in Oxford when my friend David Skinner stopped me and asked me if I wanted to go to Sarajevo where the UK were going in to evacuate injured from the siege. It was the decision of a moment and within an hour six of us were driving North with an old trailer to rendezvous with a Russian transport aircraft. It was waiting to fly us to Ancona in Eastern Italy and was going to act as our Headquarters for evacuation. At the time I had a very old diesel Mercedes which was underpowered to put it mildly. We managed to get into the fast lane of the motorway but were immediately pulled over by a police car. Apparently you aren’t allowed to tow trailers in the fast lane. News to me. We explained that we were acting under direct instructions from the Government to proceed to Manchester as fast as we could. The police thought about this and then offered us a police escort. That was fine. We were surrounded by flashing blue lights but could not go faster than 55mph, as the old diesel simply didn’t have the power. We would have been better to have a tow rope hitched to one of the police cars.
When we arrived at Manchester airport it was to find a huge Russian Tupolov waiting to transport us. Seeing as this operation was on the direct orders of John Major, we were a little surprised that we were not being flown by the RAF, but apparently the RAF do not fly at weekends! I understand that there was some re-organisation in the senior ranks of the RAF after this fiasco. We were loaded at once but nothing was strapped down, so as we took off, there were oxygen cylinders rolling down the aisle. Russians are very relaxed about safety.
As soon as we landed in Ancona we set up a medical field hospital next to the airfield where there was a Hercules ready for doing the evacuation. There was only one translator so he would go to Sarajevo while we worked without a translator at the receiving end in Ancona. It was going to take 48 hours to gather the casualties so we had a little time to spare. I decided that we would learn some Scrote (Serbo-croat) so that we could triage the casualties and make them feel a little more welcome. I went to the International Red Cross and, yes, they had translation sheets for most European languages but not Scrote because, the lady explained, the war had not been going on for very long (only 2 years!). The phrases on offer were also ridiculous. “What was your address?” is the last question you should ask a refugee if it is unlikely that they will ever see their homes again. The response is floods of tears and hysterics. So, the Red Cross were useless.
Forty eight hours is not long to learn a new language so we thinned things down. I felt that ten words or phrases were the maximum we could manage so had to decide what these were to be. Well obviously ‘Hello’ would make a good start, followed by ‘How are you?’ This is ‘Kako ste?’ . This was going to be a tricky one to remember so we converted it into rhyming slang ‘Kako ste’ = ‘Have a nice day’ . So, as we set up, one person would call “How are you?” And everyone else would chant “Have a nice day” “Kako ste”. A second useful phrase was “Are you in pain, point where?” A simple answer of “No” saved a lot of trouble, whereas a positive would be easily understood from a pointed finger. A more controversial one included in the ten was the simple phrase “Be Quiet” or “Shut up” Those of you who have worked with refugees will know that panic can lead to chaos, and that there are times when you can’t hear yourself think. You hope you won’t have to use it but it needs to be in your armamentarium. However, we had a paediatrician who was difficult to put it mildly. We had an empty hangar for our base hospital and he immediately insisted on barricading an area off with straw bales, claiming that it was a Paediatric ITU and that no-one was to enter it without his permission. That was fine with me. There was plenty of room and if he didn’t want to work in the team so be it. However just before the first plane was setting off with the official translator, he sidled up to the two of us and said he needed one more phrase. We were in a hurry because the Hercules was ‘burning and turning’ so we asked him to be quick. He wanted the translation for “lie still. This is going to hurt a little but you will be fine”. The translator and I both gave the same phrase simultaneously “Be quiet!” “No, no!” said the paediatrician” you don’t understand “. “No”, said the translator, “it is you who doesn’t understand. We don’t say what you are saying. We just say ‘Be quiet’”. Well, I am not doing that” said the paediatrician and stomped off.
When the first load of casualties arrived the picture started to become clear. The whole operation had been financed by Saudi-Arabia. The casualties being evacuated were not newly wounded, they were members of important families who had been injured in the past months, had survived and now needed rehabilitation. The whole exercise was a political one not a medical one. As we flew back it sank in to those who had not done this work before that we had been conned, and they were very upset. I requested that on landing, we should be kept from the press and moved straight to a hotel with security to give everyone 24 hours to settle down. It was a lesson to be learnt again and again. Humanitarian aid is political aid, whether it is Gaza, Haiti, Sierra-Leone or Sudan, and you should never forget that you are being manipulated like puppets by politicians trying to make the most out of any news event.
Killing your children
Harry
I have nearly killed all of my children at one time or another. The first time that I was left alone with Harry, Katherine begged me to keep a careful eye on him. Of course I didn’t. He had just started to crawl and the next moment there was a terrible sound of thumping as he rolled down from the top to the bottom of the stairs. The tumbling finished with a sharp thud as his forehead hit the stone floor. There is always a long silence after something like this happens, when they are either knocked out, or drawing breath to howl. This was a drawing of breath. I rushed to pick him up and already a bright blue egg was appearing on his forehead. Then he started to scream. Eventually he settled, sobbing with rage, and at that moment Katherine came back. The sight of his mother started the howling again and the bruise on his forehead was at its glorious peak. Katherine had the grace to say nothing.
When I was working at Black Notley we had a rather nice BMW 2000 fast-back passed down by Katherine’s father. Harry loved to potter about in the back and in those days we didn’t strap children in. I was driving between Black Notley and Colchester Hospital on a pitch dark night and Harry was playing in the back. I noticed that he had climbed over the back seat into the boot area and that he was standing up there chortling with glee. I also noticed in the rear view mirror that the rear window seemed very clean. It wasn’t just clean it was large. Then I realised with mounting horror that it was open. Harry was standing inches from the lip of the boot with the car doing 60mph. Ever so gently I started to slow down and at the same time suggested to Harry that he might like to sit down. “Why?” was the immediate and normal response to any request. How do you explain to a two year old that they are inches from death, without by implication suggesting that he might like to lean over the back and see what death was. As I stopped I heaved a sigh of relief, and shut the boot firmly.
Harry at Black Notley with the fastback BMW behind
Harry learned to ride a bike very early and when he was not in a rucksac on my back zooming through the London traffic, he was riding his own red bike on the broad pavement outside our house in Cloudesley Road. When we came to Oxford there was Shotover with an infinity of steep paths between the trees. As a general rule kids have a weak grip and children’s bikes have lousy brakes, so the combination is not good. Riding down one of the steep paths off Shotover, Harry started picking up speed and shouted out in fear. The hill was simply too steep for him to be able to stop. I couldn’t catch him. All I could do was watch in horror. Luckily he lost control of the steering too, shot up and over a bank and vanished into some brambles. He was scratched and had bruised his dignity but no major harm had been done.
John James
When JJ was two he would not sleep. My sister Jane, ever the practical GP, just suggested that we put his cot in the playroom at the far end of the house by the back door, and then shut all the inside doors so that we could not hear him. On New Years Eve Katherine and I were woken at 2am by a girl walking into our bedroom carrying JJ. “He is crying” she said. I apologised as one does, and took the child off her. She went back down stairs. I turned to Katherine and asked who the hell that was. She didn’t know either. I put on a dressing gown and went down to the kitchen to find a young girl standing there in party clothes smoking a cigarette. She said that she was walking by and had seen the light on. She had come in (we never remembered to lock the door) and found JJ. She had played with him for a while but now he wanted a bath and had started crying, so she had brought him up to us. This story posed more questions than it answered. To buy time, I said I would go and get some clothes on and then run her home. By the time that I got down again she was gone. I jumped in the car and there she was100 yards down the road tottering along in high heels. I opened the door for her and asked her where she lived. She would not tell me, so I just asked for the name of the town. It was Bicester some 10 miles away, so it was going to be a long walk home! She explained that she had been to a party in Wheatley (our village) and that someone had laced her drinks. She had left to try to walk home but had set off in the wrong direction. Then she said apropos of nothing “I could have killed your baby you know” . I answered that I was quite well aware of that but that it hadn’t happened so we did not need to talk about it anymore. When we got to Bicester I dropped her off in the town centre and never saw her again.
JJ seemed to like the lake a lot. One of his earliest birthday parties was held on the island in the lake around a smoky fire. It was pouring with rain so I rigged a spinnaker over some poles and they sat around playing gambling games. But the lake was not so benign. One winter there was ice on it and the kids went down to explore. Harry who must have been twelve was aware that he was too heavy to go out on the ice so persuaded his kid brother to be the guinea pig. JJ got most of the way to the island (well out of his depth) and then went through the ice. He couldn’t get out, and Jenny who was watching, very sensibly said that she was going to get me. Harry said “No” as he knew I would be angry with him. This was not really a good argument, and luckily Jenny ducked past him and ran up the hill to the house. First she went into the kitchen and said to Katherine that JJ was in the lake. Katherine’s mind was obviously elsewhere because apparently she said “Oh good” so Jenny ran on through to my office where I was working on the computer, and told me. After a few moments, I realised the import of what she was saying and raced out of the door and down the hill. JJ’s head was still just showing and there was blood on the snow where he had cut his throat on the ice edge. I plunged in and got him. He was very, very cold, but a hot bath soon put him right. I think it had been a very close shave.
The lake
A slightly different episode with JJ is still engraved in my mind. We used to keep a punt at Radley boat house. We had a Chinese professor visiting the Nuffield Orthopaedic Centre and because I was worried that he might be lonely I invited him to come punting with us. Harry must have been about seven and JJ five. As I loaded up the punt Harry was pretending to push JJ into the river. I cuffed him round the head and told him to stop it, as the river was running quite fast and JJ was rightly worried. The professor immediately turned to me and asked me not to do that. I was a little taken aback but decided to ask him why. He looked very mournful and said “When my children were the age of your children, the cultural revolution started and they were taken away from me. I did not see them again for seventeen years”. I asked him, if it was not too upsetting whether he could tell us more about what happened. He spoke very slowly and quietly as we punted through an idyllic English countryside. He explained that it all started gradually and then flared up until all the university teachers were being denounced in their lectures. I rather foolishly asked him why they had not simply told the students to be quiet and behave. He said “We are Confucians. We believe that all things will pass. Those who fought back were executed”. Then he went on angrily “But now if I had my time again, I would have fought back. I would rather have died than go through what happened next.” He went on to describe how they all had to admit their wrong doings and then were sentenced to work on farms in Western China, his wife and children all sent to separate areas. During that time there was the Great Famine and most of the people in the village, where he was sent, died of starvation. Then he started gently to cry. He explained that ever since then the existence of the Great Famine has been denied in China, but he said “Today I went to your great library in Oxford and read for the first time the truth about what happened to me and so many others.” He went on to explain what an extraordinary moment it was to have confirmed at last that what had happened was real not a dream. There are moments in my life when I have a glimpse of how lucky we are to live in a free country. This was one of them.
Jenny
Jenny nearly got killed twice. The first time I had made a swing from a branch of an old apple tree in the garden of Katherine’s parents in Switzerland. I set it up so that you could get on the seat from the top of an old stone wall and then swing out over a part of the garden which sloped away to the stream. So, the swing was much more dramatic than it would have been on level ground. The boys enjoyed it, but Jenny was really a bit young. She must have been only five. Anyhow she was determined to try, but the grandparents dog had been getting increasingly excited and was now chasing the swing, jumping up and biting at the ankle of whoever was sitting on it. Away Jenny went and at once the dog leapt up and bit at her ankle. In her excitement to get away from the dog she tipped upside down on the swing just as it swung back towards the wall. Her head smashed into the wall and I was sure that I had killed her, but apart from a cut and a lot of tears all was well.
Flying dutchman. We had two adults and six children aboard
The next incident was much more serious. We were sailing the old wooden flying Dutchman in the estuary at Braunton in North Devon. I had rigged the boat with three trapeze wires on each side so that the children could swing out over the water in their harnesses. It was a lovely day and all the children had mastered their fear of hanging out over the side of the boat. The tide was now falling and I wanted to bring to boat in to its trolley so that we didn’t get stuck in the soft mud at low tide. Just at that moment a new family arrived with young children who had heard of this escapade and were desperate to try. Quickly I swapped around harnesses and life jackets and with one parent to help (who was not an experienced sailor) we set off again. Jenny decided to come at the last moment to show the others how to do it. The flying dutchman is a very high performance boat and needs very careful handling if it is not to capsize. However the wind was very light so the risk was slight. Out went the children and almost at once Jenny was showing how she could actually spin upside down and do cart-wheels along the side of the boat. Somehow the tension came off her harness and the clip released (as it is designed to do). Jenny fell into the water. I wasn’t worried. She had a life jacket on, and I could get her in a minute. But when I looked back she wasn’t floating. Only her face was showing and she was struggling. I suddenly realised that she had put on a harness with its heavy metal clip but had no life jacket. I had to turn the boat at once and that meant gybing, the most dangerous manouevre of all. If we capsized during the gybe we were going to lose Jenny and maybe others on the boat. I shouted that we were gybing and no one moved. No one on board had a clue what was about to happen. Without more ado I reached forward and just swept the legs of all the children off the sides of the decks so that they all swung into the centre of the boat and I started the turn. There was pandemonium on the boat. Children had banged their heads on the boom. Others were upside down in the bilges, but the boat continued to turn. The boom swung across knocking down a couple more kids who had been foolish enough to stand up again, and we were sailing towards Jenny. We reached her as only her nose was showing and she was clearly tiring. I still have nightmares about that moment. My only other choice would have been to dive off the boat and swim to her, leaving the others to their fate. Jenny and I would then have been swept down and out of the river. Goodness only knows what would have happened to the rest.
Merit awards, research and education
Merit awards
By the time anyone reads this, merit awards will probably have gone, and a good thing too. When the health service was set up in 1948 there was tremendous opposition to its formation from the senior doctors. However, behind the scenes, there was a good reason why it had to happen. Almost every hospital in Britain was a charity hospital and they were bankrupt, overdrawn to a level from which they could not possibly recover. The opportunity to be nationalized was too good to miss. But the senior doctors had worked hard to get to their current earning potential and were threatening to boycott the fledgling health service and bring it down, as they felt that it threatened their private practice. The only solution was as Nye Bevan so aptly put it ‘to stuff their mouths with gold’. In a plan cooked up with Lord Moran (Churchill’s personal physician), they decided to allow senior doctors significant pay bonuses for committing themselves to the NHS. The bonuses were large and pensionable, and so were worth a great deal of money. The NHS was formed and I for one believe that in 200 hundred years time (if there is anyone left around) children will be taught in history classes that in1948 a small island state called Britain made a huge leap forward in civilization by making health for everyone free at the point of demand.
However, very quickly the senior members of the medical profession managed to pervert the NHS and this self-awarded bonus system so that even those doing private practice were entitled to get the awards, so they were no longer for committing themselves to the NHS. From then on it was nothing short of a self-perpetuating scandal. The awards were decided in secret and seized upon by the Royal Colleges to reward those members who furthered the aims of the Colleges. In other words, they were a salary system for the Royal Colleges. Merit awards were divided into A+, A , B, and C and eventually, I decided to try a spoof letter to the BMJ, co-authored with Alan Maynard a delightful left-wing health economist from York. We suggested simplifying the merit award system by amalgamating the A, B and C into one award which for the sake of argument we would call a ‘D’. This would be awarded for not attending outpatients, ward rounds and operating lists and would involve removing money from your salary (hence the De-merit award). We wondered how the medical profession would like this plan if it too was awarded in secret. Richard Smith the editor of the BMJ wrote back to say that this was the fastest letter to ever go into the BMJ having been read, accepted, and set to print within an hour of arrival.
At around this time I was being used by Hospital Doctor, a weekly freebie, to act as an advisor and eventually as Guest Editor. This was at a time when the GPs had asked for a 30% pay rise because they were unable to recruit any junior doctors into general practice. I was duly phoned for a hospital doctor’s opinion. Rather to the disappointment of the reporter, I said that I thought it was a reasonable idea as we now lived and worked in a Thatcherite market economy. Clearly, the reporter was hoping for some offensive hospital-centric soundbite. However, she did not give up. She went on fishing for something newsworthy and asked what I would then do about hospital doctor salaries. “Oh” said I without thinking.”By the same argument I would reduce them, as we are having no difficulty recruiting”. Now that was a juicy sound-bite and duly made the front page suitably abbreviated and sexed up. I always knew when something I said was in the media, because people tend to avoid you in the corridor, especially if they disagree with it, as they usually did. On this occasion I saw Mike Kettlewell at the end of the corridor, the senior colo-rectal surgeon, and my tutor when I was a student. I waved to him but he turned on his heel, then thought better of it, spun round, and strode up to me. “I read your article in Hospital Doctor,” he said. “I wiped my bottom with it!” and strode away. Well it was not my article, it was just me letting myself be quoted out of context. But what I did gather from the short interchange was that I had clearly trodden on a raw nerve. I also gathered, I suppose, that he read Hospital Doctor on the toilet!
Migration of Hips
It was becoming increasingly obvious to me that the development of new designs of hip replacement was nothing to do with helping patients, it was to do with justifying R&D departments that provided new material for marketing wings of the big multinational orthopedic implant manufacturers. I had been to watch John Charnley operate, and his results were as good as any that anyone has ever produced. I also listened to Ring who had a metal-on-metal implant that was a joy to put in. Unfortunately, he reviewed his own results and subsequently, we discovered that he was lying about them. When he retired his replacement was left with a real can of worms.
No one really understood why implants did and did not work, but what was clear to me right from the beginning was that operator error was a far bigger problem than design faults. All surgeons like to blame their failures on their implants but it was patently obvious that consistent good technique was more important that any design factor. I was lucky to get a leader in the BMJ about this and then gave a lecture on the techniques used by salesman. I postulated that when a salesman was handed a new implant to sell, he would go to surgeons I called ‘Toads’ (after Toad of Toad Hall) because they were prepared to try anything provided that it was new. However, these toads were also fickle and would change to a newer design (by another company) as soon as that came on the market, so the salesmen then had to target the floaters, the relatively few surgeons (< 20%) who would change to a new implant if the Toads like it and published results look good. The third and by far the largest group were the Ostriches whose heads are buried firmly in the sand and will not change implant if the world disintegrates around them. I had become involved in the design and marketing of a hip (not very successful) and a knee (very successful) which were both bringing in royalties and also exposing me to the murky world of design, manufacture and marketing. At that time an implant cost around £100 to make (depending on the length of the production run). It had originally cost £150 to buy in Charnley’s day (50% markup), but by then they were costing £400 and shortly afterward would cost over £1000, a mark-up fit for a king. All those profits were going to shareholders and massive R&D departments designing new implants which were never better and frequently worse than those that had gone before.
Obviously, you could not stop innovation but a method to determine quickly the likely success of an implant would be very useful and that is what I tried to develop. The Swedes in Lund had created an incredibly accurate system for measuring whether an implant was moving in relation to the bone in which it was implanted. It was a complex system developed by a manic depressive who collected old Russian copper coins and who committed suicide shortly after I visited him! I left for Lund on a beautiful spring day in March and arrived to find the temperature there far below freezing. I only had one light pullover and no coat. My Swedish landlady looked at me gloomily and said “You will die of cold. The Lapplanders are coming south and they are dying of cold”. It was an expensive mistake as the cost of living was very high and I needed extra clothes urgently. However, I brought the technique of stereo-radiogrammetry back to Oxford and then had to try to persuade the Department of Health to fund the project. At that time there were still only relatively few hip replacements being performed and the epidemic of failures had not hit us as it has now. I begged, cajoled, and pleaded for funding and got some but it was a real uphill struggle. Everyone agreed with my predictions of what was coming, but it had not yet come, so it did not need dealing with yet. The system cost a lot of money to set up and quite frankly, by the time that we had it working, I was bored with the whole thing.
I am more interested in new ideas than in the drudgery of day-in day-out trying to get funding and take research forward.
I cannot help but notice that in Oxford at least a considerable number of research team leaders are strong if not fundamentalist Christians. I cannot possibly understand how a Christian, whose life revolves around ‘belief’ can be a good research worker where ‘disbelief’ is crucial if hypotheses are to be rigorously tested. Maybe Bertrand Russell got it all wrong in his History of Western Philosophy. Perhaps science is not dominated by open-minded people who induce theories on how things work then test those ideas to destruction using deductive logic. Perhaps you need to have the passionate and unshakeable beliefs to give you the determination and tenacity to get research grants in your field and so become a successful research worker. If so, the research produced by these people is likely to be under very heavy pressure from bias because these people are great believers. I had become more and more interested in this subject as we investigated a blatant fraud case at the Journal of Bone and Joint Surgery which had been uncovered quite by accident. Richard Smith at the British Medical Journal set up an anti-fraud group and the first talk given to us was by Drummond Rennie the editor of a top US medical journal JAMA. He was a large bearded man and presented a piece of work that they had done. They had taken the first ten papers accepted for publication by JAMA in I think 1998. They sent a sub-editor out to the laboratory which had written the paper and arriving unannounced congratulated them on their paper and asked to see the raw data set on which the paper was based NOW! Seven of the ten labs declined and withdrew their papers forthwith. I remember there being a communal gasp from the whole audience, at which point Drummond slammed his fist on the lectern, glared at the audience, and said “God damn it. It is happening here too. You just haven’t looked”.
I was on the editorial board of the Journal of Bone and Joint Surgery and went to our editorial board with the findings of this meeting and asked to be allowed to start randomly sampling submissions to start changing the culture. The editorial board ummed and ahhed and then said no. Their reason was that it might put people off submitting articles to the journal (fraudulent ones presumably) and this would potentially damage the sales of the journal. So, at the end of the day, profit and viability were more important than integrity and trustworthiness. I resigned from the Editorial Board with a sigh of relief as I was tired of reading complete rubbish which is what 9/10 of the papers were.
At the same time, we were working on journal clubs and the question arose as to whether people were actually reading the medical journals.
Reading the BMJ
We set up an experiment with the medical students (who will do anything and are permitted to do so). At the beginning of the Grand Medical Round in Oxford, we closed the doors and asked everyone present to fill in a quick questionnaire. Did they receive the BMJ every week (70% did) and did they read it cover to cover (again 70% of those who got it said that they did). We then asked them to turn to the second questionnaire where there was a simple test on each of the eight original papers published that week. One on the title, one on the methodology, and one on the conclusions drawn. So, 24 questions and I suppose we expected a mean of something like 10. The result was 0.4 with some very angry comments scribbled on the paper like ‘My BMJ didn’t arrive this week’ and ‘it was a particularly bad issue’. To my surprise, the BMJ turned down our paper with these results at their hanging committee on the grounds that it was mere belly-button gazing and did not apply to other journals! So, we repeated the experiment with the Journal of Bone and Joint Surgery but we gave them a month to read the journal as it only came out monthly. Exactly the same result! Eventually, the Lancet took the paper but only, I suspect, to spite the BMJ.
Our humorous revenge was to write a Christmas BMJ article (these are always outlandish or spoof) on a new condition consisting of a triad which we called Polythenia Gravis. The triad was osteoporosis due to increasing age, nocturia for the same reason, and then a pile of journals in their plastic wrappers lying unread beside the bed, which are slippery and cause falls which leads to the fractured neck of femur in elderly consultants getting up in the night to pass urine.
We did a second article on the antics of research workers but that never made the light of day. Writing the articles was a team event in the evenings at Braunton and provided a lot of enjoyment.
Thromboprophylaxis
It was around this time that the pharmaceutical industry started a big push for surgeons to give thromboprophylaxis to patients having hip and knee replacements.
Duthie insisted on using warfarin which was tricky to start and even more difficult to monitor. It certainly caused some massive bleeding in some of our patients, so it was not without risk. Again I became uncomfortable with the dogma and traced back the source of the figure that up to 5% of total hip replacement patients died of pulmonary embolus if precautions were not taken. Again it all went back to a single paper published in the 70s out of the Mayo Clinic when they were advertising their availability for this new operation. All attendings at the Mayo seemed to be required to produce regular papers auditing their results, which were of no real value, other than an attempt to drum up more business. Anyhow this paper was based on only 60 patients of whom two had died of what had been called pulmonary embolus. It was by far the highest figure that anyone has ever quoted but was seized on and used every time a new paper came out advocating thromboprophylaxis. Except that having quoted this paper in their introduction, these studies then merely measured changes in the incidence of deep vein thrombosis when their study drug was given. DVT is a rather dubious surrogate measure of Pulmonary Embolus because although it is common and cheap to measure, its connection with fatal pulmonary embolism seems to be extraordinarily tenuous.
One of the things we had in Oxford was a huge database of all the patients admitted to the hospital, their diagnosis, and their subsequent re-admission or death. This is an epidemiological gold mine. Anyhow we could study 10,000 hip replacements performed in Oxford before even warfarin was used, and we found that the death rate (corrected for those who would have died anyhow, whether they had a hip replacement or not) was not 5% it was 0.9%. Furthermore, two-thirds of these patients died of stroke or heart attack, so the pulmonary embolus rate was now at most 0.3%, far far lower than the Mayo paper quoted. The paper got a big spread in the BMJ and was completely ignored. The drug companies and research workers in Thromboprophylaxis all had a vested interest in this being an important issue. When we started looking at the complications caused by thromboprophylaxis it was like cutting off the heads of a Hydra. As fast as we showed that the complication rate of one drug far outweighed its benefits, the industry would use these figures to persuade gullible clinicians to change to even newer, and more expensive drugs. Our research was actually helping their marketing, and research grants were impossible to get, as no one wanted to believe that this was a non-problem.
Casualty
One of the other things we discussed at Braunton was the effect that the media might be having on the public’s perception of health care and how they should use it. We decided to see if we could send strong messages through a soap opera and then measure whether it had any effect on attendance at casualty. We contacted a scriptwriter for the soap opera ‘Casualty’ which at that time was being viewed by 11 million people each episode. They were interested and agreed to play. I went to the Nuffield Trust in London for money, where the Dean of the Oxford Medical School, when I had been a student, was now a Trustee. He remembered me well but to my surprise, he remembered the episodes where our paths had crossed as wonderful times. It must have been him who swung the committee because we got the money that we needed. Then the Casualty script writers pulled the plug. I don’t know what scared them off, but suddenly they decided that they were being manipulated and insisted on editorial freedom. The project was in disarray. I met with the director who was obviously feeling quite guilty about things but I could not change her mind. However, she did say (in strictest confidence) that they were currently filming an episode where a suicide attempt as a gesture goes horribly wrong. The character uses paracetamol, a pernicious poison, which destroys your liver sometime after the overdose is taken. In the key scene, the suicide patient has got over the initial effects of the paracetamol overdose and has reconciled with his estranged wife when his liver fails and he dies horribly, vomiting up copious amounts of blood (very good TV!). Well, it was not what we had asked for but we decided to measure drug overdoses and in particular, paracetamol overdoses in the weeks before and then the weeks after the showing. To our absolute amazement, the overdose rate rose a staggering 30% in the week after the episode was shown.
Luckily we had also chosen to use focus groups to discover what people were thinking not just what they were doing, and pretty soon these results started coming in too. When people who had seen the episode were shown still shots of critical moments in the episode, they were able to say word for word what had been said by each actor. So the first conclusion was that popular soap operas are incredibly well remembered, and have the potential to be very strong teaching events. The second finding was that middle-class families were surprised to find how dangerous Paracetamol is. Some had watched the program and then gone straight to the medicine cabinet, removed the Paracetamol, and flushed it down the toilet. Other groups consisting of people who had taken overdoses before, were also surprised at how dangerous Paracetamol was but were now planning to use it in the future to commit suicide. So the response to any story may depend as much on the viewer’s frame of mind as the content of the drama. The director of the BBC tried to poo these results, as effectively it screwed any TV company’s freedom to produce drama which might miseducate a proportion of the population and the paper has been firmly buried.
I was doing more and more with statistics and was becoming increasingly aware that they were the ‘elephant in the room’. Everyone knew that we had to use statistics but everyone was terrified of them. In the end, they would simply stuff their data into a user-friendly stats pack like SPSS and see what came out the other end with a p-value with lots of zeroes. When challenged on the logic of what they had done they would just throw up their hands in despair. So arose Bulstrode’s laws of statistics: 1. If p<0.001 in a biological system you are either testing the frankly obvious, or you are using the wrong test. 2. If you use SPSS you will find no statistical significance in the hypothesis you are actually testing, but will find several other correlations which are chance findings. These will provide you with an endless source of speculation as to why the length of the left little toenail correlates with the incidence of generalized arthritis in males only, or some such nonsense!
So my conclusion was ‘If you need to use statistics to prove something (which they cannot do) wouldn’t you be better off just not using them and let the figures speak for themselves.
I would give a lecture for orthopedic surgeons, where I would teach them all they needed to know about statistics for the exit exam while keeping them laughing throughout. It seemed to me that most of the problem was terror combined with statisticians deliberately making things difficult to impress others with their mathematical prowess.
FRCS(Orth)
When the exit orthopedic surgical exam came in, I decided to sit it even though I was exempt as I already had a consultant job. I felt that I had not had good training and wanted to validate my competence. I also wanted to become an examiner and felt that I would be more credible if I had seen the exam from the other end too. The exam rotated around the Royal Colleges, London, Edinburgh and then Dublin. I went to Ireland to sit the exam as I did not want to be anywhere too public if I disgraced myself. Even so it was a stressful experience which I hope that I did not forget when a couple of years later I was made an examiner myself. I was always given the Basic Science viva table because no one else wanted to do it. The poor candidates were petrified of ‘all that stuff’ as one of them called it, but what I did not tell them, of course, was that they could not fail the basic science viva because I could not believe that knowledge of basic science was anything to do with whether you were a safe orthopedic surgeon or not. One poor trainee who was an archetypal rugby-playing orthopod came to my table sweating with terror. I started off gently by asking what was meant by the word ‘bias’. I will swear that I saw that question go in, and cross his cerebral cortex without stimulating a single neuron. It bounced around the cranium a few times and then died. Clearly, he did not have a clue. Before I could try to help him I saw his jaw set firmly and he started to speak. He had decided that he was going to fail and if so, he was going to go down all guns firing. “Professor Bulstrode, “ he said “Bias” He hesitated then plunged. “Bias is being sent to your table for a basic science viva”. I roared with laughter and passed him.
Examiners training
It was a short step to designing a course for examiners. I felt passionately that I had been treated badly in exams and I saw very poor behaviour amongst my fellow examiners. Many had forgotten that the purpose of the exam was to assure the public that candidates were safe to practice. They were indulging in some ritualistic rite of passage where the candidate was humiliated and terrified and then passed. For ten years the examiner’s training course was a major event for all the surgical boards. The bit of the course which they liked best was where we invited them to be difficult candidates. We had ‘Thatchers’ who once they had started talking would not stop, so that you could not ask them another question, which they might not be able to answer. We had ‘Heseltine’ servers (named after a famous cabinet minister) who when asked one question, bent their answer to deal with something else that they knew much more about. We also had ‘begging trainees’ who affected great interest in what the examiner thought, and so tried to get the examiner to talk for the rest of the viva. Finally, we had the argumentative ones who challenged everything that you say. It provided a tremendous opportunity for individuals to indulge themselves but I doubt that it taught very much.
Edcon
I had also been over to the United States to take part in a course designed to train orthopedic trainers of the future. There were only 20 of us on the course which lasted for five days and went through a lot of theories relating to adult education. I was very impressed with this course and wanted to bring it to the UK. The facilitators agreed to come if I would organize the course in an English Castle. I had to raise money for their fares, find a venue and then try to get the major organisations such as the Royal Colleges to sponsor participants. It was a major effort but it succeeded and a leader in the BMJ was the result. The course was run at St George’s Chapel in Windsor Castle and this seemed to satisfy Fred Lippert and Jim Farmer. However, it was clear that the American course was not appropriate for our needs. The course needed to be shorter, more focused on training, and run by British facilitators.
This was around the time that I met Vicky. She had done a lot of work in adult education and was a brilliant organizer working in the Post Graduate Deanery. I found that she could rapidly cut through my muddle of ideas and produce a course that worked. However, she didn’t want to do any of the presenting so I was nominated as the anchor-man at the front trying to explain the concepts and deal with the difficult customers. It was a good duo.
The course evolved steadily reducing from being three-day residential to two-day non-residential. It saved money but was a pity because the discussions in the evening were wide-ranging and fascinating. Slowly the course spread all over the world. Denmark adopted it as a national course while we also ran courses in East Africa and even in Czechoslovakia for USSR psychiatrists. That led on to the Soros Foundation sponsoring a course in Lithuania and a course for Lithuanian doctors to come to Britain. This course was held on Lundy Island in a storm and eventually, we had to be helicoptered off. We never made a penny from it, but we were lucky to be sponsored by some major charities such as the Bill and Melinda Gates Foundation, Oxford University, and national bodies.
In total, we provided one or other of the courses to over 25,000 doctors. During that time we too learned a lot. First the negatives. There was no point in providing the course to senior/older doctors. Even if they liked the concepts they reverted to didactic teaching as soon as they were back in their hospitals. The corollary was also true. The younger the doctor the bigger the effect. We could measure this because completion of the course involved submitting a description of a training program that they had designed, and then run. Finally, they had to write a reflective piece on what they had learned. Some of the projects were fascinating (teaching Bangladeshi women in the Cowley Road how to do CPR – heart attacks were common in their menfolk). Finally, we realised that students could teach other students and that they naturally had insight into the problems of learning. The outcome for the young, keen, teachers and learners were that they could identify and negotiate a training event on any subject for as much time as there was available and create a defined and relevant training event. It worked, not for all, because it was hard work and required an inventive mind, but it worked often enough to change the culture of learning where it was used.
The examiner’s training course focused on the same principles but was less successful. The examiners were older and had their favorite topics. They could not get behind the questions to identify the principle they were trying to test, but we worked with many hundreds of surgical and dental examiners.
The Deanery Books and Courses
The Deanery
When the new Deanery was built in Oxford I was made an Associate Dean with a special responsibility for training. Vicky was working there too and it was my most productive time for writing courses and, I suppose, books.
I was the new third editor of Bailey & Love, the most famous and best-selling surgical text book in the world. You can age a surgeon by the edition of the book above his desk, because you can be sure it will be there. None of us could pass our Fellowship without knowing that pale bulky and offensive book from end to end. Orthopaedics was a bolt-on when I joined, and I was determined to make it stand alongside general surgery. But it was not easy. I had my first exposure to the duplicity of doctors (or at least surgeons). They would agree to write a chapter with alacrity and promise to deliver on time. Then – nothing. Finally, if anything came at all it did not bear any relationship to what you had asked for and sometimes was simply cribbed from other books. If you want to do something well, then do it yourself. I ended up writing or rewriting most of the orthopedic section of the book and was quite proud of it. Unfortunately, we completely left out the commonest fracture of all – the Colles fracture. I don’t know how that happened but from somewhere in the Indian subcontinent there came an ever so polite handwritten letter apologising profusely but pointing out what was missing!
OTOT
I was also Editor in Chief of a completely new project – the Oxford Textbook of Trauma and Orthopaedics; three volumes covering everything you need to know in this surgical specialty. I despaired of that book. I could not get people to write. One of the chapters on audit was supposed to be only 2500 words. It did not come and it did not come. I kept on writing and getting charming replies. Eventually, an email came with an attachment. In those days attachments slowed everything down and this one took all night and half the next day to download, during which time the computer could do nothing else. Finally, I opened it to find that he had sent a picture of the view of some Irish mountains that he could see from his bedroom window. I went ape shit and wrote him a furious email. On almost the last day before everything had to go to the printer he finally sent his chapter. It was 75,000 words long – a veritable book. I received it on Friday and a 2,500-word chapter had to be in on Monday. I wrote it over the weekend using any of his material that I could and sent it in with a copy to him. He wrote back saying that he never wished to see me or speak to me again, as I had destroyed a work of art!
Another author who was very very late promised me that his wife had posted it that very day. This was after four or five failed deadlines. I decided on an impulse to phone his wife. She had no idea what I was talking about. This consultant surgeon was prepared to lie, lie and lie again when he could not deliver what he promised. I simply dread to think what his clinical practice must have been like. But the worst thing was that all the illustrations for the book went missing. After a year I was forced to write to all the authors to explain what had happened and ask if they possibly could send alternative images. Some were single originals (how stupid was that) and I had some very angry letters back. Then, some months later Oxford University Press rang me to say that they had opened a room and found all the illustrations tidily labeled in boxes. The whole affair was a dismal experience. At least Hodder the publishers of Bailey & Love were efficient and did lovely illustrations and their books sold. Each edition of Bailey & Love has sold over 100,000 copies. The Oxford Textbook had a 3,000 first print run and over 1,000 were pulped unsold. When I heard what was happening I bought as many copies as I had the money for at £100 each instead of the list price of £350. I then sold them from the boot of my car (quite literally) each time that I went to give a lecture. Within weeks they were all gone and people were clamoring for more.
While at the Deanery, Vicky and I wrote the manual and the course ‘Educating Consultants’ which was our first effort to replace the five-day American course. It was a resounding success and we could not lay on courses fast enough. We followed that course with a similar one for dentists, then for examiners, and then for appointment committees. Finally, we wrote a lovely course for registrars coming up to a consultant appointment committee. In that, we taught them how to read a spreadsheet with a very clever exercise written by David Wilson the Medical Director at the NOC. It also had a useful exercise giving people practice in facing an interview board. Candidates told us that it was not so much being the interviewee that was the learning experience, it was watching someone else and learning from their good performance and mistakes.
Tepla
We ran courses all over the world, in Africa, in Russia, in America, and in Australia. We flew Concorde to Washington just on air miles. There the course was held in a suite of oak-panelled rooms high up in the Walter-Reed hospital. The rooms are kept ready for imprisoning an ex-president or senior government official who loses his mind and presents a danger to national security. Our trip behind the Iron Curtain (which by then had rusted through) was at the invitation of the Soros Foundation who wanted to try to modernize soviet psychiatry, a worthy goal. We traveled to Tepla, an enormous 2000-bed monastery high in the mountains above Prague, where psychiatrists from all the ex-Soviet block countries had been invited to attend and their expenses paid. We arrived late at night through deep snow to be met by a UN official who was in despair. He said that their first day had been on making a presentation to the Ministry of Health applying for resources for their service. He said he wanted us to change our course and focus on preparing a business plan as they were hopeless. I got stuck into the duty-free, and Vicky started work on preparing a new course. The next morning we were faced with around sixty psychiatrists young and old, male and female. The course was going to be in Russian so translators were sitting on a gallery above us and we were given headphones. The first presentation started (luckily not by me) and within five minutes one of the audience was on his feet arguing loudly (in Russian) about something! For some time nothing came through on our headphones and then the translator started slowly “He does not like the Russian language”. We had not realized that most of the delegates were from soviet satellites and so Russian was not their first language. “ Ah! he does not like you. He thinks you are capitalist imperialist pigs, who patronise him by coming here to tell him what to do”. The translator had given us this translation with what almost sounded like relish, and was still speaking long after the delegate had finished. It was difficult to know what facial expression to put on when someone has finished saying something quite important to you but you have not yet heard what they had to say. Without batting an eyelid Vicky, bless her, took control of the situation. She called ‘time-out’ and suggested that everyone went and had a coffee and a smoke (they all smoked like chimneys) and then we would restart.
As soon as we met together outside, she suggested that we revert to our original course, and that to liven things up we should do a role-play in front of them showing what it was we were trying to achieve. She invited the translators to join us and suggested that we would all sit around a table like in a play and that the translators would stand behind us translating each thing we said. We just had time for practice, but halfway though our dress rehearsal my translator tapped me on the shoulder to ask what I meant by a phrase (I can’t remember what it was now). I was quite off-hand and said that it was just slang for ‘x’, and then went on the explain that it was the infinitive of the verb ‘y’. I don’t know why I felt I had to say that, but the riposte was quick and cutting. My translator drew himself up to his full height and said “Today I am just your translator. Normally I am full professor of English Literature at Kiev University. You have been accused once today of patronizing, please do not patronize me also!” The rest of the course is a bit of a blur. We separated off the old guard who had in effect only been prison guards. We left them at their own tables smoking and mourning the passing of what had been a great empire, and we focused on the young ones who were really interesting.
The Lithuanians were especially nice and they invited us to go to Lithuania to run another course. What a beautiful country and full of old castles. Apparently, the Holy Land became pretty unpopular for crusades because everything had been looted and diseases like malaria were rampant, so the unemployed knights applied to the pope to send crusades north into the Baltic regions where there was lots of loot and pagans, but no holy land. The pope was happy to oblige on a commission basis, and the Teutonic crusades began. As a result, huge castles were built far out in the empty land.
Edcon
We had also been running ‘Training the trainers’ courses for the medical students, always taking them somewhere unusual. We were reported to the Medical School by a grumpy teacher from another course and were told that we could no longer do this. We had a course booked for Lundy Island but no students were allowed to come on it. We invited the Lithuanians to come over and they did. We picked them up from Heathrow and whisked them straight down to Devon where we stayed in a youth hostel. The next day we were on the little steamer to Lundy. It was a beautiful day and to my amazement, none of them had ever seen the sea! But it was better than that. We got in amongst a group of Basking Sharks and saw over twenty. The captain stopped the boat so that we could watch them and asked the agent for English Nature to come on the bridge and talk to us about them on the intercom. He came on the bridge and in a trembling voice explained that it was his first day working for English Nature and that he had never seen one basking shark before never mind twenty. On the island, we were based in the lighthouse and we had a wonderful course, where on top of educational principles we taught them about English beer and about the wonders of liar dice. My only regret was that they had only seen the sea when it was quiet. They had never seen the glory of a full Atlantic gale. My wishes were to be granted and on the final day we had a great gale whistling around the lighthouse.
Andrew Farmery, a singing anesthetist who was helping us, just took to the tower and sang his heart out, against the howling wind. The following day it was still windy and the sea far too rough for the ferry. We explained that the Lithuanian’s visas were about to run out and the National Trust decided to helicopter us off two by two. The helicopter could hardly fly into the wind after it took off. It just drifted forward over the grass until it came to the cliff edge when it shot up into the air on the updraught and headed for the shore. As we drove them back up the M4 just in time for their flight, one of them said that they had a couple of questions. The first was that everyone in Vilnius had told them that they needed to see London, but they had not seen London. Did that matter? I told them it probably didn’t. Then another one asked. “Is all of England sheep, cliffs, and helicopters?” I told him “Not exactly”.
Our trip to Australia was equally good fun. We were to run one course for juniors, go off traveling, and then run a second course for the consultants at the Royal Brisbane Hospital. The first course was glorious fun. The juniors were right on the ball and the course went swimmingly. However, at the end, the Dean suggested that we didn’t come back as only three consultants were signed up for the second course. Vicky was firm that if there were only three then we would teach only three. Away we went for a glorious week of walking and bird watching. We got back and on Monday morning found 22 very grumpy-looking consultants sitting in the room waiting for the course to start. Vicky asked what was happening and the Dean roared with laughter. He said that yesterday (Sunday) a group of juniors had called the twenty worst teachers into the hospital and told them that they were attending the course whether they liked it or not, and that cover for them had been arranged. Only in Australia could that happen.
Back in the UK we decided to test whether the course actually worked. We gave the course to all the surgical trainers in Milton Keynes and to none in Winchester a similar-sized hospital. We then asked their juniors about their training style. One of the questions that we asked was how often in a week did your consultant praised you. That was a stupid question. We got zero across the board and had to change the question to “When did your consultant last praise you?” This time we got very strange answers such as “10.15 am June 12th, 1999 (two years before!). I remember because it is the ONLY time that a consultant has ever praised me.” It was clear that we were getting very little sustained effect from running this course for consultants. Some of the Trusts were using our training as a Borstal course, sending consultants who were behaving badly in the hope that they could avoid taking disciplinary action. These consultants were interesting people but it was certainly a misuse of the course. Vicky was convinced that we should focus on juniors and of course, she was right. They had enough plasticity to change their behavior and they were both trainers and learners so could use the course to improve their learning as well as their teaching. I still do most of the presentations while Vicky does the writing, the strategic planning, and marks the course work. It is one of the few professional things in my life which I have never tired of doing.
Examiners training
For several years Vicky and I did the training for all surgical examiners. We tried to move examiners away from the old style of ‘Baptism of Fire’ and the idea that passing a few is better than passing many, but the deep desire to make your specialty more prestigious by making the exams harder to pass is buried deep in the psyche of examiners. Certainly, exams have become more reliable but at the same time they have become more boring for the examiners, and there are still profound misconceptions about what exams and examiners should be doing.
The Royal Colleges are becoming year by year less relevant to clinical practice and will I assume one day revert to simply being dining clubs like the Guild Halls in London. I have a theory that organizations go through stages like the seven ages of man. In the first stage when they are just formed there is tremendous energy and excitement, but relatively little product, as they have not yet sorted out what they are doing or how they are going to do it. The second phase is one of great productivity. New ideas are being put into practice. However, fairly rapidly the third phase starts. Here there is an increasing amount of energy put into the way in which the company/college organizes itself. There is an element of complacency about production and a preoccupation with internal power struggles. If the organization is a company, this is when it is taken over, 1/3 of the staff are sacked and the organization goes back into stage two. But if it is a charity or a Royal College, stage three eats it slowly like cancer until in stage four most of the energy of the organization is devoted to internal affairs and production is a side issue. Finally, in terminal stage five there is no production and internal politics are confined to organising dinners and electing presidents. The Royal Colleges do not represent their members: they are staffed by professionals who are bored with their profession and serve no useful purpose whatsoever, apart from organizing occasions where they heap plaudits on each other. They need to be closed down and will do so when people stop paying subscriptions for nothing.
Haiti: Medecins du Monde
Part 1 - A Humanitarian Mission
I really ought to be getting used to it by now, leaving in a bit of a rush on a humanitarian mission.
It starts with the phone call and the first bump of excitement. There is a humanitarian emergency somewhere in the world and they want to know if you might be able to help. Sometimes you can’t help or the logistics are impossible. You cannot get away in the time that they want, or you don’t have the skills that they need.
In other cases the answer is ‘yes’ and that bump is the canoe being pushed off the bank of a huge river just a few miles above an enormous waterfall. At first, things seem to go quite slowly, as you start to drift down the stream. Usually, there are a few hours to pack and to think what support you will need. Then the trees and the rocks start moving past more and more quickly. You are headed for the airport, a rucksack on your back and a passport in your top pocket. This is the moment when you realize that there is no going back. You are now completely in the control of the humanitarian organization who have chosen you, and you are going to have to trust them implicitly. They will have a veritable team of young logisticians focused on you, putting everything that you need in place, airline tickets, visas, equipment, permits etc. You just have to sit in the canoe and enjoy the ride. The work for you starts later.
There is something wonderfully reassuring about the way when the plan takes shape around you, and then quite suddenly you are away out over the waterfall flying through the air (quite literally).
Of course, there is lots that you have to remember too. You must travel light but you must not forget anything you might need. It is the niggling little things like mini-screwdrivers to repair your spectacles that could spell ruin to your best efforts. Almost always a language has got to be hauled out scrubbed up and rehearsed. In Gaza it was Arabic. This time it will be French. I never was very good at French and it is a little while since I have used it, so German words and phrases flood into my mind instead of French ones. I realize how many technical words I simply do not remember and start scuffling through a pocket dictionary, forgetting each word as soon as I start searching for the next.
The flight is a surreal experience in its own right. Although I have brought work to do, I always have a good adventure book too, a ripping yarn, which inevitably captures me in its thrall. So, I am now living in three worlds. First, there is home, where I have come from. It is already starting to become remote as I cross time zones. The logistics of the journey quietly nag in the background my mind, like a sore tooth. Where is my passport? Is the money safe in my pocket? Have I got all the papers I need? Do I need to read up on some special operations? The book I am reading draws me into its crescendo of suspense and at the same time I am coming closer and closer to a place where a lot is going to be expected of me, and I so hope that I will be able to deliver. Then there are the doubts. Why on earth did I volunteer to do this? What on earth am I going to be able to do which will be of any use? Surgery in the third world and in disaster zones is always fraught with problems. The conditions there are always such that you would not normally agree to operate, but the patients have no choice, and ‘anything may be better than nothing’. However, that does not mean ‘having a go’. You need to be strategic and try to work out how you can do the most good for the maximum number with the minimum risk of doing harm. That may mean turning away heart-rending cases that you would love to try to help but should not.
The team of logisticians, working for the NGO, trust you implicitly and have very high expectations of you. They work as a team discussing amongst themselves what is best for each of them to do to make the project a success. For us specialists, it is unusual to have anyone to share our decisions with. When we do, they are usually from a different country with a different culture and speak a different language, so it is difficult to see whether they agree or disagree, and why. It is so difficult to pick up the subtle nuances of speech and gesture, which are needed if we are to avoid treading on each other’s toes.
When we land at the airport in the Dominican Republic (the opposite end of the island from Haiti), there is no one to meet us. This is frustrating because there is no backup plan so we must simply sit and wait.
Just as doubts are really beginning to set in the driver arrives, picks us up, and then starts a convoluted journey which seems to involve picking up various ladies and members of his family and shuttling them to where they want to go. We are tired but it is too complicated to say anything.
When we finally arrive at the office it is locked. The whole team have gone off to find some dinner so we must wait again. It all seems a little unreasonable until you realize that it is 10 pm local time and when we start the next morning they are all in at their desks by 7 am. So they are doing a 15-hour day, and they only took possession of this office 48 hours before we arrived. I am silently glad that I did not say anything critical.
The flights into Port-au-Prince are impossible. There are so many aid flights trying to get in, that there is said to be a ten-day backlog on landing slots. The airport is under the control of the American military and we have been told that Mèdecins sans Frontier has been banned completely for refusing to take ‘no’ from air traffic control. Our logistician team realizes that there are going to be no flights in the foreseeable future and quickly organizes a minibus to take us to Port-au-Prince, a five-hour journey over the mountains to Haiti.
The customs post between the Dominican Republic and Haiti isn’t working because it is partly underwater. It is on the edge of a lake and since the earthquake, the level has risen (or more likely the land has sunk) so the road is knee-deep in water. We cross the border when we drive through some wrought iron gates held open by a charming man in gumboots, who smiles broadly and wishes us luck, as our tires send a surge of water in front of them.
Once clear of the border and the floods the road is full of traffic going both ways. There are low loaders with heavy plants on them, and aid vehicles heading towards Port-au-Prince, and buses loaded with people and their goods heading away. At first, you could miss the damage the earthquake has done. At first, just a wall around a garden has fallen over, then you notice that a house has one story too few. The first and second floors are just sitting on a pile of rubble. As we get nearer to the center, some houses are fine, others have completely collapsed.
“Life has started again and is spreading a thin but colourful veneer over the death and destruction beneath„
There is no rhyme or reason to it. It is obvious that some houses, oh so nearly collapsed, have just managed to stay up. Others just as obviously nearly managed to survive till the final quake, then finally succumbed and pancaked down. Some areas seem relatively intact. In other, there is not a building left standing. In and around this patchwork of disaster people are getting on with their lives. Every open space is a camp of polythene sheets. Every street corner is a small market for food and staples. Brightly dressed people are moving everywhere carrying, talking, and trading.
Life has started again and is spreading a thin but colorful veneer over the death and destruction beneath. The only jarring note is the machine-gun-mounted white UN armored cars at every main junction. They are manned by white Americans in dark glasses. They look very sinister, which is presumably exactly what they want to do; but equally, it looks thoroughly oppressive. As one of the Haitian surgeons said later, as we talked about the situation, “You know every country has parts of its tradition which make them proud, however bad other things are. In Haiti, we are taught as children that we were the first black slave state to throw off the wicked white oppressor and rule ourselves. Now, after this earthquake, the white oppressor is back at every cross-road armed to the teeth and wearing dictator dark glasses. We now seem to have lost the one thing that we could be proud of.”
The airport where we plan to rendezvous with the rest of our team is a pandemonium of tented camps with national flags flying and piles upon piles of water, food, tents, and other equipment. Helicopters are shuttling in and out, while teams from all the countries involved move busily around each in their team uniforms.
I imagine that jousting tournaments in the Middle Ages would have looked a little like this with a tented camp of followers around each knight’s pavilion, and indeed this invasion of Haiti does have many of the features of a ‘crusade’. The coordination of this multi-national, multi-cultural, multi-lingual collection of people itching to help must be an absolute nightmare for the UN.
The headquarters of the French office of Doctors of the World (Médecins du Monde) is in a building which has collapsed so we are now based around the house and gardens of a businessman who has lent his house to the charity for the duration of the crisis. The house is very modern, all steel and plate glass. It was obviously incredibly expensive to design and build and only served to emphasise the staggering difference between the majority of poor living in the shanty towns in Haiti, and the rich elite who rule this country.
It has been decided that no one is to sleep in the house, because there are still lots of after-shocks and there might be another big quake which could bring more buildings down. We were each issued with a tent which we erected in the garden. The ground floor of the house served as a wonderful combination of office and communal meeting area for the team which now numbers something like 30 people. With a little coffee, some Camembert cheese, and some wine, the French have a miraculous ability to create a comfortable ambiance that we can work out of. There was a curfew after dark so nothing could now happen until first light. A quick meal, then I headed for my tent, my head torch picking out the shadows of trees: I remember that I must just go and find my dictionary and look up the word for forceps. I will need it in the morning. After my time in the Army, my tent is up and all my belongings laid out in a tidy, reachable order in minutes. In the morning I was up very early so managed to get to the shower and the loo before the queues started. Then the work began.
Part 2 - A Day in the Life
Children across Haiti have been orphaned by the disaster
I wonder if you have lived a day that has changed your life. Well, I suppose that I just have.
This was my first-day doing surgery in Haiti. I don’t want to get into gory details but I have never seen anything like this in all my life. They told me that last week was much worse. Well, all I can say is that I am glad that I didn’t see it.
We left for the hospital shortly after dawn. We have a driver who also acts as our guard, as kidnapping and armed robbery are apparently national past-times here. The grounds of the University Hospital in Port-au-Prince has become a tented camp. Each of the tents is a ward with 20 patients in it. The tents spread in every direction as far as the eye can see. One area of the grounds is a formal garden where there are trees. Here the patients are on the ground under tarpaulins stretched between the branches of the trees above. That area is called ‘The Jungle’ and is the biggest ward of all. Looking after all the hundreds of patients, there are two doctors, and some firemen from Spain in beautiful uniforms who smile all the time. There are also some Haitian doctors and nurses. At first, I was a little frustrated at how few were turning up for work but later I revised my views. Most people had lost their houses and members of their family. It was actually a miracle that any turned up at all. Just next door to ‘The Jungle’ is the rubble of a huge brand-new modern-design building, which was the new school of nursing. It collapsed completely. On the ground floor, all the second-year nurse trainees in the whole of Haiti were having a lecture. On the first floor, all the third-year nurse trainees in the whole of Haiti were having a lecture. There was not a single survivor. Haiti lost all its trainee nurses in five minutes, and many of its trained ones too. I am having trouble getting my head around this. I am trying to relate it to the John Radcliffe in Oxford.
We operated on trolleys set up in the middle of a waiting room. Michel the French surgeon had one. I had the other. Jacques, the anaesthetist, managed both tables, with a nurse assistant Fred. There were two very experienced scrub sisters and then two runners (nurses who fetch instruments and dressings and bring them to the scrub nurse). We also had two trainee orthopaedic surgeons Oda and Getho who were both Haitians, and two Haitian porters who were supposed to lift patients and transfer them to and from us and the tents outside. Jacques was the lynchpin of the team. He clearly loved ‘emergency’ situations but had that calm confidence that steadies you down, when you have a rising sense of panic that everything is going out of control. He was quietly running the whole show, anticipating everyone’s needs, and quietly suggesting what was needed next. He clearly had a military training in the way that he understood planning. But equally he was a superb man-manager/facilitator making sure that the team ran as well as possible. We had no anaesthetic gases, so the anaesthetic was either general anaesthesia managed by intravenous drugs (very tricky) or a regional block to the nerves supplying the area we were operating on. When Jacques put both patients to sleep he would stand between the two beds with his arms outstretched as if he was being crucified. Each of his hands would hover above the face of a patient. He was ‘feeling’ the air coming out of their noses, making sure that they were still breathing. If one of the patients stopped breathing, there would be a soft murmured “Excusez-moi” and he would move to that patient, ventilating them with a bag until they started breathing again. When he was away sorting out delivery of patients, Fred his assistant would take over the same role. Fred loved Pink Floyd, could play all their songs and knew all their lyrics backward but would never speak a word of English. However, he clearly felt that as I was English, I must know them personally, or at least empathise with them, so he would discuss his feelings about them with me. These soliloquys in French could go on for what seemed like hours, and I could not understand a word. So I would merely exclaim at regular intervals “vraiment” or ‘incroyable” and hope that this was the right response. At first Oda and Getho were very diffident indeed, to such a degree that I thought that Getho was bolshy and lazy. Later I was to discover very differently. Michel did not like me. I was English and a Professor and clearly threatened his perceived position in the team. At first he would not even speak to me either. Later, when he realized that I was not going to challenge his judgement or his authority he lightened up and would at least discuss cases with me briefly. On the first day the two of us, working side by side, did 25 cases all supervised by Jacques, who literally danced between the tables keeping the patients alive but asleep.
As for the wounds. No! I don’t want to talk about them. They are dreadful.
A ballet dancer for the national dance team has lost a leg. She is lovely and smiles a little, but I have got to try to save the rest of her leg. I have no X-rays. I am guessing how much more needs to be amputated to prevent infection from spreading.
Meanwhile the physicians looking after the wards are popping their heads through the door and asking if we can take another amputation or an infected wound. There are at least eight operating theatres working simultaneously in different parts of the hospital each run by different countries with different expertise. Pretty quickly we are settling in to a routine. When we first arrive just after dawn in the morning the nurses start sterilizing the instruments and setting up the surgical equipment. We head off to the tents to try to find patients who need urgent surgery and to see how our patients (whom we have already operated on) are doing. There are no staff in the tents during the night, but during the day there are Mormon volunteers and a few Haitian nurses. Many of our patients have to be brought back more than once to keep on cleaning the wounds until the infection has been eradicated and healing can start. We bring back a list of eight or ten patients on whom we want to operate and write their names and locations on the board. The Haitian porters are then sent out with trolleys to bring them in. They clearly are not used to working at this speed and several times I shame them by going out and getting the patients myself. They don’t like this but unfortunately, it only serves to make them more resentful. However, I warm to Oda and Getho as the days go by. They are patient and courteous and very good with patients, explaining in Creole what is going on, and reassuring them. They explain that there were only seven orthopaedic surgeons in Haiti before the earthquake and now five have left for Miami as they had not been paid by the government for six months and now their private practice is finished too, so they simply have nothing to live on.
Some of the clinical decisions that we have to make are easy. Many of the wounds are clean after a few days and need grafting. Our skin graft knives have not arrived but the Norwegians have a surgeon with a skin grafting knife, so we walk over to meet them and they agree to take the patients who need grafts. A young man has lost the back of his elbow. The skin muscle and joint itself have all gone but the soft tissue at the front which carries all the nerves and arteries to the hand is fine. I can’t amputate this arm when the hand is working perfectly, but the wound is already infected and I must make a decision.
I stick my head into the door of the US operating theatre. I want to meet them anyway and I need some help and support here. I run the case past a soft-spoken head and neck surgeon from New York. He listens carefully, agrees that this is a problem which needs evacuation to their hospital ship and walks over to a harassed-looking doctor in the corner with a clipboard.
Next moment I am asked if I can have the patient outside the door in ten minutes as there is a helicopter leaving for the hospital ship and they have plastic surgeons on the ship. We bring him across on a stretcher, tuck our meagre notes under his legs and within moments two soldiers from 82nd Airborne have transferred him onto their gurney, slipped him into the back of a Humvee ambulance and are away to the helicopter landing strip. There was only one day when the American hospital ship took patients. After that, they said they were full and took no more patients. However, the visit to the Americans was doubly useful. Frank noticed an unused ultra-sound machine and asked through me whether we could ‘borrow’ it. John, the doctor I asked, had no idea who it belonged to but magnanimously waved us away with $100,000 of equipment. Jacques was over the moon. He could use the ultrasound machine to rapidly and accurately position his needle when anaesthetizing a single nerve. We now had quick and safe regional blocks and could work even faster than before.
Minutes later, John the American was back in our operating theatre asking if we can take three cases as they were swamped with another influx. We were delighted to co-operate and started working a little faster still. Each patient who received an operation had written in bold letters on the dressing what was needed next, and the date when it would be needed. That was almost the sum total of the notes available.
Patients were being moved the whole time, so we might have a name but we could not always find the patient. The fire service volunteers from Spain were brilliant at finding patients. They had beautiful black and red jump-suits and always said “Si. Esta Possible” to whatever you asked. We would give them the name of the patient and with seraphic smiles and a stretcher between them, they trot off into the melee of tents to find the patient and bring him back. I don’t know how they did it as they only spoke Spanish but their way with people is wonderful to watch and left our Haitian porters thoroughly eclipsed.
When I was in Afghanistan I saw people do brave and kind things. I also saw them go that extra mile and finish a job that they really didn’t have to do. Here I saw an even higher level of commitment. Everyone in our team was working, thinking, anticipating, to the utmost of their ability. Giving of their best. Every time I needed something it was there before I even asked, and if it wasn’t there because we did not have it, then someone was running across to another team operating somewhere else to see if they could borrow some equipment or help. And these were people who have lost their homes, and members of their family and have no idea where they will sleep tonight.
We had to stop as darkness falls as there was no lighting but even then there was tons of work to be done tidying up and resupplying. Doctors of the World (Médecins du Monde) is the most fantastic organisation. While we were working, a whole team of logisticians, a chain of people, stretching back to Paris, Madrid, Montreal and London were beavering away day and night to get the right kit to us as quickly as possible. We went through hundreds of dressings every day, but as each day ended, new ones arrived from the other side of the world. Now that is what I call organization. Before it is completely dark we have to leave and get home before the curfew starts. Each day we took different routes and got further glimpses of the extent of the damage. The centre of town was a scene of utter destruction and dereliction.
Part 3 - Tectonic Plates
Hundreds of people are still picking over the ruins trying to salvage wood and anything valuable. Fires burn lazily throwing up plumes of black smoke which pervaded everything with the horrid smell of burning human flesh.
It is now 2 weeks since the earthquake but they are still burning the bodies where they find them. 100,000 dead and that is only the bodies which they have found! Who knows how many more are under the untouched piles of rubble? As the diggers start to move into clear rubble, half-decomposed bodies tumble out. I have no doubt that some of them were trapped for many days hoping for rescue but it never came. I can think of no worse way of dying.
The earthquake in Haiti is the result of a gigantic geological accident. Tectonic plates from different continents are colliding. But we have tectonic collisions between cultures too. We are trying to work along-side medical professionals who work in a completely different way. The Americans are spending hours on each case trying to reconstruct limbs that we would quickly amputate. They are horrified by our callous approach. We think they are nuts. Reconstruction requires after-care. There was no aftercare before the quake tore apart this benighted country. Now there is even less. Local medical professionals and international medical professionals are trying to work together but are also learning that we have a completely different approach to patients and their injuries. Meanwhile, the cases pour in. There are patients with amputated limbs. Then there are crush and burn wounds. I am completely obsessed with the thought of what agony these patients must have been in for the last two weeks. And they are the tip of the iceberg. They survived. Some died at once, others slowly and in agony.
On the third night, we had a meeting of the Doctors of the World (Médecins du Monde) staff back at the house where we were camped. At the meeting, it was discussed how the effort we are making now must be the beginning of an even bigger sustained program, not the end of an emergency response. We now need teams to re-fashion the stumps of patients so that they are closed properly. Then we need limb fitters and physiotherapists to get these patients going.
I wonder where the money is going to come from to reconstruct this poor and terribly damaged country, but ideas and concepts come free.
Part 4 - Living in the Field
Work will soon move to post-operative care and logistical support
When you go on a medical mission to provide emergency aid, you might imagine that you just jump onto a plane and get on with it. Nothing could be further from the truth. You can certainly do exactly that, always assuming that you can get a flight, but then when you get to the other end your problems have only just begun. Even if you don’t find yourself turned away by Immigration on arrival there are many questions. How are you going to find anywhere to stay? How do you stop all your kit from being stolen? Where will you find food? How do you get to the hospital or wherever you propose to work, and what are you going to do about language? These little problems can occupy so much of your time that you won’t be able to do anything, however much you want to. Worse still you may find yourself a drain on desperately needed resources of shelter, food, and water.
In contrast, if you are invited by a non-government organization (NGO), they handle all of this for you. The big ones have a huge team of very experienced staff who manage the ongoing programs, drop everything, and work day and night when a disaster like the earthquake in Haiti occurs. They quickly work out what they think is needed and then they build the team that they want for the job that needs to be done. It is a great honor to be asked to represent them. And of course, with the honor comes the responsibility. They have to trust you to do the best you possibly can for the injured and at the same time act as an ambassador for them in that country. In return, the NGOs do what they can to make life as pleasant as possible for their team in the field. All the staff at their head office have worked in the field themselves so they know how lonely and uncomfortable it can be.
Before we set off from Europe each of us had to think what we are going to pack in our rucksacks to be able to live comfortably and to be able to do the work we need to do, yet travel light. It is a game of guessing. Yes, you need a good head torch both to see in the tent and to operate. Yes, you need wet wipes in case there is no shower and no toilet. But do you need a laptop? How many books are you going to bring? (They are heavy). And what surgical kit do you need? We all get it wrong of course. I forgot talcum powder, and in this heat with sweaty hands I cannot get my surgical gloves on without a hell of a struggle.
Being a French team – little luxuries kept on appearing. For example, Camembert cheese, or a bottle of lovely wine. I don’t know how the French do it, but they get a special expression of suppressed glee on their faces as they reach deep into their rucksacks and draw out some rare delicacy perfectly preserved. All around there are deep Gallic groans of appreciation and anticipated pleasure. Then they cut it into tiny pieces and everyone savors a morsel, each of them looking like a free-range chicken drinking from a water trough as they enjoy every bit. It was a great bonding exercise.
We were all primarily responsible for our own work, but everyone appreciates a bit of help lifting a patient or adjusting a light. There did not seem to be any leader of the team which surprised me as the task we were doing was complex and continually changing in response to conditions. I found the concept of a tight but leaderless team rather fun. The game for all of us was to anticipate what the team needed and to do it if you had a spare moment, without having to be asked. The result was an almost completely silent room with people moving around very little.
When we went next door to the American OR there was a cacophony of noise, orders being issued, challenged and revised. People running around in a riot of activity. Are they getting more done? I don’t think so.
Over the days the work changed. There are no more amputations (or almost none) and those who are going to survive are mostly through the worst. We were now getting rid of the infection in the wounds and fashioning amputation stumps. Now we needed to get these patients out of hospital and back to being human beings. That meant plastic surgery to close the horrendous wounds, and it also meant somewhere for them to go.
That will be phase two (re-creating human beings). Then comes a third phase. Those people with leg amputations need artificial limbs. There are none in Haiti. So, the final phase must be to share knowledge with the Haitians on how to make and fit artificial limbs. Without this the survivors have no chance of independent life or of finding work. This is going to be a long slog. The next bit is not going to be half so exciting, but it is going to be just as important.
Part 5 – Reconstruction
After we had been working at the hospital in Haiti for over a week, life was settling into a rhythm. Sleep was difficult without earplugs because dozens of dogs bark all night, especially if there was an after-tremor, then there is a veritable peal of barking and howling. Quite suddenly at 5.30 am the cicadas in the trees start their monotonous buzz just like a faulty fluorescent light being switched on. It is just a hundred times louder. Then at 6.15 am sharp, they stopped again just as suddenly as they started and presumably get on with what cicadas do for the rest of the day. Their chain-saw whine wakes all but the soundest sleepers who are sprawled on the sofas and on camp beds in the open trying to find some cool breeze.
Breakfast is quite leisurely and civilized; a chance for all 30 of us to touch base and hear what everyone else is doing and thinking. At this time of day, there is never any electricity so I have difficulty understanding the French as I cannot see their faces clearly in the half-light and I need every cue that I can get to follow their meaning. Then we all pile into an old Land Cruiser for the bumpy ride to the hospital. We weave between rubble and crushed cars, past lines of people carrying water back to wherever they are currently sheltering. As we pass the Presidential palace with its ornate domes tilted at crazy angles, we enter a large park with the statue of some national hero in the center.
This is one of the largest refugee camps, a kaleidoscope of clothes drying and tarpaulins covering families. Hundreds and hundreds of people are milling around talking, selling things, trying to feed their children, find water and get some kind of more durable shelter before the rains come.
Around the corner is the hospital. Its gates are guarded by American troops. They have to be. Even at this time of the morning, there is a queue of hundreds of people waiting for treatment, pushing to be let in. We set up the operating tables as quickly as we can. The Haitian doctors will not arrive for a while. They do not have transport to bring them in, so will walk.
After ten days the hospital tried to close the Jungle as it was becoming a bit of a refugee camp for those patients who have no home to go to. But as fast as they empty it, more patients arrive. Meanwhile, lorries are arriving at the Triage tent traveling down from ‘up-country’ loaded with more patients to be seen. We operate each day for eight hours. As soon as the last case is finished there is an hour’s work tidying up and restocking for the following day, then it is back down to the gates to meet our transport to take us home.
Yesterday the building outside the gates was being cleared with a large digger and dozens of Haitians were digging through the rubble salvaging what they could. The smell was terrible as bodies tumbled out.
To me the horror was the thought that some of the people must have been trapped there for hours or even days hoping for rescue which never came. They are presumably some of the parents of the orphans who are causing so much distress for everyone. They would have been at work when the earthquake struck, and it is the big buildings in the center of the city that seem to have been worst damaged.
I tried to relate this whole situation to Oxford where I live. What if the Cornmarket and the High Street were just piles of rubble with electricity cables trailing across the road? The Westgate would be a pile of rubble with over a thousand people buried in it. What if patients from Beckley and Eynsham were still coming in by the lorry load three weeks after the disaster, their wounds covered with maggots?
What if there was a crèche of one hundred children on the Marston Road, another on the Abingdon Road, and another in Botley full of orphans of every age, brought together into camps because of the fears about child traffickers, but with no facilities to look after them? The situation was even more complicated in Haiti.
One morning I went into the children’s ward to check on a patient, to find the ward empty. There was a Mormon worker there and I asked her what happened. Cheerily she told me that all the children had been adopted. “Adopted” I said “What do you mean?” She explained that all the children had been taken to Salt Lake City where they had been adopted by Mormons. I was spell-bound “Who gave you permission to do this?” I asked. “The government” she replied. “But there isn’t any government” I responded. “What about their relatives? Have you checked that they have no relatives who will look after them?” “It doesn’t matter” she responded sweetly “You see. They are going to a better place.” So, children were (and probably still are) being kidnapped by the Mormons, and taken to Salt Lake City to swell their ranks.
Part 6 - Through the Looking Glass
We drive through Port-au-Prince each day on the way to and from the hospital. So we get snap-shots of what is happening in the city as each day goes by.
In the first days, there was just a mad rushing about as everyone simply tried to survive and find out who else was still alive. But today, a different movement is visible. Everyone is busy doing something, and there is a sense of purpose in everyone’s actions. Sure, there are still people pushing the remains of their belongings along in wheelbarrows, but now they are going somewhere. Others are carrying beams of wood or sheets of corrugated iron. But everyone you see has now got a plan and they are starting to make it happen.
The resilience of the human race is something to behold and I suppose bodes well for whatever ghastly Armageddon we finally visit on ourselves, whether it be global warming or exchange of nuclear weapons.
The local mobile phone distributor has a gigantic digger in their forecourt clearing the site. Clearly, they are going to be one of the first to have a brand new building standing in the ruins of this city. I am sure that their Board of Directors have justified this expense as symbolizing their dynamism and their ‘futuristic’ culture. It seems a pity that they have not decided to invest in their customers by building some housing, but there we go. Hooray for capitalism!
The next stage for Haiti is reconstruction. This is going to be really difficult. Actually, this city now needs to be completely razed to the ground and built again. Those buildings still standing are mostly unsafe while the rest are rubble already. But if you do that, who is going to pay for the rebuilding? This country was bankrupt before the earthquake. It is now homeless too.
Port-au-Prince is a tiny city in our Western consciousness. I think I had heard of it before this earthquake, but I don’t think that I could have told you that it was the capital of Haiti. I certainly could not have told you that the population of Port-au-Prince is over 3 million, the same as Birmingham, one of Britain’s principal cities. The authorities still have no idea how many people have died here but we do know that the atomic bomb dropped on Hiroshima killed forty thousand. This earthquake has killed somewhere between five and ten times as many. I find the numbers involved in this disaster hard to grasp.
Today we accepted from the emergency service a sweet lady in her forties. She was as light as a feather and I wonder if she has eaten since the earthquake three weeks ago. It seems likely from what we can gather that she has lost every single member of her family – children, husband, parents, brothers and sisters. Her foot had been crushed and the wound had been dressed some weeks ago, and this is why she came to us.
My heart went out to this patient. What kind of misery had this poor lady been through for the past three weeks with no close family? When we removed the bandages we noticed that the dressing covering the wound was actually moving. Underneath there were literally hundreds of maggots eating away at the tissues of her foot. Some think that the larvae only eat dead tissue but this is not true and I just cannot envisage the mental and physical torture that she must have been through being eaten alive.
It was about this time that we received our first gunshot wounds, in fact, two in a row. Oda our senior Haitian surgeon has a dry sense of humor, and he quietly remarked as the second patient was wheeled in “Ah this is a good sign. Looks as if things are returning to normal at last”.
Last night as darkness fell, gunfire started as it does most evenings in Port-au-Prince. This time, however, it was in the wood immediately behind the house. I was delighted to see that no-one flinched. All of us have worked in war zones, and what is a bit of gunfire? Then the shooting got louder and a bit more frequent. Those of us on the veranda decided to move inside. I explained to my French colleagues the concept of the ‘stiff upper lip’. They responded by opening another bottle of wine!
It appears that drug-dealing is big, in the way it is everywhere in this part of the world, and that this was probably part of a turf war. An hour later the police arrived to protect us. They were armed with Martini rifles. I kid you not! Each weapon was a veritable collector’s piece and no match for whatever the dealers were using this year. They were clearly deeply embarrassed by the incident and very unwilling to go any closer to the scene of the dispute with their ancient weapons. Somehow lying in a tent after an episode like this, you don’t feel very well protected.
In the hospital there is a plan to create a rehabilitation centre for all those who have been injured in this disaster. It is depressingly rare that NGOs agree to work together but in this case Doctors of the World (Médecins du Monde) and Handicap International have agreed to collaborate to try to create a huge integrated service providing both physical and psychological support for the thousands left damaged by this earthquake. There are actually great synergies between the two organisations and if this works it should be a quite wonderful initiative, which should make a real difference for thousands of people.
My son who is studying Aid to the Third World has just introduced me to a new phrase ‘Pink collar workers’ which I had never encountered before. If I have understood this concept correctly, pink-collar workers are people in Third World countries trained to provide international services such as Call Centres, etc. at a very low wage. You and I may sneer at them, but it is work like this which may provide some kind of future to those who have been disabled by this earthquake and so lost any other chance of earning a living.
In the hospital itself there is still no sign that we are really keeping pace with the workload. Each morning there is a queue of several hundred waiting for the Emergency Department to open, and each evening the queue is just as long. The waiting time along the side of the main road in the hot sun must be around 8 hours before you even get logged into the system, and these patients are really very ill indeed. It makes our efforts to see, treat and discharge patients within 4 hours at the John Radcliffe Hospital in Oxford very creditable indeed. I just wonder whether after all that waiting, we are providing what they really want.
Towards the end of our three weeks, Michel and I were really tired. We had done over 400 operations and Michel clearly wanted to do something more interesting than debriding wounds. I noticed that he was starting to repair hernias and do other operations not directly associated with the earthquake. That day in the morning the door went dark because it was blocked by the presence of a very large man both tall and wide. He introduced himself as Dr. Dick (an extraordinarily appropriate name) a surgeon from Salt Lake City. He was accompanied by a medical student carrying a camera. He said that he had arrived the day before and was here to help. I greeted him warmly enough but asked him where was his theatre team. He didn’t have one. I explained that a surgeon without a team was really not much use and that he would need to find a table to operate on too. As far as I was aware they were all in use. I then got back to my work and he went away. An hour later he re-appeared with a little old lady who had the biggest facial tumour I have ever seen. I guess it was a benign Parotid mixed-cell tumor that had slowly grown over many years. He said that he wanted to operate on this lady’s tumor, explaining that he was a world-famous endocrine surgeon. This time I was not so polite, and explained that without a table and a team, he could not operate and he certainly not have my table for this type of surgery. To my annoyance, Michel became involved and offered to do the operation with him. Six hours later it was getting dark and they had finished excising the tumour.
Throughout the case, Dr Dick’s bum-boy had been instructed to take pictures of the maestro at work. As he left our operating room, he turned to me in that special way that Americans have and apologized that we had no got on better. “Be that as it may” I said. “I have a couple of questions for you. Who is going to look after this patient tonight as she is going to need special care after a six-hour operation?” He waved his hands dismissively “Not my problem” he boomed “I am an operating surgeon and I am flying back to Salt Lake City tonight”. “Second question,” said I “ Did you take consent from her?” “Of course, I didn’t” he responded with asperity “She doesn’t speak English” “Third question. Was the facial nerve intact when you started and what is the situation now?” The facial nerve that controls the muscles of the face runs through the Parotid gland and is frequently damaged when even a small tumor is removed. It leaves the most terrible facial deformity. “Don’t be ridiculous” he responded “I had to take the whole facial nerve to get out a tumour this size.” With that he pointed out that he had a plane to catch and sweep out. So, I witnessed surgical tourism in its worst form. I was incandescent with rage, and my mood was not helped by Oda quietly pointing out that he knew this lady. She had been presented at the teaching hospital grand round where it was decided by the surgeons that the risks to her of having surgery were too great for it to be in her interests. He went on to say “One day we Haitians all decide that we do not have the resources to do this surgery. Then we have an earthquake, our hospital falls down and one of you blancs (white people) comes and operates on a simple table with no light and no intensive care. How interesting. You really are much better surgeons than us.” The sarcasm in the comment was not lost on me.
Part 7 - A Personal View written at the end of my time in Haiti
It seems like yesterday that I arrived in Haiti, but nearly three weeks later a lot of water has gone under the bridge.
By all accounts the initial phase before I arrived was absolute chaos, as people struggled to escape from under the rubble and to understand what had happened to the world around them. Haiti is not famed for its earthquakes. It has had the odd tremor like many places in the world, but this disaster came like a bolt from the blue. The buildings were not designed to resist an earthquake. There was no contingency plan if one did occur. But quite literally, within hours, the media were here in Haiti. Reporters are always ready. They are professionals whose bags are packed ready to leave at a moment’s notice.
Some of them have at their disposal the resources of multi-national news agencies that know how to get an airline ticket when the plane is full, and how to charter a helicopter which is already assigned to go elsewhere. Their cameras are running before their feet touch the ground. Then within hours of arriving they are demanding to know why the medical assistance still has not arrived. After all they have been here for what feels like ages in news time. But what they forget is that they used all the helicopters.
Also, we medical workers are all volunteers with day jobs. Our bags are not packed and we have to be invited by a Non-Government Organisation to help. They can hardly ask us to help until they know what is needed. Then they have to put together the team and equipment to support that job.
Perhaps it would give a more realistic picture if the media interspersed the pictures of people being rescued from the rubble with pictures of the Doctors of the World (Médecins du Monde) offices in Paris, London, Montreal, Madrid etc. with their lights on all night as the staff work flat out to prepare and equip an emergency team? Then they might want to come into some of our homes to film the conversations that we are having with our partners about whether we could/should go? That might give a more balanced picture of what is going on behind the scenes.
During the first days after the earthquake the surgeons coming in and the local surgeons who had survived were mainly occupied with amputating ruined limbs as well as trying to relieve the pressure that develops in limbs which have been crushed (compartment syndrome).
However, within ten days we were able to start reconstructing peoples’ limbs. In a few weeks from now, the long slog will start of fitting artificial limbs and getting people mobile again so that they can start living their lives as independent individuals once more.
But it is a sad time. Yesterday we finally lost the battle for another young patient. The muscle death in a crushed leg was slowly creeping up the limb poisoning his kidneys. Up till then I had tried to be optimistic with him as I cleaned out dead and dying muscles and he struggled with the pain and the hallucinations produced by the anaesthetics. Now, I had to sit down and tell him what I had known in my heart for several days. He is only 22 years old and must lose his leg above the knee. The family are heartbroken and very politely ask if one of them can be present when we do the final assessment under anaesthetic, just to be sure that it is absolutely necessary to amputate the limb. I reluctantly agree. They send his 16-year-old cousin. Brave girl, she had to stand there as I took down the dressings and exposed the wounds. I explained and showed her what we were fighting and why we were losing. In my halting French, I tried to tell her enough but not too much. Finally, she bowed her head, and whispered “Continue”. I knew that she had seen as much as she could take, and a nurse led her away.
We now need to start running down our surgical initiative, not because the demand for surgery has vanished – it certainly has not – but because a surgical team was put in place to deal with a special need i.e. to help with the injuries caused by the earthquake. That task is now finished. We are now handing all our patients back to the Haitian orthopaedic surgeons and very good surgeons they are too. Their problem is that even without an earthquake, there is far too much work for them.
The big question for all of us is what the future holds for Haiti. Is this earthquake going to be a further nail in a coffin already riddled with problems, or could it be used to be the catalyst for some kind of radical change, which would start Haiti on the road to becoming a developed country?
Part 8 - Going Home
My last few days in Haiti were difficult. I was tired and one part of me was desperate to get home to Vicky and my friends and family, to sleep in a real bed, and eat some healthy food. We had an afternoon’s break where we went to the seaside and drank some beer. The next day I felt terrible and at the end of the operating list found that I could not stand up anymore. Then I developed torrential diarrhea. I don’t remember much about it but a drip was put up and I was given three litres of fluid intravenously before I started to get a sensible blood pressure. The following day I couldn’t operate so I went up into the hills to see the work that MdM was doing in general practice and public health. Now I was seeing a world I remembered oh so well from the Sudan. Camps of people with nothing to do, coming to clinic because it was an entertainment rather than a medical need. I witnessed an interesting interchange between the feisty but diminutive Dutch lady doctor and the leader of the camp a very tall Haitian of about 30 with two side-kicks. He sauntered into the clinic and asked to speak to her, so she asked how she could help. He explained that they now had a good supply of drinking water in the camp but that there were no proper latrines. The rainy season was due soon and he wanted long-drops for the camp. Edna quietly asked him what he wanted to do about this, and he responded that he wanted her to arrange for long drops to be dug. There was no suggestion that this might be a task that they would want to do for themselves however fit and strong they were. Edna and I talked it through afterwards and agreed that it was a classic example of how ‘helpless’ people can become in an aid environment. Paradoxically on the same day we passed a large church which had almost completely collapsed. Inside there were more than twenty ‘volunteers’ working away steadily collecting and stacking bricks in preparation for rebuilding ‘their’ church. Haitians are certainly not lazy, they just need a chance to be motivated.
Although I was now ill and wanted to get home another side of me was equally desperate to stay. We now knew what we were doing and were working fast, as a tight team. Even my French was beginning to improve! But most importantly, we had got to know some of our patients very well and were very fond of them. We had looked after them through thick and thin, and they trusted us.
I think we all wanted to see them through to the end of their treatment. But we were all exhausted.
We had been sprinting for three weeks. Working seven days a week, Michel and I between us had done just under 500 operations. We had been supported by a fantastic team of anesthetists, nurses, and logisticians who just kept the patients coming and made sure that we had everything we needed to do the best job possible under the circumstances. The surge of open amputations and infected wounds was now under control. The surgical crisis was over, but now the long slow marathon of rehabilitation had to start.
It is estimated that there are now around 3000 new amputees in Haiti, so there is going to be an unprecedented demand for artificial limbs, limb fitters, and rehabilitation. Luckily two big charities ‘Médecins du Monde’ and ‘Handicap International’ have decided to join forces and are setting up a programme to get these amputees fitted with useful limbs.
In the first instance, this work will have to be done by expatriate volunteers, but the task must be handed to the Haitians as soon as possible. It is their country and at the end of the day the solution must lie in their hands. The workshops and the rehabilitation centres will be training Haitians to make and fit artificial limbs at the same time as treating amputees. It is going to be very difficult to fund, because already Haiti is beginning to slide into the media twilight, out of that bright spotlight that generates funds.
Looking back there are some things that stand out. There was a very small British input in the early stages. Oxfam have and still do a great job helping with water and sanitation. Merlin were one of the first to get a surgical team onto the ground. But for a country which I gather donated more money to help in this disaster than the rest of Europe put together I do wonder if Britain’s footprint in any way represented our concern. I just wonder if Britain needs a volunteer stabilization force ready to deploy at a moment’s notice, to help in circumstances like this. The French have one and it is very good.
Back in England, it is cold and wet but it is lovely to be home. Walking into the John Radcliffe Hospital I am literally dazzled by the clean floors and the sense that everyone is quietly busy. There are no cracks running down the walls, no blue-bottle flies wobbling drunkenly over infected dressings, no patients lying in rows of stretchers laid out on the ground, sweating in the heat. My colleagues in the hospital are all very kind and supportive. I know that they would have gone to Haiti like a flash in my place, and would certainly have done a better job too, but whatever they were thinking they were kind enough to keep to themselves.
The media still want interview after interview, and of course, this suits the NGOs very well. This is their oxygen. This is how they raise funds to do what they do, so I must do it, but actually, it is quite harrowing talking about some of the things I have seen, and of course those are the parts they most want to hear.
The interviewers are very gentle but my knees are shaking at the start of each interview as I pray that I don’t say something stupid. But their questions are sensible, and they are all very well briefed. They genuinely seem interested in what I have to say. I am rather touched because they must have to deal with this sort of thing all day every day, and it is nice to realize that they are humans too, albeit doing a tough job. “Will I go back?” they ask me. Of course, I will, if I am asked. I so want to see what happens.
I would just love to see Haiti break the downward spiral of poverty, drugs, HIV and violence that has gripped it for years. Perhaps only an earthquake can do that, but it is difficult to see how.
So really my story of Haiti ends now. I have to thank Vicky my partner, the rock in the system, always there at the end of Skype when the going gets tough and there at the end of the day to pick up the bits when I get home. I simply couldn’t do any of this without her by my side.
Reading this section on Haiti exactly four years later, a lot of water has gone under the bridge. The hospital is now at last nearly rebuilt and is solar-powered, a brilliant idea in a new build. Oda and Getho came to Britain and France after I raised the money for them to travel here and study orthopedics. I am delighted that they have returned to Haiti so will be real assets to their country. The artificial limb center is still struggling to get off the ground but some Haitian technicians have been trained. There are now estimated to be 10,000 NGOs working in Haiti. I find that number hard to credit but that is what is quoted. The government remains corrupt and the bulk of the land is owned by only three families, but that is no different from many third-world countries. It is certainly a country that has taught me a lot.
By the time I was 50
By the time I was fifty, I was bored with orthopaedics. I had been awarded a Hunterian professorship at the Royal College of Surgeons England in recognition of my position in the field, and had given a lousy lecture. I had written or at least edited a couple of books, and I was in danger of becoming a big fish in a tiny muddy pond. My foray into trauma had been a disaster. I had not learnt any modern trauma in London and did not like being bossed around by people younger than myself. I was going to have to eat humble pie for several years and work very hard to earn my spurs, and frankly I did not feel wanted or appreciated enough to be bothered. I didn’t see why I needed to try to curry favour in an organisation (I nearly used the word ‘team’) which needed me to cover one day a week but which had no respect for my ideas or competence.
The Divorce
I was also going through a huge dilemma at home. Katherine and I were not communicating. Both of us were very busy with our careers. I felt that she was not remotely interested in what I was trying to do, and I am sure she felt the same about me. The kids were now flying the nest, and Susan, one of our closest friends, was trying to help. She is, I am sure, a brilliant psychiatrist and immediately spotted that there was something wrong when I explained that in twenty years of marriage Katherine and I had never had a row! I was rather proud of this, but of course, there was nothing to be proud of. Firstly, Katherine was the one who managed things such that there never was a confrontation and ended up treating me as a fourth child with Attention Deficit Disorder. When I did try to make contact with Katherine in my clumsy and stupid way, it was to find that she was as stubborn as a mule and then I really did get angry. Over a period of time Susan and I inevitably fell in love. I found her brilliant at helping me analyze why I was so angry and frustrated, but in the end, she was not actually interested in what I was now trying to do professionally either, which was to change the educational environment of the NHS. I needed someone who would stand up to me and who actually shared my enthusiasm to change the culture and, it turned out, knew how to achieve it.
My relationship with Vicky has been anything but calm and row-free. We have gone to the wire on several occasions, way beyond in fact, to a place where I had completely despaired. However, she has the ability to decide that as the relationship is worth it, she needs to think about what it is like for me in my corner and bring me back from there. I am lucky, very lucky because that was something that Katherine simply could not do. She never got me cornered until right at the end, but once she did, I could not go back, and she didn’t know how to handle my rage. For the twenty-five years since our break-up, there has not been a day when I did not groan aloud over what had happened with Katherine and Susan, but the break-ups and the consequences were inevitable. The only thing that time has done is show me that Katherine and I were doing each other no good, in fact we were harming each other, and my sudden break (our marriage was quite literally all over in five minutes) was in the long run the best and kindest thing that I could have done with a ghastly situation. I still blame myself for what happened, and so does Katherine and all my family, but maybe one day when some of them have been through what I have (though Lord knows I wouldn’t wish it on them) they may look back and think “Well, maybe, I understand a little!” It takes two people to make a relationship work.
Certainly, that is the case with my relationship with my parents. Now I can see how much hurt I caused them and how most of it was unnecessary. However, whether it could have been avoided, I will never know. Given the personalities involved, I sort of doubt it. Years after the terrible rows that we had, my mother could still quote word for word the horrid things that I had said many, many years before. They were obviously engraved in her memory and poured over again and again, each time cutting a deeper groove of grievance. With Katherine, there was only really one row when she asked me what was wrong with her. For a moment I dropped my guard and told her the truth as saw it then; that she was boring. My guard was still down when she hit me very hard across the face breaking my glasses. Perhaps that was the only time in many years that either of us had spoken the truth, or that any passion had been shown.
Work - National Posts
Initially, I wanted a Deputy Dean’s Job in Oxford but the Dean then, a sly old dog, put his cards firmly on the table. He pointed out that you should never appoint someone you could not get rid of. He predicted that within a year I would be bored with being Deputy Dean and would want his job, and he wasn’t leaving. He was of course absolutely right, but within the year he was dead (inhaled a bee that stung him in the throat), and I was Deputy Dean working alongside Vicky on educational programs. I was not even short-listed for the Dean’s job and thank heavens I wasn’t. It is a terrible non-job. In fact all national posts are non-jobs. Hours are spent at committee meetings producing worthy documents but ensuring that no action is taken. Most of the work involves praising and congratulating others in the hope of getting some grooming in return. Underneath it all the envy and loathing is mutual. I have a sharp tongue and it only takes one well-timed remark by me to make an enemy for life. When you are not busy praising the brilliance of others, a great deal of time is spent blowing your own trumpet or feathering your own nest. If I had gone into committees and just talked as much as I liked, as many unfortunately do, I would never have noticed how much everyone feels threatened by each other, but I tried to be strategic and listen. What I heard was boring, irrelevant and mainly self-serving. But it was also all double-speak. If I reversed everything that people said, then I appeared to hear something closer to the truth than if I took what they said at face value. So, if someone thumps the table and says that their patients must come first, then what they say next is much more consistent and convincing if you change the initial sentence to “I must come first!”
Though I say it myself I gave a great speech to the Edinburgh Council praising them for their foresight, their kindness, their success as a world power in Surgery, all untrue, and I landed the job as Director of Education. I started in with a will. The secretary who ran the Education Department was a small minded, sharp-tongued, and very lazy lady. Without further ado I demoted her. She was furious and started a savage campaign against me in the College. The Scots love malicious gossip and to this day I will never know what she said but it cannot have been nice. I was only up in Edinburgh two days a week and she had the rest of the week to undo anything I had achieved.
During that summer I was away on a wonderful holiday in Spitsbergen sailing with Vicky. By the time that I got back irreparable damage had been done to my position at the College. Some people simply could not look at me never mind speak to me. The President of the College at the time badly wanted a knighthood. We call that ‘Horlicks syndrome’ after their famous advert claiming that Horlicks cures (k)night starvation. He felt very threatened by me.
Unfortunately, he was a keen sailor with a large boat which he raced passionately. He knew that I sailed a Flying Dutchman and in one of my humorous spiteful moments I called his boat a ‘racing caravan’. I actually saw the arrow go home and strike a very raw nerve. From that day on he was distant to put it mildly, and when I returned from my summer away, I was asked to stand down. No reason was given, but I didn’t need the job and I was clearly not going to get any help with any of the ideas that I had. However, at the same time, and to the President’s disgust, I was voted onto the Council by the membership of the College with a very large majority. When I say large, I had 650 votes out of a membership of 18,000. That should give you some idea of how unimportant we were.
Jim Foster was the Chief Executive. I liked him a lot. He was an ex-Polaris submarine commander and had a terrific naval sense of humor. He was also passionate about building and started a mighty campaign to buy lots of property and completely redevelop the College. It was a great and glorious plan with a hotel, lecture theatres, teaching rooms etc. The only problem was that it was going to use every penny that we had, and if anything went awry then we would be bankrupt. I did a little checking and found that if we did go into debt it was members of the Council who were liable not the membership. It was one of the few times that I spoke in Council, and you could have heard a pin drop as it sunk into the 20 members of Council how much they were liable to have to pay if things even went slightly wrong. The plans were cut back drastically, and they did go wrong. Jim assured us that we had insurance and that anyhow the surveyors were liable. We didn’t and they were not. Eventually, the matter was settled out of court with both sides paying half and their own legal fees. Result – we were out of pocket by exactly the same amount as we would have been if we had not gone to court. So now Jim was not my friend anymore. But then things got worse. I was teaching a course for doctors which included a half day on how to read a spreadsheet, as no doctor can run a service if they don’t know how they are spending their money. However, I could not read the accounts of the College which were presented in a very peculiar way which I simply could not understand. I took this up with Jim Foster as he was the chief executive and rather to my surprise he snapped at me and told me to take it up with the accountant if I was not happy. I was quite certain that was not my job to do that, so I didn’t. But I did take it up with the other Council members and to my surprise, none of them had even tried to read the accounts. They had just thrown up their hands and claimed that it was not possible for surgeons to read accounts.
Then came the annual general meeting, a very august affair where we all dressed in gowns and paraded into the grand hall. I had completely forgotten about the AGM and most specifically that we all had to vote for the accounts. On the spur of the moment, I decided that I would abstain. John Temple, the President, went through the motions and was clearly very shocked to find that I was refusing to vote. I think that he was terrified that I was going to vote against them. I didn’t. I just could not understand the accounts in their current form so refused to vote for them.
Six months later massive fraud was discovered in the accountant’s office and the accountant was summarily dismissed. I so wanted to say “I told you so!” but what would have been the point. Anyhow I had not spotted the fraud: I just could not read the accounts. However, it was now clear that I was marked as a maverick in Council. It was bad enough being English in a very aggressively Scottish College, but now I could feel the waves of antipathy. However, out of all that came a much-valued friendship. Pradip Datta was an Indian Surgeon who was passionate about teaching. He and I became fast friends. He has worked heart and soul for the College but never got a merit award presumably because he was Indian. Actually, he is more British than the British and was clearly a superb cricketer and squash player in his time. He was also clearly a very good surgeon but was forced into a career in the far North of Scotland, presumably because of the color of his skin. He ran fellowship training courses which were regarded as the best in the English-speaking world. A kinder man and a less bitter one you could not imagine. He taught me a lot about India, a country I didn’t know at all up until then. He also taught me a lot about how to handle prejudice. In turn, he has been a huge, quiet, solid supporter of what I have tried to achieve. It is an honor to have such a ‘good’ friend. He has now written a book about his life. It is a superb description of triumph over discrimination. Pradip died in 2022 at the age of 81.
The Edinburgh College is an organization that passed its sell-by date four hundred years ago. Chance has re-invented it at least once. When the surgeons from the Indian sub-continent wanted recognition of their surgical training to take back to India with them, the FRCS was their dream. The London FRCS was well-nigh impossible to pass, as I knew to my cost, and the chances of an Indian getting past those bigoted, senile half-wits was almost zero. The Edinburgh exam has always been easier (Edinburgh will deny that). Even if the standard of questions is not lower, the courtesy and friendliness shown to candidates make it far easier to demonstrate your true worth. So, foreign surgeons flocked to Edinburgh for their fellowship, and so did candidates from the North of England where there is also little love lost between them and the arrogant London consultants. So, although Edinburgh and Glasgow are small provincial towns by London standards there is an alternative fellowship available from both. The Edinburgh College of Surgeons is very big worldwide but has absolutely no influence at all in Great Britain where everything is London-centric. Edinburgh College has however built up a huge loyal fellowship that keeps the coffers well-lined. I am unclear why surgeons continue to pay a massive subscription to a College every year. Sure, it is tax deductible but several hundred pounds is not to be sniffed at. If the AA charged over £400 per year to be a member and allowed you to put a badge on your car but gave you no other service I doubt that they would be in business for long. The Royal Colleges provide no value for money to their fellowship, and it is difficult to imagine what service they could provide apart from legal defense (which would be prohibitively expensive) and continuing education which they should provide, but don’t. What the College does do well is lay on regular wonderful celebratory dinners and a magnificent degree ceremony which has proud parents traveling from all over the world to witness. The rows of beaming faces of those proud relatives are a joy to see, but over £400pa for thirty-five years! Value for money? I think not!
My final plan for Edinburgh was to start a system where we would teach junior surgeons to be trainers and show them how at the same time to evaluate their consultants as trainers. It was all going to be very simple. We would only accept ‘good’ comments, not criticism, and we would use this to identify centers of teaching excellence. So, there would be no criticism, just praise where praise was due. To say that this went down like a lead balloon would be a major understatement. Once they discovered what was going on, the Scots closed ranks, and I finally terminated my work with Edinburgh. They like to think of themselves as a progressive institution, but like all senile organizations run by burnt-out practitioners, they were about as progressive as a Lord in his Robes.
Of course, the Colleges claim to protect the public and uphold standards. Wrong! Reverse that statement! They protect their membership and uphold their prestige. The day that the Inland revenue removes tax-deductible status from College subscriptions, which must be soon, they will be dead in the water.
Ukraine
When Donetsk declared independence from the rest of Ukraine, the Western media were not very interested. It was a highly political event because it was evidence that the West was seeking to demonstrate that Russia was a dangerous expansionist power again. No reporters seemed to want to go there so the realities of the situation on the ground were not well covered.
It appears that there was a hierarchy in the old USSR, with the ‘true’ Russians at the top of the pile and Ukrainians running a close second. The others were considered way inferior. When the USSR broke up it was apparently an accident that Ukraine was separated off from Russia. Khrushchev was drunk and made a spur-of-the-moment decision which many have regretted ever since. Russia wanted Donetsk for its coal mines and steel works and Crimea for its naval bases and access to the Black Sea. Both had a large proportion of Russian speakers whose loyalty was definitely to Russia not the newly created state of Ukraine.
Ukraine is enormous. Kiev is far away in the West close to Europe while Donetsk is miles away in the east separated by forest and scattered farms. The high-speed train (provided by Korea I think) took over 6 hours to carry us from the West of the country to the East. It was midwinter and hard to imagine a more dismal landscape. It reminded me of Primo Levi’s descriptions of Eastern Europe at the end of the war when discharged soldiers had to decide whether to tramp East to a certain execution or West to a complete unknown in enemy territory. Donetsk is a dismal part of the world, the rust belt of Ukraine. The coal and steel industry has blighted the landscape and is now all closed down. The local people are cold and miserable (I am not at all surprised), and the land is ugly. It is ugly because it is mid-winter in Central Asia, because it is an area of heavy industry because that industry has collapsed, and because everyone seems to hate everyone else. But in the middle of all this, there were people trying to help the thousands of refugees who had lost their homes in the fighting.
A psychiatric hospital and a farmhouse which happened to be in the wrong place at the wrong time
It was difficult to understand things because people are economical with the truth. My job was to try to organize healthcare facilities for the refugees at the request of Medecins du Monde. I was assured that this should not pose a problem as health care in Ukraine is free for everyone.
But there was something wrong. The doctors were paid $50 per month by the state but every doctor I met was fat and well dressed with a gold signet ring and the latest iPhone. Eventually, my translator explained. She said that many things were provided free by the state in Ukraine but that in order to see a doctor an envelope of money had to be passed under the table, a ‘refresher’ for the doctor in recognition of how much they do and how little they are paid. The amount that you put in the envelope determined the quality of care that you received. It made me quite angry and made me feel a little sick. This was blatant corruption, but to the Ukrainians, it was how life was organized now that the USSR had fallen apart. I can see why many people there mourned the passing of the USSR. On top of that many people in Donetsk and indeed in Crimea were Russian speaking and saw themselves as Russians not Ukrainians. So, the rights and wrongs of the invasion of Crimea are not quite as simple as the Western media chose to present them.
It is another example of a country where nationalism can lead to irrational and violent behavior. The people who suffer are not the ones who are the origin of the violence. Next time you sing ‘Rule Britannia’ or even ‘Flower of Scotland’ remember that the emotions they engender are killers. I am afraid that my report was very negative, and MDM had no further input to this humanitarian crisis.
I had previously been with Doctors of the World to Bangladesh where they wanted us to set up a trauma hospital. We visited a very large trauma hospital run by some kind of Christian agency. Despite the huge amount of trauma on the roads, the wards were empty. The surgeons wanted money to buy the latest forms of Internal fixation used in the developed world. Unfortunately, they were not remotely interested in getting any training in the use of this tricky equipment, so I felt that their motives were very suspect. Once again I recommended that Doctors of the World should not get involved.
Gaza
Although I was contracted by Médecins du Monde (MdM) to go to Haiti, Doctors of the World, MdM’s British wing seemed to pick up on all the publicity which accrued from it. I wasn’t sure how to handle this but I really liked the director of Doctors of the World and it seemed to me that there was nothing much that I could say that would be reported in France so I might as well use the two organizations interchangeably (as they were all part of the same group).
Little was I to know about the in-fighting that can occur within and between NGOs. It seems that people who are working for principles that are important to them can be quite fierce in protecting their patch from encroachment. As Sir Christopher Bland, Chairman of BT, said “The amount of back-biting, in-fighting, and general skullduggery in an organization is in direct proportion to the nobility of its goals”. Clearly a heartfelt quote.
In retrospect, relations between Doctors of the World (DoW) and MdM (its parent) had been deteriorating for some time, and I don’t suppose DoW adopting me as one of their own did much to help. My next assignment with them was to go to Gaza over Christmas to operate on the injured, one year after the second Intifada, which tore the soul out of Gaza at the end of 2006. My role was not only to co-ordinate a push to get as much surgery done as possible, but also to ‘bear witness’ (témoignage) to what had happened in Gaza. This was a new and much more political role for me. Clearly, the organization felt that I had some independent credibility, which they now wanted to use. I had not realized until then that every NGO has to ‘take a position’ on its politics, even if that is ‘no position’. Some organizations like the International Committee of the Red Cross (ICRC) will not take a position on anything and swear all their staff to secrecy over anything that they have seen. They argue that this means that their staff can go where no one else can go, as they are trusted never to say anything. It also means that they knew firsthand about the concentration camps in the Second World War, and that they witnessed the massacres in Rwanda and Burundi but said and did nothing.
Some years ago (after Biafra) a group of doctors broke away and set up (Médecins sans Frontiere) MsF. They put their staff at great risk by allowing and encouraging their staff to work right at the front line and talking openly about any atrocities they had witnessed. In time MsF moved closer to the ICRC position of not saying anything so that they could be even more closely involved in work at the front line, and yet another splinter group (MdM) broke off and committed to bearing witness. Each policy has its pros and cons and suits a certain personality. I have to admit that I could not work for ICRC anymore, but find that the danger that MSF puts themselves into is probably counter-productive much of the time.
Gaza is another aid sink like Haiti, but it is almost as if there is a proxy war being fought there in the Middle East by the aid organizations. Israel is supported by the USA . Humanitarian and military aid pours in, presumably as a result of a strong Jewish lobby in Congress. Israel would not have survived five minutes without this aid, just as the IRA relied on the American Irish Catholics to support their campaigns. Conversely, Palestine gets huge amounts of aid from the European Community (and some Gulf countries), funneled through grants to large NGOs: so the Israeli/Palestine conflict is almost a proxy war between the EU and the USA. If either side stopped funds tomorrow the whole situation would change overnight. As it is there is a violent stalemate. (This was written pre-2023). Perhaps this is a situation that has come to pass accidentally but it does seem that if the USA and Europe have a dispute, it would be better sorted out face to face rather than through proxies and that negotiations between Israel and Palestine could better be replaced by discussions between the major donors who allow this terrible situation to continue. It is almost as if the big aid organizations want/need this situation to give them a raison d’etre.
The second issue that complicates matters is that a small proportion of the orthodox Jews in Israel believe in a second coming and that this will only occur when all non-Jews have been expelled from the historical Greater Israel which is variable in size but in some cases extends from the Nile to the Euphrates and in others just covers the current Israel plus a bit of Jordan. To them it does not matter how long this takes, it is simply a divine imperative. Against this background, a settlement between Israelis and Palestinians is unlikely to be achievable.
Before I went to Gaza I had read William Dalrymple’s extraordinary book ‘On Magic Mountain’ where he walks from Constantinople to Alexandria through the holy land, retracing the steps of a monk who did this same journey in the 9th century AD and wrote about what he saw. The overwhelming impression that I gained from this book’s description of what has happened during the last two thousand years, is of one militant religious group after another rising in strength and overthrowing the current decadent rulers. They then set about massacring men, women, and children and razing cities to the ground. Within a few hundred years this group too becomes enfeebled by power and is overrun by yet another militant group from a different religion. In fact in historical terms, the last 50 years in the Middle East have been relatively peaceful, as there have been no annihilations of whole populations. So, for the Americans to talk of a ‘Road to Peace’ after 2000 years of continuous blood-shed might seem a touch naïve.
When I arrived in Jerusalem I was taken to the Mount of Olives by the MdM Palestinian driver. It gives a wonderful view over Old Jerusalem (a singularly inappropriate name as translated it means ‘City of Peace!’). Standing there looking down on the Al Aqsa silver-domed Mosque (the third most holy site in Islam), he explained that the Israelis were excavating under the very foundations of the mosque seeking the remains of first great temple (the Holiest site in Judaism). Quietly he said that if the mosque was harmed in any way by this undermining, there would be a world war. We could also look down on all the houses in that part of Jerusalem, and he showed me how you could distinguish the Palestinian houses from the Jewish ones. The Palestinian houses have large black water tanks on their roofs because the Israeli authority routinely and arbitrarily cuts off their water supply for variable periods of time just to make life difficult. He showed how a new road and tram-way combined with purchase of houses was gradually cutting off this part of Palestinian Jerusalem from the rest of Palestinian owned land. Once the area was cut off, he explained, the Palestinians would be forced to sell up and leave, and yet another section of Jerusalem would fall to Jewish control. He described all this with barely disguised fury, and I started to get a glimpse of the deep emotions which flow here, and which are continuously being inflamed by petty irritations thought up by both sides.
There is no doubt that in the centre of Jerusalem, Judaism is currently in the ascendant and where all the money comes from. In the square around the wailing wall there are newly repaired buildings all with tasteful signs recording the name of the Americans, whose beneficence enabled this reconstruction to take place. Walking through the narrow streets of Jerusalem and along its walls, it is simply amazing how many religions and sects have managed to pack themselves into this tiny space. They are all complete bampots, and it is extraordinary that they have managed to rub shoulders at all for so many years. Each church, crypt, monastery, nunnery, mosque and shrine represents the vestiges of a previous occupation by that religion, a sort of tide line of past triumphs.
Jerusalem the Golden with Milk and Honey blessed!
The next day I was taken down to the Ehrez gate through a biblical landscape of rocky hills and scrubby valleys. The only incongruity was what appeared to be Tuscan towns perched on the top of each hill. They looked quaint in their warm limestone colors until you realized that each hamlet was in fact a brand-new fortified village surrounded by barbed wire with guard towers at each corner. The Israelis have taken all the hilltops leaving the Palestinians to creep around in the valleys below. What must the Israeli children think of the people outside the village walls scratching out a living on the barren hillsides below, and worse still what must the Palestinian children think of those who have stolen and armed their hill-tops?
This does not look like a recipe for peace in the future. But as my Palestinian guide/driver pointed out, the Israelis are in no hurry to achieve a Greater Israel. In the great scheme of things it does not matter if it takes ten years or a thousand years. It is just important that little by little, two steps forward, one step back they are moving towards this goal, and there is no room for compromise.
The Ehrez gate. The only part I dared to photograph
Before I arrived at the Ehrez gate I was given very clear instructions on what to do. The gate was built to process thousands of workers to come in and out of Gaza daily to work as manual unskilled labour in Israeli factories. But because of the troubles the gates had been closed to all but a couple of dozen people each day. I don’t know whether it is necessary or deliberate but you are treated as an animal as you go through the various security checks. No one will speak to you, look at you, or come near you. It is utterly inhuman. You need to know what you have to do next at each stage as no-one will tell you. Above you behind plate glass you can see armed guards patrolling. They are deciding whether to let you proceed to the next stage. Getting into Gaza was comparatively simple compared with getting out, but more of that later. Once I was through all the barriers I entered Gaza and I walked the long wire-netting walkway away from the gate into Gaza. Behind me, the high walls with the machine gun nests fell away and I was met by a grizzled but friendly MdM driver.
Around me I recognized the same scene as Haiti. Buildings crumpled and collapsed. There was rubble everywhere, but this was not a natural disaster. This was deliberate and malicious destruction of anything that could be used to earn a living. Gaza is long and thin so it was a long drive down to Gaza city, the roads full of donkey carts and other signs of severe poverty. Everything was dusty and run down, but there were people everywhere and away in the distance you could see the perimeter wall with its watch towers and observation balloons floating languidly above. When I arrived in the office it was clear that everyone was getting ready to move back to Jerusalem for Christmas. The head of programme had decided that as I was an experienced field worker there was no need for anyone to stay back with me, apart from the drivers who would ferry me to and from the hospital each day.
The MdM flat was on the top floor of a five-story high-rise in the centre of Gaza and the whole 5th floor was protected by an iron grill outside the front door.
The MdM Headquarters on the top floor of the middle block of flats
Before he left, the head of programme invited me to make myself at home and then explained that there had been a suggestion that the Israelis might launch some rocket attacks over the next few days. If so, the high rise buildings tended to get hit and I might be wise to leave the iron grille door open so that I could escape quickly. Then he mused for a moment and then said that there had also been talk that Hamas might kidnap a foreign aid worker, so it might be a good idea if I kept the grille closed and locked. Then he seemed to realize the contradiction of what he had just said, laughed and said “Why don’t you decide?” Personally, I did not rate choosing between being burnt alive, and being kept in a dungeon for a year or two, but after they left I stood at the window admiring the sunset over the Mediterranean and pondering on this dilemma. I decided to leave the gates open but every time I heard a sound on the stairs up to the flat I felt sure that my time of freedom, light and air was over.
Driving down Gaza to the Hospital
Each morning I set out early for Khan Yunis a town right down the South of the Gaza strip, so I was driven down the single main road which extends the length of Gaza. Many buildings along the strip had simply been destroyed either by rocket fire from fighter aircraft or by tank fire. The Israelis had destroyed at will; there could be no effective opposition. I am sure that Hamas ‘asked for it’ by firing rockets into Israel but the response did seem quite disproportionate. At the brand -new medical school in Gaza, built I think with Quatari money, the science block alone had been flattened. It was almost as if someone planning the attacks wanted to block technology training over and above anything else. As usual there are claims and counter claims about the legitimacy of the attack. The unpleasant thing for me was the surgical nature of the destruction, pre-meditated, massive and malicious.
A Highly selective attack on the new University Buildings
At the hospital which was dirty and run down, the senior surgeon met me, a man older and more stooped even than me. He was a charming man who was delighted by my halting Arabic but clearly worried about what I was proposing to do. We went straight into the clinic, which was like no clinic I have ever seen before. There were literally hundreds of people pushing and fighting to get to the front of the queue. Each time a patient was allowed through the door into the small office the assistants had to physically force the door shut again to stop more entering and to allow us space and quiet to think. We saw a variety of war wounds in children as well as adults. Mostly they were infected broken bones that had not been cleaned or set and which now were pouring pus and unable to heal. After a couple of hours, a stop was called to the clinic.
Anti-personnel mines designed to maim not kill
We had enough patients to operate on, so we set off to the Operating Room. They too were not clean and there was not a lot going on. It was clear that they were very short of implants and that my presence had been accompanied by a donation of more equipment from MdM. As we got ready for theatre I tried to think how to handle things. I don’t like operating in a foreign environment where I don’t know the patients, I don’t know the staff and I won’t be able to follow up the patients properly. I also tried to put myself in the shoes of this resident surgeon. How was he feeling about me being parachuted into his hospital, which appeared to be limited by resources not personnel? I decided that I would assist rather than operate.
The surgeon was very surprised and then obviously absolutely delighted. He was a good surgeon, better than me, and clearly loved his surgery. One of the main problems was that the operating theatre was full of flies. Flies carry infection, and when we are doing orthopaedic implants, infection is the greatest danger as it destroys all our work. I could see immediately that he was quite used to flies in the operating room and my heart sank. This was not the way in which I wanted to operate.
There was also a problem with light. There were frequent power cuts and every time that the lights went out we continued operating to the dim glow of the anaesthetic monitor, which must have been battery-powered. At one stage I noticed that the anaesthetist was nowhere to be seen. There was no-one taking care of the patient at all. When I looked through into the scrub-up room I saw an extraordinary sight. The anaesthetist had taken off his socks shoes and trousers and was now washing his feet and legs in the sinks where we do our sterile scrub-up before gowning for surgery. When I next looked he had taken off his shirt and was vigorously lathering his hair with shampoo, with never a care for the patient. I tried to rationalize his behaviour. Presumably, there was no running water in his home so he used the opportunity of working in the hospital to perform his ablutions, but all the same!
Anaesthetist washing in the sterile surgical scrub up sink
Each day after operating we went on a ward round to see the patients who had been operated on. The wards were frankly dirty, the sheets were not clean and we moved between patients lifting off dressings and then moving on to the next patient without washing hands. I tried to make some comments about sterility and merely got an angry look from one of the nurses, so I decided not to make a fuss. All that was clear to me was that no further surgery should be performed in this hospital in its present state, as it was undoubtedly doing more harm than good. I put these views very clearly in my report to MdM and heard no more from them. It was clearly not at all what they wanted to hear. I was taken to lunch with a Hamas supporter who proudly showed off his four-year-old holding a Kalashnikov and shouting “Death to all Israelis”. That was on the same day that I saw another four-year-old who had picked up a munition and blown all his fingers off. How can fathers teach their children such hate, and how can a civilized country drop cluster bombs onto a civilian population knowing that they will be picked up and detonated by children?
His hand was blown off by a tiny brightly coloured cluster mine dropped from the air and scattered all over for kids to pick up. ?Made in UK
Two weeks went by very quickly and we had one day off to visit a farming friend of the surgeon who lived close to the Rafah gate, the entrance to Gaza from the South (Egypt). The gate had been closed for some time and was in complete disrepair. sheets of metal flapping in the breeze riddled with bullet holes from the last Intafada. The farm was quite delightful and the farmer a most hospitable host. He took us out on his donkey and cart to visit the tunnel entrances that littered his land and through which all goods came into and went out of Gaza.
A local and very hospitable farmer
The tunnels are known about and watched by the Israelis and yet they are tolerated. It is difficult to understand why, because it is through these tunnels that rockets and other weapons are smuggled into Gaza. Clearly there was some game being played here by Hamas, the Egyptians, and the Israelis which I did not understand. No-one seemed able to explain it either. It was as if the Israelis wanted to strangle Gaza, but not quite to death. It also seemed that they wanted to offer the Palestinians limited (very limited) ability to fight back so that they would then have a justification to attack. The only possible explanation that I could come up with was that this was being planned by Israeli military commanders who wanted a battle to fight so that they could continue to argue for more weapons and more resources. If they annihilated Gaza and drove out everyone who lived there, the Intifada there would be over. The world would be furious but quickly forget, and the military would be cut back because there was no threat from that direction. Surely that cannot be the right explanation?
One of the people that I worked with on the soap opera paracetamol research papers was an interesting man call Greg Philo who went on to do a study of whether BBC reporting in the Middle East was fair and unbiased. His report made fascinating reading. He noted that television and radio news reporting has to package a story into 90 seconds, the attention span of their audience. The Middle East Correspondent will know all about the geography and the history of the present situation and will frequently make the mistake of assuming that his audience does too. In fact the majority of the British population do not know where the Golan Heights are nor what exactly happened in the seven day war. He has no time to give a geography or history lesson so has to present out of context. As for film, he will need to have equal amounts of footage from each side of the dispute. The Israelis can supply a highly articulate spokesperson (usually female) who speaks impeccable English and who has prepared a coherent justification of the Israeli side of the argument, and they can do this at a moment’s notice day or night. The Palestinians have no such resource but there is always footage of young boys throwing stones at Israeli tanks. So, each news item is an Israeli ‘talking head’, versus some footage of kids throwing stones. This can hardly be called balanced coverage but is the best that can be provided in a ninety second slot. The truth in the Middle East is infinitely more complicated than that.
When I came to leave Gaza I was alone. I had been given a long list of instructions on how to get out through the Ehrez gate so I set off confidently. First there was the long walk down the wire-mesh walkway towards the wall and the swiveling TV cameras which are tracking your every move. When you get to the wall there are ten gates (it is like some computer game). One of them (usually the last in the row) will have a green light beside it rather than a red. Go through that door into a white room. There you unpack your luggage and place it item by item on a conveyor belt which takes it away into a tunnel. Each piece must be separate and your laptop must be open and propped up face down. Then you must find another door to go through that leads you into a glass tube. The moment that you step into this tube it swivels shut and a scanner spins round you again and again. After a long wait the tube opens on the other side and you can step out. Above you there is the glass wall with behind it armed guards with their weapons pointed at you. You then move forward to a room with an Israeli officer and a bench. She has your luggage, and piece by piece she works through it, throwing it back on the conveyor belt when it is of no more interest to her. At one point I took one step forward (I think to save my lap-top). She immediately pointed her weapon at my stomach and ordered me to step back. Finally, after an interminable wait I was allowed to repack my luggage and go to the passport desk and I was clear. The whole procedure was an exercise in humiliation. We were treated like animals. The lady behind me had a sick child that she was taking to hospital. She was treated quite as badly as me. I felt angry, and ashamed.
So much for bearing witness. I only saw one side of the argument and I was horrified. To think that people can behave this way to each other and that we in the developed world are in effect paying for this was deeply upsetting to me. No, I don’t want to go back to Gaza again. A further humanitarian disaster is surely avoidable.
The General Medical Council
I just thought that my problems with the Edinburgh College of Surgeons was an aberration and my ambitions for national influence were undiminished so I stood for election to the General Medical Council. Forming a team with Vicky was like live membership of a Hand Christian Anderson Fairytale, where I had as many wishes as I liked. I had only to rub the magic lantern (ask Vicky) and she would put in place a campaign to get me what I wanted. Sometimes she would point out the futility of craving some position, but otherwise she would quickly sit down and map out a campaign strategy and ‘poof!’ I had it.
The General Medical Council had gone through a very difficult period. It was a huge unwieldy organization with representation from every corner of medicine and absolutely no executive ability at all. The President was trying a radical program to modernize it and was being undermined and obstructed by his membership all the time. But it was clear that something had to be done, as the GMC was failing in its primary responsibility which was to regulate the medical profession. Harold Shipman had killed hundreds of his patients before virtually handing himself in. At the same time, doctors were complaining of how biased and incompetent the GMC was. Week after week stories were being splashed across the tabloids of doctors who were incompetent, dishonest, perverted or callous.
Both the public and the government were beginning to question whether self-regulation of a profession was such a good idea at all. Looking back now, this question has widened to include the legal profession, nursing, dentistry, the police and of course the Press themselves. From the government’s point of view it is of course ideal to have professional self-regulation. The profession have to pay for it out of their salaries, and if it isn’t working properly then it is the profession not the government that takes the rap. The profession, of course, wants to regulate themselves. It gives a group of burnt-outs (like me) tremendous power, while they pride themselves that only they should be allowed to regulate as only they know the complexities of the profession. So, the turkeys were not voting for Christmas.
After a tremendous battling a new General Medical Council was created, much smaller (only 30 members) and including a high proportion of lay people. However the Executive remained untouched, led by the infamous Finlay Scott. He had been Chief Executive of the GMC since what appeared to be the beginning of time. He was a top civil servant used to manipulating, bullying and cajoling people into doing what he wanted while wearing a thin veneer of being a ‘servant of the people’. I could be wrong but I sensed that he loathed doctors, and had the utmost disrespect for them. I had never come across a creature like this before and watched, mesmerised. Although Graeme Catto (a delightful WH Auden-loving Aberdonian nephrologist) was President of the Council, it was clear that Finlay ran this ship. I rapidly got the feeling that the Council meeting were orchestrated by Finlay and that the less that was said by the imbecile Council members the better.
At the first Council meeting, Graeme made a simple appeal to the council and it was “No surprises”. He claimed to be happy to try to deal with anything but did not want to be ambushed. It seemed a very reasonable claim and was justified when ten minutes later the first ambush was launched from one of the ‘old’ Council members who wanted to know why Graeme was President. The clue to the attack was his preamble where he claimed to have no strong feelings on the matter, but just wanted to question the process. In other words he felt that he should be President not Graeme!
At each Council I got to know the other Council members better and better, and started to distinguish the various sub-groups. First there were the professional medical committee members, presidents of Royal Colleges, chairs of numerous BMA committees. Sometimes I wondered whether they had remembered which committee they were at today, and indeed on one occasion I did speak after one the Council members who was also on the BMA council, reminding him that this committee was to protect the public not doctors. He never forgave me.
These committee professionals felt that they had a duty to deliver a weighty speech on every topic raised. Sometimes it would only be a typo on page twelve, but each speech would, for the benefit of everyone else in the room, show that they had read the papers fully. I very much doubt that they understood the principles involved, or the potential consequences of the proposals; on the few occasions when they got beyond the typos, they merely looked at each issue in terms of how it might affect doctors like them, while proudly claiming to represent society at large.
Then there were the portfolio folk; they were the lay members, all charming citizens mainly women, who were available to serve on any quango you might care to name. To them this was merely one of their days in the month, and if it wasn’t medicine then it would be electricity, social work or whatever. They too felt the need to speak to every item, by representing Joe Public against the medical profession. Finlay Scott listened attentively to all these fine speeches and then, quite rightly, took no notice of anything that anyone said. The work had all been done and dusted by his team before Council met. Sometimes when especially galled, he would spend a little time explaining to us benighted individuals how his brilliant civil servants controlled by him had produced the paper that they had. These speeches were delivered in a world-weary tone of voice and to say that they were patronizing was a grave understatement. We were merely rather irritating little cockroaches in a game that only Finlay really understood.
So, there I was, at last, in the centre of power in the medical profession, completely hamstrung. I had burrowed, kicked, elbowed, squirmed my way to the top of the dung heap, only to find the whole thing melt to ashes in my hands. It was very rare that I felt that I had anything useful to say. If I did, then I said it either at the wrong time or so badly that it did not get heard.
The evenings before the full Council meetings were interesting. We had a dinner to which a good speaker was invited. These talks were, to me, fascinating. They looked at the philosophy of regulation, and the law of the land. Some were very critical of the GMC. However, now that I was one of them I felt frustrated and angry about the criticisms. They were true but not fair. Now that I had seen how ineffectual an organisation like the GMC must be by virtue of its make-up, I could understand why we failed to deliver on what the public, the government and the medical profession wanted.
I had joined the GMC feeling very strongly that regulation of doctors was not nearly strict enough. I had seen my consultant in London come into the operating theatre drunk and break a patient’s leg. I had seen consultants harass juniors physically and mentally and I was itching to see these wrongs put right, but two things blew my certainty out of the water.
First was the Reith lectures by Onara O’Neill, a Cambridge philosopher. I was listening to one of her lectures while driving along, and had actually to stop the car in a lay-by so that I could listen carefully: I was so stunned by what she was saying. Obviously, it is ludicrous for me to try to summarise what a top philosopher is saying but I will blithely carry on and try. Her argument was that the public has to trust all professionals whether they are doctors, lawyers or plumbers. They have to trust because those ‘experts’ know more about their area of expertise that the average man on the Clapham Omnibus. The government has a responsibility to ‘protect’ its people and therefore may/should make sure that professionals are regulated by people competent to do so. The purpose is to weed out charlatans and those who may harm the public who must trust them. However, if these regulatory bodies over-regulate, then every competent professional will spend a disproportionate amount of time being checked, instead of getting on and doing his/her job. And, however heavily you regulate, you will always fail to catch some of the cleverest and wickedest of your professionals. So, like so many things there can be no absolute; there has to be a compromise. You need to minimise the regulation to allow the majority of good professionals to get on with their job, but then you have to take the flack that there will always be some wicked or naughty doctor who slip through your net however well it is set. I had never thought of it this way, and realized that heavier regulation was simply not the answer.
A major problem we were facing at the GMC was what I call the Inland Revenue issue. As I have learned to my cost the IR only investigates a small proportion of taxpayers. There are some folk who are very unlikely to be dodging tax and even if they are, it is likely to be small amounts. An example might be school teachers. They only investigate very few teachers (perhaps one in one hundred) chosen on a random basis. However, builders are always assumed to be fiddling with their taxes so they get investigated regularly. Orthopedic surgeons who are not declaring any earnings from private practice are a dead give-away because the proportion of orthopedic surgeons who don’t have a private practice must be vanishingly small. I am not saying that I was unique, it just felt like it sometimes! I kept on being investigated because I was an orthopedic surgeon who declared no private practice (because I didn’t do any).
At the GMC we knew perfectly well where the bulk of the problems lay. They were in locums, single-handed practitioners, and doctors who had come from abroad. However, if we were to focus our attention on these folk, we would find ourselves being accused of racial and probably sexual discrimination. It was far better to allow incompetent doctors to continue to practice than to risk the opprobrium of the left-wing press. The second problem that we had with revalidation was that doctors do a variety of things from operating through to public health, and even straight administration. Were we going to remove doctor privileges from those who were not actively working with patients? Of course not, because some of the worst offenders were on the GMC itself. There was plenty of evidence and there is even more now that doctors doing lots of what they do as doctors are better and safer than those having the occasional stab at it, and yet we did not dare set a minimum threshold for clinical practice. That meant that anything we set as a standard had to be a) universally applicable to whatever branch of medicine was being practiced, b) should not discriminate against part-timers, and specifically c) should not look too closely into the gloomier corners of medicine where there is found a high proportion of those who cannot cope with main-line medicine.
It will come as no surprise then that the revalidation procedure adopted cannot assure the public that it will catch all dangerous doctors (that is impossible), but equally it will seriously add to the burden of busy, competent doctors who do not need any more paper work to wade through. There was not a Council meeting when it was not mentioned that a quite disproportionate number of foreign doctors were being hauled up on disciplinary matters and what were we going to do about it. Instead of saying, let’s make sure that we are focusing on poorly performing doctors, whatever their colour or origin, we backed off and increased the regulation on those doctors who needed to be left alone to get on with a good job.
Jane and the GMC
On top of this, I had only been on the GMC for a couple of years when my sister Jane’s case was re-opened and the GMC started to investigate her. I know that she is a very good and caring doctor and found it incomprehensible that she needed to investigate again. In my opinion at that time, this was a witch hunt, and it was horrible to watch. Once the media have latched on, there is no letting go. Within the GMC, the Council itself is completely ring-fenced from any disciplinary work, so there was no way that I could know anything about how the case was going, never mind influence it. However, some years after I left the GMC some aggrieved doctors (who had been struck off by the GMC) discovered the family link and started a web-based campaign accusing me and the GMC of a conspiracy. I should have declared a conflict of interest as soon as the re-investigation started, but there never seemed to be a right moment, and Jane and I were not talking at the time anyhow. Certainly, her problems had no effect on my career in the GMC, and I was not able (nor would have I tried to) influence the outcome of her case. So, I suppose I am now tarred with the same brush too. Well her case certainly did not have any effect on my ineffectual time at the GMC, and I remain proud that she did the best that any doctor could. One day society will catch up and come to terms that all people have to die, it is just a question of whether they are allowed to die with dignity, or forced to go through prolonged misery because their relatives and carers cannot accept that there is a time when people should be allowed to go in peace.
I have to put in a footnote here in 2018. I have now read the Baker report and it makes dismal reading. It presents a doctor who developed a method for coping with a work load which was impossibly heavy, when what she should have done was resign. It involved creating an environment where sedation without explanation became the norm for patients who had been promised rehabilitation but for whom there was none. I am sure that there was ‘no time’ to see relatives and discuss their views and worries, but the result of this was that some relatives became convinced that Jane had shortened the lives of their relatives. The Baker report confirms that. In this day and age shortening life is simply not acceptable to some people even when the quality of life is dire. However, it was almost as if Jane sailed on blithely with her policy of making very heavy sedation available to all patients certain that she knew best. That is never good medicine. It will be interesting for you to see how much the public attitude to ‘end-of-life care changes during your lifetime.
Orion
My next adventure was the culmination of a campaign. I wanted to be a ship’s doctor traveling to Antarctica, but all the jobs were sewn up. Most companies use Phillipino doctors as they are cheap and will work long contracts. And I didn’t want to work on one of the big cruise ships some of which are in reality only mobile old people’s homes. They tell me that it is cheaper to go on a cruise than book into a nursing home, and you get better care, so some old people cruise until they drop – quite literally.
Orion 11
Finally, I got an offer of a job on a small expedition ship travelling through South East Asia. I knew this company also went to Antarctica so I felt this was a chance to get on the ladder. The company sent me my tickets and a long list of do’s and don’t’s and I was off. The only slight problem was that they had issued me with a ticket coming back to the UK rather than going out. It was lucky that Vicky noticed. The flight out was a long one and half way through there was that fateful call on the PA system “Is there a doctor on board?”
I suppose that it is surprising that it doesn’t happen more often. An elderly patient was slumped down in the crew area in the space beside an exit door. A couple of hostesses were bustling around and a worried looking husband is nursing a bag full of pills. She looks horribly pale and is holding her chest. Hmm! I wonder what equipment they have on board and where is the nearest airport that we could divert to. I say hello to the patient. It is really difficult to get down beside her and I really can’t feel a pulse at all. “Where is the pain?” I ask. She points to her stomach then her hand wanders up to her chest. Will her hand move left (bad news) or right (not so worrying). It goes neither way, so that doesn’t help much. “Does it radiate anywhere?” She doesn’t seem to understand that question and doesn’t answer. Her husband intervenes leaning down over us. “She is diabetic you know. Here are her medicines.”
The air hostess arrives with the medical bag. Not much in there. An old anaeroid blood pressure cuff (notoriously unreliable and the valves often don’t work). Still it concentrates my mind. Time to be systematic about this. The pulse is fast and thready, in fact it is only just palpable. I reckon that it is about 100 but I keep on getting interrupted while trying to count. “You’re feeling better already aren’t you?” I suggest hopefully. “No I don’t think so” she argues feebly. A hostess arrives with an oxygen cylinder. It can only be a five litre cylinder so that won’t last long. Anyhow we switch it on (is it really on?) and I worry that once we have the mask on her face, that we are asphyxiating her rather than helping her to breathe. She still looks very pale and I feel it is time that we got her flat. That means laying her out on the floor across the galley. The hostesses expertly lay out a duvet and she is manoeuvred onto the floor instead of slumped in a chair. A senior hostess from club class bussles in, complaining that this really is most inconvenient as it is right in the middle of serving meals! I mean, for heavens sake, where can you die on an aircraft without being a bit inconvenient?
A pause while I go throught the medical bag and make another abortive attempt to get a blood pressure, and at last her colour starts to improve. Now she volunteers that she really is feeling better. The pulse feels slower and stronger but I still cannot get a blood pressure on the anaeroid. We find a blood sugar testing kit in her bag and she helps by pricking her own finger. The sugar level is fine, but by then I have already given her a glass of sugary orange juice just in case her sugar was low. Gently we help her up and she eases her way back to her seat with her husband. The cabin staff are effusive in their thanks. Can they get me anything. Well, yes I would love to be upgraded from economy to business but I am too embarassed to ask. “A glass of champagne?” “No thanks” and I work my way back to my seat in steerage and a cold meal.
Flying down from Hong Kong to Vietnam the first thing I noticed was that there were no less than sixteen elderly passengers in wheel chairs to be loaded onto the aircraft. That seemed a terrible lot. The one next to me was chattering away cheerfully in Vietnamese but was carrying a Canadian passport. Were these all refugees coming to visit home after years away?
As the plane dropped in to Ho Chi Min over the Mekong delta, the paddy fields flickered bright green between the banks of low cloud. These were the killing fields of the Vietnam war fifty years ago. They look so harmless now. Another completely crazy war all grown over, just like the poppy fields of Flanders.
The Mekong Delta
Mention the name Saigon and my mind conjures up pictures of the final days of the Vietnam war, a mad, drunken, drug-crazed city imploding like a McCarthy novel, with everyone running for their lives and helicopters being tipped into the sea. However, the name Ho Chi Min City is for me redolent of the brutal oppression of totalitarian communism. Wide streets. Grim concrete apartment blocks and everyone in overalls. Before either of these phases, Saigon was apparently a lovely rather sleepy French colonial city.
Actually, Ho Chi Min city is in many ways like any Southeast Asian city. It feels like Chennai, warm, muggy and teeming with people, but it is clean. The roads are swept, and there are no three wheel tuk-tuks driving you mad with their noise and pollution. Everyone stops for traffic lights and there is very little hooting, so the wide streets are almost pleasant to walk along.
Ho Chi Min City – warm and pleasant
There are green central reservations, smart new skyscrapers, and empty streets. That is, until the traffic lights change. Then you see accelerating towards you down the boulevard, an avalanche of scooters. It looks like a great natural wonder, a scene from the ‘Frozen Planet’ when the arctic rivers thaw in spring and burst out of their ice coat. Cars seems to be carried along on the wave of scooters like ice floes in a raging torrent. Then just as suddenly the lights change and for a moment the road is quiet again until the next flood starts from another direction. Communist and bleak? Not a bit of it. Modern skyscrapers with Prada shops on their ground floor line clean streets bordered with trees and flower beds. There is poverty here but the young women who seem to run this part of town (certainly they drive all the scooters) are immaculately and expensively dressed. In fact there are no old people here at all. The occassional old lady with a straw hat and piles of bread balanced in baskets at each end of a bamboo pole, but no old men at all. I know, because I was looking out for them. People my age would have lived through the Vietnam war as teenagers but there are none here. I wonder where they are, and where their memories have gone? It is hard to believe that this city has gone through so many different phases in less than one hundred years. Just now it seems to be booming.
Finally I get to the docks and find my ship.
Well she is not a cruise liner but then nor is she just a boat. Just under 5000 tons she was built for a wealthy customer in Monaco as his private yacht but would not now even be in the top 50 of these for size. She has been converted to take around 100 guests in lovely double rooms. As the doc I get a small room next to the sickbay, with the rest of the 70 crew share rooms one deck below the rest of the ship.
The clinic on Orion undergoing a long overdue inventory
Most of the ratings on the ship are Filipino and absolutely delightful. The officers are Bulgarian, Ukrainian, South African, and British, an eclectic mix if ever there was one. We then also carry five expedition guides who drive the zodiacs and look after the clients ashore. Orion is specifically designed to do expedition work and since she is small she can sneak into places where cruise ships cannot go. We can beach our passengers in all sorts of remote places. I joined the ship at Ho Chi Min City (Saigon to you and me) and we sailed in the evening down the incredibly busy Saigon river. It is the same size as the Thames below the barrage but is jammed packed with tugs and barges moving gravel and containers up and down the river. There may be a world recession but there is no sign of it here. Weaving our way between all these boats around the hairpin bends of the river was really good fun to watch. Not so much fun for the captain and the pilot who on a couple of occasions ran out onto the bridge wing to yell Vietnamese imprecations at the helmsmen of boats that seemed only feet away.
Saigon river
Overnight we steamed up the coast to Phan Thiet and anchored just off a small river mouth which is a major centre for the fishing industry. The sea is littered with thousands of boats from small round coracles used by the inshore shrimp fishermen to sea going trawlers with tottering wooden superstructures. Day and night there are boats pouring in and out. This is a world centre for making a fish paste called Nuoc Mam. Without doubt the fishing industry here will collapse within the next few years. No ecological system could possibly survive this onslaught. Apparently over 1000 new fishing boats have been commissioned just in the last ten years. The coracle fishermen are changing over to fibreglass coracles which are fitted with an outboard which they dangle over the side. Otherwise they move by sculling with a single oar, or simply rocking the boat so that it is driven along by its own wash. I cannot conceive what is the benefit of trying to fish from a round boat, but new ones are being made, and can be found far out to sea bobbing in the ocean swell. The big trawlers tow them in long lines of up to twenty presumably to bring them to more remote fishing areas.
A fishing coracle. “They went to sea in a sieve they did. They went to sea in a sieve. And the sieve went round and round and they all cried you’ll be drowned….”
The sea and shore line is absolutely filthy, covered in litter and rubbish. The local officials seem very embarrassed about it and have employed teams to bag up the rubbish and take it away but each tide seems to bring in another load of plastic bags, expanded polystyrene and the bric a bric of mankind. I have no sense of smell but I gather from the others that it is lucky that I don’t! Cerrtainly the sea edge seems to be a popular open latrine.
So far the medical work has been light but of course, if we get a break out of D&V I could be pretty busy. Part of my job is testing the water for E.coli and the air for Legionella.
Testing the water
It is a long time since I last inoculated agar plates and read results from culture media. The expedition leaders seem to want help with the shore trips so I am delighted to be involved.
One of the perks of the job is that spouses are allowed to join you on ship so Vicky should be coming soon to spend a few weeks with me once we start on some serious exploring.
Some days later…
The first few days as a Ship’s doctor have been a complete blur. On a cruise ship (this is not really a cruise ship – only an expedition ship) there is just so much going on behind the scenes, which the passengers do not, and should not, know about.
I have got to find my way around the ship, and of course, everyone thinks I know where the upholsterer is (yes we do have a ship’s upholsterer!). My sickbay is one of the centers of the ship. Most people come by there for one reason or another and I am busy trying to learn names. We have over seventy crew (more than we have passengers) and they are all cheerful, all Filipino, and all complete hypochondriacs.
The clinic on Orion
Today we are at sea all day heading 300 miles north up the Vietnamese coast. This is a chance to check things that otherwise could not be done because we were busy embarking and disembarking passengers, supplies, water etc. First off was a fire drill. My radio had somehow changed the channel so I was a bit out of the loop, and the first officer on the bridge was not amused. Anyhow my five-man first-aid team led me off smartly at the run to our ‘fire’. However, almost immediately we were driven back by a team in asbestos fire suits who informed us that there was smoke and that we had to hold while they did ‘indirect fire control’. Hoses were run out all over the place down on level 2 while the passengers were serenaded on the top desk sublimely unaware of the ‘hell’ going on down below. Anyhow, before we got to our casualty there were new orders that we were to ‘abandon ship’. Off we went to our lifeboat stations where the crew had all been transformed into different people. Luminous blue jackets informed us what their task was, matched by labeled baseball caps just in case we could not read their tabards. Finally, we were all stood down and team leaders (to my surprise that included me) were summoned to the bridge for a ‘debrief’.
Orion from one of the Zodiacs
Some general praise, then four or five ‘dressings down’ followed by a heated discussion on how we could avoid fire-hoses crossing fire-doors (which are supposed to be kept shut). I asked the chief engineer who was standing beside me, how often this happens, and without hesitation he answered “every week without fail” and then mentioned in passing that he was on the Clipper Odyssey in 2004 when they really did have to abandon ship in Alaska after they hit a submerged reef. I thought about our major incident practices in the hospitals at home, once every two or three years! Now wouldn’t that be impressive if we did a weekly practice in the hospital, alternating between major alerts, fires etc.
Firefighting drill. Each week over 40 crew have to dress fully and deploy
The additional bonus of this exercise was that I felt it was a good team building event and I got a much clearer idea of how skilled some of the quieter crew were.
Life jacket practice for the passengers
Straight after that, it was ‘Cabin Inspections’. The captain, first officer, hotel manager, chief steward, and I lined up and went through every single cabin in the crew’s quarters. The crew lives up to four in a cabin in bunks with curtains around each bed. Everything they own has to be fitted somewhere in that cabin. A check is made for food (forbidden) unused electric cables (not allowed) and general cleanliness. I must say I felt a little uncomfortable. At least in the Army the soldiers “stood by their beds” while their lockers were inspected, while we just went from cabin to cabin prying and poking our way through everyone’s personal belongings. But as the captain said it is critical that every part of the ship is clean and safe, and they have agreed to this in their articles of sailing.
My main work at the moment is learning where everything is in the sick bay (from syringes and needles to stool specimen pots if we get a break out of D&V). While I work my way through, I am updating the inventory and chucking out time-expired medicines. I am just hoping for a few days more before anything major happens so that I can at least look as if I know where things are.
The last doctor did not like going ashore but I am keen to see as much of the countryside as the clients do. My argument that the doctor should be where the clients are, was welcomed so it looks as if I will get to see a lot of Vietnam.
Apparently the last captain was a gunnery officer in the US navy and was heard to mutter on one visit to a village built underground in tunnels (because of American bombing) that he was pretty sure that he was responsible for some of the bomb craters scattered around the village.
Yesterday we stopped at a beautiful village Hoi An brimming with tailors and shoe makers. They will copy any clothes or shoes (within hours) and the prices are just ridiculously cheap. What an enterprising people they are.
Hoi An. Fabulous tailors and shoe makers
Haiphong
Our first set of guests have now all disembarked and set off for Hanoi. On their last day, we anchored off Cat Ba Island, which is part of the huge Haiphong National Park. This is rated as one of the seven wonders of the world and we had to the luck to be anchored in its centre. It is a fantasy-world landscape, like something out of a science fiction computer game, where vertical pillars of limestone, festooned with vegetation, rise hundreds of feet out of the sea. Their bases are actually undermined by the waves so they look as if they must topple over at any moment. But the monkeys (Stub-tailed Macaques) were clearly finding the habitat ideal, crashing through the vegetation chattering and arguing the while.
We were in Zodiacs (rubber dinghies), but there were clusters of backpackers in Kayaks also exploring the creeks and islands, and here and there beautiful great wooden junks have been built as floating luxury hotels.
It was a real pleasure to go out first with the guides, ostensibly to ‘recce’ for the best places to take the clients. The guides are all so mad keen on birdwatching, botany, and geology that we soon forgot our job, and at times we were squabbling louder than the monkeys on the cliffs above us. We have seen more wildlife here than anywhere else in Vietnam so the concept of a National Park with people living in it seems to be working. They have a good rule. We are not allowed to take our boats into the local floating villages. If the villagers decide to allow guests, then they bring them to their homes in their own boats and on their own terms.
If contrast is the spice of life, then today is a curry. We are now docked in Haiphong harbor, the port for Hanoi. Noisy, dirty, and very very busy. This is the ‘East’ doing business. There are just so many ships moving up and down the river, and so many new wharves being built that recession is not a word that would even cross your mind. I wonder if this is what London docks looked like in their Victorian heyday.
The Saigon River – busy
All local goods are unbelievably cheap here. Cobblers and tailors will copy shoes or clothes for you in hours at unbelievably low prices, while the food is spicy and delicious. I wonder whether, like China, their currency is being held artificially low against Western currencies to stimulate business. If it is, then they are certainly succeeding. Tonight we will get our next set of clients and set off south again back down Vietnam. It is a long thin country, and by all accounts, the roads are so bad that an expedition boat like this is probably the best way to see it.
My first trip on Orion had been fraught with anxiety. I had never worked as a ship’s doctor before, and the company employing me were nervous about me too. They insisted that I should contact their chief nurse daily to let them know what I was doing. I was the only doctor on board and only had a nurse who normally worked as a cabin steward but who could be called in an emergency.
On one cruise we sailed out of port into a full gale. So, the first night I was up going from cabin to cabin giving sea-sickness injections. It was all done very quickly in the dark. I would dash into the cabin, draw up the syringe, inject a buttock, and be on my way. We didn’t actually have anything for sea-sickness just sedatives like Chlorpheniramine, and Chlorpromazine, so I just gave whatever I could find. I think it just put them to sleep. The next day was calmer and by dinner time everyone was back on form. We officers ate with the guests so I made my way to a table where there was a space between two very large Australian ladies. I introduced myself as the doctor and my introduction was brushed aside as they explained that we had already met as I had given them sea-sickness injections the night before. Without thinking I replied “Well then, I will probably recognise you better by your buttocks than your faces. For a moment there was a ghastly silence, as it dawned on me that my remark had probably lost me my job. Then, as only Australians can, they burst into fits of laughter.
Within a few weeks we had our first major problem. A very wealthy French couple in a stateroom on one of the highest decks were feeling sea-sick. They decided that there was much less movement lower in the ship, so dragged their mattresses out of their cabins down to reception and set up camp there, completely blocking access for everyone. I was getting a little fed-up with having to send daily reports, so decided to make this the topic of my report. I sent a picture of the shambles in the reception area, explained what the French guests had done and requested permission to turn the fire-hoses onto them, to drive them back to their cabins. I had not allowed for the complete inability of Americans to understand irony. A signal flashed back that on ‘No account was I to use fire hoses on guests’
When I am working in a hospital I can order a blood test and a few hours later the answer comes back. Here on the ship there are a rack of boxes each containing a machine which does a certain technical job. But that relies on me being able to find the box, set up the machine, calibrate it and then perform the test. But it is not just blood tests that I have to do. I also have random alcohol tests on the crew, tests on the water we take from the shore (checking for contamination with coliforms), and then tests on all the showers for the dread Legionella. So, long hours are spent in my office poring over the instruction manual of some weird gadget trying to work out how to get a valid answer out of it. I cannot remember when I last inoculated an Agar plate but it must have been when I was a preclinical student in the early 1970s. And here I find myself now, with the instruction manual in one hand and a wand wafting through a bunsen burner flame trying to inoculate a set of chocolate agar plates before tucking them into the incubator. However, instead of having to read them, I just take a digital photo of each and email it to Otello somewhere in Italy who then gives me my results and kind comments on the quality of my plates and the labeling.
But there are other things to do as well. This afternoon my quiet clinic (I was trying to work out how the INR machine works) was invaded by the Captain leading a jabbering gaggle of boiler-men and electricians from the engine room. At first it was impossible to work out what had happened. A furious argument had erupted between one of the Philippino engineers and a Romanian electrician. But slowly the soft Irish brogue of the Captain percolated through. Somehow electrode cleaning fluid had been poured into one of the lead acid batteries and a cloud of gas had enveloped the two workers. My simple question “What is the chemical composition of the cleaning fluid” was greeted with a further outbreak of argument. “Acetone?” “No” “But it says acetone on the container”. “Yes but that is not the original container”. I was firmly nudged off my chair by a large Romanian electrician who started searching on Google, while arguing at the same time. The Captain very wisely slipped away, as no-one could be seriously affected by the gas if they could argue so forcibly. Finally I had to get out my stethoscope and make as if I wanted to listed to some chests. I hissed for silence while I performed this ‘magic’ procedure, and damn me the room fell quiet. Wonderful things stethoscopes. I can’t hear a thing through them, but by sticking them in my ears and waving the trumpet over a chest, I can get a room to fall silent. That gives me 10 seconds to think what to say or do next. As soon as I took my stethoscope off again, all hell broke out yet again. So then I decided to hide behind paper-work and sent them all off to fill in an accident report form detailing exactly what had happened. In the meantime I Googled acetone and sulphuric acid as that seemed the likeliest combination to have produced the gas. Hmm! that produces sulphur dioxide, a fairly toxic gas. But wait a minute it also produces acetone peroxide a white crystalline powder that is highly explosive even when it is just rubbed or crushed. When they all came back with their forms filled in, I asked them whether there were any white crystals lying around the site of the spill. “No”, they assured me, looking a little puzzled. I heaved a sigh of relief. We are not going to be blown to kingdom come – today at least.
Vietnam
I went to the War Museum yesterday, a huge building in the centre of Ho Chi Min City (Saigon). I have never before been to a museum where ‘we’ were on the ‘wrong’ side. The ones that I have visited have been full of information about the brave deeds or our ‘boys’ which eventually led to victory. This one, of course, focused on the American war (as they call it) from the viewpoint of the Vietcong. Paradoxically the most telling part of the whole exhibition was the floor devoted to the dozens of war photographers killed during that war. The most poignant pictures were taken by Western photographers, because it was they who ‘brought the war home’ and stopped what had by the end become ideological carnage. For them, art and belief had been brought together to create the front page spreads of Life Magazine. I wonder whether in a few years, there will be a similar museum in Kabul erected by the Taliban. If so, I may not want to go to see it. History is one-sided. It is the story according to the victors. I would not like to see all the effort we have put into helping Afghanistan converted into a set of pictures of the slaughter of women and children, torture of prisoners, and destruction of villages, but I fear that is what it will portray.
A group of young Vietnamese men gathering for a Cock Fight
It is difficult to talk to the Vietnamese about the war, as those whom we meet and who speak good English are obviously a special sub-set who are pro-western. However, sitting talking to Mr. Khoi, the soft spoken ship’s agent, he just says that they want to forget the past and move towards growth for the future. This clear view is not borne out by his non-verbals as he ducks eye contact and squirms on his seat. Nor is it borne out by the streams of school children pouring into the war museum and heading straight off into the prison cells created to show the vile conditions that innocent farmers (Vietcong) were held in, and the awful tortures to which they were subjected. If I had visited that museum when I was aged eight I would never have forgotten it all my life.
Vietnam today is a puzzle for me. It is a centrally controlled state like China I suppose, so Twitter is banned as is criticism of the government. There is no free press, nor are there are beggars on the street. That is not allowed. You have to pay for schooling and for health care so those two rights which we regard as basic are not available to the majority of the population. However, the country is clean and tidy and growing like hell, which is more than can be said for the West! Who knows whether it is we who need to move away from our notional democracy where no-one votes anyway, banks rule the economy, and both laws and policy are increasingly determined by faceless bureaucrats in Brussels. Perhaps we too are embracing a centrally controlled autocracy, while pretending to live in a free democracy.
There is heartbreakingly little wildlife in Vietnam. No seabirds at all. It is tempting to think that this is a result of Agent Orange, but there are no seabirds in most of the rest of South-East Asia either so we probably need to look further afield for the reason. It cannot be a shortage of fish because even if it looks as if they are massively over-fishing, there are still many being caught. Surely it cannot be pollution. There is lots of it, but much less than in the Gulf of Mexico.
I am puzzled. All I do know is that the trite explanations of our wealthy guests “too many people my dear. Something must be done” are not right, nor is the unspoken accusation from my Vietnamese workmates that it was Agent Orange.
I have now cruised the 1000-odd kilometres up and down the coast of Vietnam three times and am beginning to get a feel for it at last. Our guide over the last three days has been a very articulate young man, son of a senior officer in the South Vietnamese Army and the youngest of eight children, whose parents were put into an arranged marriage when his father was sixteen and his mother was thirteen and who, according to him, discovered within the first week that they did not like each other very much! He is very outspoken about the regime and the way in which the South Vietnamese have been persecuted since the North won.
It is quite clear that the transition from a centrally controlled communist state in 1975 to the present situation has been a traumatic one. Now, everything has to be paid for privately or with a bribe. That includes child-birth, kindergarten, schooling and university. There is now no unemployment benefit, nor any mechanism for caring for the elderly if they have no family. The enormous difference in salaries between the middle classes and the poor means that a great deal is available to the middle classes, but at a cost, while very little indeed is available to the peasants whether they are fishermen or rice farmers. Families are limited to two children, and sons are hugely favoured over daughters so, although it is illegal, gender abortion is common and there are 125 boys for every 100 girls. This problem is compounded by the fact that South Koreans come to Vietnam to ‘buy’ wives. The history of the country is hugely complex with wave after wave of peoples coming down from the North and conquering what is a very rich and fertile land. The colonization by the French, and then the support by the Americans for the South Vietnamese against the communist North, we know about. The invasion of North Vietnam by China in 1979 is much less well known to us, but again resulted in an enormous loss of life. Their reliance on Russia failed with the collapse of the USSR, and life in the 1990s must have been very hard indeed. Everyone is now busy trying to get rich with bribes, investment in hotel complexes, or building shrimp farms. The interest on bank loans was 27% per annum up until last year but has fallen this year to only 16% so clearly you have to be sure of the return on your money before borrowing. The whole place seethes with activity, ambition and inward investment.
Nothing is very formal but life does revolve around enormous meals served four times a day. As ‘officer crew’ we have to choice of eating ‘posh’ with the passengers or ‘rough’ with the crew deep in the bowels of the ship. From a medical point of view there is amazingly little to do. The first week was spent finding out where everything was and updating inventories, but now there is just a lot of paperwork and then various bits of bacteriology to check that E.coli is at bay and that Legionella is nowhere to be found. So I have been trying to get on every trip ashore that the passengers do, so that I can get to see a bit of Vietnam too. The guides are very keen on wildlife so they make very good company, and then we also have the local Vietnamese guides.
I don’t know about you but old temples overgrown with jungle celebrating some abstruse religion don’t do much for me especially when most of them were bombed to bits by the Americans in the Vietnam war because they were thought to be harbouring Viet Cong (and I am sure that they were). What is much more fun is bicycling through the villages and rice fields looking at how ordinary people live in Vietnam today. I am just not sure how I would feel if a bunch of Vietnamese appeared on bicycles in Stanton St. John and started working their way through our gardens chattering, poking, prodding, and laughing, But hey! I suppose that is tourism.
Guests and crew
I, like the captain and the other officers, wear white flannels with shoulder flashes, during the day, and change into black trousers at 6 pm.
A few of the guests treat us all like servants, and I must say I find that quite disquieting, especially when I wonder if I have ever done that under similar circumstances myself. Others keep very quiet and it is of course they who are likely to be the most interesting. One groups stands out and this group I call the ‘merry widows’ although many are accompanied by meek husbands. They have and will continue to live life to the full until the day that they drop. They come on an expedition ship because they are outgoing and inquisitive (in the nicest possible way). They are socially wonderfully confident, and are very easy to get on with. A second group are the younger (mid forties) successful businessmen and women. They are on their iPhones and Blackberries as they come aboard and may relax after a couple of days, but there again they may not. You can see in their eyes that everything that they see around them is being measured in terms of whether they would approve of this if they were running the ship as their business.
The guides are another group apart. We usually have five on board and their job is to keep the guests entertained from dawn to dusk. Most of them are exceptional biologists who know all their plants, animals, and geology, but at the same time, they have to be organizing quizzes, driving zodiacs, making sure all the guests are back on the bus and all the one hundred things necessary to make each guest relax and feel pampered. It is a really tough job, and not nearly as glamorous as you might think. Much of their time is taken up photographing the guests on their trips out and then collating a DVD with background music as a memento of the trip.
Halong Bay. A national marine park with lovely caves
But the main preoccupation of everyone is food. Food, food, food. Huge breakfasts, enormous lunches, and gargantuan dinners are all prepared to gourmet standards. You could put on a stone in weight in a week on this ship. The Maitre’d is a completely wonderful Hungarian who chatters and cajoles the ‘merry widows’ into eating yet another lobster or whatever it is that he has on his menu today.
As a doctor, my role is very peripheral indeed. I suppose I am here as a long stop as everyone is wonderfully fit. The elephant in the room of course is food poisoning. If we get an outbreak on the ship all hell will break loose. Apparently, it happens not infrequently on the big cruise liners, and I just hope that it never happens to us. The worst is apparently when you the doctor get it too, and are expected to minister to the guests and crew when you feel like death warmed up yourself.
The Mekong Delta
Four weeks of travelling Vietnam from end to end and I certainly feel that I know the ports well and the rest of the country a little. We have dipped our toes into the culture and failed utterly to understand. I know it is not politically correct but I find interminable visits to temples built to some abstruse and obsolete religion wearisome after a while. I would rather know about the people now, but they remain inscrutable. There is a huge sense of energy here. Everything is changing. Forests are being cut to wood chips for Japanese paper companies. Sand dunes are being gentrified into enormous golf courses surrounded by empty luxury villas. It all looks a bit contrived and more than a little tacky. There is no doubt that a few people are getting very wealthy here but as is so often the case when communism converts to capitalism, most people are getting poorer and they were very poor beforehand.
We have now turned south pursued by cold wet and rainy weather and turned into the heart of the Mekong delta, an enormous alluvial plain made of eroded mountain ranges. The ship is too big to get into the really wild parts so the river banks have been disappointingly lined with prefabricated factories and glimpses of fish farms. The Mekong delta is the second most ecologically diverse area in the world after the Amazon, but it might as well be a desert for all that we can see of it. Perhaps there are areas full of birds and other creatures but the part we can see about as biologically diverse and aesthetic as the Manchester ship canal during the last recession.
The personalities in the ship (both passengers and crew) are now filling out in 3D and full Technicolor. Some improve with this closer knowledge and others don’t, and of course you have to remember that you are stuck on the same ship with them until your or their contract finishes. This makes for some interesting dynamics. As the doctor I am party to more of these issues than perhaps I would wish.
You have to wonder why people choose to come on expedition ships rather than staying at a hotel or going on a cruise liner. Some are complete expedition ship junkies and love the blend of excellent food and zodiac dinghies heading into unknown places. They have already been to Antarctica, Northern Australia (the Kimberlies), New Caledonia, Papua New Guinea and a dozen other places I haven’t even heard of. However, one very quiet elderly lady presented a very different picture. Her husband is softly dementing (is that the right adjective?). She told me that he is on his best behaviour in company but that he lashes out and shouts at her when they are on their own. So she is booking cruise after cruise for as long as he is on his feet, as he is happy and she is safe.
The crew of the ship are mainly from the Phillipines. They are the most atrocious hypochondriacs and clearly there is an ongoing discussion in the crew mess to decide what symptoms presented to the doc give the best yield of medicines. They are very shy about coming to the clinic as they are terrified of losing their job if they ‘officially’ have an illness. However, like moths to a light bulb, they are equally unable to resist consulting a ‘captive’ doctor. So most consultations are corridor requests. This makes things tricky for me. The consultations are hurried, often cover a deep anxiety, and are usually aimed at getting some medicine, preferably an antibiotic! And if they are from the engine room, I am not always sure of their names. I shall have to coin a new acronym. FaCoHyCoSeCo (Fast, Corridor, Hypochondriac Could be Serious Consultation)
Orion anchored offshore ready to offload passengers onto a junk
Of course, all passenger consultations occur when you are already seeing a patient or just sitting down to dinner. I don’t know how Dr Finlay (an old TV series about single-handed GPs) ever got a meal, a shower, or anything else for that matter. This is especially frustrating when the patient then says “Oh doctor, it isn’t anything important. I just wanted to ask what you think about……”
At dinner the other evening I told the table my story about going out to dinner in London years ago and being asked by the lady on my left about her bunions. Having tried to fob her off for a while, I realized that she was not going to let the subject go, so in a fit of madness I reached under the table and hoisted her foot onto the dinner table explaining to the other guests that she badly wanted to discuss her bunions so why didn’t we all join in.
I could see that a few at the table digested the moral of this story and the conversation moved away from medicine to places that people had visited and other ‘safe’ topics.
I am allowed to donate a bottle of wine to the table where I sit, but I don’t feel that I can be a doctor on duty 24/7 and drink so there is an amusing verbal dance while the guests choose the wine, which I am donating. All the guests are really interested if you can get them to talk about themselves and what really interests them, so dinner can be great fun.
Our first set of guests have now all disembarked and set off for Hanoi. They were a pleasure to have on board. Bluff Australians mostly, mad keen on golf. On their last day we anchored off Cat Ba Island, which is part of the huge Haiphong National Park.
Exploring a National Park by Zodiac dinghy
Sea sickness
As we travelled down Vietnam and around into the Gulf of Siam the weather remained stormy, with bad with strong winds, rain and lumpy seas. We were in the tail of the cyclone which hit the Philippines. The stabilizers on the ship were not working and the ship was rolling about a bit, but nothing to justify the epidemic of sea-sickness which started to afflict most of the passengers. We have sea-sickness tablets to hand out but to mix a metaphor, these were a drop in a very lumpy ocean. I found no less than six different treatments for seasickness in the medicine cupboard, most of which I had never heard of before. You always know that when there are lots of choices in treatment for a condition, then none of them will work. Otherwise, of course, if something did work then there would be only one definitive treatment.
I was also being bombarded with advice from passengers who had been on cruises before. Each of them had a unique treatment and each was different. Each wanted to tell me how far into the Drake Passage they were, and how high the waves rose over the mast. Their cures for seasickness varied from ginger tea to Ondansetron, a fairly expensive drug that is commonly used in hospitals to prevent vomiting after anesthetics have been administered. I know that amongst each group of seventy-odd passengers, there will be six or eight doctors and an equal number of alternative medicine bampots. However, just to make things more difficult, some of these will also be doctors. So, I have a variety of opinions which may arise from a world famous specialist in disorders of the middle ear through to born-again lunatics running companies selling ground-up lizard tails as an aphrodisiac (and cure for sea-sickness!). But, to add insult to injury, they are not only telling me what I should be doing, they are telling all the other passengers what they think that they should be doing, and depending on how persuasive they are the mood of the ship changes.
Those who are smitten with proper sea-sickness become the most pathetic creatures, shorn of all will-power. I was called to a cabin by a very anxious man who told me that his wife had collapsed. Indeed she had! She had obviously been on the toilet when she finally lost the will to live and slipped off the side and down between the toilet and the wall. She was of a shape that meant that she was going to be difficult to extract as her ample buttocks had now expanded to fill the space below the rim of the toilet. Only one of us could get to her at a time, and the ship was both pitching and rolling like a lamb in spring. As I got a firm hold on her arms, I felt sure that there was no way that I would ever be able to get her out, especially as she was currently pretending to be dead. However, I had made no allowance for the movement of the ship. The next moment the ship had rolled towards me, and like a cork leaving a champagne bottle she sprung from her den and waltzed backwards with me across the cabin until my heels hit the edge of the sofa when I quite literally sank beneath her. Her husband kindly came to my rescue and we dragged her into bed, where I took a little pleasure in giving her a large injection.
Meanwhile the other passengers had discovered scopolamine skin patches and they all wanted them. You stick these little round chemical-laden plasters behind your ear and they are supposed to provide a slow but sustained release of one of the unproven anti-motion sickness drugs about which little is known except that it has its fair share of side-effects which include hallucinations. These are not a good idea on a ship as they can result in the passenger attempting to mimic the Good Lord and walk on water.
So the first thing for me to do was to get onto the internet and start doing a bit of a literature search. Not a single trial could I find, except one which reported that Ondansetron does not work for motion sickness. One down six to go. All the rest of the drugs have similar side effects, and did you know 1.5 in a thousand people have hallucinations from taking penicillin? Who would have guessed that?
Anyhow these are no ordinary patients, the passengers on this ship. They are all highly successful business people. You would have thought that 100 patches (each of which lasts three days) would last 70-odd passengers a week (assuming that some have ayurvedic wrist bands, and others just like vomiting). Not a bit of it. Within 24 hours the patches have all gone, and passengers are begging me to give them more. Apparently, some of these cheeky monkeys have been stock-piling them for their return to Australia or the USA where they are only available on prescription. So, as soon as this last lot of passengers leave the ship I emptied the pharmacies of Singapore of all their motion sickness patches and doubled the price at which we sell them. As soon as we sail they have gone too. This is a market gone crazy.
Some of the passengers do what is called a back-to-back and stay on for a second cruise. They had spoken to the new passengers and apparently ‘infected’ them with the meme that survival on this ship is only possible with skin patches. So now all the passengers have the little buff patch stuck on the bone just behind their ears. It looks as if we have been involved in a paintball attack! As far as I know, some of them may be hallucinating too!
I devised a classification for sea sickness depending on its severity
Class 1 – “Why did you book us on a cruise? You know that I hate the sea!”
Class 2 – “Get me off this ship now. I don’t care what it costs, the helicopter of whatever. Just get me off!”
Class 3 – “Just leave me to die. I am turning my face to the wall and am resigned to my fate.”
Expedition Cruising
Ships cost a fortune to run and so they have to be working all the time, day and night, week after week, year in and year out. I suppose most of us are used to working nine to five, five days a week, and then turning out the lights and going home: but that doesn’t work for Emergency Departments and nor does it for cruise/expedition ships.
The nights on passenger ships are short. The last party animals don’t give up drinking, dancing and singing until well after midnight, and then some of the passengers start surfacing around 5.30 am (the insomniacs and the bird-watchers). Even during the few quiet hours of the night, the ship will be sailing to a new destination. Bridge officers and engineers will be working away at their posts. Then there are longer cycles of time. Every ten days a new group of passengers come on board hoping for the holiday of a lifetime. For the first few days, we are trying to learn their names, their likes and their dislikes. Then in the last few days of their holiday, they are working themselves into a crescendo of partying trying to draw us, their new friends, into the fun. Within an hour of us waving goodbye to the last guest, a new silent watchful group are coming aboard and we are trying to appear warm and friendly to yet another seventy-five people of every age and from all over the world, who are hoping for their holiday of a lifetime.
Dancing with local children In Indonesia
Dancing the night away on board
Then there is the crew cycle. For the first couple of cruises, you are a new boy. You don’t know how anything works or where anything is, while the rest of the crew appear to have been there since the beginning of time (and some have!). However, most work a three-month or at most a nine-month contract, so at the end of each cruise, some crew leave and are replaced by new boys. Quite suddenly you find yourself an ‘old dog’, a part of the furniture. Before you have had time to get used to that new role, you are at the end of your contract and are saying goodbye to a team who have worked with you 24/7 and have now become a close family. Most of the crew are from the Philippines. They live four to a cabin that has no portholes (it is below sea level) and despite this, they are always immaculately turned out cheerful and friendly. To top it all they organize amongst themselves a show of song and dance which is semi-professional and is put on every ten days for the passengers.
Deck crew singing YMCA and flexing their muscles in the crew show
Orion II at dawn in the S. China Sea
I suppose that an Emergency department is not dissimilar. You come on duty and all the staff are there working away as if they have been there since you were on duty yesterday. They know exactly what is happening and you are feeling your way into the shift. It is ‘Alice through the Looking Glass stuff’. It is as if you have run to stand still, You usher in a new patient, listen to their concerns, treat if you can, complete your paperwork and usher in the next patient. There are lots of patients to see, just as there were when you went off duty yesterday. Over the hours the number of patients needing to be seen rises and falls, but the machine rolls on. Some staff vanish ‘off-duty’ while others appear in their places. Then quite suddenly your shift ends. There are still lots more patients to be seen. After a few months in the department, you are an old hand not a new boy, and many of the staff working with you have changed. The machine is remorseless. If you were to have the misfortune to fall under a number 9 bus, no one would notice a thing. There would be a quick bit of gossip “Oh, did you hear what happened to Chris?” and within days you would be forgotten.
In my three months on Orion II we have traveled up and down the coast of Vietnam four times from Saigon to Hanoi. That is not as bad as it sounds as a return trip is a chance to see something that you hadn’t realized was so interesting last time. Then I read the book ‘The Cat from Hue’ by John Laurence. If you read only one book this year then get onto Abebooks (www.abeboooks.co.uk) buy it second hand and read it. Who would have thought that a book about the Vietnam War could be so riveting?
Then, on to the islands in the South China Sea snorkeling and exploring National parks, The only disappointment is – no birds in the South China Sea- don’t ask me why. They just are not there.
Borneo
Borneo. So this is the land of Orang-utans and of immeasurable areas of pristine jungle. Well not quite!
We set off from Oh! so clean, Oh! so sophisticated Singapore with new guests including one very special one – Vicky – who was re-joining the ship after cooking non-stop over Christmas for her children. The weather had improved and for the first time we saw the sun as we sailed down to some lovely islands off Northern Borneo which were as beautiful as any I have ever seen. The beaches where we landed have never been visited by Westerners before and the snorkelling on the coral reefs was to die for. I admit that I did momentarily spare a thought for all of you back in mid-winter in the UK, as I drifted through a Technicolour coral garden, the warm sun beating down on my back. Inland, the trees were full of monkeys and covered in very large pitcher plants which get their nutrients by trapping insects.
Landing on a deserted beach on New Year’s Day on A pitcher plant ready New Year’s Day greeted by the ship’s saxophonist Gus. to trap an insect. They have smart little caps over them to prevent them from filling with rainwater, and once your eye is attuned to them, you can find them everywhere!
We ail around to the south of Borneo island, and down to see Orang-utans. Orion has a special relationship with various wildlife charities, in this case, a charity focused on the conservation of Orang-utans. There are several charities that are trying to save Orang-utans but the whole business has become complicated by the fact that the babies are utterly delightful, and so the ‘rescue’ of babies has started to dominate the conservation effort. The sanctuary that we visited has over 300 of them and there is another nearby with over 600. The only problem is that there is nowhere for them to go once they are adult because the forests of Borneo are being cut and burnt to the ground at a mind-boggling rate (50 square meters a second!). Huge tracts of land are being cleared ostensibly to plant palm oil trees. These hugely productive plants are an incredibly important and valuable source of revenue for third-world tropical countries and provide productive work for many. The oil that is obtained is used in almost every refined food in the west, as well as in most cosmetics. Various conservation groups want us to boycott food with palm oil in it, or at least only buy from sustainable sources to save the jungle. And that is where the complexities of third-world trade/conservation rear their ugly heads. For a start, there is plenty of spare land on which to grow Palm oil trees but forest is still being cleared and burnt at an enormous rate. Why? Well because the tropical hardwood timber cut down when the jungle is cleared, yields money right now, not in five years when the Palm oil plants have grown. And where does all the ill-gotten timber go? Well, first to China where it is made into furniture and then sold on to us with ‘Made in China’ written on it, so we imagine foolishly that it comes from a sustainable Chinese source.
And the palm oil? Well, it has dozens of names on product labels so we cannot know which foods use palm oil grown on land that was recently pristine jungle, so we cannot boycott products that are destroying rainforests. The rate of forest loss is accelerating not slowing, and the orphaned orangutangs whose parents have been killed will have no jungle to return to when they grow up, however well they are cared for now. It is truly a heartbreaking situation as we consider the future of this lovely country, sitting on the ground with the young Orangutans playing and bouncing all over us. Our passengers this time are mainly socially influential Americans who have adopted this as their ‘social awareness’ issue. We have a superb lecturer on board who has not pulled any punches on the ethical dilemmas of the situation, while at the same time we have the redoubtable Dr Galdikas who is responsible for setting up the main Orang-utan charity (Camp Leakey) and is working her audience like only Billy Graham could. The result has some wonderful polarisation between emotion and rational arguments. Neither side scored well on pragmatic solutions.
Vicky with Otto
Up to no good?
The emotional arguers were talking about orphans not conservation of wild life, while the rationalists were convinced that some simplistic argument like banning people from cutting down trees (and stopping 3rd world people from breeding!) would somehow make everything alright. Sitting on a luxury expedition ship didn’t make our position especially comfortable either.
North of Borneo
We are now retracing our steps from Singapore up to North Borneo (Sarawak and Sabah to be exact). The weather has settled into hot windless days followed by gentle barbecues under the stars each evening. We have a new group of guests, far fewer this time, but as we pass through the Anambas archipelago, they are asking all the same questions as before. Indonesia is an unusual place, for it really is a huge continent that has sunk beneath the waves. Only the tops of the hills are exposed and they form a scattering of tropical islands spread over an enormous area. Some, like Java and Sumatra, are very heavily populated, others only have tiny fishing communities or are completely deserted. The communities are not especially poor as they have found oil and gas here, but they have only just started to get any central support and they are very, very remote from each other.
Visiting the village in Zodiacs
The first time that we came through the islands we only stopped to snorkel around some of the off-lying islands as we did not have permission to visit any of the villages. However by popular request we asked if we could visit, and today we unloaded the passengers into Zodiac rubber dinghies and landed in one of the small fishing villages built on stilts out over the sea in front of a steep forested hill-side. This was the first time that the village had ever been visited by Westerners so they were quite as interested in us as we were in them. The whole village turned out to meet us, and we were greeted with drums and dancing, and then led along the raised walkways to their central square. There the children laid on a wonderful exhibition of traditional dancing all dressed in the most wonderful brightly coloured uniforms.
It was quite clear that the villagers had done an amazing job tidying up the village. There was not a spot of litter, and all the houses were surrounded with pots of pink flowered Bougainvilleas. The houses are simple wooden clap-board with corrugated iron roofs, but beside each there is an enormous satellite dish. One of the seven year old boys dancing had a very disfiguring facial tumour bulging the bridge of his nose forward between his eyes. We had a facial surgeon from France with us who instantly recognised it as a neurofibroma (I didn’t know that you could get von Recklinghausen’s of the face). Anyhow it will continue to grow and deform his face unless some fairly major surgery is undertaken. The passengers are all keen to set up a kitty to pay for this surgery which will need to be performed in Singapore or Australia. But of course it is not quite as simple as that. We have not yet checked whether he or his family want him to have the surgery. There is also the slightly awkward question of why we want to help this child and not any other one. Just because we have met him, why should we want him to be treated differently from anyone else. Presumably there are lots of treatable children scattered over the thousands of remote islands which make up Indonesia.
School children including the boy with the Neurofibroma (on the left) and the dancers
Whenever we get to a beach Vicky cannot resist walking along the water’s edge looking for unusual sea shells. Today as soon as the children realised what she was doing, they started collecting for her and showered her with every kind of shell, delighted to be helping her.
Each time we have stopped near a reef to go snorkelling the conditions have been better than the last place, clearer water, bigger fish and more vibrantly coloured coral. Several times, in different parts of the world I have been assured that the local reefs are the best in the world. After a short while snorkelling on them, I can only assume that those making the claim have never dived anywhere else. But yesterday the reef was as good as any that I have ever seen. What a great feeling it is to be drifting over a technicoloured forest surrounded by hundreds of fish of every colour under the sun.
These beach barbecues were quite surreal; a virgin beach never visited before, a delicious barbecue and then before darkness fell, all was cleared and not a trace of our passing was visible.
The one thing that I missed was scuba diving, but even that happened quite by chance. We had diving equipment on board to inspect the bottom of the ship if there had been any damage. The captain was a keen scuba diver and the guests were due to go ashore to lounge on the sand and have a barbecue. He asked me if I could/would like to do a dive with him. I jumped at the idea but was a little more hesitant when he admitted that there were no depth gauges or watches. So, we would simply be diving on the amount of air left in the tanks and staying above 30 feet depth by guesswork. The plan was that we would be taken 2 miles up-current from the ship and then let ourselves be carried down the current towards the ship surfacing at around 40 minutes when our air ran out. The first officer was asked to launch a Zodiac at 30 minutes and start looking for us. He looked worried. He didn’t seem keen to lose his captain and legally the ship is not allowed to sail without a doctor.
The dive was fabulous. We were swept down a channel between walls of coral. There were lots of fish and turtles. We didn’t have to do anything except maintain our depth and enjoy the view. Finally, my air ran out, and we surfaced with our orange marker buoy, to find no less than four Zodiacs cruising around looking for us. The first officer was clearly leaving nothing to chance!
Later we dived on the Great Barrier Reef, where they claimed that the diving is the best in the world. Strange that, because everywhere that I have dived (Maldives, Mafia, Zanzibar, Santa Martha, The Whitsundays, Galapagos) they all claim that theirs is the best diving in the world. All I can say is that they obviously have not tried anywhere else!
Diving on the best of the great Barrier reef
We also traveled along the North coast of Papua New Guinea, anchoring at the mouths of rivers and traveling into local villages where we were greeted with a lot of dancing.
This gentleman sprang out of the bush as we were making our way to a remote village. The effect was clearly all that he had hoped for
One of the dancers dressed to the nines
The highlight of traveling along the north coast of Papua New Guinea was a brilliant plan by the captain. He arranged that dinner on a special evening was to be out of doors on the quarter deck. As the main course was served, we came alongside an active volcano which was pouring lava down its side to the sea and covering us with a light coating of ash which crackled as you ate your salad. As the side of the volcano was steep, we were able to come very close indeed to the lava, an experience of a lifetime.
Australia & New Zealand
We then moved on to New Zealand, first of all visiting White Island, another active volcano. Here we were issued with breathing sets and were able to wander over the steaming fumaroles. Even the guides were amazed as they had never seen the island on a sunny day!
Of course, since then it erupted while there were tour ship guests visiting. A lot of people were killed and others were severely burned. I don’t think that guests will ever visit White Island again.
White island. Sulfur fumaroles and boiling mud
The beaches in New Zealand were lovely and mainly litter-free, and of course, absolutely deserted apart from a few local fishermen.
Our trip to Brisbane was to pick up a shipload of solar eclipse watchers. Apparently, there is a group who travel the world to see every eclipse. It was tense up to the last few minutes as there was some fast-moving cloud, which nearly obscured the moment of the eclipse. It was fun to see once but ten times…..?
Having worked our way down the great Barrier reef we headed to Norfolk Island which was a bit like Surrey suburbia in the middle of nowhere, lovely English houses surrounded by paddocks with horses. All very strange.
Norfolk Island
New Zealand
Orion now started a circumnavigation of New Zealand, both North and South Island. We swam with porpoises and saw towns frozen in aspic since the 1930s.
Swimming with porpoises. They really seemed to enjoy the company
We visited the most wonderful wineries and then headed down to South Island. This time we entered Doubtful sound from the sea and landed on the very point where Cook first made landing in New Zealand.
Fjordland from the sea with Doubtful and Milford Sound.
Cooks landing site
Finally, we dropped down to Stewart Island one of my favorite places, because there lives the Stewart Island Robin which was down to only forty individuals when it was saved from extinction. Its fate is to be far too tame with no fear of terrestrial predators like cats.
Stewart Island Robin. If you scratch the ground with your shoe he will land on the toe looking for insects that you have disturbed
Sub Antarctic islands
The normal route for visitors to Antarctica is from Ushuaia in South America across the Drake Passage to Graham Land, a rough but short two-day journey into the Weddell Sea with the opportunity to visit South Georgia and the Falklands if you extend the cruise. Orion went down the opposite side of the world from New Zealand into the Ross Sea in Antarctica from the opposite side of the world. It is a much longer journey (10 days rather than two) and very few ships go that way. I persuaded Vicky to join me again, quite a feat as we had to cross the Southern Ocean and she is not keen on rough seas.
The bonus of the New Zealand route to the Ross Sea is a chance to visit a string of islands on way down, each of which is teeming with wildlife. Macquarie is on a par with South Georgia but then there is Campbell Island, Enderby and the Snares. Finally there is the bonus of the Ross Sea where both Scott and Shackleton had over-wintering huts.
We made two trips down to the Ross Sea from Bluff on the southern tip of South Island New Zealand. After Stewart Island we headed south to a small group of uninhabited islands – the Snares. Except that of course they are not uninhabited. They are heaving with birds, giant flocks of Sooty Shearwaters and thousands upon thousands of Snares penguins.
The ramp on the Snares with thousands of penguins commuting up and down
Penguins leaping in towards the cliffs
And Snares Penguins themselves in full plumage
Then we set off South again until we reached the Enderby Islands, the location of some simply terrible ship-wrecks in the late 19th century. The crews struggled to survive for years before the survivors were rescued. Now the islands are again un-inhabited, but are the breeding ground for Sea Lions,
Massive sea lions guarding their Harems
Inland on the Enderbys is thick forest which at least provides shelter from the wind
A rescue hut erected after the disastrous ship wrecks
South again to Campbell Island, a treeless island with beautiful mega-herbs dotted with Albatross nests. Its west coast are some of the most unforgiving cliffs that I have ever seen.
Albatrosses nesting amongst the strange vegetation
By the time we reached Campbell the wind was hurricane force. Extra weights had to be put into the zodiacs to stop them from being blown away in the gusts as we evacuated a guest with a broken leg. As we set off South again we were hit by a huge wave which stove in the rails in front of the bridge. The Captain decided to turn back to take shelter in the lee of Campbell Island, but as we turned another wave hit the stern and stove in the railing there. That meant a lot of report writing.
The next bit of the journey south was spectacular with bigger seas than I have ever seen before. They were over 30 feet high but the length between each wave was so great that the ship managed most of them fine. Poor Vicky, however spent most of her time encased in a life jacket, ready for a quick exit.
South from Campbell is Macquarie Island, which is equivalent to South Georgia in the quantity of wildlife.
You may not approach wildlife but they can approach you!
Vicky being fought over by males
and watching the world go by
The seas were rough and the Zodiacs could get swamped while trying to load
The final part of the trip was into the Ross sea to visit Shackleton’s and Scott’s Huts on the ice shelf. On our first trip down there was no chance, the ice was far too thick, so we played games of cricket on ice floes at the mouth of the Ross Sea.
Adelie penguins watching the ship.
Playing cricket on an ice-floe when no further progress was possible
Stopping to visit an iceberg
Reloading the zodiacs
The view from the crew’s nest looking for leads. One of the best things I have ever done
Once in the Ross Sea the sea cleared of ice, so it was time for a swim. It was cold! One of the least pleasurable things I have ever done
We could not get near Shackleton’s Hut but Scott’s hut was extraordinary. There was a blisteringly cold gale outside and everything inside was perfectly preserved
Scott’s hut
View across to Shackleton’s Hut
On our third trip down to Antarctica we received an SOS from a French sailor who had been rolled, dismasted, and abandoned ship. He was now in his life raft. We were the nearest ship but we were three days sailing away, in the wrong direction. Nevertheless, Maritime law required that we respond. Most of the passengers were furious. Their trip to Antarctica was incredibly expensive and a life event and the rescue of a French sailor was not on their agenda.
However, we turned round and set off to rescue Monsieur Alain de Lord. Apparently, he was sort of part of the Vendee Globe race but had decided to set off a week early and more importantly had not taken out the mandatory 100,000 euro insurance cover in case he needed rescuing. The Australians dropped a total of six life rafts before one landed close enough for him to transfer from his own tiny life raft into something safer. Apparently, his own life raft had rolled over three times pitching him into the sea, so that he had to then climb back in. He said that if it had happened one more time he would have been too exhausted to climb back in. The Australians kept an aircraft circling over him at all times until we arrived. Apparently, this involved no less than six aircraft refueling, flying there and back, and then circling over the raft. It was lucky that there was an aircraft. The wind was gale force with a fog of spray blowing over the 25-foot waves. Despite his raft being orange, we only finally spotted him, when he was only 200 yards away.
There was no way that we could take him in over the stern in the heavy seas, so the plan was to sail upwind of him then turn sideways on and drift down onto him, the ship itself providing shelter from the wind. One of our most experienced Zodiac crews was launched and quickly went alongside his life raft and snatched him. Now, the problem was to get him from the Zodiac onto the ship. One of the loading doors in the side of the ship was opened to
receive him. The only problem was that now that the ship was stationary the stabilizers no longer worked, and the ship started to roll. Apparently, there is a condition called ‘oscillating roll’ where each roll is worse than the last, and that is exactly what happened.
As the Zodiac came alongside the side door, it actually submerged so the rescue team and a very large volume of water poured into the ship. My medical center was immediately below this door so I had foaming sea water up to my knees. Then the ship rolled back and the side door was shut. I had a ‘Titanic’ moment when the water was up to my knees – then the water poured away down into the bilges. The ship has huge pumps so we were in no danger. Surprisingly de Lord was in quite good condition all things considered.
Monsieur de Lord. His yacht was a small fast ‘café racer’ totally unsuited to the sea conditions in the South Pacific
We sailed to Tasmania to drop him off, so I had a wonderful chance to visit this beautiful island, while the passengers worked up a case for compensation against Orion. It is rumored that Orion went bankrupt over this, but what is for sure is that the ship was sold to National Geographic straight afterward.
The Territorial Army and Sandhurst
One day I returned from a Council meeting of the GMC and grumbled to Vicky that I was completely wasting my time doing committee work. Instead of commiserating, she was very robust with me. Right away, she pointed out that it was me who wanted to get onto the GMC, and that if I didn’t like the work, then why didn’t I use my skills somewhere else where I would be appreciated? I have to admit that I was a little miffed by her response, and rather querulously asked what I was supposed to do instead. Again she showed little sympathy, and pointed out that “only I knew what I wanted to do”. There is nothing more irritating than advice that is robust and that is completely right. In a final bid for help, I complained that I didn’t know what I wanted to do. Vicky went and got me a blank sheet of paper and a pen. She divided the sheet into four squares and suggested that I do some thinking, writing into each of the two top boxes a) what I was good at, b) what I was not good at, and in the bottom two boxes, c) what I liked doing and d) what I didn’t like doing. She was kind enough to bring me a bottle of decent wine and then told me to get on with it.
It was quite hard to start with but got easier as the wine went down. Finally, I had finished. I had done the task but was no further forward. I could see no pattern in my answers. Vicky took the sheet of paper, scanned it and then suggested that it was blindingly obvious what I needed to do: I should join the Army. She showed me that I wanted to work in the third world again but didn’t want to get into danger the way that I had in Sudan. Paradoxically, the safest place to be in a third-world country is in the center of a group of first-world troops. I was a little shaken by this conclusion as I have always prided myself on being a pacifist and was heartily ashamed of myself for not turning up to the march against invading Iraq. I tried to point out to Vicky that I was a pacifist but she was having none of that as I wouldn’t be going anywhere to shoot people, just to mend them. I rang the TA recruitment office first thing in the morning. In fact she dared me to ring them, knowing full well that I cannot resist a dare. Actually, I knew that I was quite safe because I was 56, far too old to join the TA, so I played along.
The next morning I rang the TA and spoke to a very nice lady who called me sir (I like that!). Quite quickly the questioning got on to my age. I admitted that I was 56. At which point she pealed with laughter and politely pointed out that most army officers had been retired off by that age. However, she did finish the interview by asking me my specialty. I told her that I was a trauma surgeon. There was a long silence, and then quite quietly she asked me if I would mind holding the line while she fetched a more senior officer to speak to me. The Brigadier had a plan. He wanted the training given to the medical teams assessed for relevance to the work they were doing in the field. He needed a trained trauma surgeon who was prepared to go through pre-deployment training, and then do a deployment as a supernumerary at Camp Bastion in Afghanistan. That person would then do a report on what was and was not relevant to needs.
The report was done but I doubt that it was ever read. But it did mean that within a week of that telephone inquiry I was up at Strensall Barracks in Yorkshire, a grim place, where I took the Queen’s shilling and was smartly promoted from private to major. A very kind sergeant-major took me away and showed me how to wear my uniform and as much else as he could in one day. I could see from the look in his eye that he was worried. I stayed up there for a weekend and then I had to go to Sandhurst. I’m sure the Sergeant Manor knew, but thankfully I didn’t, that they were going to eat me for breakfast.
Sandhurst
Most officer recruits into the Army go to Sandhurst for a year either straight after school or straight after university. A small group of men and women who have come through the ranks are accepted for a commission but they are all under 30. Sandhurst is a lovely imposing building and is set on the most beautiful grounds. It looks like nothing more than a glorified film set for an Edwardian drama. Young soldiers march or run from (a) to (b) saluting everything that moves and a few things that don’t.
There is, however, a short course entry through Sandhurst. It is called the Vicars and Tarts course and it is where lawyers, doctors, vets, and chaplains do six weeks of intensive training to prepare them for the Army. In that short time, the instructors try to fit in a summary of the whole year’s worth of training given to the cadets.
The instructors have been told that none of the vicars and tarts are allowed to fail, but that standards cannot and will not be compromised. This puts them in a difficult position, and although they are unfailingly polite their exasperation with us was palpable. The course is not so hard for those who have been in the TA all their lives (as all the others had). They know how to dress and how to march. I had not got a clue about anything. I had no idea that the way you wear your beret is crucial, and within five minutes of the first parade I was marked down by the sergeant major as someone who was taking the piss out of the army. As soon as drill started things went from bad to worse. We were all us bad, but I was dreadful, and the more I worried about it, the worse I got. It was February and the first drill was at 7 am when it was still dark. You had to be out and ready in the correct uniform for the day by 6.55 sharp.
Training the Army way
Sandhurst has a lot of trouble with its ‘vicars and tarts’. Their policy for ordinary soldiers is simple. First, smash them, destroy them, crush out every morsel of identity, and rub their noses in the dirt. When things cannot get worse start building automatons from scratch, who respond instantly and identically to all basic stimuli without thought, comprehension or care. The ‘Vicars and Tarts’ course is full of professionals. The Army knows that they cannot and should not put them through this exercise in de-personalisation but they can’t stop themselves. One minute they appealed to our better reason, the next they treat us like unthinking morons who needed reprogramming. Lectures were given in unheated rooms partly to make you uncomfortable but mainly to stop you from falling asleep. If you felt yourself falling asleep you had to stand up at once. If you failed to do this and nodded off for even one second, you were called out to the front and put ‘on your buckle’. That meant dropping to the press-up position on the floor and continuing with press-ups while the lecturer continued his lecture. As we were all expected to be able to perform at least forty without a break this could be a prolonged affair.
I could not march, and the more that I worried about it, the worse my marching got. It was clear that I had to be able to march, turn, and stop without thinking. So, at 5 am every morning I was up on my own and marching up and down, setting off, halting, wheeling and about-turning. Hundreds and hundreds of times, but even then, every time an order was given I had to think “Is it left foot or right?” and then “Shit!” it was too late. It was also clear that you had to be fit, very, very fit to
survive the course, so each day I was running at least 3 miles on top of the exercise they were giving us, and that was plenty. I lost 2 ½ stone (35 lbs) by the end of the six-week course.
There were some glorious moments. Watching the cadets at dawn in their scarlet uniforms marching and counter-marching past the Palladian buildings gave you a little empire-proud lump in the throat. But being pushed into a room full of tear gas and being made to take your gas mask off was purgatory. I cannot think how anyone continues to protest when there is even a sniff of that evil stuff around. You are weeping, choking, coughing and your eyes are in agony, all at the same time. We stripped guns again and again, even though we were never going to use them. We were made to shoot right-handed (I was once a good shot left-handed). We read compasses using Minims instead of degrees, and I learned lot about how to read a landscape from a map. I really liked the idea of deciding what you are going to see in advance of lifting your head from the map. At the end of each day, we had to clean all our gear, especially our boots, and then damn me if they didn’t put us straight through mud the following morning. I never got to bed before 11 pm, and then had to be up at 4 am getting my kit ready for the day, so I was chronically short of food and sleep. The course built steadily to a crescendo. We got thrown to the PT instructors who put us through agonizing fitness tests again and again. They really are the most self-adoring pricks you will ever meet. The joke in the Army goes “How do you drown a PT instructor?” and the answer is “Leave a mirror on the bottom of the pool”. Everything had to be done at the run and done just so, or you had to do it again, and they enjoyed finding fault with everything that you did.
Of course, within this hectoring and training is the peculiarity of rank. You are trained at Sandhurst by soldiers who are not officers. They are the best, but they are not officers. So, while bellowing in your ear and persecuting you, they are calling you ‘Sir!’. Very strange. It would be a bit like medical students only being taught by nurses (which is not far from what really happens).
On exercise
Pretty soon it came time for us to go out on exercise. Sandhurst is surrounded by wild heathland, put there by God to train soldiers, so off we went. The first day’s exercise was map reading. All pretty straightforward but an order of magnitude more complex than I have ever done before. Then we had to dig up soil, fill sandbags and build a fort with a watch tower (Sangar). This was real ‘frontier’ stuff, but it was bloody hard work, especially as the walls had to be thick enough to resist a rocket attack. It was below freezing that day, so the work was the only way to stay warm. Our third exercise was to patrol an area using hand signals only, then set up a camp with a perimeter wire and guard points. There was no time to lay out our kit. We just had to dig scrapes in which we were to sleep out of line of enemy fire, and then we all moved out to guard the perimeter as evening fell. I was exhausted and it seemed that no sooner had I lain down and taken up guard position that I received an almighty kick that physically lifted me off the ground. I had fallen asleep ‘on guard’ and this was a court-martial offense. I had always prided myself since reading ‘Kim’ on being able to fall asleep wherever and whenever, but this was not an asset here. As soon as it was pitch dark, the first patrol guards were set and the rest of us retired to our scrapes to grab a couple of hours’ sleep before it was our turn to patrol.
Three of us had dug a scrape together, two lady lawyers and myself. I had volunteered to help them as they were making such a pig’s ear of the job. My enthusiasm had created a scrape deep enough to give us cover, but also so deep that overnight it filled with water and iced over. When I got up at 2 am for my stint on patrol the ice all around my sleeping bag (and in it) broke with a gentle tinkling. Before dawn, we had to be up again ready and in position for the possibility of a dawn attack. After that we returned to our scrape to pack up our sodden and frozen gear. I felt it was time to give a short speech to my fellow scrape dwellers. I thanked them for their hospitality, pointing out that it had always been a fantasy of mine to sleep with two women, but now that I had achieved this, I was not so sure that it was all it was cracked up to be. They had the grace to smile.
Giving up
Next, we were taken to a camp in the hills which we had to guard against attack. The Gurkas were loaded with blank ammunition and attacked us again and again from every side. Each of us took it in turn to be the commanding officer trying to organize the defenses. There was a camera team with us, who had been given permission to film the exercise and who got in the way and seemed very pissed off with the poor light. By the time that my turn came, it was dark and snowing. We were not currently being attacked and the instructors had all vanished into a heated cabin where they were having coffee. I hoped that I was in for an easy time. Then came a report that one of the watch towers was not manned. I was puzzled because I had just sent one of the padres there to do guard duty. He was nowhere to be found. Now I had to organize a search of the fort and reported my worries to the instructors who all looked equally worried and piled out of their hut to help with the search. Finally, we found him crouched in a corner whimpering. I went to talk to him and found that the camera team had followed me and now put on a spotlight to record this ‘failure’. The padre was a broken man. He was cold and tired and certain that he had made a big mistake in joining the Army. I tried to empathize with him and explained that we were all tired and cold but that we were only a few days from the end of the course, and that he should try to hang in there. But he wasn’t having any of it. He wanted his family and was walking out of the gate now. He had no idea where he was, He had no money but he didn’t care. I was really worried about his mental state and was pretty unimpressed with the help or lack of it that I was getting from the instructors. I was also feeling very much like him. I too was tired, cold and confused, and fed-up with this soldiering game. He set off for the gate and as I started to follow him, an instructor put a hand on my shoulder and ordered me to report to the instructor’s hut. I did as I was told, while another instructor went to fetch the padre. When I got into the hut, the instructors were roaring with laughter as they reviewed the film. The whole thing had been a set-up to see how I would handle the problem. I was furious. I had totally identified with the poor padre and could not bring myself to speak to him afterward. The instructors did have the grace to say that they had some of the best footage of this scenario that they had ever seen and would like to use it for teaching. It took all my willpower not to tell them to go and put it where the sun don’t shine.
But there was no time to rest. The following day there was a brutal obstacle course, then a night exercise where they tested leadership. This time we had to approach a guerrilla camp where they were torturing one of our soldiers. We could hear him screaming again and again and it was extraordinarily realistic. We had all been told to remain absolutely silent when we were not in command. Our patrol leader had been promoted from the ranks and he quite literally froze. He knew that if he took us into the camp we would be ambushed but that we could not stay where we were and listen to the torture. For 20 minutes we stood there and waited for orders but none came. Eventually, we moved on to the next exercise. I never did hear what we were supposed to have done. Exercise after exercise. New tasks, each with a twist in the tail until we were so tired and so bewildered we did not know what we were doing, but the end was in sight.
One afternoon was spent clearing a bomb site and then moving across a minefield. Little did I know that months later I would be seeing this work in action. As it was we were on our faces on the ground creeping forward over the leaf litter, probing softly with our bayonets at 45 degrees, trying to feel for a mine under the ground without setting it off. The exercise became wholly engrossing, as we inched forward in a line marking off the cleared ground as we went. I hadn’t realized how realistic the whole exercise had become until, to my horror my mobile phone went off in my pocket. I nearly jumped out of my skin with fright, as the ringing and vibration jagged my shredded nerves. I really thought I had set off a mine! Then there was the problem of the sergeant commanding us. We weren’t supposed to be carrying mobile phones and they certainly were not supposed to be switched on, so my hand dived to my phone to switch it off. As I did this I glanced at the screen to find that the caller was the General Medical Council, doubtless phoning me to advise me of some change in time of one of the interminable meetings that I had to attend. My fright at the phone going off was now converted into rage. I wanted to ring the GMC and shout at them that they had dared to phone me while I was in the middle of a minefield trying to detect anti-personnel mines! Then, finally, I had to laugh at myself. This was quite ludicrous. We were only playing boy games on a wooded English hillside. I really was starting to take myself and the whole business much too seriously.
Drill
Our daily drill was moved from one of the small squares onto ‘God’s own acre’ the central drill square of Sandhurst where no one was allowed to walk or to move diagonally. This square was guarded by the colour sergeant, and as soon as he clapped eyes on me it was war. Tick, tick went his measuring cane ‘Mutter, mutter – who the fuck is that?” “Mutter mutter. Major Bulstrode step out, andddddd Halt! Rest of platoon diisssssmissss!” I waited as the clicking cane came closer and then a very ugly face was stuck in mine. “Major Bulstrode. What is your problem?” I was tired and fed up with the drill. I had tried really hard but as soon as I marched I looked like John Cleese doing a funny walk. Without thinking I answered back. “You!” I said. “You are the problem.” You and your drill sergeants make me so nervous that I cannot march properly. I have practiced day after day and I think I am getting worse not better.” The words poured out and I expected to be charged with insubordination or whatever immediately. Not a bit of it. The Sergeant major thought for a moment and then said soothingly. “Major Bulstrode. Walk with me, side by side. We are going shopping at Tescos … you and me. No! don’t move your arms, just walk” and off we went diagonally across the square. After ten steps he invited me to start to swing my arms gently. Almost at once everything fell apart. In an instant, his voice became a parade ground bellow. “Major Bulstrode, what the fuck is the matter!” Out of the corner of my eye I saw the rest of my platoon sinking to the ground with mirth. Clearly there was more work to be done, but I was a marked man as they all remained convinced that I was trying to take the piss out of them.
While preparing for our passing-out parade we had all gone off to order mess dress. Men love dressing up and these scarlet and black uniforms made even old farts like me feel quite dashing.
Death by drowning
But there were more field exercises as well. The weather was now bitterly cold and we had to carry a casualty (a very heavy straw-filled dummy) across the hills and then down a stream, where we were likely to be attacked at any moment. I won’t bore you with all the details of the various reconnaissance parties which had to be sent forward before we could move but suffice to say the route that we were forced to take followed a stream which became a river. God, it was cold! But worse was the fact that one of our party was pathologically frightened of water and could not swim. As the stream got deeper and deeper, he became more anxious. We had been warned that we had to finish the exercise with our whole team intact, so we were going to be as slow as our weakest member. We gently encouraged him along while trying to look after our straw casualty until we finally reached a weir, followed by a barbed wire barrier across the stream. The only way past it was to duck under it, and it was at this point that our weakest member finally mutinied. He was not going over the weir and he was certainly not going under the barbed wire barrier. There was no time for negotiation. It was getting dark and we were all getting colder by the second. I was standing behind him and signaled to the team in front that I was going to trip him and then push him over the weir. They would need to catch him. Soothingly I said to him over his right shoulder that he was not to worry, we were going to find another way. As he turned to look for this way out I hooked his legs from under him and tipped him head-first over the weir. Before he could even struggle the team members at the bottom of the weir grabbed him and stuffed him deep under water and under the wire. When he surfaced he was hysterical, his helmet was down over his eyes and I think he thought that he had gone blind.
The next stage of the course was a culvert about 40 feet long through which the stream ran. There was only a narrow air gap at the top and it was almost impossible to keep your mouth and nose above the surface as your helmet forced your head down. I could see that this too was going to be dreadful for him, so before he could recover his breath I pulled him backward with me into the tunnel. We actually moved down the culvert very quickly carried by the current. I had him in a lifesaver’s hold and for a few moments he seemed to relax. I was just reassuring him that we were now coming out the other end and that everything would be fine when we did indeed come out of the culvert into a pool that was over six feet deep. We were in full battle gear and both sank straight to the bottom. Actually, we sank so quickly that it was easy to bend my knees and spring back up off the bottom still holding my companion tightly. As soon as we surfaced, I struck out for the bank which was only a few feet away dragging my water-logged padre with me. As I got to the bank someone shouted. “What about our casualty”. We had all let go of the straw man on the stretcher and he was now bobbing away down the river. “Fuck the casualty,” said I “We have a drowning padre here” and started hauling him up the bank. No sooner was he sat on flat ground than a voice bellowed in my ear “Major Bulstrode, on your buckle!” I dropped and started my press-ups as I was delivered a ludicrous dressing down on my failures as a doctor in deserting my patient. As the mud rose and fell to the rhythm of my press-ups in front of my dripping nose, I speculated on how I would feel if I just stood up now, and delivered a hay-maker of a left hook to this prick of a junior officer who was standing over me in his immaculate number 9 uniform. Luckily I was more concerned about the poor padre. It was the same man who had agreed to simulate the walk-out and had so upset me. I think he was sure that this was my revenge. It wasn’t. There was no time for anger or revenge, we were all far, far too tired and desperate to finish the exercise.
Passing-out
Finally, it was time to pass out. There was a brutal fitness test including a cross-country race, thousands of press-ups, a horrendous route march, and an obstacle course that completely trashed us and our carefully burnished boots. Then it was time to dress in our brand new mess uniforms for the mess dinner. Partners and wives were invited. Swords were used to cut the necks off bottles of champagne, and there was much singing and shouting. The next day was the final passing out parade. I think everyone had despaired of my marching, but as I passed the General’s podium and the call went for “Eyes right” I saw the Regimental Sergeant Major next to the General glaring at me and me alone. So help me God I nearly stumbled! Then it was over. Vicky and Jackie Webster (my PA) had come to watch which was very sweet of them.
Finally, it was time to clean weapons before we handed them in. We all badly wanted to get away but four hours later our commanding officer was still walking around with white gloves on, finding smears of soot in the most intimate recesses of our weapons. Not one of us got away in under five hours. I was practically weeping with frustration at the end.
Deployment
When you are in the Territorial Army you are training all the year round in bits of your spare time but it all seems quite gentle and relaxed. OK, there are uniforms and weapons and living in barracks, but there is no sense of danger or urgency. Now, however, with the Afghanistan crisis, if you join the TA, it is more than likely that you will be called up to join the regular army on deployment in the field. You won’t just be filling the shoes of a regular soldier who is now going into ‘theatre’ as they call it. You will be working alongside regular soldiers. It does not matter if you are a chef, an engineer, an accountant, or a doctor, you will still be expected to be able to drop everything at a moment’s notice and help get everyone out of an ambush. Of course, we cannot possibly work to the standard of the regular soldier but you will be doing exactly the same job, and you will be expected not to let them down.
Preparation for deployment is all about this change in gear. It has an awful inevitability about it. If being in the TA is a bit like drifting down a river in a canoe through an unknown and wild country, then receiving your call-up papers is a bit like hearing, far ahead of you, the increasing roar of a great waterfall. Almost at once, the river beneath you starts to change. Placid water starts to swirl and foam. Rocks shoot past ever more quickly and you suddenly realise that you have committed yourself to something very big, potentially dangerous, and completely unknown. Even those who have been on deployment know that the situation in theatre is continuously changing, so that experience from the year before has little relevance to what is coming now. For those of us who have never deployed before, the fear of the unknown is palpable. We are grabbing every snippet of information we can get, mulling over it, and asking ourselves quietly “Will I be able to cope with that?”
In retrospect, the first part of mobilisation started quite gently although it felt daunting enough at the time. Packing your bags. Getting your home and work sorted out is not much different from going on a long holiday, and at least there are no children to worry about. But then the day arrives, and you drive across the country and report to a guard house, and then the barrier comes down behind you. Changing into uniform, laying out your kit in a room alongside three others. Weighing each other up. Not knowing how much to say or not say. Say too much and you are a loudmouth. Say too little and perhaps you will be labelled stand-offish. How much are you allowed to ask them? They all seem so cool, and yes two of them have deployed before and have their kit unpacked and tidied away in minutes. How can I ever get myself organised like that, I wonder. Then comes the brutal process of de-personalisation. From now on you must not do anything differently from anyone else. You must swim in the middle of the shoal, twisting and turning in absolute synchronisation with everyone else. You must all dress the same, eat at the same time, carry the same notebooks, have the same papers. The problem is that the regulars know what is normal, you don’t. But they also don’t want to be badgered with inane questions, and assume that you know what they have learnt years before, and which is now almost instinctive, so it is difficult to find things out without sounding like a pathetic wingeing child.
Next morning at the first parade the instructors are nervous too. They want to impress the new group. Their uniforms are crisply ironed and covered in badges demonstrating extreme strength, bravery, skill etc., but they are also on the look-out for trouble in the ranks, watching out of the corner of their eyes for anyone who is not the same as everyone else, a beret at the wrong angle, a pocket button undone. Any clue that a new employee may not have not signed up wholeheartedly to the spirit of the regular army is being noted and discussed quietly.
The lectures start. The army has a standard format for lectures. Lights down. Switch on Powerpoint. Introduce yourself and your topic. Then click to project a funny video clip. However the army computer is not powerful enough, so the presentation jams. We wait for the jam to clear, then are presented with 60 PowerPoint slides in 20 minutes. At first, we take notes diligently: then as the information pours in, pencils slow, and our minds wander as we try to digest what we are being told and its implications. Salaries, pensions, insurance, wills, next of kin, letters home, emails, contact numbers if the family is in trouble. Day after day we fill in forms. Name, rank, number, regiment. What on earth does the army do with all these pieces of paper? In the evenings we meet up in the bar and back in our rooms, and people start to loosen up. Faz is a young newly qualified doctor. He is a Muslim fasting on Ramadan, and because of his honesty, he is now being offered a very low salary from the army. He is passionate in his beliefs about mankind but also immensely kind, and a little bewildered by what is going on. Just at the moment, he is trying to get around the fact that his honesty is going to cost him a small fortune. Mick is an old hand who has come through the ranks to become an officer. He is a natural fixer of all problems and a brilliant teacher. He cannot see anything broken without wanting to mend it. He has a tin of WD40 in his rucksack and starts by oiling all the hinges so that the doors don’t creak when people go out for a pee in the night. He also has a set of tools for mending bedside lights, broken ruck-sac straps, etc. There is a wonderful glint of pleasure in his eye as soon as he sees anything which needs mending, followed by a seraphic smile of pleasure when he finds he has exactly the right tool to do it. He has also spotted that Faz and I are very confused by what is happening and quietly explains the what’s and the whys and the wherefore to us each evening, warning us what the next day is likely to bring. But on top of that he becomes the leader of our small group because just outside the gate of the camp, there is a large Tescos supermarket. As soon as work is finished each evening, Mick disappears off to Tescos, and then an hour later reappears with milk, tea, a kettle, an iron and ironing board, a couple of bottles of wine and some canapés. He also has a portable fridge in the back of his car. Soon our room is the social centre of the ten or so IRs (Individual Reinforcements) who are being mobilised on this course. It is extraordinary how a few creature comforts convert you from being a shy timorous beastie shivering in your corner to someone happy to start building friendships with the others on deployment, all bound together by a sense of common adversity.
Faz is the last to come out of his shell. He is much younger than the rest of us, swarthy and bearded, a devout Muslim in the middle of his Ramadan fast. But the twinkle in his eye is not the flash of fanaticism it is pure inquisitiveness and a mischievous search for fun. He wants to understand the world and more importantly he wants passionately to ‘do good’. He cannot resist speaking when he should remain silent and finds himself embroiled in arguments when all he thought he saw was someone being treated unfairly. His morality is based on simple parables. It is a long time since I heard philosophy debated this way. Each time he got really carried away in an argument with a regular soldier, Mick’s and my eyes would meet and we would groan. What is the point of arguing complex ethical issues with a regular infantryman? But on the other side, it was also pure pleasure for us oldies to hear how clear is the difference between right and wrong to someone young. I think that both of us were a little jealous.
An army marches on its stomach and someone in the High Command has clearly taken that adage to heart. The food that the army provides is plentiful and delicious, but there is always an exception that proves the rule. In this case, it was the camp where we started our deployment training. We, officers, took our meals in a separate ‘officers mess’, a glorious colonial building set on a hill with oak paneling and tons of memorabilia. The residents of the mess clearly deeply resented us ‘birds of passage’ and made us as unwelcome as they could, without openly spitting at us. They threw one of us out of the mess for not having the right clothes when he had only just flown in from New Zealand and had not yet been issued any kit. To crown it all they had the most miserable mess steward it has ever been my misfortune to meet. And they deserved him. He had them all eating out of his hand by sighing and moaning continuously about how hard he tried but how little he was appreciated. It is a long time since I have had such an overwhelming urge to kick someone up the backside, and that was clearly what the regulars lacked the spunk to do.
As the days went on lectures started to be replaced by exercises which we had to pass. Map reading, safe weapon handling, first aid under fire. Each test was preceded by an incredibly rapid ‘revision session’. I was again and again reminded of the apocryphal sergeant major saying “For those of you who have not heard this before, here is a reminder” Dire warnings were given that if any of us failed a test we would be stood down, and yet the rate and amount of information being put in was enormous, so failure was inevitable. And behind it all was the roaring waterfall coming closer, the insistent thought “This is not a game! They are teaching us this and then testing us because next time it is going to be for real.” As the days went on, it all became almost a routine, except that the pressure was increasing.
One morning we were sent down to the quartermaster’s store in groups of ten. There we were issued piles of the most beautiful brand new top quality kit I have ever seen. Fabulous boots, kid skin gloves, gortex jackets, and bulletproof jackets. The army is not playing ‘Dad’s army’ games with kit anymore. We are as well fitted out as any soldiers in the world, and it feels really good to be treated like that. But back in our rooms, it is increasingly clear that we have far too much kit to fit into our rucksack and sports bag. Worried discussions about weights allowed, and trial packings leave no one sure how we are going to get all our kit out to Bastion. “They have to be joking! 6 kg of hand luggage, and we need sleeping bags, clothes for 3 days, body armour and helmets, and if you are taking anything fragile like a laptop it will be broken into pieces in your main luggage. The body armour and helmet alone weigh 5 kg.”
Meanwhile, there has been a storm and there are conkers on the ground. That evening aided by some lovely malt whiskey smuggled in by Mick, we drilled our conkers with a rifle cleaning kit tools, strung them up and started a noisy contest in the corridor. Finally, one of the junior ratings came and complained about the noise. We are all a little embarrassed that soldiers have to tell officers how to behave.
The tests are coming thick and fast now. Fitness tests, endurance tests. We are none of us nearly fit enough and despite all the efforts of the instructors we are all starting to fail one or more tests. No one is quite sure what this will mean, but the army machine carries inexorably on, and before we know what is happening next, we are loaded into coaches and taken all the way across Britain to the next stage of our training. Now we are deep in the southeast corner of England. A new room, new roommates. John is the doctor from New Zealand whom I have only seen from afar. A wiry man his face always smiling. Very unassuming, but an absolute mine of information on mountain medicine and pre-hospital care. He never volunteers information so at first you don’t realise quite how knowledgeable he is. But, as soon as you ask, he has been everywhere wild in the world and knows first-hand some really useful things about diagnosing and treating patients. Ian is an anaesthetist from the East Coast of Scotland, quiet, and scrupulously polite. He is an Intensive Care Doctor and obviously loves his work. The more stress you put him under the calmer that he seems to become. His problem is that he is not very fit, and is thoroughly annoyed with himself and the army about this. One of the reasons for this is that he is a minimum-energy person. He refuses to get racked up about anything and will do something when it needs doing, not before, a walking example of the advantages of ‘just in time’ manufacturing. Andy is a hard-drinking hard-working Northerner with a broad accent, the kindest nature, and a wicked sense of humour. He is a veteran of Army service, snores loud enough to beat John, and burns the candle of life at both ends.
The weather is now even colder, wetter, and bleaker and the training moves into a new phase. We have now been joined in with all the troops going out to Afghanistan at the next change-over, so the lectures are now to over 400 troops from every specialty. The conditions are much more primitive and there is something slightly unpleasant about the atmosphere here. The video clips used to lighten the interminable PowerPoint lectures are full of guns and explosions. The lectures are now very close to the bone, and examples of mistakes made relate to soldiers killed in the past few months who broke a simple rule. Mines, suicide bombers, ambushes, booby traps. How do you spot them? How do you protect yourself? There is just so much to remember. For the regulars, this is just brushing up of well-worn techniques. For us, it is a blur of terror. Here, inside the camp, they have a complete replica of a town. It was originally built to train soldiers before they deployed to Northern Ireland so is an exact replica of the centre of Belfast. Gurka soldiers are everywhere creating reality for us to learn. They act as insurgents, while others show how to return fire, retreat from ambush, and counterattack. The place reverberates with gunfire and explosions. We are broken into small groups, to be taken through each scenario. The instructors are obviously tired of repeating the same exercise 3 or 4 times a day, day after day, but work away at it as if our lives depend on it, which they do. A large bluff sergeant major gives us an ‘off the cuff’ lecture about handling prisoners standing on a street corner in a mock-up of the Falls Road in Belfast. The instructor is trying to explain how tempting it is to break the rules when one of your colleagues has been hurt. He goes just a little too far and Faz (our young Muslim doctor) is on his feet, challenging what he has said, and pointing out that it breaches the Geneva Convention. We hiss at Faz to sit down. The instructor is livid and starts to argue. He knows he has gone too far in his efforts to keep himself and us awake, but does not like being humiliated in public. For the rest of us, there is a growing realization that this is not going to be nice. There are going to be some hard decisions to make and sometimes circumstances are going to be beyond anything we have ever experienced before, so we do not know how we will behave.
To put the final cap on our anxiety, they put us through the ambush trainer in small groups. Two of us are called forward to be guards with rifles. In front is a cinema screen on which is acted out an attack by a suicide bomber. The rifles are loaded with blanks but also have computerized laser systems that record when the gun was fired and whether it was on target. It is drummed into us that we must give a challenge before opening fire unless ……. Unless…… It all seems so clear in the lecture, but now it does seem so easy. We are in a darkened room sitting just behind our two colleagues who are standing with their bodies poking out of the roof of their mock-up Land-rovers. Away in the distance in the film, a car stops at a roadblock. People get out and quite suddenly one of them is running straight towards us yelling prayers to Allah. On my left one of the nurses fires, then hears her colleague give a challenge and starts to challenge herself. Her voice is drowned by three rapid shots from the right. In seconds it is all over. I am not at all sure what we saw, what happened, and when.
Now the nurse and the other regular soldier who had been volunteered as guinea pigs are being interrogated by the Special Investigation Branch, just as they would be in real life after such an incident. They are asked to describe exactly what happened second by second. The nurse who is a new employee like us has got the color of the car wrong, and the number of people wrong, has fired a shot before challenging, and has apparently hit the suicide bomber in the foot when all she meant to do was fire a warning shot. The soldier on the right is a regular. He describes in precise detail exactly what happened correctly in every detail. The nurse thought the event had lasted over 15 seconds. He correctly identified that the whole thing was over in 5 seconds. In that time he had issued a challenge and fired off three lethally accurate rounds. I think every one of us in the room who was in the Territorial Army, realised at that moment the light years between our skills and ability and those of a highly trained infantryman. We all came away very pensive. For all our skills we were going to be nothing but a liability to the regular army and we had better not forget it.
Straight outside and we are marched off to do minefield training like they did at Sandhurst but even more realistically. They show us real mines, put us into a mock mine field and get us to crawl back out inch by inch using our bayonets to feel for mines. This is just what a doctor had to do a few months ago when treating a soldier who had inadvertently wandered into in a mine field and blown his leg off. Lying there face down on the grass, my bayonet sliding over my knuckles at 45 degrees in and out of the soil, my thoughts are dominated by the realization that this has to be done right. Next time will be for real, and one slip will have terrible implications. I wonder whether I will even be able to be calm enough to remember what to do, never mind actually do it? Will my hands shake so much that I will not even be able to hold the bayonet?
Then there are exercises involving ambushes on foot, and in vehicles. As the Gurkas race to and fro, firing, laying smoke, counter-attacking, the instructor is explaining that this is what happened last month in Iraq when two died, or last week in Afghanistan when no-one was hurt because they did the right thing. It is all much much too real and too close now. Do people really lay down covering fire while your colleagues retreat, or do you just lie there trying to be as inconspicuous as possible hoping that the next bullet does not hit you. Watching the infantrymen at work demonstrating the techniques, shows that they are quick, confident, and very efficient. Clearly, this is the only way to survive. Again that terrible realisation. Next time will be for real. Will I really be able to remember all these steps in the heat of the moment? Will I physically be able to persuade my body to aim a gun and lay down covering fire? Now no one is taking notes. Those of us who are deploying for the first time have a hunted/bewildered look in our eyes. We know that we are forgetting critical routines as fast as we are learning them, and the roar of the waterfall is now very loud indeed.
Quite suddenly this stage of our training has ended and we are frantically packing for waiting transport, then sitting around for hours in the autumn sun when the transport does not arrive. Hooray for the Army. “Hurry, hurry, wait, wait, fookin’ well hurry up”. Once again the tempo ratchets up one stage. We changed our uniforms from standard UK green camouflage into our brand new desert uniforms, issued to us a week before. Now we are again one step closer to the job we are going to be doing.
The final stage of the training involves traveling to the other end of the country again to work for 3 days in a mock-up of the hospital that we will be staffing in Afghanistan. The whole of a field hospital is laid out in a large hangar, and as nearly as possible contains all the equipment and facilities that we will using at Camp Bastion. Around us, and invisible to us are a huge team of actors, make-up artists, administrators, chefs, and general staff who will bring the mock field hospital to life. Their job is to make the hospital real, so that we feel as if we are working inside the Hospital at Bastion working at full blast. No sooner has the exercise started than outside we hear sirens, and field ambulances start reversing into the unloading area. Gurneys are wheeled out followed by a team of security staff who will check that the injured have had all their weapons removed and that bombs are not being smuggled into the hospital. Then the patients start sweeping into the emergency department and the whole system swings into action. Ex-soldiers who have lost limbs are made up with blood and gore to look as if the limb has just been blown off. Afghanis living in Britain are now back in their national clothes, with burns, bullet holes and fractures replicating exactly what has been seen by our troops recently in Afghanistan. Within seconds we have forgotten that this is a mock-up and are totally involved in the work we know and understand. Now we are the ‘infantrymen’ performing our routines quickly, and efficiently. On the balcony above, the faculty, their numbers swelled by visiting dignitaries, watch and assess the speed and skill of the care given. The casualties are being managed by groups of medical staff who are by the minute welding themselves into tight teams. At first there is a bit of confusion, some orders are called wrongly. Sometimes two people are trying to do the same job, but quickly we settle into our routines and everything becomes slick and quiet. Pain is controlled. Wounds are dressed. Tests are ordered. Patients are comforted, wrapped in blankets to keep them warm, and moved into the rest of the hospital for definitive care. As the patients start to spill out of the Emergency department, operating theatre, X-ray, blood transfusion, and the wards all come to life under the watchful eye of the faculty. They are looking for blocks, failure of communication, and staff who cannot do the task they have been allocated. Everything must be as realistic as possible. If an artery needs repairing then there is an animal tissue on which the real task can be performed, so that the theatre teams can practice getting out the right instruments and dressings. At the very center the hospital the hub (Hospital Management Cell) starts its invisible task of gathering information, analyzing it, and communicating with the outside world. They are making sure that everything is anticipated and coordinated within the hospital. Here more than anywhere beds are at a premium. So, the moment a patient comes in, plans are being made to get him out, back to his unit, or back to the UK for further treatment.
The hours pass rapidly, the faculty moving from individual to individual, probing, questioning, checking that everyone knows what they should be doing and are confident that they can do it. Meanwhile, we are all getting to know each other. All the others in my department are from the North and speak with broad accents (to me). They all know each other, and they are good; confident, calm and well-practiced. Their leader Mick is everywhere at once. He knows everyone’s name and has a good word for every member of the team. For the first time in the Medical Corps I see the leadership the Army boasts about. It is a complex task with some simple rules and it really works. He remembers my name first time and starts drawing me into the team too. It is not difficult. They are so welcoming, but some of the accents are really hard for me to understand. It is clear that they are having the same trouble with mine. For me it is a blur of names Ian, Shaun, Tony and me being addressed as ‘Sir’. This is going to take a bit of getting used to. I get tangled in a scenario, end up giving confusing instructions, and the team falls apart. I try to take the blame for this but the team will have none of it. I began to see what a really strong team is about. Everyone around me is passionate to get this right. All have their own ideas on why it went wrong and who was to blame, but there are no recriminations, just a quiet determination not to let it happen again. On the following morning, I find that I had been removed from the resuscitation team and placed in the minor injuries department on the other side of the main entrance. I am mortified. Obviously, I was not good enough to be a member of the major teams.
However, my paranoia was ill-informed because the next really difficult scenario comes across to the Minor side as the faculty want to test our strength on our weak flank. Good army tactics. I didn’t have long before I was totally embroiled in a really difficult scenario. An Afghan family have come in. Both father and mother have shrapnel wounds to their legs. Between them is their only child who is very still. Through the appalling wailing and shouting the ambulance crew explain that they cannot find anything wrong with the child. However, both parents have shrapnel injuries to their legs but are only concerned about their child. They are both shouting at the top of their voices in Pashtun. I suddenly realized that being moved onto the Minor side is not a down-grading it is an opportunity to test me harder than ever.
A translator is found, but I cannot hear what he is saying over the noise. I start examining the child leaving the translator to explain to the parents what I am doing. There really is nothing wrong with the child, so where is the trick here? The husband will not allow any men near to his wife, but also wants to guard his child. I am caught between a rock and a hard place and the translator is now starting to argue with the patient. This situation needs to be brought under control. The Army calls this ‘gripping’ a situation and are clear that this is a key leadership skill. I literally grip the arm of the translator to get his attention, and then ask him quietly to explain to the father that his first job at the moment is to look after and reassure his child. I can see from the look in the translator’s eye that he understands what I am trying to do and approves of this move. As he explains this to the father, I have a chance to listen to the rest of the team. One of the experienced nurses has a really good idea. We bring three couches close together, putting the child on the middle one. Then we put a curtain around the wife. Now she can speak to her husband and child but her modesty is not compromised. We put the translator at the end of the curtain so that he can talk to either the husband or the wife by tipping his head one way or the other around the curtain. Female nurses start checking the mother while male nurses work on the father. Still, the wife will not allow herself to be examined and starts wailing. This sets the husband off again, and we are at an impasse. Suddenly the instructor stops the scenario. The silence is palpable. We start tidying up. I am completely drained and bewildered as to where we could go next. I walk across to thank the translator and the actors. They are all together in a huddle, and I ask them “What was I supposed to do?” “Oh” said the translator “You did fine, as far as it went. You just do not understand Afghanis. The wife must protest loudly against anyone examining her, so that her husband knows that she is protecting her virtue.” “So, what was I supposed to do.” I asked. Oh said the actor “If you had come to me the husband, and said that I needed to examine my wife, then I would have given permission.” “Yes” said the translator “and if the wife had made another sound, then you would have told her to shut up or she would get beaten. Then there would have been silence.” I thought that I was culturally broad-minded, but now I realize that I had a way to go.
On the evening before we finished working in the simulated hospital, we had to pack our rucksacks and kit bags and have them ready to load into the transport lorry by midnight. The following morning, as we started the final day of hospital simulation, we realized that we had the uniforms that we stood up in, and a light ruck-sac containing our sleeping bags, washing things, an iPod, a book, and a change of underwear. I think we all felt very vulnerable. We would not now see our luggage for three days. Too late now to worry whether you need an extra shirt or a puffer jacket, the game has started. As we clambered up into the coach that evening we were all wondering what we had forgotten. The coach as usual had a video and radio 1 blaring out. The choice was the lowest common denominator and those of us who had packed earplugs fitted them as tightly as we could.
Well after dark we arrived at South Cerney airbase in the south of England. We had now crossed England four times, and even I was getting used to the mental dissociation this produced. The barracks there was a large room with rows of bunks in two tiers. A one-metre gap between the bunk rows meant that it was lucky we had so little luggage. Vicky, my wife, drove down that evening from Oxford to give me the right sleeping bag. Short talk in the front of the car under the watchful gaze of the gate guard, and away she went. We had no idea when we would see each other again. Sleeping bag out. Washing things. Head torch, and sleep.
Up again at dawn and off in a coach to Brize Norton. Brize is quite like a Ryanair airport, with hundreds of people, a few seats, and lots of anxiety. The RAF obviously processes plane loads like us every day so they are very relaxed. We are not. But it was handled quickly and efficiently with hardly any waiting around and then we are boarding a Tristar. Officers up front, other ranks behind. The seating for the officers is absolutely palatial, with huge amounts of legroom, but the view is slightly spoilt by the pillars down the center for the stretchers when the plane is being used to bring back casualties. I am sat beside a very garrulous, very ambitious young colonel who clearly has his sights set on a senior staff post in the very near future. I decide to humor him and ask a few questions about the army. From then on I can sit back and relax. He explained to me in great detail, and very clearly, how the army organizes itself. It certainly passed the time and gave me an insight into the nature of the ambitious officer in the Modern Army.
Kandahar
There is dust on the steps (a fine powder we are to come to know well). The airport is in complete darkness apart from the blue and red landing lights. Above, there are bright flickering stars. Before dawn, it is cool but not cold. Dark buses quickly moved us over to a huge barn where there were literally hundreds of us milling around, everyone’s face etched into a rictus of concern. Barking voices, clipped steps.
Taking a break at Kandahar before flying on to Camp Bastion
Everyone sank to the ground as if they had fainted. The RSM looked not the least bit disconcerted. The sergeant major called “Listen-in” and all fell silent. Then an extraordinary thing happened. He asked for 10 volunteers to move luggage. But before he could finish the sentence, indeed the moment the word volunteer was uttered, the 100 soldiers at the front, as a man, let out a deep sigh. They had heard all this before. Then we were divided into ‘chalks’. Group by group we went out, identified our luggage and loaded it onto pallets. Then when our turn came, we were bussed across to the dimly lit loading ramp at the back of a Hercules. Clamber up and strap into seats facing sideways. Body armor and helmets on, day sacks tucked between our knees. Sheep in a truck on the way to …. Then huge forklift trucks dazzling us with their light loaded on pallets of our luggage and freight while the loaders scrambled all over the pallets like monkeys, head torches illuminating straps and cables to their intercoms. Shouted instructions on safety, then the doors closed and the noise rose to a crescendo. Bose headphones drowned out the noise with Beethoven. Very appropriate. All tilted over sideways as the plane climbed under full power then in no time the lights were being turned off for the descent. Immediately I started to feel disorientated. Shutting my eyes made no difference. I was turning and rolling in space. Now we were all tilted forward, our balance confused by the noise and complete darkness. It felt as if the plane was tipping over sideways and turning on and on. My conscious self said “This is not possible. We would be upside down by now” but my semi-circular canals continued to report roll, pitch, and turn. Because my headphones were on I must have missed the call for “Brace for landing”.
The final approach is as steep a dive as possible (to avoid enemy fire) culminating in a mighty crash as the Hercules hit the ground hard. Then came the scream of the engines as the reverse thrust was applied. My pulse rate was now very high. Apparently, the Hercules was designed with “all the sound inside”. Now I understand what they mean! The moment the plane stopped the back dropped open and the palettes were forklifted away, and we were ushered into Bastion. Even brighter stars and looming lights in the distance. Over everything the thrum of engines. The Hercules would not be staying on the ground for a moment longer than it had to. Re-load and away back to the relative safety of Kandahar.
Afghanistan
So this was Camp Bastion.
We found our luggage and off we went to the transit accommodation, a huge barn shaped like a half-sunk pipe, 40 feet high, 80 feet wide, and 180 feet long with dim fluorescent light flickering where the bulbs were failing. Row upon row of double bunks. There must be over 200 beds, with more camp beds at one end and then chairs for a lecture theatre beyond them. 3 feet between the tiered bunk, and one foot between the camp beds. Everyone men and women too tired to worry about dignity or modesty tumbled into bunks 6am and we had been traveling for 26 hours. Ear plugs in, eye masks on and within what seems like seconds (2 hours) I am being shaken awake. “Why haven’t you collected your weapon, the RSM is shouting for you?” Where the hell am I? Why is it so hot? Who are all these people? Tumble out, find the paperwork then stumble off to collect and sign for my rifle. Now it must stay beside me at all times. Is there time for a shower? Can I find my washing things? Now everything is out of both bags and scattered all over my bunk bed. Folded uniform tumbling onto the dusty floor. Coins rolling away under the bunk. We have to find our magazines because we need to fire our rifles to check their sighting. Everything is a hell of a hurry because we are apparently late arriving. Everyone is setting off to look at the camp. It is a cross between Mordor and Mad Max. As soon as the sun is up, it is hot, and there is dust everywhere. We are surrounded by temporary buildings, pallets, masts, and metal shipping containers piled three high. Lorries, armored vehicles, and armed soldiers are moving everywhere in clouds of dust. It is huge, as far as the eye can see in every direction. I wonder whether this is what a medieval castle would have looked like inside when it was at war. It is just an incredible mess on top of a building site. What on earth have we committed to?
We had dived into Camp Bastion and landed in the dark. We were immediately bussed off to an enormous hangar full of racks of bunks and told to get our heads down. As soon as dawn broke I and many others were outside to see what on earth we had let ourselves into. The first impression was of bright bright sun and sand. We were in the middle of a desert and even at 6am in winter it was starting to get warm. Around us were shipping containers, walls, and walls of them stacked on top of each other in lines that were kilometers long. Everything at Camp Bastion had been brought up through Pakistan on container lorries. There seems to have been no attempt to return any of these containers so they form the sides of the streets of Bastion, like rusty communist housing blocks. They stretch as far as the eye can see. Between them, there were villages of tents. Finally, in the distance, we could see the walls of the base. They were made of Hesco bastion. I suppose the camp was called Bastion because of them. I had never seen them before but I was to see a lot of in the future. Hesco is a heavy-duty wire netting frame with a woven plastic sack liner.
It packs flat for transport and is then opened up and filled with sand, or gravel when it is needed as a rocket-proof wall. Each bag is about four feet square but they can be stacked two or three high to make quick assembly walls which are proof to all but the most determined attack. Bastion’s walls were made of miles of these bags, with concrete guard towers at each corner. I believe that they even come in containers now, folded up like a Jack-in-the-box. If the doors of the container are opened and it is dragged along the ground the Hesco bags unfold automatically and can then be filled using a front loader. Later I was to see a new base being built, and the walls really were erected in a few hours. Every time I saw those Hesco sacks I smiled inwardly remembering how long it took us to build even a flimsy structure using hand-filled sandbags back at the Chapel. Hooray for automation.
In short order, we were ushered to the mess tents for breakfast. There were three of these, each with several hundred seats: the choice of food was enormous, and you could have as much of it as you like. At one end of the server, there was ‘Fat boy Breakfast’ – bacon, eggs, sausages, beans and fried bread. At the other was continental with croissants and fruit. I had heard that an Army marches on its stomach. The generals organizing camp Bastion had clearly taken this advice very seriously indeed. In the mess tent we were faced for the first time with the differences in uniform. We were in smart well creased brand new desert fatigues. The troops just finishing their tour were in faded uniforms already worn out by the sun and the sand. Oh How we wished our uniforms looked like that (they soon did). But the coolest dudes were young soldiers who looked as if they had been shipwrecked. They had long hair, and beards and their uniforms were quite literally in tatters. Taking courage in both hands I asked the soldier next to me who they were. He looked up from his ‘Fat boy breakfast’ and explained that they were in from the FOBs. I did not know that FOB stood for Forward Operating Base, and had to ask. I could see this soldier eyeing me and wondering what the hell kind of greenhorn had been sent out now. He explained that Bastion was the HQ for a large number of small bases all up and down the Helmand river. These bases had nothing much in the way of washing facilities or creature comforts and the soldiers tended to let themselves go a little when posted there. It was a badge of honor to come back from a FOB looking as thin and trashed as possible. He then explained that the sergeant majors allowed them three days of wandering around looking like this, and then they were ordered to ‘clean up’, and were issued with new uniforms.
Straight after breakfast, we were ordered back to our hangar where one corner was laid out as a lecture theatre. In strode a very cool-looking major with Gucci dark glasses and a pistol strapped to his thigh. I can’t have been the only one in the audience to think “Well here we go. This is the real thing”. There was a quick explanation about the layout of the camp which I don’t suppose any of us heard and then we were marched out to collect our weapons for sighting.
Apparently, now everything comes in by air or by Jingly lorries driving over the mountains from Pakistan. Bulldozers, everything. Awesome. Coffee sitting in the sun outside the NAAFI. Sitting at tables in the sand. Warm. Just like a summer holiday. Back into the transit accommodation. Gloomy – flickering lights. No room to stuff everything back into overloaded bags. Dust everywhere already. Quickly oil rifle before briefing then out to sight the rifles. Briefing on IEDs all laid out in front of us. Lots on ECM, and how careful we must be. Nodding forward on the chair, so tired. Then a long march in the blinding sun outside the walls to the shooting range. Hot, no hat. No dark glasses, no water, body armor, helmet, rifle. The gates have Sangars on either side (tall guard houses surrounded by wire and grilles. The walls are 10 feet high solid concrete. Then it is out into the empty dusty desert. A few Afghanis scurried around looking for collectibles. The officer waved his pistol at them and they ran away. 11 at a time. Those now familiar orders. Rounds five of 10 loaded. Make ready. Five rounds of fire. Dust spurts from the breeches as the rounds eject. Targets jumping too with spurts of sand. Then another group and another. Then it was over. Passed and we were marching back. Back to the crap bin to clean rifles. It was too dark inside to see, and outside it was bright but too hot.
Sighting our Guns
Soon we were striding out of the main gate of Camp Bastion into the desert in our full battle dress with helmets and body armor. It was very, very hot. In batches, we lay in the sand sighted our weapons and fired off a series at the targets 100 meters away. Range discipline seemed pretty slack after Sandhurst and Chilwell, and no one seemed to care much whether we could shoot straight or not. We were then allocated to our tents. These were right next to the hospital and had 8 beds in each. They were large and airy and AIR-CONDITIONED. I simply could not believe what I was seeing. The tents were heavy-duty double-lined canvas and a huge flexible pipe led in from a generator outside blowing cold air through the tent. If you wished you could erect a net all around your bunk space for privacy, but that made it dark and airless. Most of the officers chose gloom and privacy while the soldiers went open plan. There were 8 tents arranged along a corridor which had its own shower block. We might be under canvas but no effort would be spared to make us comfortable. In our block of 100-odd tents there was also an outdoor gym and a recreation hall, and immediately across the dirt road outside our tent complex was the entrance to the Camp Bastion Hospital.
Briefing on arrival at Bastion – short notes
The Now-Zad Local elders want both sides out. They just want to run the region themselves. 200 Taliban fighters control everything. Foreign fighters are flooding in. The main Taliban leader was killed five weeks ago.
Musa Qala township is the key centre for Taliban and for drugs. There is no government influence there. Drug barons are pumping in money. US special forces failed to capture the town.
The Kajaki dam is very difficult to patrol. It provides electricity for Kandahar. It needs a new turbine. We must get a 6km security zone before contractors will come in. It is not in the Taliban’s interest to breach the dam.
Sangin township has 250 Taliban. It was the centre of the drug business. The local nationals have driven them out. IEDs (Improvised Explosive devices) which act as roadside bombs and suicide bombers are on the up.
Geresh township is the 2nd city of Helmand on Highway 1. Tribalism is a big issue. Maize is now over 2 metres high and is due for harvesting in 10 days. Then the poppy will be sown for 2nd crop. There are 400-500 fighters. 3 suicide bombers killed in September.
Lashkar Gar town contains the Government centre for Helmund and is the centre of the Afghan development zone. 100 Taliban. The Chief of Police is a warlord and can work on either side. The Afghan National Army is good but the police are corrupt.
Garmisir Rural district is desert in the south. It is a key route for new troops in from Pakistan. There are trenches and defences. The attrition rate amongst Taliban here is huge as troops are sent here first for blooding. It is difficult to patrol, and the Taliban have heavy machine guns.
Sunday 14th October was our first night in our permanent tents. Seven of us in an eight-man tent. There is so much space. We each have 7ft by 4ft. It is wonderful and the leavers have left some kit behind. So, we have a fridge, a kettle and some chairs. There is a string for hanging coats but no coat hangers. A bedside lamp and a cot with a mattress. Also, a hanging canvas cupboard. There is room for everything, and at last I can unpack completely and put things in logical places. Tom beside me is a huge and slightly plump very Scottish nurse incensed by Daz putting up a big Union Jack. His small St George’s flag fell down! He is gentle as the day is long. Beyond him is David Barrett, the Methodist padre. Very young, very shy and very solitary but delighted to talk to anyone. Opposite him in complete contrast is Steve, the lab technician.
The following day was our first chance to shadow the medical team who we are replacing. We were made to feel very much in the way, so went off to make a brew. This is going to be a hard transition.
The following day we were taken to breakfast with the head of the Command Post. I had to button it as he was so didactic, confrontational, and WRONG.
Wow, what a day! Squaddies with broken legs were brought in by MERT (Medical Emergency Rescue Team) then an Afghan shot through the chest and abdomen by American special forces. He was a bit quiet and we saw the full trauma team go into action. I was utterly pissed off as I was completely ignored, indeed told to stand behind the line. Then three Estonians blown up by a land mine. I got one case who was absolutely fine. The leaving senior nurse kept on complaining that I was losing control of the situation. It was not so much that it was out of control. It was just that if I spoke quietly no-one took any notice and just got on with what they were utterly competent to do. It was obvious to me that their way of doing things was quite as good as mine, so why create noise and turmoil by changing things? Clearly not the army way. Anyhow they were all relatively uninjured so the outcome was good for them and the Taliban.
John took me away to lunch to calm me down. He was really good at it.
There was an evening meeting of the consultants to discuss what to do about the hospital being full of Afghans. There was a presentation on how there is no back door to the hospital for the Afghans so if you ventilate them there is no way out. Keith Galbraith said that in Bosnia locals were recovered and then extubated and if they died they died. He then pointed out that the American always keep two ITU beds empty and reserved for Americans. Col Gulbourne pointed out that practicing on the Afghans honed our skills for British troops. Others pointed out that it is not right to keep beds empty when there is such a need. Eventually, it was decided to do it on a day-by-day basis.
Each day I wake completely disorientated. Ear plugs block out all sound, and the tent is completely blacked out. It is just the vibration of the air-conditioner outside the tent, the heavy vehicles and the Chinooks flying over which wakes you. All are deep throbbing low-frequency sounds.
Today was our first day on our own and everything is quiet as the grave. I had a run at dawn with a lovely stiff breeze. Then the wind dropped and the place became hot. This evening a huge pall of smoke hung over the camp. The wind has changed and the smoke from the fire pit is blowing over the camp is sitting like a pall 50 feet thick. Apparently, the camp burns 5 tons of paper and plastic every day. The incinerators have all been destroyed by grenades left in the rubbish bins when soldiers come back from patrol, so there is a glowing red fire pit on the horizon 3 miles out to the east, and if the wind is in the wrong direction the foul smoke covers Bastion.
A&E was very quiet and those who came in were all snatched by Chris so I retired to the treatment room and typed up reports etc. Email was up, so there was lots of news from Vicky which was a real morale booster, then a long talk with her in the afternoon which was an even bigger boost. I was invited to come to the theatre with Ben to assist on an abdomen but Phil Lawson arrived at the last moment and insisted that he wanted to assist, so I backed down. I have not seen him as assertive as that before. It is a good chance to do some filming. I hope I got some good footage of Ian and the other anaesthetist. The atmosphere is lovely in a tented operating theatre, sort or warm and cosy around the lights. It would make a good painting. All the staff are really good. However, Ian lost his temper again. I have named him Mr Grumpy. He seems quite pleased with the soubriquet (always wanted to use that word).
The British ambassador is supposed to visit this evening but no sign of him so we went to supper instead.
I have been asked to move in with the Colonel. Trod very carefully to make sure he was happy, then said I was happy with my present crew. Firmly told that it was for the others in the pod who would not be able to behave normally with senior officers around. Tricky.
John is to be the Clinical Director. This is very good indeed.
Got back to the pod to find my pod mates very pissed off about me moving. I was rather touched. They are such a nice gang. Steve the lab technician came in and started talking about some row he had had about the working time directive (I think). His Scots is so broad that it is almost impossible to understand what he is saying and his humour so dry that it has me rocking with laughter.
The air is clear again this morning. Late going for a run so ran alone. Slow and stiff. I did a short course using side-streets I don’t normally take. I joined the ward round at 7.50 am this morning. Lots of people on it (probably too many) but I wanted to take part to make surgical notes. The first ward had beautiful notes from the night staff but clearly doctors notes were not being completed. Irwin led the round with Ben Bannerjee. It was the usual farce. 2 consultants talking quietly and fast at the front over the patient. There was very little ‘s’ subjective. How is the patient (pain, worries etc). Also there was very little on the objective (pulse, temp,blood-pressure, etc.). Finally there was nothing on assessment and then a garbled plan was made as they moved to the next bed. I had to stop the round twice to make sure notes were properly written-up. The second ward had very little written by the night staff and on 3 patients they had finished the page but not put in a new sheet. Grrr. The key issue with the Afghanis was discharge. I felt lots of discomfort over the transition from good care to nothing. Mike Massem tried to hi-jack the round re his infection area and wanted some poor soldier going for a wash arrested. The soldier looked gob-smacked and the nurses hushed him down and promised that something was happening.
Resus today. John Apps got a tiny baby dumped on his couch as three came in off the helicopter in a rush after an explosion. The child had shrapnel wounds to the abdomen and that is what she was coded as. However, what had not been coded was that the child had been treated at Bastion 3 weeks before and now had a colostomy which the father wanted closing, so he had hitched a ride on the helicopter when it came in to pick up the casualties. Chinese whispers and the child became part of the emergency on the manifest, and was raced into the resuscitation room at speed with the rest of the casualties. She was directed to table 4 where John Apps a delightful, gentle but highly competent GP was waiting to be allocated a casualty. She was placed on the couch, and he said he looked down and the child smiled at him. Funny he thought, this one doesn’t look like a case of serious abdominal injury from shrapnel, but obeying standing instructions for serious cases, he started in with his scissors cutting off all the clothes. He was horrified when he exposed the abdomen to find the bowels hanging out. He said he nearly fainted especially as the child was still smiling at him. He was frantically trying to think what to do next when the nurse beside him spotted his discomfort and pointed out that the bowel hanging out was in fact a nicely formed colostomy which was clean and well healed. He said that by then he was so bewildered he nearly had to sit down. Then the father enquired whether he could have some more clothes for the child.
My resus was a young soldier blown up by an IED while patrolling on foot. He had been peppered with stones and dirt. His eyes were very sore and he seemed drowsy. I was allocated to be in charge of the airway with CP as doc in charge. I did everything fine but he then went in and repeated the whole thing. Then he checked the cervical spine which I had forgotten to do, so I buttoned it. Penetrating injury to eye. CT and transfer home.
It was weird sitting through the trauma meeting listening to others pontificating when that would normally be me. I must remember that in future. The dynamics remain very tense indeed. People are so rude. 20 people waiting to start the trauma meeting and for CP to present. He came in and said he was busy checking a CT and would be for another 5 minutes. Someone asked if someone else could check the CT eye for him. ‘No’ Could someone start presenting for him ‘No’ and he walked out. Hmmm!
The trauma meeting presented all the cases admitted in the last week.
Wednesday 2 children picked up an unexploded shell and it went off. The older child lost his right hand and had fragments all over his legs with an open tibial fracture. The younger had multiple fragment injuries to the buttocks.
Thursday. A 10 year old male Afghan was brought in electrocuted by 400v. He had 9 % burns to his back, burns to left hand and right heel (? Entry and exit). He also fell 2 -3 metres. He had flash burns across chest. His CPK was 5000, but he made a quick recovery
Friday. 23 male afg. Fell 4 metres. Glasgow coma scale falling. Arrived after 8 hours right pupil fixed and dilated Ct showed extra dural. Decompressed – but brain infarction and died.
Suicide Improvised Explosive Device (SIED).
- Male Afghan with bilateral femoral fractures. Both lower legs had been blown off. He had Below Knee amputations. Tracheostomy. He was then ventilated overnight. In the morning he was transferred to the Czeck hospital where there was a misunderstanding about ventilators and he died.
2.Unstable fracture dislocation T12 with cord compression
- Bilateral destroyed feet and ankles. Bilateral below knee amputations plus tracheostomy. Given 6 units of blood pre-hospital. ? necessary.
Intra-osseous lines into fractured bone seemed to work OK. One IO went into epiphyseal plate of shoulder. Discussion about their value.
- Afghan with calcaneal and talar fracture. Open fracture tibia other leg
- 23 year old male 44% superficial burns (washed his turban in petrol) apparently occurred the day before but tagged on to the MERT.
- 20 male Afghan admitted with a Transthoracic gun-shot wound. 700ml haemothorax. Chest drain. No urine output for 6 hours. T11 sensory level with CSF leak. He will die slowly. He was rooting through bodies looking for the remains of his father with the police shot him as a looter. Who to believe?
Saturday 13th October
Danish soldier. Metal plate fell on knee. Posterior cruciate and collaterals are torn. Cas vac (flown back to Denmark.
Sun 14th Oct SIED near Pakistan. 24 casualites
- Multiple lower limb fragments. Head injury fragment across brain. When he was extubated he died. He should not really have been sent.
- 17 male Afghan multiple fragment injuriess and ruptured eardrum T2
- 11yo male Afghan. Fragments in neck and arm.
- 20 yo Afghan male GCS15 Hole in right temporal area. Recovered without surgery
- Afghan male. Fragment traversing brain. Epileptic Fits when he regained consciousness. He was extubated and died.
Mon 15th Oct
- RTA into wall of Bastion. 2 children. One fractured femur one open tibia Died.
Tues 16th Oct
- Danish soldier frag across brain.
- Fractured tibia
Tues 16th Oct.
- Drive by shooting bullet through lungs and chest.
- 15 yo male afg burns on leg
- 20 male afg gun shot to face broken jaw expanding neck
- 3 estonians in IED
Late A&E. A loose round exploded in the turret of a Saracen and blew the 3 inside up.
All covered in dust but no significant injuries. Lucky!
Evening in the tent ironing and and listening to Daz Ritchie and Steve talking about buggery in prison. All have very near relatives who have done time.
Friday
This morning went for a run with Ritchie. Just before dawn the air is cool and clear. We ran fast and well with a great sprint at the end. 4.2 miles in 35 mins makes just under 8 min miles which is I suppose 5 min ks. Pretty knackered afterwards. There are lots of people running at that time some alone some in groups. iPods and water bottles.
Then back to move my kit into the colonel’s tent. Needed to do a recce to make sure I would fit and how I would lay things out so as not to piss anyone off. Decided to value myself so bought a quilt cover and nicked a spare duvet. Matching sheet too. Comfort!!
Lots of re-arranging to be done until it was just so. Lucky because the colonel mentioned later that it looked tidy so he had clearly checked.
Security is surprisingly low profile here. 138 dead in one bomb blast in Pakistan today not far over the border. It is not a matter of if /but when we will get one here. Rumour mill says that last night they found a car packed with explosive only 8 km from the gate. Perhaps that explains the mighty bang lat night.
In A&E a MERT led by CR brought in a soldier who had a wall collapse on him in a fire-fight. I did primary airway with Chris Wright leading. I think we did fairly well. Acute abdo and silent rigid abdomen. Straight to theatre ruptured bladder and bleeding into the perioneum.
Another MERT in the afternoon taken by John. Estonian with his leg blown off. Apparantly he was nearly good enough to be in the national football team.
I went off to the ramp ceremony for the Danish major killed by an RPG earlier this week. Eerie experience. It was held on the airfield as the weather was changing. Sand blowing in wraithes across the loose gravel, and dust everywhere. The sun hot but dark red from the dust. 400 Danes lined up shirts out beards looking scruffy. Lined on 2 sides of the square over 1000 British troops looking smart. They march and salute differently too. Coffin out under a flag. Dismal looking bowed half shaven Danish vicar. Shun stand easy. Shun. 2 hours. Really tiring. 25 british soldiers fainted. Extraordinary sound. Often a soft groan from them then the hiss as they slid down and the harsh scraping of their boot heels on the gravel as they are dragged back through the lines and laid out to recovery. Some of them grinning inanely others talking loudly and inappropriately, obviously oblivious of where they are.
The Hercules backed into the open square tailgate.
A long and quite inappropriate delay as the passengers and luggage are loaded into a small port at the front. The whole scene is drowned by the noise of the propellers and the engine still running. Finally in goes the coffin and the Herc glides away takes off and then does a low pass back over us. Two hours of standing then back in the land rovers in a wave of dust. Pity there were no bugles or even pipes. The Danes seemed really grateful that we all attended.
Rumors of a car bomb outside the wall last night. Denied in the O group just one of the conveys had contact with the enemy.
The evening spent not leaving the hospital as there were some D&Vs to admit. Dithering about whether they needed drips and U&Es or not.
Saturday
Digital nerves
FAST scans.
Iron filing in eye
“The Afghans have teeth like a good recce patrol. All camoed up and well spread out.”
The Taliban use tattoos to mark rank. Sickle is Mujahaddin.
5 grenades found in dustbins this week left by outgoing troops.
O group this evening. Tough arguments about the size of ward rounds and hand washing.
“He’s a cunt”
“The colonel doesn’t like you talking that”
“No, I suppose he would not, e must hear it a lot of the time”
D supp
Sunday
The big convoy has gone off on its RIP. 80 vehicles. 1.5km long. Very short of Foden support trucks. Sounds like a complete logistical nightmare. Apparently, they have had to send out troops first to clear forward then the convoy goes out. Trucks that crash or break down have to be towed because they are fully laden with goodies. The convoy can’t stop because then they are a sitting target. They have to be within 10 meters of each other to get IED protection.
We got a collision, which took 3 hours to evacuate. Apparently, they have to first secure the area from the air and on the ground checking for insurgents booby traps and mines. Then they have to get the casualties out. When I got the driver, he was not a happy bear. He has been out three times on these convoys and has been attacked or involved in an accident each time. He says they just feel like sitting ducks. I should imagine it is a bit like Wildebeest crossing the Serengeti plains.
The results was not made any easier by CP who obviously felt that my examination was cursory so he repeated it in front of me, having simply brushed me aside. He pressed the spine so hard that the case said it hurt. Then tried to order a set of X-rays and finally a CT scan. Lo and behold they found an abnormality in the neck but it was a congenital fusion C5 on C6. By now the poor man had been in a neck collar for 14 hours. Phil Barlow gets peculiarly agitated when we talk about clearing the neck. My understanding that ‘clearing the neck’ is a preliminary
Monday
Very quiet morning. Stayed out of A&E as much as possible. Afternoon things really hotted up. Apparently, the convoy was attacked by a suicide vehicle that swerved in from nowhere and clipped one of the lorries. Noone waited just opened fire at once. He still detonated but only one injured shrapnel to leg.
Food in the mess 9 choices. Well cooked. As much as you want. Over 6000 people to be fed in 2 hours at 2 canteens. Then bed. 2 of us linked by a creaking tier of beds. The snoring was astounding. Slow machine guns, wails, hoots etc. Blinding headache from the stress so got up and did some writing. Very peaceful to be alone for a few hours. Then once settled back to bed earplugs eye patches and deep dreamless sleep until shaken awake with the temperature rising fast. Actually woken by the physical shaking of a helicopter coming in low to land. Met up with Mick and Chris. Talked about the boat race but I was too tired to think.
There are no birds in this place. The sky is empty.
At the back of the tent, there is a leaky sewage pipe. A tomato seed (from feces I presume) has germinated. It is the only green thing in Camp Bastion, so we have designated it a National Park and plant of extreme rarity and beauty. Scattered everywhere are broken military vehicles presumably blown up by land mines. Apparently, they are cannibalized for parts.
Sleep at last after an enormous and very good meal.
Just heard that Phasan has taken native clothing out with him to FOB Robert and is planning to make friends with the locals.
Life expectancy in Afghanistan is quoted as 47 years the lowest in the world.
Infant mortality 247/1000. Lifetime maternal mortality 1:6.
I wonder how these figures are collected. I think they just get quoted from one underdeveloped country to another.
Helmand province is the poorest province in one of the poorest countries in the world. No doctors will work there.
Setting up the tents
We were moving in just as the previous regiment was moving out and the first thing to do was to loot as much spare kit as possible. It was not cricket to steal from your tent mates but other tents were fair game. I had been allocated a tent with 7 soldiers (presumably because I was supernumerary) and so I was privileged to see looting going on firsthand. One of our tent members was left to guard ‘our’ stuff while the others slipped out smartly and started clearing anything moveable from other tents. Bedside lights, duvets, electric kettles, and a small fridge all started appearing in our tent. My decision about whether I was going to get involved was taken out of my hands when one of my soldiers handed me a duvet and a bedside light. “There you are sir. You will need these and I have spares”. There were a couple of attempted raids on our fridge, which were smartly driven off. Now we had all the necessities to ‘make a brew’ and to store cold drinks. Quickly the other members of my tent laid out all their gear beside and under their beds. Helmet, webbing, body armor, weapon, boots head torch, and then their spare uniform. Then they all fell onto their beds to relax and take in the surroundings. An hour later I was still trying to lay out my kit, having watched how they did it out of the corner of my eye. Later I was to learn that this layout is absolutely critical and must always be the same. If you are called onto duty in the night you need to be able to get out without putting on a light, and without making a sound that would wake your compatriots.
The other place which was a surprise to me was the gym. Well, not one gym. There must have been seven or eight gyms in Bastion, each of which vied with the others for Gucci equipment. The big ones had rowing machines and weights, but most importantly they had mirrors. The weight-lifters seemed to spend hours in front of these mirrors admiring their muscles as they pumped their iron.
The centre of Bastion even had a NAAFI and a Pizza Hut but this was nothing to Kandahar which had an enormous raised wooden walkway around a central basketball pitch. Lined along the outside of a raised walkway (like you see in wild-west towns in Cowboy films) were shops selling ice cream and pizzas. It made an extraordinary contrast to the grim industrial look of the rest of the camp.
The Hospital
While I was there the hospital itself was still tented. It looked like a Second World War design and was modular with a central spine corridor. There were then side corridors every 40 feet leading into wards, operating theatres, laboratories etc. The roof was low and the canvas dark green so the feeling was gloomy and claustrophobic. However, it had the great advantage that you could not go anywhere without passing down the central corridor, so you got to meet everyone who worked at the hospital many times each day. This made communication very easy. Later I went around the new hard-top hospital with its hermetically sealed doors. It was light and airy, but totally soul-less.
No sooner had we finished our tour of the hospital than the tannoy announced ‘Op Minimise’ and outside we could hear a Chinook thudding in to the landing strip next to the hospital. Our guide explained that this was a casualty coming in. The call of ‘Op minimise’ meant that all communications with the outside world were now being cut off so that if anyone was dead or injured their next of kin would hear first from the Army not the media. Those of us who were going to be working in the ED headed straight for that end of the hospital anxious to get a clue as to how these situations were managed. When we arrived at the ED we were told bluntly and very rudely to fuck-off. I am not sure why the incumbents felt that they needed to be so rude but apparently, there were some ‘issues’ which presumably they wanted to keep to themselves. I never did find out what this aggression was all about but certainly we were perfectly welcoming when our replacements arrived.
Within days the grumpy old regiment had left and we were in sole charge of the hospital. We had two general surgeons, an orthopaedic surgeon, a neurosurgeon, an A&E consultant, two General Practitioners, two physicians, a paediatrician, three or four anaesthetists and then all the support staff to go with this. It really was quite a high staff ratio for what worked out to be, on average, one casualty a day.
MERT
Pretty soon war had broken out amongst the anaesthetists. Some were needed in the hospital but there were also slots to go out on the helicopters to bring in casualties. Everyone wanted to do that, despite the fact that as one of them said “It is not a question of if one of us gets killed, it is when!” The group of doctors and nurses who manned the MERT (the helicopter rescue) lived in a different area and became very aloof from the rest of us. This was doubly annoying as we all wanted to be part of their team! There were many acrimonious arguments about who should or should not go out on the MERT. The noise and vibration on the helicopter were so great that it was impossible to do anything medical during the flight. So, really, there was no reason to have a
doctor on board at all. The argument which was adopted was that the doctor was there to stop the paramedics doing anything silly. As it is doctors, not paramedics who do silly things when patients are being transported, this argument was a bit rich. However, not content with this ridiculous argument, disputes then broke out as to whether you needed to be an intensivist or aero-space trained to be the doctor who would stop others from doing silly things. Each person, while claiming to be quite dispassionate actually presented their qualifications as the only ones which were suitable for this type of work.
I now started to notice that the doctors who were in the regular Army as opposed to the TA were all a little mad. They seemed to only be interested in doing exciting and crazy things but were not very safe or competent working in a team with the rest of us. It was quite embarrassing to listen to, if I had not badly wanted to go on the MERT too!
A&E
As the casualties started to roll in, we started to learn to work in teams. I had a cine camera and wanted to film the resuscitations but there was strong opposition to this. I wasn’t clear of the reason except that some people were clearly very frightened that they were not competent, and they weren’t. This was a steep learning curve for all of us. None of us had worked together as medics and the types of injuries coming in were not those that you would ever see in a civilian practice. For a start, casualties came in as a group, and the information that we got in advance was never very accurate. We were supposed to receive a signal called a nine liner, which described the type of incident, the number of casualties, the severity of their injuries, and time of arrival. It came to be known as the nine liar, as the information we got was so wrong. We discovered that when the casualties were picked up by the helicopter, the doctor in charge of the MERT would speak by radio to the co-pilot giving the 9 liner. The co-pilot would then relay that message to the Apache helicopter flying cover above, as the Chinooks did not have direct comms with Bastion. The Apache pilot would then relay the message to Bastion comms who would pass it on to the hospital comms staff. Lots of background noise, and busy non-medical radio operators meant that it was a miracle that any message was intelligible at all.
At first everyone was so eager to be involved in the resuscitations that it seemed sensible for me to stand back and observe what was going on. The first thing that I noticed was that as everyone became more experienced there was less and less talk and most importantly only one person spoke at a time. I also noticed that there were fewer and fewer ‘collisions’ between staff both reaching to do the same job, or crossing past each other to do jobs that the other could have done better. In fact, it became clear that you don’t need to video resuscitations to measure the quality of the work in resuscitation, you can just measure ‘talk’ and ‘collisions’. Most of the major injuries we were seeing were IEDs, roadside bombs detonated under passing vehicles. Our vehicles were totally un-defended against this type of attack, but as fast as we armoured up the underside of our vehicles the Taliban increased the size of the bombs, so that we remained vulnerable. The big moves of equipment were done by convoys of vehicles travelling at night. They had to stay very close together so that the convoy was not too long. The drivers were using night vision glasses which have no penetration in dust and which are very slow to acuire an image. What your eye sees is delayed several seconds by the scopes and if you head moves (as it must driving a truck over rough ground) it is completely blurred. As a result, there were lots of collisions within the convoys and vehicles going off the track into the sand and then rolling over because they were top-heavy with armour.
Routine work
There was also a lot of other work to be done in A&E. We had 10,000 troops on the ground at that time and there were plenty of minor injuries on base, never mind the military activity outside the base. I enjoyed this work, so was happy to work on in A&E when the others disappeared off to the mess to wait for another major casualty. During that time, I got to know the TA nurses in A&E very well. They were almost all elderly, male, and highly competent. I learned lot from them about how the equipment worked and how the system worked in the Army. Among other things, I taught myself how to use the slit-lamp. That was to come in very useful quite shortly.
Within a few weeks, we had all settled into a routine. There was not nearly enough for everyone to do, so every time a Chinook came in all the surgeons headed for A&E. This became a real nuisance as they are nothing but trouble in the early stages of a resuscitation. So, we painted a red line on the floor. No one apart from ED staff was allowed to cross that line until they were invited. The surgeons then used to hang over the line like dogs waiting for a bone, (quite literally) and on several occasions had to be ordered back over the line.
Damage limitation
Although this was only a tented hospital the equipment and staff available to us was extraordinary. We had portable X-ray machines which were state of the art and which I had never even seen in the UK. At any one time, we had 60 units of ‘O’ negative blood. This is probably more than is available in the whole of the South of England. We had the latest and most expensive blood warmers. Whoever equipped this hospital was determined to prove beyond any doubt that our soldiers, once injured, received the very best care that money could buy. As soon as we had stabilised the patient they were transferred to the operating theatre where damage control surgery was performed. This meant simply tidying things up so that the patient did not bleed to death in the next 24 hours or die of peritonitis. So holes in the bowel were just blocked off by stapling the bowel shut on either side (ten minutes of surgery instead of an hour). If the abdomen was opened it was not closed. It was just sealed with a plastic drape (ten minutes instead of an hour). However, if a limb could be saved with a vessel repair then this was done. Otherwise, wounds were cleaned but not closed. As soon as the damage control surgery was complete and the patient was stable he was loaded into a C71 aircraft, fitted with an intensive care unit, and flown directly to Birmingham, where definitive surgery was then undertaken at their Trauma center. So, a soldier blown up in the field in Helmand province might be retrieved within 30 minutes by a MERT helicopter and brought to Bastion within another 30 minutes. There he would be transferred to the operating theatre within an hour, and four hours after that might be on his way to the UK. He would likely be anaesthetized throughout so might be concussed in Helmand and wake up 18 hours later after surgery in Birmingham. It must have been very bewildering for them.
The cost of this exercise of cas-vac from the field, damage control surgery, evacuation, definitive surgery, and rehabilitation is difficult to estimate. The Chinook costs thousands of pounds an hour to fly and is accompanied by two Apache helicopters as top cover. The treatment at Bastion must run into hundreds of thousands of pounds as must the flight to the UK and the treatment in Birmingham. I suspect that with rehabilitation the total bill will not be much less than one million pounds per major casualty.
The work at Bastion was humdrum 95% of the time. Just like everything in the Army, there might be moments of high excitement but the rest of the time was spent, waiting, waiting, waiting. Every afternoon, I ran round and around the inside perimeter road, but I could not see out. The Hesco walls were far too high, but if I went into one of the Sangars (guard towers) I would meet a very bored guard tucked away behind his wire net mesh, and then I could look out over the desert. As usual, there is nothing pretty about a desert. It was a mishmash of sand, stones and rubbish. Nothing rots in the desert so junk accumulates, plastic bags are blown by the wind, heavier things just lie half-buried in the blowing sand. You can go as far from civilization as you like, but plastic bags rattling in the wind will follow you and ruin both the peace of the place and the view. The guard towers are laced in wire netting to block Rocket propelled Grenades, but through the wire netting, you can see in the distance to the North snow-covered mountains. This was the Afghanistan that I wanted to see but we only got tantalising glimpses at dawn when the air was still clear. Later the dust haze would rise up and the Death star called Camp Bastion would float isolated in the desert. I gather that in its heyday some two or three years after I left, it housed 26,000 troops and its perimeter. wall was ten miles long, and had two runways, one over 3000 meters long. What an astounding waste of taxpayers’ money!
The Burn Pits
Camp Bastion supported a whole industry in the desert. Afghan children searched the shooting ranges for bullets and casings to sell for scrap. The rubbish produced by Bastion could not be disposed of by industrial incinerators for a simple reason. When the soldiers came back from the FOBs they tended to throw away the grenades and ammunition which they still had on them but had not used. My favorite disposal was to drop them into the rubbish bins. When these were emptied into the clean-burning incinerators originally fitted at Bastion they blew them up, so the Army had reverted to the old-fashioned business of a fire-pit placed one kilometer downwind of the base. All waste was burnt there. By all accounts, it was a dangerous place to work but the Afghans who tended the fire were also able to scavenge all sorts of valuable scrap provided they didn’t mind the risk of being blown up by a grenade. To my amazement, the fire pit apparently burnt 5 tons per day of paper and plastic. This was because all the food arrived in boxes and meals were served on plastic plates with disposable cutlery (to reduce the risk of dysentery) but even so I was amazed at this figure. At night the fire pit could be seen lighting up the sky. In the day a pall of acrid black smoke rose from the same spot. The column of smoke looked very biblical rising up in the desert. If the wind was in the wrong direction then the smoke blew back over the camp, darkening the sky and causing everyone to choke and splutter. There is nothing Green about an army in the field!
The lorries bringing supplies to Bastion arrive at the main gate after their long drive up from Pakistan. They then had to wait in a compound outside the gate for 48 hours just in case they had been fitted with booby trap bombs.
Jingly Market
Once a week a select group of traders were allowed in to hold a half day market selling pirated videos, Jewellery and antique guns. They did a roaring trade as we were a captive market. I got to
know the jeweller quite well as he spoke arabic. He sold sapphires amongst other things and as I got to know him he would allow me to take sapphires to the hospital with the potential buyer and look at them under the slit lamp. All sapphires have flaws, but the slit lamp allowed the customer to see exactly what they were getting, and I loved looking deep into these blue jewels.
In an attempt to keep us amused, we would host visits from other units to show them how the hospital worked. In return, they would show us what they did. Each unit prided itself on their patter and practised a really good demonstration. Our first visit was to the Danes. They had a small contingent but were equipped with Leopard tanks. When they first arrived, they patrolled without helmets or body armour (as we had done). Then a group of them were leaving a meeting when a suicide bomber took them out. Shortly after that one of their soldiers died after being treated at Bastion Hospital. This was my first repatriation ceremony and an extra-ordinary event it was. Every spare British soldier at Bastion volunteered to form part of a guard of honour for the Danish soldier, so when his body was flown out there were nearly 1,000 troops in serried rows dwarfing the Danish contingent. The coffin draped in the Danish flag was slowly marched out and a full funeral ceremony was held in the open at the side of the main Bastion runway. While this was going on a dust storm blew up blanketing us in dust and a deep orange light. As the storm quickly cleared a Hercules aircraft appeared overhead, landed, and then reversed until its tail was close to the padre and the coffin. The Hercules is one of the few aircraft that can manoeuvre backwards as well as forwards on the ground, and this is what makes it so useful in out-of-the-way places. The pilots did the turn perfectly and then left the engines turning over as the rear door dropped and the coffin was carried into the plane. Then the doors shut, the plane taxied away, took off and did a final pass over the parade at low level and the last post was sounded. It had been a very emotional ceremony, but what made it even more so was that the Regimental Sergeant Major of the Danish contingent now marched out into the centre of the square and in a bellow that could be heard right to the rear-most ranks, thanked the British from the bottom of his heart for turning out on parade. It was a lovely spontaneous gesture and did much to bond us all together in ISAF the combined European force fighting in Helmand.
Visits
Shortly afterwards the Danes invited us over to see their Leopard tanks two of which had broken down, and so were on base. What enormous machines, but inside there was absolutely no room at all. The crew lay in stretchers and all the space was taken by the breech of the gun and the ammunition loaded beside it. The tank might be able to do 60mph and shoot with deadly accuracy over 5 miles but the working conditions for the crew were diabolical. Roll on robot tanks!
Our next visit was to see how the dogs worked at Bastion. There were rumors that the guard dogs at Bastion lived in air-conditioned kennels and had better living conditions than we did. Well, it was true. They did have air-conditioned kennels and were molly-coddled by their keepers. No better conditions than ours, but no worse either! First, they showed us the sniffer dogs trained to find explosives. Their reward for finding it was simply for the trainer to throw a tennis ball for them to fetch. It was amazing how quickly they quartered the ground until they found a buried charge. Then they stood over it, tails wagging delightedly, waiting for their tennis ball reward. There was something rather disarming (quite literally!) about how they put so much effort into finding something so dangerous, just to be rewarded with a tennis ball throw. These dogs return to the UK after their tour of duty and are adopted by a family. The second set of dogs could not have been more different. These are dogs brought from broken homes in troubled areas in Britain. Some of them have been trained to fight, and all of them are lethal. They are guard/attack dogs and answer only to their one master. They are very difficult to use in the field because they will as happily attack a British soldier as a Taliban and they cannot easily be called off. Apparently, the Taliban are terrified of them, but they are rarely used because of the problem of control. They brought one of these dogs out with his handler and dressed one of the male nurses up in a quilted suit with a metal grill helmet. When the handler, with his dog, got within 50 yards of the nurse they told him to run for his life. As he started running away, the dog was unleashed. It covered the ground in seconds but when it was still 10 yards from the poor nurse, staggering along in his padded suit, it took off and hit him on the shoulder with its teeth instantly locked around his upper arm. The speed and ferocity of the attack literally cartwheeled the poor charge nurse head over heels. He then lay quite still but the dog did not stop. It continued to try to chew him until the handler finally dragged it off. These dogs will never return to the UK. They were dangerous before they came out to Afghanistan and there is no way they could be rehabilitated into any kind of ordinary life.
Some parts of Bastion were off-limits to all of us. There were areas where the SAS stored their gear, and other parts which were simply closed to all of us; goodness only knows what they did there. In the work-shops were the remains of vehicles that had been salvaged after roll-overs or roadside bombs. Most of the vehicles damaged in the field were simply blown up on the spot to deny them to the enemy. It was far too dangerous to spend time trying to repair or tow them in. The wastage was unbelievable, the evidence all around us every time we went for a run round the camp.
Ethical problems
My time at Bastion was boring, with very little to do for days on end even when the fighting was at its heaviest. The wards were kept empty. That was deliberate. Everything had to be ready for a major disaster and influx of casualties. We did not only take British Soldiers. Any Afghan soldiers who were injured in our battle zone also came to us. It was also agreed that any civilians who ‘might’ have been injured by our fire should also be treated at Bastion. The local doctors on the ground in the FOBs made the call, and not infrequently if a Chinook was coming in to collect an injured soldier an injured child would be slipped on board at the same time. This was easily done, because when the Chinook lands it raises an enormous dust cloud which envelops everything for 30 or 40 meters around. The helicopter may only be on the ground for less than a minute, just long enough to load the casualty. They burn and turn during this time throwing dust and gravel everywhere. The moment that the injured are aboard, the helicopter lifts up and flies forward frequently firing off chaff in every direction to divert any enemy attack. At this stage the gunners front and rear may actually be outside the aircraft floating on their harnesses like space walkers swinging their machine gun mounts in front of them. Inside the airframe the dust and noise is indescribable. None of the doors are closed during the flight and the Chinook is fast so the wind whistles through the air-frame.
One child we received was only five and had shrapnel injuries to (hands and face) from the close explosion of a Rocket Propelled Grenade (RPG).
She was an absolute favorite in the ward. Her wounds were grafted and dressed and within a few weeks, she was ready for discharge. The translators got hold of the family but then reported back to us that they refused to take back the girl because she was scarred and therefore un-marriable. We got quite cross about this cross-cultural misunderstanding and insisted. Her parents then changed their argument and said that she would be killed by the Taliban if she was returned to their village because she would be seen to have collaborated with the enemy. Now we were all very cross, and unceremoniously dumped the child with her family back at the village. Some weeks later news came that she had not been picked out by the Taliban – the whole family had been executed; parents brothers, and sisters for ‘contact with the enemy.’ We were now beginning to understand the true horror of this war.
After six weeks at Bastion, I had completed my report but was asked by the team if I would stay on for another six weeks as they were going to be short-staffed. I agreed and found myself being treated as a bit of an old-timer by the new doctors coming out. I had now mastered quite a lot of the equipment including the lovely expensive slit lamp that we had for treating injured eyes. A slit lamp is basically a microscope for looking at the surface of the patient’s eye so that you can see debris or cuts in the cornea. We had quite a lot of these as bomb blasts and strong winds blew all sorts of rubbish into people’s eyes. Eyes are a little bit scary until you get used to them so I had become the person to be asked if an eye needed treating as I rather enjoyed the beautiful view that you get of the human eye, once you have got over your fear of its fragility.
Screaming Ghurkas
One day a Gurkha sniper was brought in screaming the place down. Gurkhas don’t scream. They are the toughest people that I have ever come across. This one was shouting that something was eating his eyeball. The magnification of the slit lamp is enormous and when I focused it onto his eye I was confronted by a giant creature from a science fiction movie trying to burrow into the white of his eye. Actually it was not much bigger than a pin head, but its jaws and claws were black and menacing. As soon as the light of the slit light fell onto it, it raced away into the folds of the conjunctiva and started to burrow again. Taking courage in both hands (finger tips actually) I chased it across the poor Gurkhas eyeball with a long and very sharp needle until I had it cornered and could impale it.
The relief for both the Gurkha and me was palpable. I discovered from the internet that this creature was the larva of the Bott fly, a large horse-fly which, like a mammal, hatches its eggs inside its body. Then when they are ready it flies towards the eyes, nose or mouth of a goat or camel and at the last moment squirts the larvae at its prey. As soon as the larvae land on their pry they start burrowing into the flesh, where they grow while eating their prey alive. These Gurkha snipers lying out in the desert were considered perfect prey for the Bott flies. My second case had a total of 23 larvae in both eyes. It took me 2 ½ hours to catch, impale and remove them one by one. When I started clearing these eyes, the process had been a long sharp needle connecting two very frightened people. But over time I settled into this fascinating task even if the patients did not.
Ethical dilemmas
However, our ethical dilemmas were not over. A young Afghan soldier was brought in following a bomb blast. Shrapnel had gone through his lungs filling them with blood, but another fragment had transected his spine. We knew he was paraplegic the moment that he arrived on the Gurney in the Emergency department. He had no feeling or movement in his legs and he had an erection, an absolute sign that the spinal cord had been cut. This injury is no problem in Britain where we have specialist spinal injury units and where patients can be fitted with wheelchairs and home aids. In Afghanistan, it is a death sentence. There is no spinal injuries unit in the whole of Afghanistan. There is no one to teach self-catheterization or pressure sore care. All spinal injuries in Afghanistan must die. It is just a question of when. As soon as we realized the issue we were facing I stopped the resuscitation. Without fluids and a chest drain, we could have let him die there and then, and that is what I suggested it might be the kindest thing to do. However, in these cases if there is even one dissenter, then we have to continue. There was, a deeply Christian nurse who said that we simply could not and should not let someone die. So, we stopped the bleeding, sorted out the wounds and moved him to the ward. There he started to learn English and was much loved by the nurses who gave him their undivided care. But as always happens he developed pneumonia and once again I pointed out that it might be kinder to let him go than face the future in Afghanistan. This time all the nurses were up in arms. They really liked their patient and were certainly not going to allow him to die without antibiotics. So, he received antibiotics and physiotherapy and recovered. Then came the day when his wounds were healed and there was nothing more active for us to do. The colonel ordered that he was to be discharged to clear beds in case they were needed by our own troops. There was absolutely nowhere for him to go except back to his own village where I have no doubt he died slowly and horribly with a blocked urinary catheter and infected bed sores. His discharge caused a lot of anger and anguish from all of us as we realized that we were a little medical bubble in a cruel third-world country. One of my recommendations to the Army was that part of the re-deployment work-up should be to discuss in small groups cases such as the scarred child and the paraplegic soldier so that the ethical issues could be clarified in a calm atmosphere rather than at the end of a soldier’s bed with nurses crying and doctors cursing.
Changing tent
The tour of duty was now turning sour for some. The novelty had worn off and for everyone but the doctors there were still many more weeks to run. The colonel in charge was not a good leader and was now beginning to feel the strain. He asked me if I would share his tent as he was living there in solitary splendour and I suspect he needed the company. His excuse was that it was not appropriate for someone of my ‘status’ to be slumming it with the ordinary troops (although I have to admit that I was rather enjoying the camaraderie). The invitation was little short of an order so I moved, and immediately noticed a change in attitude towards me by all the staff, which I did not like one little bit. The colonel clearly needed someone to talk to and unfortunately started by boasting about all the surgical textbooks he had pirated onto his laptop. I am afraid I got very holier-than-thou and pointed out that I wrote textbooks which were being bankrupted by people like him pirating them. He rather lamely pointed out that he hadn’t pirated any orthopaedic books. There was no helpful answer to that. The next day I moved back out of his tent without discussing it with him, and moved in with the group of squaddies who had invited me to join them in their eight-man tent originally. It was the best thing that I ever did. They were jubilant to get me back and I learnt a lot.
Soliloquy
My first problem was understanding anything that they said, as they were all from the Celtic fringe and when they talk amongst themselves their accents are very broad indeed. The second thing I discovered was that all their spare time is spent watching war movies where they are clearly imagining themselves as the heroes. It became clear to me that each and every one of them dreamed of the opportunity to be a hero and just hoped to god that they wouldn’t let themselves and their mates down if the chance did arise. They were also clearly quite keen to show off to me, a green-horn officer from England. So, one evening was spent describing how many relatives they had in jail and how one smuggled knives and drugs in to them. I simply could not believe my ears, but made sure that I kept my mouth shut. I was not part of this show, just the audience. The Glaswegian lab technician could and frequently did, deliver a long soliloquy on the meaning of life as he saw it. This would be delivered by him lying on his bunk on his bank gazing dreamily at the ceiling. At first I found them very hard to understand as his accent was so broad, but as I got used to it, I found that these talks were pricelessly funny and very far ranging. He had no problem with discussing Shakespeare in the same breath as ‘The Terminator’ or the morality of doing a lab test compared with fighting as an infantryman. The other soldiers in the tent would interrupt occasionally, not so much to argue with him, but more I suspect to egg him on. I was just intrigued by this extraordinary mind in a person who did such a humdrum job.
One of the rooms in the tented hospital had become a sort of officer’s mess. There the surgeons gathered when there was no work to do and played bridge. I have always hated bridge. My father played all through the Second World War and then tried to teach me. His exasperation with my inability to grasp immediately the subtleties of the game gave me an abiding hate for it. The surgeons bid, and bickered through the empty days, then had to work for twelve or eighteen hours at a stretch when there were casualties in. I decided I was better off in the Emergency Department where at least there was something to do.
Changing job
By the time Christmas came my three months were up, and I was starting to look at a departure date. One day I received a message that the regimental commander of the whole medical set-up wanted to see me in his office. I thought it was about the bust-up that I had with our colonel so went along prepared for a roasting. Instead he asked me if I knew anything about refugees. He knew that I had worked with refugees in the Sudan so it was clear that the question was leading somewhere. I admitted that I did, and he then sprung his question on me. They were planning to attack and drive the Taliban out of a new part of Helmand and were expecting a major refugee problem. Would I stay on and help co-ordinate the refugee work. It meant another 3 months in the field, but I would be based at a town called Lashkar Gar not Bastion. I suggested that it might be a good idea to discuss this with my wife, and without another word he pushed the phone on his desk over to me and sat back with his arms crossed. I had no idea that there were phones patched directly through to the UK. Goodness only knows how they worked. I got to speak to Vicky at once. She was very good about it and just said ‘You have to do what you have to do’. I put the phone down and he told me that I was on the next flight out to the UK for 2 weeks leave and then I would return to the new job. This sudden leave was completely disorientating. I still was not sure where I had come from and now belonged in the small world of the Army. Vicky must have found me completely distrait because I knew that when I went back, things were going to be unrecognisably different, and I actually felt quite uncomfortable out of uniform.
As soon as I got back to Bastion after what seemed like only a couple of days away I reported to the colonel. His office was humming with activity. Things were moving forward very quickly indeed. Musa Kala was being attacked and the Taliban had run for it without putting up any fight. I was needed up there pretty much right away. The colonel wrote a chit for me and ordered me to go straight to the quarter master’s stores. When I arrived at stores there was a long line of squaddies waiting to change pairs of boots and worn out socks. At the desk were the usual bunch of stores men, all bored and studiously refusing to change or help with any kit. Quite suddenly there was a shout “Is Major Bulstrode here?” I answered and an order came “To the front, sir – at the double” I squeezed past the long queue of the disgruntled, to be confronted by the senior quarter-master who took my chit off me, read it and then whistled out loud and said. “Watch this guys!” Over the next ten minutes the most amazing top-level kit was laid out for me to sign-for. Gortex jackets, special lights. ammunition, special glasses, you name it. The rest of the soldiers in the queue just gazed in awe. I was going front line. I thought that I already had good kit but now I was to get the very best kit that the British Army had. I could scarcely carry it all back to my tent where my fellow tent mates gathered around, fingering all the ‘Gucci’ kit. Thirty minutes later an order came down that I was to be ready to fly out to Musa Quala in 15 minutes. Transport was waiting for me now to take me to the helicopter strip. I had no idea where to start, but the rest of the tent did. In ten minutes they had packed my Bergen with everything I needed. The rest of my gear was scattered over my bunk. I started to tidy it away in my locker. “Don’t you worry, sir? Everything of yours will be safe. We are your mates. We will guard it.” And they did. When I got back weeks later nothing of mine had been touched, despite the fact that theft was rife in the tents. Talk about honor amongst thieves!
Musa Quala
I could hardly lift my Bergen rucksack. It must have weighed nigh on 40 kilos but they hoisted it onto me and away I went into the field, lugging my beastly SA-80 weapon and loads of ammunition. When I arrived at the embarkation point there were about twenty of us ready to be lifted up to the front-line. The colonel arrived a few minutes after me to give me a final briefing. There were nine tons of medical supplies on pallets ready to be airlifted into Musa Kala on my say-so. I had just to assess the situation, decide what was needed, and make it happen. Finally, he turned to me and said “You are the luckiest bastard I know. I would give my right arm to be going to do what you are about to do”. Then he turned on his heel and marched away. Minutes later we were clattering up the loading ramp of a Chinook which was burning and turning throwing dust ready for take-off. No sooner were we in our seats than she started to lift. Chinooks don’t change sound as they take off. The rotors turn at the same speed and with the same sound all the time; the pilots just adjust the pitch of the rotor blades. So, the take-off is a most peculiar feeling. the ground just seems to fall away from you. For the first time, I saw the whole extent of Camp Bastion as we rose and turned towards those mystical mountains that I had only glimpsed over the Hesco barriers of Camp Bastion. At first, we went high and fast, but then as we went deep into enemy territory the Chinook dropped to ground level and we started ducking and weaving through the sand dunes alongside the Helmand River where it runs through the desert. A lot of the time we were actually below the level of the small hills and frequently we were tipped right over on our sides as we turned and weaved up the narrow valleys. We were trying to present the most difficult target possible to any enemy on the ground. There was no way they could predict which way we were going to go as I don’t think even the pilots knew that until a split second before they decided. While flying low and fast, no-one on the ground would be able to keep us in their sights for more than a couple of seconds. The front and rear gunners were swinging in and out of the aircraft on their harnesses, sweeping the ground with their machine guns, ready to fire at a moment’s notice. Suddenly the Chinook was flaring and we had landed. There was a mad rush for the ramp. We had to get off before anyone else could get on and the pilots did not want to be on the ground a moment longer than they had to be. We were in the heart of enemy territory, surrounded by mountains whose sides would make perfect firing points. I ran with the others down the ramp, dragging my Bergen with me. The next moment I was grabbed and signalled to crouch and hold my sac. The gale around us rose to a hurricane as the Chinook lifted off and suddenly we were in peace and quiet on a gravel beach beside the Helmand river. Before I could admire the view someone shouted “Everyone under cover, double quick” and I saw around me everyone hoisting on their Bergens ready to run for the gates of the base ahead of us. I got my Bergen onto my shoulders but then physically could not stand up. I could feel my quadriceps straining but my knees simply would not straighten. I was in a complete panic. I was stuck on my hands and knees. Two soldiers running past simply grabbed me one under each arm and hoisted me onto my feet. Then I too was jogging forward with the rest, hurrying to get under cover before we came under fire. Up ahead of me was a Hesco wall with a gateway tucked obliquely like a mediaeval castle. On the Sangars above the gate Gurkhas were manning heavy machine guns ready to give us cover if we came under fire. In what seemed like no time we were all inside the gate and dropping our loads, exhausted from the sprint. The FOB at Musa Quala had only been erected in the last 24 hours. Indeed it really wasn’t even finished. The FOB was built around a large house which had belonged to a drug baron. Ten feet in front of it, a high wall of Hesco had been erected with guard posts on it. Now the Gurkhas were filling sandbags with shovels to create blast proof walls against mortar attack. Inside the building there was no lighting but laid out side-by-side were rows of camp beds. I was issued with a bed, told to put my Bergen beside it and issued with some food rations by the Sergeant Major who was very welcoming, but puzzled at what I was doing there. However, he was far too polite to ask me directly. As soon as I had got my kit stowed I went and lent a hand filling sand bags as that seemed the only useful thing that I could do and everyone else was busy with their own tasks. The Gurkhas were tickled pink that they had a major helping them and we got to work with gusto. This was work I remembered well from Sandhurst! Every window had to be blocked with sandbags as quickly as possible.
First Patrol
Dinner that evening was prepared by the cook brewing up a large pot of boiling water. Each of us wrote our names on our ration pack and dropped it in until heated through. I thought the food was excellent, but there was only a choice of three dishes and I should imagine that after several months of comp rations, the lack of choice could get monotonous. We went to sleep with our weapons and ammunition magazines beside us in immediate reach and with a head torch at the ready. The following morning ablutions were under a very cold tap in the yard fed by a hand pump from a well. We were urged not to let any dirty water spill back into the well as we would all be drinking and washing in this water for the foreseeable future. Straight after breakfast, I was informed that I was going on patrol through the centre of town with a squad of six Gurkhas. My task was to get first-hand information on the availability of food, medicines etc for my ‘refugee report’. We armoured up quickly. It was going to be a foot patrol lasting 1 ½ hours through the centre of the town. We were to be one of the first patrols to go into the town so there was a high element of danger. I was petrified. This is what I had been trained to do, and now I was confronted by the reality, I racked my brain to remember the lessons I had learnt at Sandhurst, Rhyll and Chilwell. As we passed through the gates the guards on the machine guns cocked their weapons and we fitted live magazines. I suppose that I was technically in charge of this patrol but I was acutely aware of my inexperience. So, apparently were the Gurkhas around me, who were chattering away rapidly in Gurkali. Finally, the sergeant turned to me and apologised for speaking in a foreign language in front of me: then in the most tactful tone of voice he asked me if I had even been on a live patrol before. I answered that I had not. “No. He said. We thought not. Why don’t you unload your weapon, and concentrate on what you have to do, and we will focus on protecting you.” I thought this was a very tactful way of explaining that they needed to know where any shots would be coming from!
For the next 1 ½ hours I was the centre of a quite extraordinary dance. I had three Gurkhas on either side of me with loaded weapons. As we moved down the streets, they dipped, turned and weaved along beside me, continuously talking to each other about what they were seeing and how much of a risk it posed. I saw for the first time professionals doing what we had feebly tried to replicate in training, six pairs of eyes working as one, identifying and neutralising threats from windows, roofs, drains, and alleyways. I asked the Gurkhas about it afterwards, and they explained the dance very simply “That is how we stay alive, when in close contact with an enemy”. At first there was not a soul to be seen. All the shops had their shutters down and the streets were ominously quiet. Then we turned into the main street. A few people appeared, mainly standing on the sidewalks and watching. I felt like the hero in a film like High Noon, where everyone is watching for the final showdown. We worked our way up the main street towards the central monument. Last time the British took Musa Quala, two years before, they had negotiated with the Taliban to convert the town into a demilitarised zone governed by the local people. As soon as they then withdrew, the Taliban moved in, rounded up the major and the local councillors and hanged them all from the central monument. Clearly, there had been a misunderstanding over the negotiations.
In the main street one or two of the shops had opened their shutters and I could see dried vegetables and other staples for sale. When I moved to take a closer look my Gurkhas asked me not to go too close as they could not then protect me properly. What was clear was that most of the population of Musa Quala had fled from the town, but to where we did not know. It was also clear that there was still food in the town. So, starvation was not going to be an issue. We were now in the middle of winter and the river was running over gravel beds in front of the town so there was no shortage of water. All I now needed to know about was the availability of medicines. We finished our patrol and I filed my first report. No people, plenty of food and water. Back came the message. Where are the people and find out about medicines?
More Patrols
So, it was time for a second patrol. I was more confident now and so was the major in charge of us. This time we went out in a larger group with a translator. The translators have to keep their faces covered at all times. If the Taliban discover who they are or the family they come from they will be killed. They rarely wear body armor (mostly out of choice) and do a very dangerous job. On the second patrol, we visited the industrial area and saw where the opium is refined, then we went to the medical clinic which was closed but which we ordered the guard to open. It was clearly a well-run clinic with good supplies of drugs, even if it was closed at this rather tense time. I then asked the translator if there was anywhere that the local people could buy medicines. He rolled his eyes to heaven and answered “Everywhere”. I was puzzled and asked him what he meant. “Come and see” he said. In the next half hour we visited no less than seven pharmacies in a town of only a few thousand people. Most were now open again so I could go in and talk to the owners. All were very polite. Some even spoke English. All had very full supplies of all the basic medicines as well as some quite esoteric ones. There was no shortage of medicines in Musa Quala! In fact I was beginning to discover that Afghans are the most terrible hypochondriacs and have a very sophisticated knowledge of Science-based Western and alternative Eastern medicines. Certainly, any Taliban we captured had their pockets stuffed with packets of antibiotics, vitamin tablets and heaven knows what other kinds of rubbish. That evening I was able to report that there was no medicine shortage. Overflights of the desert had shown no gathering of people out in the desert so it appeared that the people of Musa Quala had cleared out of the town and gone to stay with relatives in farms up and down the valley while hostilities were likely, and would now filter back into town the moment they felt it was safe to do so. This meant there was no refugee problem either.
My report to Bastion was not at all welcome. Palettes of medicines and relief supplies were all loaded ready for transport to Musa Quala accompanied by a press corps. I had to be very firm in my report and insist that medicines must NOT be sent as otherwise all the pharmacists who made a living out of selling medicines to these hypochondriacs would be out of a job, and we would antagonise yet another group. I never did hear what happened to all those pallets. They are probably still sitting in a container somewhere on Camp Bastion.
For then on I took every opportunity I could get to go out on patrol and see another part of town. I visited the Taliban hospital which was a terrible mess and had drip sets and needles scattered everywhere. We went down the back alleys into the opium fields. Everywhere I was looking for signs that things were going wrong. They weren’t. The local people were coping perfectly well with a change in power and would presumably cope equally well when power returned to the Taliban. Inside the FOB things were not going so well.
Fighting in the FOB
A contingent of Afghan soldiers and of police had been brought in. There is no love lost between the Army and the Police especially as the Police are seen to be badly paid, poorly trained, very corrupt, and high on drugs most of the time. That night, just before we got to sleep, a row broke out between some soldiers and police and the next minute shots were being exchanged inside the FOB. The Sergeant major next to me rolled off his camp bed onto the floor pulling on his helmet, and taking cover behind his Bergen. I quickly followed suit. Eventually, the shouting and shooting died down and we were able to climb back into bed and sleep.
Day by day FOB Musa Quala changed into a properly organized base with offices, a kitchen, and latrines, although the sleeping quarters remained very cramped. That was no great disaster as it was now mid-winter and bitterly cold. Each time a Chinook came in we had to stand to at battle stations. There were flights most days as Afghan bigwigs and ISAF generals wanted to visit the newly captured territory.
FOB Edinburgh
The FOB at Musa Quala looked out across the braided river to rich-looking compounds on the far slope of the river valley. That side was very definitely a Taliban country.
The following day I found that I was going there in an armored patrol. Up over the hill in the desert, we had just created yet another new FOB called Edinburgh. I was to go there to check on medical facilities before being flown back to Bastion. The armored convoy was pretty horrible. I was stuffed with my Bergen in the back of a closed Snatch Land-rover, wrapped around the legs of the top-cover machine gunner. Under his feet were the batteries and electrical equipment for blocking the triggers for roadside bombs so there was nowhere to sit and the road was very bumpy. Not surprisingly we were also trying to move quite quickly. The boxes of electronics under me were designed to create three electronic bubbles around each vehicle. One jammed TV remote control. One jammed mobile phone signals and the third jammed signals from the controllers used for radio-controlled toy planes. these were the three types of controllers favored by the Taliban bomb makers. A lot of the time one or more of the three devices was not working. When that happened the vehicle was not supposed to go out on patrol, but if we did that every time one of the bubbles was down we would never ever have gone out. Top cover, the guy whose head was sticking out the roof was supposed to be looking out for wires crossing the road, and signs of digging in the road. I persuaded my top cover to let me come up too as two pairs of eyes looking for wires would be better than one. It was much nicer, but more dangerous, having your head sticking out the roof, than being jammed in the dark inside and being thrown from one end of the load space to the other.
FOB Edinburgh was quite extraordinary. It was a Hesco fort in the middle of a flat sand plain with a backdrop of the snow-covered Hindu Kush mountains miles away to the North. Much of the kit to build it had been dropped by parachute so there was parachute silk everywhere. The medical team was in a small tent with their sleeping quarters in a scrape no more than a foot deep with a tarpaulin pulled over it.
It was just like the scrape I had made at Sandhurst, just a little deeper and wider. It snowed in the night, so they had been buried under a couple of inches of snow, but I have never seen men looking happier. It is clear that this is what they joined the Army to do, and they were loving every minute of it. In the distance, Prince Harry and his other cavalry friends were racing around in high-speed circles in their tanks making a tremendous amount of dust and clearly enjoying themselves enormously. We all knew that Prince Harry was there but it had been agreed that no one would mention it, because once the story broke he would have to be recalled. Of course, his cover was blown eventually but I gather that he felt that his time in Helmand was one of the best times of his life. All around us in the desert, we could see individuals on foot or on small motorbikes peering over sand dunes at us or hiding behind rocks. They were what the Army called ‘dickers’. They reported to the Taliban what we were doing so that the Taliban could coordinate their attacks on us. They were usually simple shepherds who had been given a mobile phone, and sometimes even a moped. I am sure that the Taliban were well aware that we could intercept all these phone calls, but nevertheless, we had a team of Pashtoo speakers who told our commanders what the dickers were doing, and indeed what the Taliban planned. Close to Musa Quala, there was a large radio-telecommunications mast and neither side attacked this. I suspect that both sides wanted comms as badly as the other so neither side cut of their noses to spite their faces.
To Lashkar Gar
From FOB Edinburgh I was flown back down to Bastion in a Chinook and my new life in Afghanistan began in earnest. I had one night to pack and then I moved to Lashkar Gar, a small base in a big town which was in fact for reasons that were not at all clear to me, Brigade Headquarters. It was a tiny base and very vulnerable to attack, but there seemed to be some unwritten agreement between the allied forces and the Taliban that neither would attack the other in Lashkar Gar itself. The Taliban had one of their biggest hospitals there (or at least the NGO hospital that they used) and we had our Brigade Headquarters. It seems hard to believe now but each day there was a shuttle service of helicopters between the various bases. There wasn’t a flight every day and some went to two or three bases in a row but I duly jumped on a Black Hawk bound for Lashkar Gar. The helicopter shot off at ground level rolling from side to side up the waddis. This pilot was clearly going for maximum fun. Within five minutes we landed and I jumped out. I was just staggering out from under the blades with all my kit when I looked up to see a board saying ‘Welcome to Geresk’ I didn’t want to go to Geresk! My heart sunk into my boots. I had flown to the wrong place. I spun around and started racing (staggering) back to the aircraft, which had finished unloading and was taking on its next load of passengers. I got there just as it took off, and was literally hauled on board by my fellow passengers. I felt such a complete idiot. living for 3 months on Camp Bastion had taken away any understanding of where we were in relation to all the other bases which were merely names to us. I disembarked at the next stop which really was Lashkar Gar, in a compound barely big enough to take the helicopter.
The last half mile of the flight had been over the centre of the town flying at top speed and zero height. Anyone complaining about the noise from Heathrow probably needs to talk to the inhabitants of Lashkar Gar who have to put up with a helicopter flying over their rooftop at high speed at any time of the day or night.
I was given a camp bed in a tent in Grenade alley. It is called this because the tents are just inside a thin perimeter wall. The Taliban could lob a grenade over that wall any time that they liked. During my days there I learnt to lay everything out beside my cot in exactly the same place every night and to memorise their positions. I would have seconds to move if we came under attack. This kind of thought concentrates the mind marvellously!
I was in an officer’s tent so there were nets around each bunk and everything was very dark and gloomy.
At Lashkar Gar I was attached to CIMIC, the part of the Army which tries to liaise with the civilian populations. It is a small group in the Army and not a popular posting as it specifically excludes killing people. Here I learnt much about three important issues opium, water and medical care. It had a little garden tended by an Afghan (they loved flowers and gardens and I can understand why.)
Opium
When the Taliban were in charge, opium was not grown in Helmand. They did not approve of it as a drug so any farmer caught growing it was executed. The green belt (the irrigated land on either side of the Helmand River) is fertile alluvial soil and with the addition of irrigation (put in by the Americans in 1950) it can grow two, and sometimes three crops a year. That makes it some of the most productive land in the world. Most of the land is owned by senior government officials, and farmed by tenants. A smaller proportion of the land is owned by independent local land-owners, while some of the borderline land on the edges is farmed by very poor peasants trying to eke a living from marginal land where the irrigation does not reach. While we were there, we had a fascinating talk from an American who was in charge of the ‘worldwide poppy eradication program’ and had just come from the Golden Triangle in the Far East. He pointed out it was uneconomical to grow corn in Helmand because both Canada and Australia were dumping corn their subsidized surplus onto the world market and so it was impossible for a farmer in Helmand to compete at that price. So corn was out, apart from as a staple crop for poor families to live on, not sell. Vegetables grow very well on the green-belt soils and are very lucrative provided that you can get them to the big city markets. At the time, there were roadblocks manned both by the Afghan Army and the Taliban, both of whom would take a tithe of every consignment passing through. By the time the produce reached the market (if it ever did), the profit margin would be gone. So, vegetables were out despite the fact that demand for them in the big towns was untapped. The only crop which could be grown was, and is opium. This is the only option for farmers on the margin because the buyers of the opium will lend money and seed to the farmers in return for a guaranteed first call on their crop. It is also first choice for everyone else because it is the only crop which gives a good return on investment. He went on to explain that growing poppy is very labour intensive, as there are several stages when the poppy plants have to be tended by hand (sowing, weeding, thinning, cutting, and gathering). The itinerant workers who do this kind of labour are the poorest in the country, so opium growing injects money directly in the poorest part of the economy as well as helping the richest. This is really important as otherwise any money injected into the economy is embezzled by the rich and or politicians. The Americans had arrived with tractors, ploughs, and sprayers ready to start the eradication, but were faced with a number of logistical problems. The first was that they morally could not touch the marginal lands because these farmers and their families would starve if their crop was destroyed. They were specifically forbidden from touching crops being grown by government ministers and governors, so were left with less than one third of the land where independent land-owners had their farms. These farmers are canny and make sure that they do not put all their eggs in one basket. Despite the huge profit to be made on opium growing, they make sure that they are also growing corn, and vegetables, so that whatever happens to the market, they will always have something to sell. When he showed us the map of Helmand only one tenth of the land under opium was ‘appropriate’ for spraying and ploughing. He also explained that the tractors rooting up the poppy were going to need protection from both the farmers and the Taliban, and he had been warned by Bastion that civilians injured during the opium eradication would not be eligible for treatment at Bastion Hospital as they were not military personnel. The project was doomed by politics from the start. But then, as he philosophically pointed out, whose problem is heroin anyway – the West or the East. I asked him why we did not simply let them grow opium and then buy all the product and burn it. His argument was that Helmand would then go over 100% to growing poppy and we would not be able to afford the bribe. Given the amount we were spending on fighting there, the idea of buying all the poppy seemed to be cheap at the price, whatever it was. I now gather that opium production in Helmand has tripled. What a waste of beautiful fertile irrigated land. The Americans claim that the Taliban make much of their money from dealing-in and selling opium. I do wonder whether that is true. The Taliban have always hated opium as they so clearly demonstrated when they were in power. The local tribal chiefs who are not necessarily Taliban seem to be the most likely people to be handling this business. It just seems to be too easy to say “Taliban bad, opium bad’, so the Taliban must be making their money out of opium. It makes me quite cross when I find myself accepting facts unquestioningly simply because they fit with my ignorant prejudices. It would be just as easy for the Taliban to say that the Americans were supporting the opium growing. After all they are the end users, and it is the government that they are supporting which owns the bulk of the land growing it.
Water
Just like the Nile in Egypt the whole of economic life in Helmand centers around a narrow ribbon of land on either side of the Helmand river which drains down from the snows of the Hindu Kush and vanishes into the desert in Baluchistan. In the 1950s American Aid built a large dam at Kajaki, which formed a 100 metre deep lake. This dam is used for hydroelectric power for a large part of Southern Afghanistan, and it is also vital for the irrigation canals which create the green belt on either side of the Helmand river as it travels south past Lashkar Gar. The dam and its turbines were never finished and had not been maintained properly so by the time we were there only one of the three turbines was working and then only intermittently. Part of the redevelopment plan for Helmand was that the army should help repair the dam, replace the turbines, and sort out the irrigation system. However, this meant that a convoy of vehicles moving at no more than 4mph would have to work their way up to Kajaki, once the road there had been widened and strengthened to take the lorries carrying the turbines. The Taliban appeared to oppose this plan (God knows why) and the civilian contractors who were to fit the turbines were justifiably anxious about working under gunfire and RPG attacks. Looking back at it now, I cannot see why the Taliban would possibly oppose the repair of the dam and its generators. If the West were foolish enough to do this complex task at no cost to Afghans, why would anyone possibly oppose it. Once again I was left bewildered. I can quite understand that the sight of any Western troops would induce trigger itch in any young Taliban fighter, but if the work being done was to the benefit of the local people then why would they try to prevent it. I suppose that it is another unanswered puzzle of Afghanistan. Perhaps they wanted to prevent ISAF taking the credit for the work, but I sensed that the Afghans really did not understand why we were there anyway and just wanted us out in principle, because we were foreigners. No PR exercise was going to change this simple idea. Perhaps the Taliban fighters were in the main, so diffuse that they really were not under any central command and so each individual did what he or she thought best. I suspect that many of the Taliban fighters were in fact youngsters from over the border and by Afghan standards were as foreign as we were. Be that as it may, the refurbishment of Kajaki dam, so critical to the economy of that area, has even today still not been completed, but there is a film called ‘Kajaki’ which comes closest to reproducing the conditions that I saw in the field.
Dr Eynatullah
CIMIC worked with the local people so my first job was to meet the Medical Officer of Health for Helmand province. The meeting was not easy to set up. Either I had to go in an armoured patrol all the way to Bost Hospital at the other end of town, or he had to come to the ISAF base. If he was seen entering the base by the Taliban he might well be executed by one of their militants so the compromise was that we would meet in a building just outside the walls of the base, where we had troops permanently stationed on guard. I had to attend in a helmet body armour and with my weapon. He was merely in his city clothes, much more comfortable in that heat. To my delight he spoke halting but good English. His face was not like any Afghan I had met. A trim beard covered his lower face while his eyes were Mongolian, but most importantly his face was always fixed in a kind smile. I learnt later that he is a Tajiq from the far northeast corner of Afghanistan on the border with China and the old USSR. He stayed in favour because he was neither Pashtoo (from around Helmand) nor Farsi (from around Kabul) and so was effectively a ‘Polish pope’ He was no threat to either side.
I liked him immediately. He was thoughtful and clearly cared passionately about improving the health of the region. His most endearing trait would be to listen to my latest plan intently with his head cocked on one side, and then with the inscrutable inflexion of the East respond with the simple phrase “Why Not?” That short phrase and the way in which it was expressed could have meant anything from “Over my dead body!” to “I can’t think why we haven’t thought of this before. Let’s get on with it.” It is a phrase that I now use as often as possible when I want to think about how to handle something next.
My problem in CIMIC was not so much with water as with sewage and its contamination of water supplies. Lashkar Gar was a big town with a huge refugee camp on one side, and it was growing fast. It had no infrastructure to speak of and the ISAF planners wanted to rebuild the town as part of their reconstruction programme. Actually there was some infra-structure. In the 1950s the Americans had also built a sewage system in the centre of the town, while they were building the irrigation canals in the green belt. But as is so often the case there was no mechanism to train up locals to look after it, nor to pay of its maintenance, so it fell into disrepair. There were now whole families living in the central tunnels, as apparently, it was very cool in the tunnels, so living space was strongly competed for.
Afghans regard themselves as very clean people but they have some habits which we regard as disgusting. I am sure that we have some too which they regard with equal distain. Some of them date back to their rural origins, and as a very conservative people they are loath to change. An Afghan farmer gets up well before dawn, and the first thing he does is to go out into his fields and defecate and urinate there, returning nutrients to the soil, and admiring his handiwork (crops not faeces). After that he will wash and say his prayers and is ready for whatever the day brings. Afghans who have moved into towns sometimes continue their rural habits so it was common for urban Afghans including the governor of Helmand province to slip outside their front door just before dawn and defaecate against the wall on the side of the street, as the nearest proxy to a field. The problem is that this is exactly where the children play during the day. So the children are playing in faeces. Now, the sun is so hot in Afghanistan that all organic matter dries out in hours so I suspect the issue of cross-infection was not nearly as bad as it appeared to be in our minds, but even so something needed to be done. Dr Eynatullah and I met over this again and again. The planners laying out the new town with its roads, electricity and water supplies needed to know what we planned. Most well-off houses had a well in their back yard so it was clearly not appropriate to build long drops so close to a well, so I offered to arrange to build municipal long drops at the end of each street. Eynatullah vetoed this idea outright. They would be smell and would not be used. More importantly, it was treating Afghans as primitive people. This last issue was always a contentious one in my mind. Lashkar Gar was one of the cities that Alexander the Great had conquered on his way to India. This part of the world had evidence of some of the oldest cities in the world, but just now it was a third-world country with no infrastructure, appalling health indices, and no money. It took all my effort to avoid saying “But you are behaving like primitive people!” Despite all the problems they have suffered the Afghans are intensely proud and the last thing they needed was any obvious things pointing out. They wanted a proper sewage system with flush toilets. Unfortunately, I had just seen the flush toilets in one of the new Afghan army facilities, where the toilet bowls had been clogged up and then broken by stones dropped into them by the soldiers. Afghans like to wipe their bottoms with stones and are simply not prepared to change their favourite method just because we put in porcelain toilets.
The cost of putting in a sewerage system in Lashkar Gar would be astronomical, and there was no taxation system of rates which would support its upkeep. Not that the cost of the war wasn’t astronomical too. It just seemed a waste after what had happened to the American system put in 50 years before. So here I was arguing against a proper sewage system.. My ancestor Timbrel Bulstrode had shown in 1896 that faeces from an open sewage outfall was contaminating oyster beds in Chichester and that this was causing an epidemic of typhoid, and here I was not supporting a proper 21st-century sewage system for a growing town. He would be turning in his grave. Eventually, I went back to the planners and said that it had to be a proper sewage system or nothing. “Right” they said “It’s nothing”. So if any of you visit Lashkar Gar in years to come you may wonder why a big thriving agricultural town has no proper sewage system. Well that is the reason.
At the same time, UNICEF had released an interesting video from Nepal. They had a similar problem of defecation in the streets by older people who had only recently converted from rural to urban living. In the video, they had educated the primary school children about the dangers of a closed loop created by faeces contaminating water supplies. They had then gave each child a whistle, cardboard labels and a black felt marker pen. Each time the children caught an adult defecating anywhere but in the latrines they blew their whistle to attract the whole village’s attention to what was going on and then marked the turd with a stick and a label with the perpetrator’s name on it. Within days the habits of whole villages had changed and the latrines were being used. I suggested using the same strategy in Helmand. Dr Eynatullah came up with his usual inscrutable “Why Not?” but interestingly it was the translators who took me to one side and begged me not to try this. They explained that respect for elders was a very strong tradition in Afghanistan and if the children humiliated the elders with their whistles and labels, the Taliban would without doubt execute the children. So, another good idea bit the dust when confronted by cultural reality.
Health
The other area that I was involved with in CIMIC was health. Dr Eynatullah invited me to visit Bost Hospital. This was a major logistical exercise to organize, as I had to go in a patrol of three Snatch vehicles and would only be able to stay for one hour. After that, we would be leaving too much time for the Taliban to prepare and launch an attack. The preparation for each visit to Bost (and I did many) was enormous. The patrol had to be planned the day before and a new route through the town planned. We were never to take the same route twice. As soon as we arrived at the hospital troops fanned out to the perimeter and took up defensive positions, while I went in to the meeting. The first thing that I noticed about Bost hospital was that it looked and smelled clean. To me that is really the only thing that matters, because it means that the staff want to work in a good hospital, and so anything that we do will be valued and made good use of. The equipment in the hospital was Russian and over thirty years old. The only reason that much of it was working was that it had been so strongly built in the first place that it was indestructible. Nothing was mechanised so there was nothing to break down. The main problems were not ones that you face in a British hospital. First there was no perimeter wall and so people wandered in and out stealing things and generally getting in the way. The second problem was that the electricity was very variable and the voltage fluctuated so that sensitive electrical equipment got blown up. The third problem was a list as long as my arm of equipment that was needed.
On my second meeting with Dr Eynatullah we had a very powerful and almost enthusiastic ‘Why not?” response. We were in trouble again at Bastion because the wards were full of Afghan nationals – soldiers, police and children who had come in on the MERT and now could not be discharged because they still needed ongoing care but not intensive care. The nursing staff were up in arms about discharging Afghans, especially children to no care at all, firstly because they would die and secondly because all the work that we had put in would be wasted.
My idea was to upgrade Bost Hospital until its facilities were ‘equivalent’ to Bastion so that patients could be transferred from Bastion to Bost with no compromise to their care. It would then be the responsibility of the Afghans to decide what to do next.
We were building a school of Nursing at Bost and I wanted nurses to come up to Bastion to see how we did nursing “Why not?” said Eynatullah. Well I’ll tell you why not. Female nurses do all the work in Afgahnistan, male nurses work as doctors. Female nurses are not allowed to travel without chaperones and would certainly not be allowed onto an Infidel base without all sorts of breaches of security that our commanders could not possibly allow. The male nurses were happy to come but they wanted to be paid to be trained as they would be missing days when they would otherwise be earning, and I felt that they were not the people we needed to get to if we wanted to improve nursing care. We got permission quickly to build a perimeter wall, to put in a generator, and rewire the hospital with a surge protector and automatic change over to a generator when the mains power failed. This is what the Royal Engineers are trained to do and they got on with things with a will. The next thing I needed was medical equipment, Lab blood machines, anaesthetic machines, operating tables (the list was enormous). I got my list together and went to see the Brigadier who was in the middle of a very ‘kinetic’ phase (lots of fighting). He was in a hurry and I explained my plan for clearing Bastion. This clearly interested him. If the hospital is more than half full, all new military action has to be stopped in case there are not enough beds for our own casualties. Clearly there had trouble over this and nothing irritates soldiers more than having to stop fighting! He cut to the chase and asked me how much money I needed to re-equip the hospital. I took a stab in the dark and suggested that over time it might be as much as …… and here I took a breath … one million dollars. I didn’t need to watch his face for a response. He simply barked out “You’ve got it” I stood there with my chin hanging open, only to be told “Get out of here. I have things to do. One million dollars is nothing. It is what I spend in a good day on munitions”. As I backed out the door he warned me that I had two weeks to spend the money, and then it would vanish. Clearly there was an underspent budget. I rang Vicky that evening and explained my ‘problem’. This is where she comes into her own. “I can handle this” she said “ What do you need?” Within hours suppliers had been found, delivery times checked and the show was on the road. We had 14 days to get one million dollars of equipment to the gate of Bicester North base, where all kit that is to be flown to Afghanistan is assembled. After I left Medecine sans Frontier took over Bost hospital and made a big fuss about the money I had wasted getting the ‘wrong’ equipment. I could just imagine some arrogant Frenchman delivering these scathing comments. What he either did not know or did not care was that i had only 14 days to get all the kit. I tried wherever possible to get the same equipment as we had at camp Bastion so that we could train the Bost Hospital staff at Bastion, and so that if there was a break down the spares would be the same. Anyhow, Vicky did it with a day to spare. I do not know how, but certainly, there were some companies who really pulled out the stops to deliver within this extraordinarily tight dead-line. For me the frustration was that I was now finishing my tour and was anxious to see the equipment up and running. It was not to be. I just had to hand over like everyone else and hope that the next person had the same vision as me. I had started to learn Pashtoo. I was building up a good working relationship with the local Medical Officer of Health and now I had to go. The Americans did a tour of two years, and I can now see why. The only problem is that it two years away and destroys your home life.
While I was in Lashkar Gar there was a diplomatic incident. Mohamed Karzi had been on the phone to our Brigadier accusing a patrol of shooting one of his policemen. It was late evening when I was called to the ops room where the captain on duty had been ordered to find out what had happened. The captain of the patrol which was supposed to have fired the shot was in the ops room. He emphatically denied that any shots had been fired and had indeed checked all his patrol’s weapons and found that there were no rounds missing. However, he admitted that they had fired flares. These are fired when it looks as if a bicycle or bullock cart will be blocking the road ahead, as the patrol must avoid at all costs being stopped in case this is an ambush. I spoke to Dr Eynatullah who checked and assured me that the casualty was not in Bost Hospital. There was another hospital in town run by an Italian NGO. It took wounded from either side but as Bastion dealt with government troops the bulk of its cases were Taliban. We had been told on no account to go near the hospital to avoid causing political problems but it was clear that this injured policeman was in the Emergencia hospital. The captain asked if I would volunteer to go down with a patrol to see the patient and report on the situation. I agreed without having any idea of what I was letting myself in for. Very quickly a six-vehicle patrol was put together. We were going to cut through the center of town at high speed and then cordon off the Emergency Hospital so that I would be safe from the Taliban attack while I went in to check on the patient. We drove fast through the town. In high-risk situations, you drive faster than normal to reduce the time that you might be a target. If anything appeared ahead of us we fired flares to warn them to clear the road at once. Very quickly we were outside the Emergencia hospital and troops were spilling out to cordon off the street and check the windows of the buildings overlooking the hospital entrance. When we knocked on the door the night watchman refused to open, saying that the hospital was closed. The captain explained through the translator that if he didn’t open the door we would blow it in. He bowed to superior force and opened the door. He now insisted that only I the doctor was to be allowed in, and that I must leave my weapon behind as they allowed no weapons in the hospital grounds. The captain in charge of the patrol was not at all happy with this, but I could see the logic and suggested that I should go on in. However, I also asked that if I was not back in 15 minutes that they should come in and get me. I stripped off my weapon and webbing and set off into the hospital following the night watchman down dark solitary corridors. I was busy trying to remember each turn in case I had to return against their wishes. Finally, I was ushered into a large ward where there were around forty beds. Each contained a heavily bearded man. They all looked like Taliban to me and were pretty shocked and unhappy to see me there. My patient was in one of the far beds. He had a laceration to his eye.
It was quite clear that this was not a bullet wound nor had it been made by a flare as there was no soot or burn around the wound. The only thing I could think was that he had been on the back of a pick-up truck and had ducked as a flare flew over the truck and had struck his eye on one of the stanchions on the back of the lorry. I took some photographs of the wound and then made my way slowly back to the gate. I did not want to hurry because I did not want to appear frightened. When I got to the gate I was met by a very relieved Captain who had only been going to give me a couple more minutes before the patrol went in to find me. We were able to report that this injury was nothing to do with us, and I was just relieved that I had got out of the lion’s den without injury. I still think I deserved a medal or at least a ‘mention in dispatches’ for this.
My next journey was to Kandahar and then to Kabul. I wanted to try to link up with public health work being done all over the country. In Kabul we were put up in the British Embassy. Security was very, very tight as the restaurant where the diplomats went for dinner had just been blown up by a suicide bomber. I wanted to visit several hospitals and to see the headquarters of the BBC world Service (Pashtoo) where I had heard of a very interesting experiment going on. Once again I had to apply to go on patrol but this time we went in two unmarked Toyota Landcruisers. They would reconnoitre the route and destination the day before, and then I was taken lying on the floor in the rear of the vehicle so that I could not be seen in Uniform. This was a pity because I got to see less of Kabul than I would have liked. In each hospital that I visited the manager’s office was packed with expensive but broken medical equipment. One of the jobs that I had set myself was to find somewhere that repaired medical equipment but before I could even ask the question they were asking me the same thing. Donating old medical equipment to the 3rd world feels much better than scrapping it, but what would be much more useful would be to donate some technicians and spare parts to mend old equipment that has broken down.
The visit to BBC Pashtoo was a revelation. They were producing a radio serial based on the British ‘Archers’ programme. The Archers was apparently set up in 1950 after the second world war during rationing to educate farmers at the same time as providing general entertainment. It has always had a farming advisor who suggests plots which will educate farmers in improved practices. The Pashtoo programme was called ‘New homes, new lives’ and went out twice weekly, a story of a typical farming family in Helmand province. Just like the Archers it had embedded in it useful information about farming but in this case also included advice of child rearing and health. It was estimated that it was listened to by more than 80% of the women in Helmand as it was one of the few contacts that they had with the outside world. When one of the characters died a village in Helmand held a funeral ceremony for that character. It seemed to me a quite brilliant way of getting round the refusal of Helmand men to allow their women-folk to have any chance of being educated or keeping in touch with what is happening outside their compound.
Women in Helmand
It is said that women are treated in Helmand very badly indeed. It is true. This is not just Western propaganda. I once asked Dr Eynatullah whether they saw many immolations in Helmand as Afghanistan has a reputation for young wives setting fire to themselves when married to a cruel old husband. He answered briefly but clearly enough. “There is no need” he said “Opium is freely available. They kill themselves with that!”
The Taliban were determined not to allow girls to be educated and most were removed from school anyhow at the age of 12 to be married off. This may seem barbaric to us but we should not forget that Samuel Pepys married his wife when she was only 14, and as for human rights, it was not so long ago that only some women in Britain were first allowed to vote (1918).
I asked many Afghans about their treatment of women. Some denied that there was a problem, others simply would not talk about it. Only one man made an effort to explain what he thought was going on. He explained that marriage in the East is very different from the West. In the West we strive to equalise and share everything so both husbands and wives help with child care and both may be bread winners. In many Muslin countries including Afghanistan there is division of labour rather that sharing in a marriage. The woman’s job is to have babies and to rear them. The man’s role is to earn money for the family to live on, and to protect his wife and children from danger. Helmand is, we agreed, a very dangerous place. So, if the head of the house decides that the only way that he can keep his wives and children safe is to lock them in the compound and forbid them to go out, then that is indeed what must happen. The argument is logical as far as it goes but I feel sure that the reasons for this dynamic/behaviour are more complex than that, and involve men wanting/needing to dominate and even, to a degree which I can’t quantify, women choosing/allowing themselves to be submissive.
Mosquito nets
Aid programs from NGOs were at a virtual stand-still in Helmand. it was felt to be too dangerous and I think they were right. While I was in Kabul I met with the head of the International Committee of the Red Cross (ICRC). In many ways, they are the leaders of the international aid community. If they feel that they cannot work safely somewhere then most NGOs take their lead from them. The ICRC jet had been fired on last time it had tried to land at Lashkar Gar and had two holes in its fuselage, so they were not keen to come again. Despite that, none of the aid organizations would have anything to do with the military, partly because they are all very left-wing, and partly because they don’t want their staff associated with and therefore confused with military personnel. I can completely understand that but still it was frustrating when NGOs like Oxfam, for whom I had worked in the past, would now not even answer a letter from me! ICRC was much more pragmatic,and we had a useful discussion about what the priorities should be. The commonest cause of mortality and certainly morbidity (apart from war induced trauma) is probably malaria. Mosquito nets have proved to be a triumph in the battle against this debilitating disease which also kills young children. Anti-malarial tablets are expensive and have side effects. The newer insecticide-coated nets are cheap to manufacture and work really well. An insect has only to touch the net to be killed by the insecticide, so it does not matter if the net has a hole in it (provided it is not too large), or is not properly tucked in. I wanted mosquito nets for Helmand as it seemed to offer the single thing that would make a really big difference to health care indices. When I suggested this to Dr Eynatullah I got the inscrutable ‘Why not?” combined with a warning that there must be no suggestion on the nets that they had come from ISAF. In Kandahar I found a Dutch charity which had 10,000 spare nets in Kandahar but no way of getting them into Helmand province. We agreed to team up. Transport in the military at each base is controlled by one man titled Bow-wow. (I have no idea what the acronym stands for). I went in search of Bow-wow at Brigade headquarters and eventually found a middle-aged man looking utterly frazzled with three phones on his desk, all ringing at once. In a gap between phone calls I explained my problem. He listened for a minute and then went ballistic. “I am trying to fight a war here” he pointed out as another phone started to ring, and he launched into a shouting match over where some ammunition had got to. I retreated and went to another desk where I was talking about my flight back to Bastion and then Lashkar Gar. Suddenly Bow-wow shouted across “Hey Chris! Come here quick”. Well, he had remembered my name. That was something! He explained that one of the Hercules aircraft which was in for repair was airworthy again one day earlier than expected. If I wanted it was mine tomorrow. Clearly, he was one of those people who thrive in the middle of chaos and are forever looking for quick solutions. Ten thousand mosquito nets was part of a Hercules load. The rest was filled in minutes and my nets were on their way to Bastion. From there they were slung in pallets under Chinooks, marked as ‘Urgent medical supplies’, and 10,000 nets arrived in Lashkar Gar. I was so proud. It was probably the only useful thing that I did in my time in the army.
The nets turned out to be incredibly popular first because they were very large and so could accommodate a whole family and second because they also served to keep the flies off in the day and the sand flies off in the evening. The sand fly (Phlebotomus) is a strange creature. They are vegetarian until the female breeds. Then she needs one feed of mammalian blood to be able to produce eggs. She cannot fly more than one metre above the ground so attacks by the fly can be avoided by sleeping on the roof of your house. This is what the men do, but the women and children are obliged to sleep on the ground. When the sandfly is infected with Leishmaniasis, its feeding proboscis becomes blocked. This sends it into a feeding frenzy where it attacks as many humans as it can. Presumably, the Leishmaniasis parasite has evolved this effect on its host to make cross-infection more likely. The nice thing about the insecticide-impregnated nets is that although their mesh is not small enough to prevent the passage of the Phlebotomus fly, they always land on the net before passing through the mesh and are killed by the insecticide.
Polio
I wanted to get involved with the polio eradication programme too because Afghanistan was running a big programme to immunise all children and was close to eradicating polio from once and for all. The programme was huge with thousands of volunteers going out on a given day and trying to saturate whole areas. For a country in the clutches of a war it was a pretty impressive programme. Here the “Why not?” became a “Definitely not!” Dr Eynatullah explained that although our help with helicopters especially would be immensely useful in getting vaccine to remote places, the possibility that the programme would become associated with the Western military would sign its death-knell. Again, the situation in the third world is always a little more complicated than you think.
Now that immunisation programmes have become tainted with the search for Osama bin Laden (the Americans used the cover of an immunisation programme to discover where he lived) we may see a spread of polio once again through the badlands of Pakistan and through into Afghanistan. I wonder if the assassination of that one man (which was really only revenge on a man who had passed his sell by date) will be worth the cost in terms of children’s lives spoiled and destroyed by polio.
Sangin
Sangin is a town at the top of the Green belt, the fertile strip that runs down through the desert of Helmand either side of the river. It is one of the strong-holds of the Taliban but also had a British base there, which came under heavy fire for a lot of the time. I wanted to go there to talk about building a new hospital and a new school. It was a vain hope as the ‘atmospherics’, a term the army used for the mood of the people, were not good when I was there. I landed on a Chinook carrying ten thousand dollars in my pocket rolled into a wad held by an elastic band. The colonel had handed it to me just before we took off saying that it needed to go directly to the Major in charge for ‘incidental expenses’(? bribes). We crouched and clung onto our Bergen rucksack as the Chinook lifted away in a violent dust storm of rotor wash, and then the air cleared. In front of me was something from the set of Mad Max. A huge house with large balconies had every gap lined with sandbags and two heavy machine gun posts in Sangars on the roof.
A Hesco wall surrounded it and when I got inside I found that all the soldiers were wandering around shirtless. Discipline in the very front-line bases was pretty easy. There were enough things to worry about without bull-shit. I dragged my Bergen in sat down for a brew of tea and then checked my pocket before going to hand my ‘petty cash’ over to the Major. It was gone. It must have fallen out of my pocket. I knew I had it as I came into the base as I had felt it in my pocket, so I had lost it in the mess having tea. I searched all over the floor – nothing. One of the sergeants asked me the problems and very embarrassed I explained. He looked at me for a moment and then said. “Leave this with me, I will be back in five minutes.’ Sure enough five minutes later he was back with the wad of money. I started to ask him how… and he just winked “You don’t need to know” he said. “Leave it at that”. So, I did. I never did discover what had happened but I suspect that they had a pick-pocket in their midst, and this was all being sorted out on an informal basis, before any searches were started. With great relief I handed the money over to the major and started unpacking ready for my first patrol. There was a very tense atmosphere at the base. Two soldiers had been killed recently by incoming fire, and there were bullet holes in the walls and soot stained collapsed walls where RPGs had exploded. Everyone was on alert all the time, and I felt very uncomfortable indeed. It is one thing being watchful on patrol. It is another thing when you should be in the security of your base. Before we went on patrol they launched a small (2 metre wing span) remote controlled aircraft to check for any Taliban activity. I had never seen these before and was very impressed. They had an electric motor and only a short range but allowed a check to be made that there was nothing waiting in ambush just outside the gate. This was of course only the start of what was to come in terms of drones, but I was hugely impressed with how much information these simple machines gave them.
While I was there the Army had decided to attack a Taliban strong-hold tucked away up a side-valley. There were no roads so in good Kipling style they decided to use mules to carry the mortars. The first thing to do was to test whether the mules were gun proof and would not run away when firing started. So, the mules were being led up and down inside the perimeter wall while guns were fired, and flares set off. The mules took not the slightest notice. Their life is a grim one and they clearly have no energy for histrionics. Perhaps there was a lesson in this for all of us.
But it was also telling that the most modern military machine in the world was reverting to mules for transport. Afghanistan was winning again. As I took off from Sangin to return to Lashkar Gar the automatic attack alarms on the Chinook were activated. The next moment we were the centre of a stream of pyrotechnics flying out in every direction aimed at confusing a heat seeking missile and temporarily blinding anyone trying to fire an RPG.
To celebrate that excitement the gunners quite suddenly decided to fire off a whole lot of rounds as soon as we were out over the desert. Of course they didn’t warn us so we were shaken out of our complacent dozing for a second time, with tracer arcing out over the dunes.
Grim Reaper
But not all of the military technology was old-fashioned. In the cot next to me in Lashkar Gar there was a young officer who I never met. He always seemed to be on duty during the few hours when I was in the tent sleeping back at base. However we did finally meet, and went through the agonising embarrassing rigmarole that the British undertake when introducing themselves to each. The first decision to be made is whether to introduce yourself at all, or simply pretend that the other person does not exist. Having decided that sharing a tent did require us to introduce ourselves the next thing is not to say too little and be marked as ‘stand-offish’ nor too much and be labelled the ‘club bore’. Both of use were doing, I suppose, semi-secret work and of course neither of us really knew what would be interesting to the other. This slow dance was quite suddenly transformed by a soldier coming in to tell my fellow officer that he was wanted urgently in ‘the office’. Acting on the spur of the moment, I suppose, he asked me if I would like to ‘see’ what he did. I followed him round to a corner of the camp that was surrounded in barbed wire and ‘No entry’ signs. I had run past it many times on my running circuit of the camp but never really wondered what was there. We entered a shipping container. All hard-top offices were shipping containers. The inside had a bench down one side with TV monitors on the wall. It was the forward command post for the drones. The screens showed us what the drones were seeing, and the one of particular interest was up over the mountainous border of Waziristan and Pakistan.
If I was Tom Clancy I would give you all the technical specs, which were now being fed to me, but this is all history now. I am sure that the drones are infinitely more sophisticated than these ones which were I believe Israeli built, powered by Wankle engines and could stay in the air for upwards of 18 hours. They flew high enough to be inaudible from the ground and had infra-red cameras so that they could work at night as well as during the day. Apparently they were piloted at take-off and landing by geeks who used to fly radio-controlled planes and who had now been recruited for this specialist role. Once air-borne they were controlled remotely from Stuttgart or somewhere in the Southern United states. This forward station run by ISAF controlled the cameras and the weapons.
The ‘rush’ was because the cameras had spotted two humans crossing into Afghanistan. I was told that they were Taliban. I asked how they knew and I was told that if they had sheep or goats with them they might just be innocent shepherds but the fact that they were crossing without animals meant that they had to be Taliban. Just then my colleague moved the cross-hairs onto the two figures and pressed a button. Seconds later the infra-red cameras flared with the glow of the rocket exploding. The two people, whoever they were, did not exist any more, and we had just fired off 60,000 pounds worth of rocket. To say that I was shocked would be a mild understatement. I was completely speechless. My mind was a blur, coming at the problems in lots of different ways. Did we have a right to shoot people whom we only suspected of being Taliban.
Should they have had a chance to surrender, to be tried, found guilty and punished accordingly? What would their parents think. No-one would have witnessed the attack, so they would have simply vanished on their way into Afghanistan. What if they were the bread-winners of a family? My officer friend was jubilant. A clean strike in open country. No collateral damage. I was to see later the shambles one of these rockets makes when it hits a nomads tent. Not everyone died at once. Some died very slowly of a mixture of burns and wounds, and they were the children, otherwise referred to as collateral damage.
I had been getting this overwhelming feeling that my time in Afghanistan was not dissimilar to a bit-part actor in the ‘Star Wars’ except that instead of being on the side of he goodies, I was part of the dark force. When I went to meet Dr. Eynatullah I was dressed in full armour with a helmet and anti-blast glasses, hardly a uniform designed to engender trust, and friendliness. Now I was seeing our latest weapon seeking out suspicious people, possibly going about their everyday business, watching them from so high in the sky that they don’t even know it, and then obliterating them in a flash, all in the name of a war against a force which probably has no real identity, but is just made up of disparate groups who hate the hegemony of the West and seek justification in Islam.
I had been attached to CIMIC to try to help the transition from ‘kinetics’ (the army word for shooting) through to reconstruction. I talked with Afghans each day who were courteous, intelligent, and constructive, but some of whom were probably helping those who were fighting us at night. As one of them said “We are the most hospitable people in the world, provided that you were invited. You were not!” That said it all.
The Army paid lip-service to reconstruction, but each time I mapped out a plan there would inevitably be the question “But will there be any shooting?” I would answer that there was no reason why there should be, only to see the faces around me fall. I had to remind myself that these guys were trained killers, no more, no less. Civil reconstruction was only of interest to them if there was a realistic chance of a shoot-up.
Well the tour is coming to an end. Seems like only yesterday that I arrived here totally bewildered by the whole place and warily watching the tired old ‘end of tourers’ with their faded and torn uniforms going de-mob happy, packing their sacks, and vanishing.
Six months later I notice that compared with the new arrivals, my uniform is all faded, and tears are appearing in the trouser pockets. The new arrivals look so bright-eyed and bushy tailed, and now I see them watching us out of the corner of their eyes, wondering what it must feel like to have done so long out here. It is actually rather irritating having new faces intruding on our cosy camp. There are new people in the tent but I now have a corner position for my bed (top dog position) and I can see them eying me like jackals, wondering when I am leaving, and calculating whether they can get my bed, the bedside lamp, and anything else I might leave behind. All these changes mean a break in routine. Break in routine means that things go wrong. I have in my sponge bag a plug for the sink (there are no plugs in the sinks here – I don’t know why). Yesterday morning I must have left it on the side of the basin. This morning it is gone. Damn! Well I hope someone else looks after it as carefully as I have guarded it all these weeks, and that they will not feel quite as pissed off as I do having dropped that guard for just one moment. And, I suppose, that is what much of life is about out here. It is about very precise routines and never dropping your guard. On patrol a slight inattention can have lethal repercussions, but even in the camp our lives are so tightly compressed that anything that gets lost or broken has a quite disproportionate effect on quality of life.
So, now that the tour is coming to an end we are all getting de-mob happy. A bit like swallows chittering on the telephone wires before leaving on migration. Each day a new statistic goes up on what proportion of us have been ‘ripped’ (RIP = replacement in place). Today it was 25%. By this time next week it will be over 50%. The helicopters are churning in and out disgorging new troops, re-loading, and flitting away over the roof tops.
All the uniforms are starting to look brighter and fresher but the badges are changing too. We are all supposed to look the same, but on each uniform there are at least 6 or 8 subtle distinguishing marks which tell you something about who this person is, what they do, and what they stand for. Belt buckles are slightly different in some regiments and some people wear a ‘stable’ belt stripped in the colours of the trade specialty they follow. Then there is the rank slide set firmly in the middle of the chest, which tells you with pips, stripes and crown the rank of the person. Shoulder flashes are also colour coded by trade, but it is here that the beloved dagger of the commandos, is worn along with many other less prestigious insignia. And we have not even started with headwear yet. Then there is the state of your uniform. If you have been out in the front-line at the FOBs (Forward operating bases) you are not expected to wash, get your haircut or be able to look after your uniform. In fact most people are scrupulous about hygiene carefully washing in a mess tin each morning. But when you come back to Brigade Headquarters you are allowed, indeed expected, to have long unbrushed hair, half a beard and a quite revoltingly dirty uniform hanging off you metaphorically in tatters. The FOB mobsters also cultivate a sunken haunted look around the eyes, brought on in part, I think, by the excruciating pain of constipation caused by eating compo rations. After a few days of stalking the camp, letting everyone know that they have been ‘out there’, they are tapped on the shoulder by the sergeant major and then they smarten up and rejoin civilised life. But even amongst the rest of us, there are those who have smartly ironed uniforms and those who appear to have slept in them, and probably have!
The regulars do seem to do more ironing than the TA and actually appear to enjoy it. They can put perfect creases into a uniform (no tram lines) while watching the football and carrying on a conversation about their ‘effing’ commanding ‘effing’ officer, all at the same time. It is not true multi-tasking because I don’t think their brains are occupied with any of the tasks. It is rather like watching a praying mantis copulating, strangely mesmerising, but utterly mindless. Anyhow it keeps them happy.
My final patrol
My final patrol in Afghanistan was up to a hospital in a town called Gereshk. The army were itching to get up there and I wanted to inspect the hospital but we were going into very hostile territory indeed. The patrol was carefully planned. We were to leave well before dawn so that we could arrive at the hospital early, well before the dickers would be up and about. We were to spend only twenty minutes at the hospital and then we were to move on with Afghan troops and rendezvous at an Afghan Army base situated on the main road which crosses Helmand province and which was then the only tarmac road.
As we quietly mustered in the dark head torches set to red (to avoid drawing attention to ourselves) the young captain leading the patrol came up and introduced himself. He explained that he was new, part of the change-over RIP (replacement in position) and asked if I had been on patrol before. I explained that I was coming to the end of a seven month tour and that “Yes” I had done a lot of patrols. His reply surprised me. “Fine then” he said “You are top cover”.
Top cover is the soldier who mans the machine gun on the roof of the Snatch Landrover. He is the eyes of the patrol and its first defence. He is also the first to get shot and if the vehicles runs over a mine usually loses both legs, if they are not just broken to pieces by the upwards force of the explosion. I tapped my shoulder flash (a red cross) and pointed out that as a doctor I was a non-combatant. He thought about this for a moment and then in a soft Irish accent suggested that I might like to remove my arm-band as it made a good bright target for the enemy. A quick revision lesson in how to use the weapon and we were off, our triple bubble of electronic jamming gear already playing up. I have to admit I liked being top-cover. I could see all around and felt a little more in control of my life than when I am crouched down in the back of a Snatch in the dark wondering if, when and where an attack might come.
We came into Gereshk in the half-light. People were quietly moving about in the streets wrapped tightly in their shawls, opening shop fronts, buying tea from the vendors, while the bakers were taking out the first flats of bread. The hospital was completely still. A cordon was quickly formed around the hospital while we went straight on in. there were patients but no nursing staff. patients are looked after by their relatives or not at all. The equipment looked terrible but most important, the hospital was dirty. There was litter in the corridors, and rubbish everywhere. There is no point in investing in a hospital if those in charge do not have the motivation or control to keep it clean. My 20 minutes was up in no time and we were hustled to the vehicles by the very anxious captain. He felt that the atmospherics were bad and that there was a possibility that an attack was already being organised. Within minutes we were on our way, along another road through the township to the main road and our rendezvous with the Afghan Army.
When we got to the main road it was decided to close it while we crossed. I am not at all sure why we chose to do this but in seconds soldiers were loping down the road in both directions getting ready to stop vehicles and check them. But something was very, very wrong. The vehicles didn’t seem to see the soldiers flagging them down and so did not slow at first. The response of the soldiers was to drop to one knee and take aim. This seemed to be a signal they could not avoid so one by one they stopped at the last minute, were checked, and allowed to pass on. However the whole business was nerve-racking as it was clear that the soldiers were within seconds of opening fire. I was on point duty to one side but was watching each event with horror, as it was me who was going to have to deal with the injuries if our soldiers did open fire. Then shouting and shooting started but it was behind me not in front. I was in the prone firing position but facing the wrong way and without any cover of any sort. I scrambled for new cover and tried to work out what had happened. Apparently two young boys dressed in black jellabas and head bands (the unofficial uniform of the Taliban) had ridden out of a side street into the middle of the road-block. They had not stopped on the three warnings so two soldiers had opened fire but missed. The boys had thrown themselves off the motorcycle and were lying face down in the road keeping very still. It was the work of a moment to check them and hear their story. They had no weapons or suicide belts but were simply going to work, when they rode straight into the road block. Thank heavens the shots, taken in the haste of the moment, had missed. If they had hit I suppose that this would be the scenario where a cover-up would have to be arranged.
Cyprus
At the end of my tour I wanted to stay on. I was learning Pashtoo. I had huge respect for some of the Afghans and great sympathy for the dilemma in which they found themselves, but most importantly I wanted to oversee the upgrading of Bost Hospital so that Afghan citizens could be safely transferred there from Bastion. It was not to be. No-one under any circumstances stays on. When the regiment leaves everyone must leave too. I can see the logic of this but the penalty in loss of continuity of policy must be disastrous. Each new regiment arrives determined to do things differently and better than the regiment before and are doomed to learn the same mistakes all over again. By the time I moved back to Bastion ready to be flown out, the camp was full of new faces. The hard-top hospital had been finished. Doors closed automatically with a soft hiss, and you could cut the atmosphere with a knife. No-one was talking to anyone else and all sorts of demarcation disputes had broken out. I was one of the FOB lot. My uniform was in tatters, my hair was long. I had been to places that these people could only dream of. The battle of who was to fly in the MERT was going full blast. I had flown Chinooks, Black Hawks and Sea Kings all over Afghanistan. As the Colonel said to me as I first set-off to Musa Qalah. “You must be one of the luckiest majors in the army to see what you are going to see.”
When you fly back to the UK, all troops are obliged to go through a thing called decompression. The aircraft out of Kandahar first lands in Cyprus, and you are taken to a base which is linked to a beach. During that day you can swim, or lie on the beach, and then in the evening they lay on a cabaret and hand out alcohol. We had been dry for 7 months. The cabaret was heckled and shouted down until the comedian gave up. I felt sorry for the guy (but I assume that he was paid well). He was perfectly good but the soldiers were in the mood for trouble. I was tapped on the shoulder by one of the Majors who suggested that it might be better if I retired to the Officers’ mess now. I had no idea why, but when I came out a couple of hours later to go to bed, I understood why. There were soldiers strewn everywhere. Some were simply drunk and asleep. Others had vomited over themselves and then gone to sleep, while a small groups were still fighting (rather ineffectually as they were so drunk) but Military Police were standing guard to make sure that no-one got a good kicking or any other horrible injury. In the morning we were all mustered to the coach. Some of the soldiers could hardly stand and had to be helped by their colleagues. Meanwhile a team of Cypriot women were filing through with buckets and mops, cleaning up the blood and vomit before the next group of soldiers arrived later in the morning. For me it was a sad end to my tour. I had seen soldiers who were little better than criminals (which is what many of their relations were) behaving in an exemplary way, looking after me and each other with loyalty which I found quite humbling. Now I saw them reduced to animals by alcohol. I can quite see why the US forces forbid alcohol. We should do the same both on duty and in public off duty. Our forces do themselves a great disservice with their drunken behaviour.
David Richards
My return to the UK was terribly difficult for me and I am sure for Vicky. I was now a soldier. I had worked in some dangerous places where I had to anticipate and do things right every time. Now I was bringing that home with me. The first time Vicky drove me out of Stanton St. John there was a car coming the other way fast. I found myself struggling to find my weapon and to hit the floor convinced that the on-coming car was a suicide bomber. Nights were terrifying. Clearly I had to work out some scenarios in my mind, and my dreams did this time and time again, waking me screaming. At work I really could not take the issues seriously. They all seemed so trivial compared with the stuff that I had been doing for seven months, and it was all that I could do not to point that out. At home Vicky had run everything without me for seven months. She had rebuilt the house and sacked the builders. She could sort out and repair burst pipes and broken down cars. I felt completely redundant but she was very good about it, making me feel valued and welcomed back. Each evening I had to go through a ludicrous pantomime of laying out all my things by my bed (phone, keys, cards etc) just as I had in Afghanistan. I was also pretty miffed to be smartly retired out of the TA having reached 58 the compulsory retirement age. I returned my kit with very mixed feeling and was promptly billed for a missing Bayonet which I know I was never issued – bastards!
Some six months after my return, I got an email from a lady who said that she was a Army wife, and was running a charity to get medical textbooks to Afghan medical students. Could I help?
I was at a bit of a low at the time so replied briskly that indeed I could, but it was not what Afghanistan needed. My curt reply got an equally swift and curt response “well what do they need?” To which I replied “Do you really want to know?” She did. So I wrote. I wrote a long email laying out my worries and frustrations about our mission in Afghanistan. It started with “If I was an eighteen year old Afghan, I would have a Kalashnikov in my hands and I would be shooting British troops and this is why…..” I read it once and pressed the ‘Send’ button with a wonderful feeling of getting something very heavy off my chest. There was no sharp reply to this email, but a couple of hours later, Caroline wrote back that she had taken the liberty of forwarding my email to her husband who was somewhere in the house (alarm bells started to ring!). She went on to say that I might recognise from the surname Richards that he was Chief of Staff of the Army and would probably want to see and talk to me about what I had written. i pointed out that I was no longer in the Army, but she replied that he was really interested in what I was saying.
Sure enough within days both Vicky and I were invited to a conference on Afghanistan being held at Ditchley Park. We sat through an extraordinary day with speeches from the US Ambassador and other worthies, none of which bore any relation to what I had seen. At the end of the day David Richards came and introduced himself, a charming unassuming man, but clearly with a sharp mind. We briefly went over what I thought of the meeting and he nodded in agreement.
Since then we have been in contact sporadically. I wrote to him about drones and pointed out that there would be a war crimes tribunal once the Afghan war is over. America has not signed the Hague convention and so are immune from prosecution, but we have, and I suggested to him that killing people by drone on incomplete evidence in a friendly country without giving them a chance to surrender or be tried in a court would probably constitute a war crime, especially in those cases where they were subsequently found to be innocent. He promised to think carefully about that and said that it was first on the agenda at his meeting with General Petraeus (Head of US military) that evening.
When Pakistan flooded I suggested that he should stop hostilities and move all his helicopters over the border to provide relief aid to the people trapped by the flood. I felt that this would do much more for hearts and minds than any further military action in Afghanistan. He didn’t agree with that.
Now looking back, it all seems so unimportant. It was another war we should never have got into. History will judge, but it already looks as if we have done far more harm than good. However one meeting was interesting. David Richards wanted to meet Jon Snow, the anchorman for Channel 4 news, off the record. We had met Jon and his new wife at a dinner recently, so we invited everyone round to ours for a meal under “Chatham House Rules” So they all came complete with heavy security the like of which Stanton St John hasn’t seen before or since. Vicky was highly amused by the dinner because as she said afterward “For the first time at a dinner, you didn’t say a word!”. Both were obviously keen to lay out their analysis of what was happening but the most interesting moment came late in the dinner when Jon asked David about cyber warfare. David Richards was obviously uncomfortable about discussing it, until his wife Caroline who is delightfully outspoken burst into the conversation and said “Oh for Goodness sake David, don’t be so pompous – tell him!” David went on to explain that tanks, guns, submarines and rockets were all completely redundant. The new threat was cyber warfare which could bring our power generation, water and sewage services to a stand-still, and that defence against this mode of attack was where every pound of defence expenditure should be going.
At least I have seen a lot of Southern Afghanistan from aircraft, helicopter, land-rover and even on foot. Most people coming out here never get off base. Their duties are at a desk, so they never see what an extraordinary country this is. The landscape is some of the bleakest I have ever seen, ragged raw mountains being driven up by continents colliding and being eroded back down by sun and wind. No wonder the Afghans are passionate about flowers and trees. An old man tends a pretty little garden in the centre of camp full of marigolds and night scented stock. He has created a microcosm of dykes, sluices and irrigation channels. I cannot be the only one itching to get down on my hands and knees in the mud to help him direct the water down the little irrigation canals. Outside in the green belt there are miles and miles of these channels growing two crops a year. The green belt, as it is called, is bounded by the high sand dunes of the desert. Out in the Green Belt the Poppy Eradication Programme is working with nearly 100 vehicles and three helicopter gun-ships above, ploughing up poppy. Unfortunately they are not ploughing nearly as fast as it is being planted. Stuck in the middle of this extra-ordinary struggle over poppy flowers are the peasant farmers and their labourers hocked to the eyeballs trying to make a living off the land. It is a country of no right answers, just very hard decisions.
Everest
While I was at Patriot Hills in Antarctica I met one of the Everest Guides. He asked if I would like to be the doctor to one of their expeditions. These top Guides are the most extraordinary people. As well as being top athletes they have to be great organisers and then they have to be psychologists for the frail egos of their clients. None of them seem to make much money out of the job and of course they are only earning as long as they are fit.
Mt Everest
There are two windows in the year for climbing Everest, spring and autumn, when for a couple of days, at most, the prevailing winds change and it is possible to climb without being blown off the mountain. There are also two routes to the top. The North route through Tibet was taken by Mallory and Irvine, while the south route up the Khumbu glacier was used by Hilary and Tensing. Access to the routes depends on the politics of the time. Both are now open and both are expensive. A license for the south approach through Nepal is now $10,000 per person travelling in a group or $25,000 solo, and only a limited number of permits are issued each year. Your oxygen bottles, food, and porters will cost you an absolute minimum of $30,000 and most pay $55,000 on top of the permit. Many people climbing Everest are doing it as part of the Seven Peaks Challenge (the highest mountain on each of the seven continents). If you want to do that, then the full house probably costs around half a million dollars. So the clients are a self-selected group of reasonably fit, very wealthy and psychologically troubled individuals who believe that climbing the highest mountains in the world will somehow cure their ennui.
The evening that I was due to fly to Kathmandu Jenny fell (threw herself) under a train. I heard the news just as I was on the way to the airport. I knew that she was unhappy and not well, but had no idea how bad she was. I too had been very unhappy at that age and had simply thought that she was going through the same sort of thing; but this was an order of magnitude more serious. By the time that I arrived at the Chelsea and Westminster Hospital several of Jenny’s friends had come to visit her and they were all drunk. Jenny was subdued but actually quite sane and clearly regretted what she had done. I was just stunned that anyone could have the courage to do what she had done. I know that acts like that are not associated with courage, but I saw it as a very courageous act indeed, driven by what must have been complete desperation with her situation. The psychiatric nurse was kind and gentle and clearly well versed in dealing with people who were very wound up. He explained that Jenny would be admitted as an inpatient to a psychiatric hospital for at least a month and that during that time it was very unlikely that I would be allowed to see her. No-one, not even Jenny, will know to what extent my behaviour and the divorce was responsible for Jenny’s psychiatric problems, but I was possibly a contributory factor. I will never forgive myself for that. However, clearly I was not needed/wanted at that stage and a decision needed to be made. Was I going to Everest or not? I took the flight (? took flight) to Kathmandu.
I think on careful reflection it was the right decision, and certainly Jenny has come to no further harm. However it made the next weeks absolutely purgatory as I beat myself up for handling things all wrong, and this had many repercussions for her and for me for years to come.
When I arrived in Kathmandu I was very, very tired. The team all were waiting for me. The chief guide Mike was a delightful man: calm, quiet, friendly and very insightful. He was a qualified physiotherapist who had given up everything including his wife, for climbing. His only possessions were a pick-up truck and a shipping container in Oregon (in which all his worldly possessions were stored). The clients were another matter. One was a very beautiful (and she knew it) banker from South Africa who was being sponsored to do the Seven Summits by her bank. She was divorced too, and had young children, and talked a lot about the problems of getting good servants when she was not talking about herself.
The second was a lady from Hong Kong. She was also clearly a high-powered executive and was out to prove something, her marriage having just broken up. The third was a delightful Irish property developer who really did seem to want to enjoy himself. He was the most unlikely property developer I have ever met, a devout Guardian reader, who had come to sport late and was now making up for lost time. The last one was a wiry ginger-moustached South African who ran a company which made flags. I suspect that they focused on Swastikas. He ran ultra marathons and was now doing the Seven Summits. He was aggressive, prickly, outspoken, fascist, opinionated and stupid. Apart from that he was fine!
My first job was to go into town and buy all the medicines that we needed for the trip. I was given a budget and told that they all needed to fit into two metal trunks. Otherwise the decision on what I should get was mine. I hadn’t got a clue but luckily Mike was prepared to help and advise me. Kathmandu is one of the very strange cities of the world because, like Jerusalem, there are large numbers of hugely different people rubbing shoulders together. The traditional Buddhist religion with its monks, its Stupas, and bodies being cremated beside the river (which has unfortunately dried up), is mixed with modern Marxist Nepalis who are stirring up a revolution.
Then on top of this there are children sniffing glue and sleeping on the streets, and then tourists, tourists, tourists, buying expensive hiking equipment and gawping across the chasm between the cultures of rich West and poor East.
The first part of the trek to Everest is a flight to Lukla, high up in the hills. The runway there is the steepest and shortest I have ever seen. It is at 12% slope and only 460 metres long and 20m wide, so only short take off and landing aircraft can use it. The planes literally climb up to the runway, land up the slope and then turn swiftly across onto the flat parking apron before sliding back off the mountain again for take-off. The tiny airport terminal is surrounded by a high chain link fence. Behind it are literally hundreds of porters, waiting and hoping for work.
They are all young and wiry and have come in from the valleys all around. Our porters were all pre-arranged so we moved to the local hotel while loads were apportioned. Our camp was four climbers, a senior guide, a camp manager and a doctor, ten sherpas, and then over two hundred porters. There is no doubt that climbing Everest trickles money down to a lot of people. You don’t carry much on the walk in, just your camera and your day bag. Everything else is carried for you. The porters carry 40lbs on a head strap but many of them double their load to double their earnings so are carrying 80lbs or more. For most of them, their loads are heavier than they are. They only wear flip-flops and carry a special stick which they can use to prop up the load when they are resting. I have never felt so embarrassed in my life sauntering up the mountain path being over-taken by boys carrying double crates of Heineken beer on their head straps. I suppose they don’t care what they are carrying provided that they are paid, but there seemed to be something especially wrong when they are carrying luxury Western goods. You would have thought that if we want these luxuries we could at least carry them in ourselves. I tried lifting one of their loads on to my back using their head straps but simply could not stand-up. They all thought my attempt (and failure) was highly amusing.
There is no road up the valley to Everest, so it is a walk of over a week. This is a very good thing as it gives everyone time to settle down and acclimatise. However it also gives Westerners a chance to catch the local D&V. In fact you would have to be very lucky indeed to get up that track without being smitten. The walk into Everest base camp is an expedition in its own right. We walked about 10 miles each day clambering up a river valley. Sometimes we were high up the side of the Khumbu valley in Rhododendron bush. Then just as suddenly we would descend right down to the side of the river where often as not we would cross by a narrow suspension bridge.
Tucked in the narrow valley floor were tiny farms, which looked as if they must flood when the river was in spate. The path was very busy, with streams of porters and yaks working their way uphill and then unloaded porters literally running back down to collect another load. Day after day we went higher, catching glimpses of immense mountains on both sides, which are considered trivial by Himalayan standards. Namche Bazaar is quite a large town halfway up the track, and around it are some truly beautiful mountains. It is strange to walk around a large town which is over four days walk from the nearest road.
Namche Bazaar – the home of D&V
The walking was hard and clearly, everyone was sizing each other up for endurance and fitness. In Namche, one of the clients got food poisoning and from then on didn’t look right. There is little I can do about that as a doctor. They become dehydrated so fast and then take so long to recover.
We passed through Tengboche monastery one of the greatest and most beautiful in Nepal, set on a spur with great views of mountains in every direction. It is extraordinary to think of the money which must have been sucked from the poor peasant farmers around to fund such a fabulous place.
Temboche Monastry
It looks very old but was actually razed to the ground in an earthquake in 1934 and then burnt to the ground in 1989. I feel sure that it is not the sort of edifice that Buddha had in mind when he founded his simple religion.
Mike decided not to take us up the standard path but instead to take us over a pass which is at nearly 19,000 feet high. The slog up to the pass was brutal and then the descent was even more cruel on the legs. It was steep, and stones dislodged by people at the back were sizzling past those at the front. Despite every effort we could not get our food-poisoned Hong Kong lady to be careful. It was difficult to decide whether she was stupid, obstinate, or ill, and I could see Mike looking worried.
Top of one of the passes
At the top of the pass something gave way in my left knee and from then on I was lame. It was a long way to go to our camp that night and I for one was wrecked by the time we got there, especially since we had been obliged to cross a large crevassed glacier with high lateral moraines to reach the village.
Everest base-camp
The next day we reached Everest Base camp. What a sight. First of all you can’t actually see Everest because it is hidden behind other mountains, so that is a little disappointing. But at the crest of the ridge, you look down onto the Base Camp and it is an impressive sight. All around you are prayer flags crackling in the strong wind. Below is the Khumbu glacier curving round from its precipitous fall from Everest.
Everest Base Camp is at a touch under 18,000 feet (5,360 meters), so there is very little oxygen. You have to do everything slowly. If you stop to cough or lift something then you will be left gasping for breath for a minute afterwards. And do you cough!?! Everyone coughs all the time. Just when you think that you have got on top of it, you are seized with another paroxysm. Not since I was a child with Whooping Cough do I remember such panic-making asphyxiating paroxysms of choking.
It is bone numbingly cold at night with the temperature dropping to minus 20 C. The glacier under your tent creaks, groans and shudders all night, and then another avalanche roars down the cliffs around us shaking the ground, then sending a puff of powder snow over the tents making them rattle furiously just in case you fall asleep for a few minutes. However, the moment that the sun falls on the tents in the morning, all is well again. The temperature soars 40 or more degrees in minutes and it is shirt-sleeve order unless the wind is blowing. Then at 4pm, as the sun sinks behind the mountains, the temperature crashes again and it is Moon boots (with 3 pairs of socks underneath), quilted trousers over long-johns, T-shirt, pullover, fleece, puffer jacket, hat, and gloves. I am afraid that I am such a cold-blooded creature that I tuck a Hot water bottle under my puffer, just to provide a bit of extra heat. At night it is a brute getting undressed and climbing into your sleeping bag. It is soooo! cold. You have to share your bag with your hot-water bottle. It is far too cold to get up for a pee in the night so you have to pee into a bottle inside your sleeping bag. As you imagine it requires care, and then the bottle must stay in the bag with you, otherwise it freezes. Sounds rugged doesn’t it? Not really. At sun-up the cooks come round with ‘bed tea’ and a hot flannel for a rub down. So before you have to leave the warmth of your bag, there is a lovely mug of tea. Then there is breakfast. Fresh fruit salad, yoghurt, bacon and toast if you want it, and fresh brewed coffee, basking in the early morning sun, with the iPod sound system playing some nice music. While we are working through the day, the Sherpas will check our tents for level floor, tighten guys etc, and do our washing for us. There is a bucket shower which we can use twice a week. Lunch is soup then some canapes. Dinner is a full blown 3 course meal, and then it is cards in front of the gas heater until it is bedtime.
And what is the camp like? Well we are quite small. We only have four clients trying to reach the summit of Everest so the staffing levels are low in comparison with some of the other camps. Our patch of the glacier is around 50 by 70 metres. It has a large dining tent which will seat up to 20 if it has to. Beside that tent is a similar sized cook tent with several gas burners, and behind that is another tent the same size which is the common room for all the sherpas. In the other direction is another slightly smaller tent where communications take place. In this tent there is a main two way radio, multiple hand sets, a solar charger, inverter, satellite phones, and 2 lap-top computers. My medical tent is behind that. One wing has stretchers, oxygen, drip set and a bed for a patient. The other wing is my living quarters while the alcove of this tent holds the trunks of medicine, extra drip sets, oxygen, plaster etc. Further away across the glacier is a shower tent with a clever electric pump for taking the warm water brought from the kitchen in a bucket. There are two toilet tents and then a single arctic sleeping tent for every person on the expedition, guides, camp manager, clients and sherpas. I am still not quite sure how many staff we have. There is a chief guide Mike who alternates his time working in Antarctica and doing work like this. He is supported by Ank Gorje a Nepali guide who has only summited Everest 13 times (he has had to turn clients back at least four other times)!! Then there is a camp manager, three cooks (down here – another one now up at Camp 2). Finally there are a large number of Sherpas who carry supplies up the ice-fall, help around the camp, and will support the clients at high altitude. They smile and laugh all the time and there is never anything which they will not do to help. I estimate that there are at least ten of them some of whom are up the mountain now moving supplies up and laying out the fixed ropes.
The camp is pitched inside a horse-shoe of mountains all over 23,000ft. Their faces are cliffs of crumbly sedimentary rock plastered with ice and hanging glaciers. There are at least three avalanches a day down these huge slopes. At first we ran out of the tent to watch every one, but now we only jump for the really big ones. The weather has been great so far with clouds and snow only rolling in late in the afternoon, but no doubt that will change as the monsoon comes near. In moonlight the cirque of mountains looks eerie. Circling around the cliffs and camp itself are lovely Choughs
(my favourite bird), the odd raven, some sparrow like birds (possibly Accentors) and recently a beautiful light pink bird the size of a thrush with a deep purple face.
So all in all. It may be high and it may be cold but they do what they can to make it luxurious.
Everest Base Camp (EBC) is now part of a lovely National Park so everything that is brought in for each climbing season must be taken out again at the end of the season. That means every single tent, every bit of rubbish, and all human waste has to be taken back down at the end of the season on a porter’s back. For eight weeks EBC is an encampment of over 700 people, and the number of porter loads needed to create this virtual village, supply it, then completely dismantle it again is quite mind-boggling. And it is all to get fewer than one hundred climbers to the top of Everest, each of whom will be paying around $100,000 to climb the mountain.
Each year the base-camp is re-built on a boulder strewn slope which forms the surface of the Khumbu glacier after it has finished tumbling down the narrow gap between the mountains Nuptse and Lho La. Most of the surface ice has been evaporated or melted away by the sun, so it is a groaning heaving slo-mo cascade of boulders which slide over each other day and night moving some eighty metres a year. The tents must be pitched on this slithering jumble of stones, by clearing small spaces with pickaxes and pitching the tents on a bed of flat stones laid on the ice below. As the glacier is moving all the time, the tents have to be re-positioned time and again to try and give the floor some semblance of being level. Each April hundreds of little orange tents blossom between the boulders like a desert coming into flower. Each camp flies its own banner, naming the group and their country of origin. Fluttering overall are the Puja flags, red, white, blue and green – coated in prayers which slowly shred in the wind. Each year before climbing the mountain the Sherpas have a ceremony asking for forgiveness from their Gods for defiling their mountain homes. The culmination of this ceremony is the raising of a highly decorated pole crowned with Juniper in the centre of each camp. From these poles the long guy ropes lined with Puja flags then spread away across the camps like multi-coloured spider webs.
Within days the bleak monochrome glacier landscape is transformed into a garden of fluttering colour. The clients are middle-aged and highly successful bankers and professionals who are having a full-blown mid-life crisis. Most of them will be trying to do the ‘Seven Summits’. Their goal is to climb the highest peak in each continent of the world. Mt. Kilimanjaro in Tanzania (Africa), Mt Carstensz in East Papua (Australasia), Mt Mckinley (Denali) in Alaska (North America), Mt Aconcagua in Argentina (South America), Mt. Vinson in Antarctica, Mt Elbrus in Russia (Europe), and Mt. Everest in Nepal (Asia). To be guided to the top of all these mountains will take you several years and cost not less than $500,000, so this is not for the faint-hearted (financially) but you will join an exclusive group of high-altitude mid-life crisis. The paradox is that these astoundingly complex, luxurious and well-organised companies which can fire an over-funded, overweight, unfit, mildly depressed but driven soul to the summit of the highest mountain in the world are run by individuals who in their day were some of the greatest climbers ever. They would have gloried in the purity of their sport, but now make a living from packaging that dream into a Las Vegas road show, which must make their toes curl in their boots. Luckily there are lots of very beautiful mountains in remote parts of the Himalayas and the rest of the world which are not the highest or the hardest, and which can draw the wilderness purists to indulge their passion.
Mt. Everest is hidden behind other smaller mountains which would tower every other mountain anywhere else in the world. The route from base camp starts up the notorious Khumbu ice-fall. This narrow waterfall of ice is both difficult and dangerous and posed a formidable problem to the original explorers of this route. Now a team of Sherpas known as the ‘Ice-doctors’ put fixed ropes up the ice-fall, bridging the most difficult chasms with lightweight ladders. As the glacier moves and creates new threats of collapsing blocks of ice, they will move the ropes and ladders daily to make the route as safe and quick as possible. The icefall is still difficult and dangerous but is no longer the formidable barrier it was to the original climbers. Even so, on the first day of our parties’ ascent of the Ice-fall a set of Seracs (Ice towers) collapsed like a pack of cards ending metres from our senior guide. The clients will ascend the Ice Fall twice during their attempt on Everest. Each Sherpa will do over 30 ascents in the same time so their risk of being hit by an avalanche is over 10 times greater. Recently one icefall killed over 20 Sherpas, and they are the family breadwinners, so such an event is a disaster for a whole family.
At base camp, our team and many other teams have permanent chefs to prepare meals for the clients and for the Sherpas. The camp is as comfortable as possible as there is a lot of waiting to be done here. Above Camp 2, at the start of the season, the Sherpas are currently carrying up 8 km of rope to create a stair-rail all way up the mountain to the South Col. This makes the mountain quicker and safer to ascend but would presumably have the Hilary and Tenzing wondering what the hell has happened to mountaineering. The Sherpas carrying supplies up the glacier will dump their loads at one of the high camps then race back down to Base camp so that they do not use up any of these valuable resources. Slowly a dragon made up of Sherpas and their headlights is winding higher and higher up Everest, tramping a path, creating a staircase (with stair rails) just to enable a hundred odd mid-life crisiseers to say they have stood on the highest point in the world. I wonder what the Sherpas think about this extraordinary pilgrimage.
The Khumbu glacier key to the ascent from the South
On the moraine beside it, the base camp is built. That year there were over five hundred tents. At the beginning of each season the first sherpas for each team bag an area of the moraine for their camp and start clearing stones. You can’t remove all the stones because the whole moraine is made of a tumble of boulders. But they move the ones that stick out most and put them in the deepest holes, and try that way to make a slightly flatter surface. Then they erect the sleeping tents, the dining and cooking tents and the latrines. It must be cold and hard work, but there needs to be accommodation for over 2000 people at the peak of the season. One company (the biggest and the most expensive of them all) has just relocated from the North side of Everest to the South and has brought all their gear with them. They have a very large geodesic dome as their main living area. This has a 50 inch plasma TV and a huge Scalextrix track for the clients to play with while waiting to climb. There is also a fully stocked bar with bar stools and a wooden floor covered in a mock tiger skin carpet.
One way of waiting for the weather
I cannot imagine how many porters it took to carry all this up the mountain and carry it back down at the end of the season. The owner of this camp is a hard-nosed Northern Englishman who drinks a lot of whisky. One evening I asked him about what made him do this (he also owns the largest consortium of climbing guides in Chamonix). To my amazement, he explained that as a young man, three of them had made an attempt on the South West face of Everest. They had become trapped close to the top by a storm and after three days decided to abandon their camp and descend. After a few hours, they realized that this was impossible because of the wind and climbed back to their camp only to find that it had blown away, and they still survived. This was one hard man.
Very soon someone is going to want to build a road to Everest Base camp and that will be a disaster. There will no longer be any work for thousands of porters. Tourists will be bussed up and back in a day in fitted oxygen masks I assume, and will completely miss the wonderful experience of a long walk far away from any vehicles.
Already the ‘benefits’ of civilization have reached to the top of Everest. A transmitter mast has just been erected in sight of Everest so there is mobile reception at base camp and on the mountain. The Sherpas absolutely love this as they can keep in touch with their families, but it has chipped away at the remoteness of the experience. There are now two separate satellite-based weather systems reporting on the development of the monsoon so it is possible to predict the safest dates for the push on the summit. Most climbing companies at Base Camp have access to at least one of these. A team of Sherpas now goes up each season and brings rubbish off the mountain, used oxygen cylinders, discarded food, feces and the bodies littered on the mountain, some of which are appearing each year as the ice retreats. There is a helicopter landing site at Base camp and now the newest helicopters can get high up on the mountain where they can drop climbers and supplies, and more importantly rescue injured or sick climbers.
Medical tent at base of Khumbu glacier
Much worse is the bannister that they now put up Everest at the beginning of each season. At the same time that Base Camp is being cleared and built, highly experienced Sherpas are climbing the Khumbu Glacier and marking out the safest route up this lethal ice-fall, where the glacier tumbles rapidly down a narrow defile. The ice squeezed through this narrow gap moves several feet every day so the glacier is very difficult to climb and very vulnerable to avalanche and ice-fall. For the rest of the season they will be climbing up and down this high-risk corridor making it safe for the clients at great risk to their own lives. Most of the sherpas climb the ice-fall at night carrying supplies up to Camp 2 because it is colder then, so ice is less likely to break away. When the season is going full blast you can stand at night, and look up the Khumbu glacier. It is a stream of bobbing head torches as the Sherpas carry load after load of supplies up the mountain. The long winding chain of lights reminds me of the Chinese myths of Dragons in the mountain.
An avalanche just above the med tent. Two years later after the earthquake the whole area was wiped out
Above Camp 2 more Sherpas are attaching ropes to the bleak face which leads up to Camp 3. The clients and their Sherpas clip their harnesses into this fixed line so that if they slip they will not fall. This is not climbing anymore. This is an exercise in step-ups on a big hill. Clients paying top-wack have two Sherpas accompanying them at all times, carrying their oxygen, and their kit and guiding their footsteps. I mentioned
to one of the senior Sherpas that I would like to climb the mountain but that I did not want my feet to touch the ground. In other words, I wanted to be carried up. He spotted at once the irony of my comment, and after a moment’s thought riposted with “well we would only need one extra Sherpa for that”.
At the top of the mountain, things have got pretty cosmopolitan. Guards have to be left at Camp 3 to make sure that members of other teams do not steal oxygen or food supplies. It happens every year. On the final ascent, there is actually a traffic jam, a queue to get up Hilary’s step, and a backlog of people trying to get back down again.
The whole business left me horrified and bewildered. I have always dreamt of climbing Everest but it was never going to be like this. There is also a tricky ethical issue. Once again this year several Sherpas have been killed, buried by an avalanche while setting up fixed ropes for clients to climb up. The clients climb through this danger zone only twice in the season but each Sherpa will risk their lives over thirty times. They are paid an absolute pittance for this work, which is really just to indulge the middle-aged crisis of some Western plutocrats. I am sure that the Sherpas would say that they want the work and that it is their decision to face the risks. I am just sad that it has to be this way. It was all especially poignant for me when the Sherpas performed a beautiful and complex ceremony (the Puja) when they started the ascent of the mountain.
A Puja to pray for luck during the climb
They are clearly very superstitious (religious). Who wouldn’t be when faced by these odds each season? But it is very clear from the seriousness of the ceremony that they are acutely aware of the risk that they are taking and worry about it a lot. If they are killed it is not just them who suffer. All their family will have lost their main bread-winner and there is no social security in Nepal.
The team, young, strong, kind and cheerful. Each has an extended family relying on them coming back safely
I suppose that the beauty of it all is that the pre-occupation with Everest leaves the whole of the rest of the Himalayas relatively untouched for those who love mountains for their own sake.
Base camp was a peculiar place, and pretty soon I became bored with it. We were surrounded by a cirque of mountains and each time that an avalanche came down the cliffs around us (which was at least once a day) the ground around us shook and some seconds later we were all covered with a fine spray of spin-drift. A couple of years ago the Nepal earthquake caused a massive avalanche that buried most of the base camp. There was no medicine to do, and the main hospital tent that served those expeditions who did not have their own doctor was American and not at all friendly. Our camp manager was having a clandestine affair with one of the chief Sherpas, clearly carried on from last season. There can be nothing clandestine in a small camp so their charade was really rather silly. She was obviously bored and very soon I found that she was reading all our emails. I don’t mind people reading my stuff. I would just rather that they did it openly. When I started to send Vicky letters in locked files, the camp manager became very icy with me indeed.
The day after we arrived, Mike took the Sherpas and the clients to an ice-cliff to look at equipment and its use. Mandy the South African banker had the wrong crampons and had spent a small fortune buying new ones in Kathmandu. She excelled herself now by putting them on upside down. I saw Mike’s lips go thin. If this client could not even put crampons on, how safe was she going to be on the mountain? She did her ‘I am a helpless baby girl’ act and Mike and the Sherpas all fell for it hook line and sinker. While abseiling down the ice-cliff after climbing it, she promptly turned upside down. Mike turned brusquely to the senior Sherpa. She was to be tied tightly to a Sherpa throughout the whole climb. She had paid her money. Now the risks for her and from her had to be minimized. It was then that I became aware that there was clearly an unwritten rule amongst the Sherpas, and this was that you did not come back down the Mountain without your client. There had been some bitter accusations made after the great storm which led to the book ‘Into thin air’. Some guides and Sherpas had stayed with their clients and died. Others had abandoned their clients and might as well have died there and then for the opprobrium they garnered.
The South African fascist was now coming to the fore. He would ask long convoluted questions about diet and then give his opinion before I could answer. This was, I suppose a good thing as I hadn’t got a clue and didn’t think it mattered much anyway. He also sniveled all the time, which was irritating, and proudly told us of his life in South Africa. He had two Doberman dogs called Rommel and Himmler who were trained to attack blacks. He went running every day but carried a revolver with him. He explained that if he was to be approached by a black man he would regard this as an attack and would shoot him. He told us this with relish as if this was something he was looking forward to doing. At first I was just horrified that such perverted people still existed on the earth. Then I got cross, but luckily realized that it was pointless arguing with him as he had no insight at all. So I took to teasing him, asking him seriously whether he thought his gun was big enough to do the job. He took all the questions with the utmost seriousness while James the Irish climber, who I liked, was quite literally choking with laughter in his soup and Mike was looking on very disapprovingly, worried only about the happiness and welfare of his clients.
I took long walks each day to try to keep sane. I was terribly worried about Jenny, I was missing Vicky terribly, my knee was sore, I was bored, and I found the company uninteresting. There were however some really interesting people in camp who had been great climbers in their heyday and now ran expedition companies. I found their stories fascinating. My longest walk was back down the track for six kilometers or so to Gorak shep and then an ascent of the peak Kala Patthar, which rises to just under 19,000 feet and gives wonderful views of Everest. At first the path was busy with walkers, then the wind got up and it started to snow and I found myself alone on the mountain with a long slog ahead. I wasn’t overly worried as the path was clear, and soon enough I got to the top, which was covered in prayer flags. Between the snow squalls, I could indeed see Everest, but this was no place for hanging around. The wind was blowing a full gale with squalls of snow and I was cruelly short of breath. In my usual inimically stupid fashion I decided that I would take a different route down and head straight towards the Base camp rather than taking the dog-leg of my original path. There was a reason for the dog-leg and this soon became apparent. There was a loose rock cliff several hundred feet high between me and the glacier below. I made several attempts at climbing down it and each time wisely lost my nerve, climbed back up and went further along. Finally, I got down, only to find that I couldn’t see base camp anymore, and was lost in a complex set of rocky moraines. I was now very tired and my knee was not holding up at all well. I didn’t have a compass with me, nor did I have a radio. I had told them at camp that I was going to climb Kala Patthar but not the route that I was taking. I gradually realized that I had broken a large number of rules and was now not in the safest of positions. Several hours later I arrived on the main path from base camp to Gorak Shep, a very tired and relieved man. There was still a long slog back to Base camp but at least I was on a frequented track. I felt terrible. I was unbelievably tired, quite depressed at what a stupid risk I had taken, and found that my left knee was getting worse and worse so that I was now limping all the time.
When you climb Everest these days you try to climb high but sleep low. So our climbers had done their first trip into the Khumbu glacier. We went partway up the ice-fall to meet them. It is a forbidding place and quite exhausting. No sooner have you climbed one ice tower than you have to descend into a crevasse to climb the next. It feels like two steps forward three steps back, and every serac looks ready to collapse at a moment’s notice. This is no false threat: the crump of collapsing towers of ice occurs every few hours. Our party was not looking happy. The Hong Kong girl was blue and did not know where she was. She was hallucinating and clearly had only made it down because the Sherpas had effectively carried her down the route. Mike had been bringing up the rear when a serac collapsed higher up the icefall and started a mini-avalanche. He watched with horror as the avalanche bounded closer. It only stopped at the base of the serac he was standing on. Quietly he admitted that he had thought that his number was up. The clients had not even noticed. It was clear that Hong Kong girl was not going to be safe on the mountain. She wanted to compromise by only going to Camp 2, but I felt that it was the Khumbu icefall, which was the most dangerous obstacle to evacuation and Camp 2 was at the top of this. So, although very cross, she left the mountain, mouthing all sorts of threats of litigation against Mike and myself. I do wonder whether she would have made it safely to Camp 2 but did not see why Sherpas should risk their lives even more than they did already, just to indulge her ego.
The next stage of the expedition was to go very low in preparation for the push to the top. We headed back down the path to Gorak Shep and then on down towards Tengboche. This time we clambered up the side of the valley over a pass and into another valley system. It was a lovely empty place with lots of wildlife and I enjoyed a couple of days there, but when it was time to go back up, I felt that I needed to go down. My knee was not going to cope, and I was worried about Jenny, not that I could do anything. It was a lovely walk down with an elderly Sherpa along a path we had not taken on the way up, and soon I was back in Lukla admiring how much the rhododendrons had come on since we started the climb up.
After the solitude of the mountain tracks, Kathmandu seemed even more frenetic. The three remaining climbers all made it safely to the top and back again, but I was long gone back to the UK. I am very glad that I have been to Everest Base camp but am glad I didn’t stay a day longer. Climbing can be a little like diving. You crave to go higher (deeper) but once you have done it you realize that it is cold, dangerous and not nearly as beautiful as the lower/shallower places.
Vicky and I went on a walking tour through the foothills of Northern India with Annapurna far away in the distance. The walking was lovely, up through forests then down through farm land ploughed by oxen. There were birds and flowers, beautiful scenery and friendly people. Who needs to be staggering around on a boulder strewn moraine at 18,000 feet with a blinding high-altitude headache, when there is so much to see and do lower down? The same applies in diving. Who needs to go to dark cold and dangerous depths when all the beauty in the sea is in the top ten feet?
I have to do these things just to see what is there, but I am not sure that I need to repeat them.
Nepal – Earthquake 2016
Humanitarian work - Nepal
Part of the price you pay for doing Emergency Humanitarian work is that you become a complete news junkie. My ‘hit’ is on the hour every hour; Radio 4 during the day, then the World Service through the night when I can’t sleep. The philosopher Collingwood in his book ‘The Nature of Time’ pointed out that the shorter the period of time between each news report the higher the ratio of bad to good news. So, my hourly top-up consists of an overwhelming number of news stories where human misery predominates. I have now visited many of the places that routinely crop-up as disaster hot spots, and so every news clip also conjures up sights and sounds of when I was there last, and sets me wondering if and when I will be going there again.
Knowing that any one of these ‘news emergencies’ could result in an immediate deployment keeps me in a permanent state of anxiety. Each day at home may be the last for several months so I find myself going slightly hypo-manic trying to finish all the tasks I have set myself before night falls, in case I am on my way again by the morning.
When I worked at the Nuffield Orthopaedic Centre it was a 6 ½ day week, so every Sunday afternoon was a precious chance to catch up with things at home. Humanitarian work makes every day at home feel like a Sunday afternoon, with all the stress that entails of trying to get everything finished. I gather that this makes me challenging and slightly manic to live with!
I missed the initial response to the Nepal earthquake, as I was away at sea, working as a ship’s doctor. In retrospect that was lucky, because Medecins du Monde (MdM) sent a surgical team immediately, and they got nothing done. First, they got stuck in the Gulf for three days because no more planes were able to land in Kathmandu. Then their equipment got impounded at the airport. They came back very frustrated.
My job on this second deployment will be to make the transition from Emergency Response to a sustainable long-term programme for MdM in Nepal. This is not something that I have done before and should be a real challenge. MdM were doing a major mother and child health programme when the earthquake struck and immediately converted their work into Emergency Relief. The mother and child programme was only due to run until the end of 2015 so reconstruction will need to be geared towards getting everything up and running while working out what is going to be done next.
Each member of a humanitarian medical team has different strengths and weaknesses. Surgeons appear to be very useful in the acute emergency, and their work makes good copy for fund raising. But they are not such good value for money in a quiet time when the problem is the need for clean water, nutritious food, family planning and a reliable vaccination programme. The converse applies to family physicians, who may be just another mouth to feed in a disaster but can be the backbone of a sustained programme. My role this time will certainly not be as a surgeon. I just hope I can do the transition. But the real unsung heroes are the administrators and logisticians who have to actually make the project run. I will meet the team when I arrive in Kathmandu. They will be watching me and I will be trying to get their measure too. Let’s hope it works!
Watching the news today there was lots of footage of boat people being rescued from the Mediterranean. Many of the aid workers were wearing face masks and my hackles started to rise. “Why were they wearing face masks?”. It cannot be anything to do with protection from infection because firstly there is no reason why refugees should be any more infected than anyone else and secondly if you are worried about aerosol transmitted infection, then it is the refugees who should be wearing the masks not the care workers. I fear that the real answer is not a pleasant one. It is a way of signifying “I am cleaner than you”. It is also a way of hiding your identity and your humanity, so that you can order people around. It can only add to the terror of the refugees on the boats, plunged into an alien world controlled by people who don’t speak your language and then won’t even show their faces. I just hope that I am not going to see face masks in Nepal but I fear that I will.
14th June 2015
Four days in and the hand-over has been completed. I am now notionally responsible for 12 ex-patriates, and 70 Nepalese staff. We are one of many hundreds of NGOs trying to improve the welfare of the people of Nepal, especially the women and children.
Médecins du Monde (MdM) France has been working here for nearly 20 years, first in TB and HIV then in Sexual and Reproductive health (SRH), Psycho-Social Support (PSS) and Gender Based Violence (GBV). I am having to get used to these new acronyms if I am to understand what is being said to me.
Everything came to an abrupt stand-still when the first earthquake shook the centre of Nepal in April. Everyone knew that it was going to occur somewhere on the southern borders of the Himalayas, but not exactly where. In fact the epicentre was in a remote rural area, so Kathmandu was only damaged but not flattened. The pancaked buildings and slow burning fires that greeted us on arrival in Port-au-Prince, Haiti are not seen here. Nepal was bouncing back when an aftershock (a pretty big earthquake in its own right) shook the country again. This time it was not just the ground that cracked, lots of people cracked too. A month later many are still sleeping in tents in their gardens, their confidence in the safety of their houses destroyed. There are still aftershocks every day. I must admit that I cannot feel them, but the Nepalese can. They are highly attuned to that horrible wobbling feeling that sets your heart racing and your eyes scanning for the nearest exit. And some people feel that worse may be yet to come. The monsoon is just starting. Torrential storms of thunder, lightning and rain are rolling into the mountains. This is inevitably going to cause landslips, which will bury roads and villages tucked away in the floors of valleys. Some landslips have already blocked rivers. When the dam of mud finally bursts, a tidal wave of water pours on down the valley sweeping away everything in its path for miles.
As the General Co-Ordinator my work is at Headquarters, networking and pushing paper. Now I know what it must feel like being a General in the Army. All the fun is going on out in the field where young volunteers, freed of all administrative responsibilities, work their way up-country in helicopters and four-wheel drives exploring this beautiful country and trying their best to bring help to communities which have been cut off for weeks, and which have lost most of their clinics, schools and houses. I sit here and worry about whether they my staff are safe.
The Nepalese are quite as delightful as I remember them, hard-working, uncomplaining, cheerful and polite. You have only to engage eye contact, clasp your hands and say “Namastee” for their faces to break into a smile, and for them to return your greeting with interest.
Much of our work here relates to women and children’s health. In order to wring money out of the Western donors, the NGOs have to present a story of horror, rape, domestic violence, and child trafficking to raise funds for their work. I have no idea how big the problem of gender based violence is here in Nepal, nor whether it is better or worse than elsewhere in the sub-continent or even in Oxford (given all the recent arrests there). But it cannot be very edifying for the normal good Nepalese citizens to have this kind of dirty washing hung out to dry in the world press. I just wonder how we would feel in Oxford if a team from Japan arrived to assess the level of domestic violence and to offer psycho-social support to victims while plastering their media with gruesome stories of the horrors of being a young girl in Oxford. It seems a shame that we have to humiliate a community in order to help them.
NGO support goes through flavours of the month, and for an NGO to thrive, it should always be just in front of the crest of the humanitarian fashion wave. Access to clean water, child nutrition, family planning, HIV and refugee status all take their turn in the limelight. I suspect that displaced persons is going to rise again to the top of the priority list as hundreds of thousands of refugees start pouring into Europe, the Southern United States, Indonesia, and elsewhere. Even here in Nepal the people living in the mountains are pouring South (I was told this morning that 60% have already left). Some will return after the monsoon, but many will become urban poor, permanently adding to the bulging shanty towns found on the edge of every third world city. They then become Internally Displaced People (IDP), a group whose chances in life are profoundly compromised.
We are used to hearing edifying tales of Russian Jews and Huguenots fleeing religious persecution to start a new life in an hospitable country and then thriving. Their stories are heart-warming, the triumph of determination and hope over adversity. Unfortunately they are the exception rather than the rule. Certainly in the third world displacement is not far off a death sentence. I just hope that doesn’t happen here.
Visit to the Field, 18 June 2015
Yesterday was my excuse to visit the field and see what we really are doing. The inspector from the European Community wanted to see the project first hand, and how could I possibly allow him to go without being there too?
The day started with a bang – quite literally. I had started in the office at 5.30am to get some paper work done and just after 6 the whole house rocked as if it was a railway carriage crossing some points. I leapt for the door and was relieved to see the night guards doing the same. Nothing more happened so we all had a good laugh although all the lines went down for the rest of the day.
It was a three hour drive to our first site, high in the foothills of the Himalayas. My assistant was clearly very anxious and as I probed his worries, he explained that he had been trapped here by the first earthquake. The local doctor had apparently seconded him to help with the post-mortems which had to be carried out in the field as there was no way anyone could safely enter the hospital (it had partly fallen down). He is not a medic and some of his descriptions of what he was asked to do had even me reeling. I dread to think what it has done to him. He was especially worried about land-slides, as they had caused the most horrendous injuries. As we moved into steeper and steeper valleys the landslips became more and more common. The road had been cleared but the debris was on both sides, reminding us what was hanging above our heads, steadily being loosened by the monsoon rains and ready to pour down any moment. There was no way to calm his anxiety. It was completely justified!
There are cracks in the ground everywhere and landslips where they have never been seen before
It is stunningly beautiful countryside, rather like the pictures you sometimes see on the calendars in Chinese restaurants. Steep, steep hillsides etched with line after line of terraces. with forest above vanishing into cloud. There was no view of the snows at the top of the valley. They were hidden in thunder clouds, but when they are out I gather that they look glorious. What was not hidden was the high tension electricity cable spanning the lower part of the valley which caught the MSF helicopter and killed everyone on board a few weeks ago. I just hope that they had no time to realise what had happened, but the cable is three or four hundred feet up!
The terraces grow three crops a year. Maize grown before the monsoon is being harvested now, and then the terraces will be flooded to grow rice. Immediately after the monsoon. they try to take a crop of wheat. These farmers are certainly not grindingly poor, but most of the farming is done by hand or with bullocks and looks to be very hard work. Near the floor of the valley the terraces widen to become broad fields. In amongst the green maize there are piles of stones with the odd bright orange tarpaulin. As we got closer I suddenly realized that these had been villages. Dry stone walls don’t like earthquakes.
The remains of the village beside the mobile clinic. Corn stores, money, and animals are still buried there and the monsoon is starting. They cannot rebuild until they know whether a land-slip will now come through the village and bury it.
Later we came to the town of Choutara built on a knife edge ridge thousands of feet above the valley. The main street is the ridge, while the houses are perched each side on the steep slopes. It is a wealthy town and so some of the taller building are made of concrete. They had not collapsed: the houses had simply toppled over backwards down the slopes and were now left like Easter Islands statues tilted at every angle.
The first health centre we reached is a fine new building and looked perfectly all right from the outside. I was just about to ask why it had been abandoned when we stepped inside. It had been built without any steel reinforcing rods and it is a complete write-off. Walls and ceilings are piles of rubble. For the sake of a few pounds they have lost a hundred thousand pounds worth of building.
The brand new Primary care health centre looked fine from the outside, but inside…..
Then we set off on foot to one of our mobile clinics in the countryside, crossing the river on one of those glorious suspension bridges which I absolutely love, swinging high above the roaring river.
The bridge across to the mobile clinic which is an hour’s walk up the valley
After an hours’ walk we got the first mobile clinic site. Matthieu, the log assistant (who has Kayaked across the Atlantic), was in seventh heaven building a hut out of local materials to house the clinic once the rain starts in earnest. He was in amongst the local farmers who clearly found his enthusiasm a good balance for their competence. I was very jealous. He was so obviously having a good time, despite the rain every night and the leeches, which are everywhere.
As we slowly worked our way along the winding roads back to Kathmandu it was reassuring to see that that there had been no more land-slips but the rain was starting again, trickling into the cracks and putting inexorable pressure on the slippery red clay. The land-slides started again that night and by morning the road was completely blocked.
Transition from Emergency to what..?
Each night now it is raining hard with bursts of thunder and lightning. But at dawn there is a minor earth tremor (presumably that is the sun pulling sideways on the Earth’s crust) and then the weather starts to clear into a wonderful summer’s day with huge thunderclouds piling North to collide with the Himalayas.
Everything is chained to the ceiling or the floor. Why? Because when the quakes come, things fall down and hit you on the head.
But this is not the only collision here. France and Nepal are both very bureaucratic countries and the meeting of the two is loaded with paper-work. I wonder how anyone could possibly have time to read it all. Our permit to remain in the country as an NGO has to be approved by meetings in no less than eleven separate ministries. The current application is somewhere in this labyrinth and once the earthquake came we lost contact with its progress. So now we are going to have to send one of our senior Nepali administrators deep into the government offices to find it and start it on its slow journey to completion.
The government has declared that the emergency will be over next week, and that then all the extra bureaucratic rules, which apply normally, will come back into play. Well, if they think the emergency is over they should come up into the hills and see for themselves. Now that the monsoon has started the roads are becoming increasingly difficult with landslides blocking them almost every day. Very little rebuilding has started because (people claim) they are waiting to see where the landslips will come down before committing all that time and money to a rebuild. But the alternative is for the local farmers to carry on living in a pile of rubble under tarpaulins throughout the next three months of the monsoon. Apparently as many as 60% of the population in the hills have simply decamped and gone to stay with relatives in areas less badly affected. These relatives will mostly be in Kathmandu, a sprawling city already bursting at the seams. The rural populations in all under-developed countries are leaving the land for better job prospects in a city and Nepal is no exception. This earthquake has merely accelerated this trend. In the autumn some will return to the hills but many of the youngsters will not. Perhaps they are right. Maybe there is no future for them in these beautiful hills.
And staying on bureaucracy, for the past two weeks we have been trying to get hold of a consignment of emergency drugs sent out to help our work, but which had been held at customs. We had until tomorrow to clear them because then the government has declared that the Emergency is over and 30% import duty is payable on everything including Humanitarian aid. Our joy at finding the drugs at last (which had been moved to the Government Health Service Compound) was tempered by the fact that boxes had burst open from being left in the rain, and that they were now broiling in the sun at temperatures far above what is recommended. Our meeting with the Government Chief Pharmacist was also a bit tricky. I have never heard a Nepali be sharp before but clearly someone (not us) had made him a bit cross and his staff were on tenterhooks. As soon as greetings were over he bluntly explained that the drugs now belonged to the Nepali government and that he, not us, would decide where they were to go.
As he spoke I sat there thinking about this. I suppose he is right. It is his country and they understand better than anyone the whole problem and the last thing that he or any other Nepali wants is International NGOs trundling in and disrupting things, favouring one area over another. I think he was expecting an explosion of indignation from us, but none was forthcoming. Tentatively, we asked if we could have any at all as some of our clinics were running out. Brusquely he retorted that we were quite entitled to request drugs from the Nepali Government Stores just like anyone else, and that if there was any in stock we could have it. Manny, our gentle giant of a Medical Director asked if we could look at the inventory list so that we could order what was available. The pharmacist threw up his hands. He explained that there was so much coming in and out of the stores that he had no idea what was in stock never mind the quantities. Slowly it dawned on us all that we were in a classic third world bind. The simple idea of ordering stock only works if the supplier knows what he has got. He did not. However, our failure to make a fuss was clearly having an effect and after a barked order in Nepali, our drug consignments Way Sheets were brought in and he quickly marked off what we could have and what he would be keeping. He was taking half. As we left the office I kept reminding myself to think positive. We had found the drugs and we might be getting 50%! Examination of the sad looking pile in the courtyard showed boxes missing and others with spoiled drugs. We certainly would not be getting 50% of useable drugs, but at least that has cleared up a situation that has involved hours of phoning and searching.
Our 4 tons of drugs found at last in the boiling sun, but what a mess! Actually it was not as bad as it first looked and most were OK.
It is funny how timing works. We are desperate to get hold of a digger to clear the road each time there is a landslip, so that we can get the staff up to the mobile clinics. Blow me down if we don’t hear that the great Mr JC Bamford, designer, and builder of the mighty JCB might be able to donate one for just this purpose. He was my childhood hero ever since an exploded diagram of his radical new JCB was centerspread in my Eagle comic which arrived every Wednesday! Now then how do we get that digger and sneak it in through customs?
Dogs
If Kiev is the City of Bells and Kabul of Muezzins, then Kathmandu is the City of Dogs. Not just dogs – barking dogs. They bark all day and they bark all night. They bark alone and they bark together. The only time they are quiet is around 3am if it is raining hard! I know, because I have lain awake waiting for them to start again.
I have become a bit of a connoisseur of dog barks and can now recognise many of the locals, from the yappers, through the howlers, to the gruff boomers. But it is more complicated than that. There are clearly two types of dog in Kathmandu. The house dogs are the elite, fat and well groomed, the Brahmins of the dog world. They are guards and bark to protect their territory. They live behind wrought iron gates and high walls. The other group are lean, mean and scruffy mongrels who belong to no-one and wander free through the city. Clearly the house dogs see the street mongrels as the ‘Hells Angels’ of the canine world, but envy them their freedom. Never have Kris Kristofferson’s lyrics ‘Freedom is just another word for nothing left to lose’ been so true. On the other side, the street dogs see the house dogs as living in ‘Heaven on Earth’. It sounds to me as if a lot of the barking is just about this envy. The Bobby McGee mongrels gather round a gate and quite deliberately irritate the guard dog inside. He or she responds predictably and a wild barking hullaballoo is set up where both sides threaten a real rumble in the jungle if this wrought iron gate were not in the way. Then the mongrel pack trots off, tails high, to drive another house-dog crazy. The funny thing is that both sides seem so envious of the other that they lose much of the pleasure of their own life. The compound dogs pace and whine for freedom, while the street mutts trot from gate to gate on the off chance that one might be open, and they can enter heaven.
My time in Nepal is coming to an end. Médecins du Monde is now a big player here with over seventy staff. The people in the hills seem grateful for what we are trying to do, if a little frustrated at how little it is and how slow the progress. They have to live through this monsoon under a loosely strung tarpaulin draped between stones. But there is nothing passive about their response. They are tough independent people and doing everything they can to get their lives going. Many have sent their women and children down into the lowlands where they are at least safe from landslides, while the men plant the crops, guard the land and wait until the monsoon is over before starting to rebuild. Yesterday just west of us there was 10 inches of rain in 3 days. If that happens here, then whole hill-sides are going to slip down and bury the demolished villages. The men here know that, so don’t want to start rebuilding until they know that the danger is over.
My work is mainly centered around obstructive bureaucracy. The Nepalese government really does not want us here. They want the aid, money and equipment but not us expatriates, and I can see their point. It is their country and they want to run it. What we sometimes call corruption may actually only be a system of commissions where a permit requires a fee, and that is how a civil servant supplements his meager income to live in the manner he sees fit. If you want to read about the same system in Britain read Samuel Pepys diaries when he was secretary to the Navy and you can see it described perfectly. What must be frustrating for these civil servants is to see expatriates handling these matters without needing to be paid a commission because they already receive a salary adequate for their needs. I fear that this is yet another example of a collision of cultures where the danger is that both sides think the worst of the other.
The bit that I won’t miss is the multitude of organisations whose name starts with UN followed by an incomprehensible jumble of letters (eg UNIBLOT). Their life revolves around writing reports. Of course, we need information to plan but they have taken this process to a new and higher level where it becomes an exercise in its own right. They send out emails that are instantly recognizable because they have an enormous UN logo on them and then a sentence starting ‘ We humbly request….’. Humbly, my foot! If you don’t comply, then another email arrives, copied to everyone, to shame you into filling in yet another massive form. To add insult to injury a lot of my hundreds of colleagues have not yet learnt the difference between ‘Reply’ and ‘Reply All’ so they send their answer to everyone. I have to say I simply do not want to know why several dozen NGOs that I have never heard of want to tell me that their report will not be ready until tomorrow. Any simple training ideas to persuade people never to use the ‘Reply All’ button ever would do wonders for my Karma!
Yesterday we held our first meeting/party for all the staff and for the first time I got a glimpse of how big this project has grown (from twelve staff before the quake to over seventy now). All of them from the cleaners and the drivers up are genuinely passionate about what they are doing. It has been a real honour to work with them.
Most of the team at our first big meeting in the pouring monsoon rain
Reflections on being General Coordinator for MdM France in Kathmandu Nepal June 2015
Nepal is a very old and proud country with a high level of education for its elite. It has had its fair share of problems recently with a civil war and now a double earthquake which has done huge damage to a fragile infrastructure.
It is a beautiful country with some of the nicest people that I know and so attracts a lot of INGOs and aid. These have increased massively during the period immediately after the earthquake such that the country is awash with INGOs, new and established. The situation is not as bad as Haiti but there are undoubtedly similarities. The amount of aid causes anxieties on both sides: on the donor side that it is being siphoned off by corrupt individuals: on the recipient side that it is being wasted on expatriate staff and white elephant projects. The local newspapers regularly feature articles critical of INGOs (the most recent was the UN delivering rain damaged and rotten rice to a remote village). The government is clearly concerned that the sheer size of the INGO sector threatens their control of how the country is run, especially the health care sector.
The second problem, which is as old as time itself, is that it is easier to give than to receive graciously. International Non-Governmental Organisations are all about
- relieving those who live in the developed world of their guilt for those less fortunate than themselves ,and
- distributing this largesse, money, goods or expertise to those who need it and most importantly will prosper and be grateful for its receipt.
There is commonly a dissonance between the three drivers ‘What do they Want?’, ‘What do they actually Need?’ and ‘What are we able to Provide?’.
Where there is a large overlap between these three (a very rare situation) then Aid is easy to give, is welcome, and should have a positive effect.
Where there is actually no overlap (a much more common situation) nothing can succeed until there is some overlap between the circles
There is overlap between these three circles in Nepal but it is by no means total. MdM France has made a huge effort to address this issue and has a closer relationship with the local wants and needs of Nepal than any NGO I have worked for in any country.
The policy of the government reflects their ambivalence about this situation. All INGOs must now have a local partner and are officially only allowed one expatriate on staff. Any drugs or equipment being brought in by INGOs automatically becomes the property of the government for them to decide on where it is to be allocated.
In Haiti it became clear that the INGOs had become so powerful with their resources that they effectively hijacked the government and started to run the country themselves. Nepal is clearly determined not to let this happen. As one of the larger INGOs in Nepal, MdM has to be acutely aware of this issue. We are continually organizing meetings at local and government levels to listen to and respect the wishes of the government (national and local). This keeps these circles as well overlapped as possible. I believe that over a period of years MdM has built a bank of trust and respect supported by some very canny national staff, and it pays great dividends. However, like a garden, it needs continual attention.
Training
Training is an integral part of capacity building. We all talk about how important this is. We know that we should be training local staff, so that in the long term, there is no need for expatriates to do any of the jobs.
If we were all so comfortable with this concept that we were prepared to act on it, every ex-patriate on this and other projects would have a national shadow who would be trained in how to do their job. The plan would be that within a prescribed time period their post could be taken over. So, why don’t we do this?
The first and most obvious explanation is that we are currently in an Emergency situation and that every resource we have can and should be devoted to resolution of that emergency. But I wonder if that is only part of the explanation. Underlying this there is an anxiety which I encounter all the time in my work in training trainers in medicine. Not only is there the fear of doing yourself out of a job, there is the anxiety that in truth, half the time, you don’t actually know what you are doing or why, and so do not want to be exposed to the harsh light of reflective learning, where there is a risk of exposing that what you are doing is illogical or frankly harmful.
Beneath that level there is a much more unattractive possibility. This is that we may not believe that a National is educationally or culturally capable of doing our job. This argument could be rationalized on the grounds that ‘the country would not be in such a mess’ if the Nationals had been capable of managing the situation in the first place. This is clearly a spurious argument because how many of us ex-patriates would or indeed have been able to manage to change things under these circumstances. It resonates with the story of the Irishman standing at the roadside being asked directions to a far-off place called Limerick. His enigmatic response was “If it was myself wanting to get to Limerick, then, faith! I would not be starting from here”.
In the MdM programme here we have over seventy members of staff of whom twelve are expatriates and they occupy all the senior posts in the organization. I can find no sign of a programme to bring forward those Nationals who are in junior management posts, nor
indeed to provide ongoing training for the nurses and doctors employed by us. This was the most significant criticism made to me by the national staff as I talked to them informally.
I have no doubt that all MdM expatriate staff have regular appraisals, with discussions about aspirations, career plans and training needs. I do wonder why we are not doing the same with our National staff. In the short time that I have been here I have identified five National staff who could and should be receiving training and mentoring to fast track them into more senior management posts, and indeed all the National staff from cleaners, guards and drivers upwards must have development ambitions which we, as a good employer, should be trying to discover and address.
The team here has been one of the best I have ever worked with. The degree of commitment at every level has been tremendous and one of my main jobs has been to stop people from working too hard. Not once have I had to egg anyone on. But I think we also owe them a ‘duty of care’ to address their professional needs, which is a second goal, perhaps not as important as our primary goal but in the long term will probably be more productive for Nepal.
One of the issues which has been identified as a huge problem in the whole sub-continent is the welfare of widows. Once the Bread-winner in a family is lost, the widow and her family go to a brother where she effectively becomes a second wife or house slave. If there is no family member to take her then she is on the streets.
If we trained these widows as health care workers, then we would get a double bonus. More health care workers, and a job and status for widows in society.
Sierra Leone Moyamba 2015/6
The media and finding out what I have let myself in for
“Why are you doing this?” said the CNN reporter as the cameras started to roll. What an obvious question, but still I had not really anticipated it, and so had no answer. I was being interviewed just as I was dressing up in full protective gear; training to manage patients with Ebola in Sierra Leone.
But for now we were in the garden of the Red Cross Headquarters in Geneva, a cold blue autumn sky framing golden leaves drifting gently down onto a self-satisfied lawn. Around me were forty other NGO workers from all over the world, nurses, doctors, electricians, logisticians. Outside them a crowd of camera men and reporters were doing their best to suck some of the fear and excitement from us and transmit it to their audiences.
Suited up in PPE. At 35 C and 100% humidity this is going to be a bundle of fun to wear
So why was I doing it? Certainly it is the most dangerous thing going on at the moment short of volunteering to fight for the Islamic State (what a stupid name – neither Islamic nor a state).
I love taking risks, but equally I like to know the odds. This course was laying out those odds for me in spades.
I also love new challenges. Few people know much about Ebola and even fewer about caring for patients who have it. I have deliberately used the word ‘care’ rather than ‘treat’ because there is no treatment. This may not be an epidemic, which spreads much outside West Africa, but there will be others after this, and if there is anything that the Ebola epidemic has taught us already, it is that we are totally unprepared for the speed at which a disease can spread through a modern highly mobile society.
For the first day of the course beside Lake Geneva we had suffered ‘Death by Powerpoint’: lecturer after lecturer just back from Ebola-land describing their experiences with graphic pictures. Dead bodies lying in the street as if they had just fallen over on their way home from a drinking session at a bar: bodies being carried out of their houses surrounded by grieving relatives. Emergency treatment centres (EMCs) looking eerily like concentration camps with wire fences holding back sad faces. But the key pictures were of terror. Space-suited health workers reaching out and drawing in men, women, and children frozen with fear, to spend their last days incarcerated in a place where from now on they will not see anything but a face hidden behind masks and goggles glaring through a mist of condensation: and they call this caring! I cannot imagine anything worse for the poor patients.
Moyamba, Sierra Leone. The EMC under construction by the Royal Engineers in double quick time
The facts and figures tumbled out, one on top of the other, until your brain could absorb no more. Opinions were mixed with a fine dusting of evidence based medicine, but it was only a dusting. Lots of talk of treating patients and their families as human beings, backed by pictures of aliens in space-suits taking children away from their mothers. It looked like a medical student parody of care, if it was not what was actually happening.
Médecins sans Frontièrs (MSF) were leading on this training course, sharing the load with the International Red Cross. There is an ethos to MSF which is almost military. A certainty that their way is the best way which borders on arrogance but which is based on a lot of experience. They were the first to sound the alarm about Ebola and for months they were ignored by the world authorities, who thought they knew better. There had been quite a few Ebola epidemics before but all of them had remained in rural locations and died out spontaneously. But from day one this seemed to be different and MSF spotted it.
Now Ebola has three countries in its thrall. Health care has broken down in Liberia, Sierra Leone and Guinea. Hospitals have been abandoned by their medical staff (those who have survived). Within days of the onset of fever, it goes on to kill more than half of its victims in a horrible mess of pain, vomiting, delirium and diahorrhea.
I am going to be working for Médecins du Monde Spain. MdM or Doctors of the World is a lovely charity to work for. The staff are passionate about what they do. I have worked for them before in Haiti and in Gaza and they take very good care of their staff. They are all about caring, but Ebola is not. It is about staying alive by sticking to an almost military discipline about where you go and what you do. Caring comes a long second after ‘Being Careful’. If you catch Ebola from a patient it will be because you broke a rule through carelessness or tiredness. If you get Ebola you may well infect other staff members and will certainly involve everyone in a massive expense of repatriating you.
I asked a colleague back in Oxford about his views on repatriation of infected staff.
His response was pithy and uncompromising. “Rule 1” he said, is that “You never move infected patients if you can possibly avoid it. It risks spreading the infection, so no-one should be brought back to the UK under any circumstances”.
“Rule 2”. If you volunteer to do this kind of work you should be aware of the risks that you are taking and should not expect others to risk their lives trying to help rescue you when you get ill.
“Rule 3” he finished, is “If you are going out to set-up treatment centers for the locals but there is to be a separate special treatment center for any infected expatriate staff, then how come the standard centers are good enough for them but not for you? Isn’t that blatant racism?”
I had to admit that I found his arguments logical if a little brutal, but this was an argument we used to have when I was young and a keen climber. If we needed rescuing and that put rescuers at risk, we felt that we had not asked them to rescue us, so the risk was not our problem. Oh, the self-centredness of youth!
Ebola has caught mankind at its weakest point. West Africans are apparently very touchy-feely people. They shake hands, they embrace, they cuddle and they kiss. That is how Ebola is transmitted. Worse still, the dead bodies are highly infectious. Their West African culture expects bodies to be carefully washed and to be cuddled after death. This is just what Ebola needs for transmission.
Like all terrible diseases, the origins of the infection are murky. It is possibly caught from wild animals (fruit bats) and eaten as bushmeat. Isn’t it just so appropriate, that it is caught from eating a creature that looks like a vampire and lives in the deepest forests of darkest Africa, and then is spread by acts of kindness?
The personal stories are harrowing. One worker just back from West Africa described a family of eight all being put into quarantine after one of the family developed Ebola. One by one they succumbed to the disease and then died, leaving only an 18-month-old alone who had survived but had to remain in the compound as she was infectious. There was no member of the family to look after her, so two children from another decimated family cared for her even though they themselves are only ten and eleven years old. One day, she slipped past her guards and clambered through the fence into the infection-free rest area where staff were resting un-protected. At the sight of the child in the disease-free area, the staff all ran for their lives, away from the bewildered child. Only once a staff member had gowned up in their suit could the child be led back into the ‘proven disease ward’.
The hysteria in the rest of the world is frankly embarrassing. North Korea has closed its borders. Australia and Canada will not issue visas to people coming from Ebola-infected countries. Medical staff showing no symptoms and therefore not infectious are quarantined in their home countries. We accuse Africans of being superstitious, but really we are no better ourselves.
Mission 22nd November 2014
PPE is the name given to the bright yellow ‘Cosmonaut’ suits, which you see the care workers wearing when working in Ebola centres. There are surgical boots and scrubs, a whole-body waterproof suit, a thick apron, a hood, two face masks, goggles or a visor and double gloves. It takes a minimum of ten minutes to put it all on and nearly twenty minutes to take it off, because each layer needs to be sprayed with chlorine before it is removed and at no time must you ever touch the outer surfaces of each layer (as they may be contaminated). You need a helper, who calls out and checks each stage of suiting and doffing. Then you also need a ‘sprayer for doffing’ who covers you in chlorine solution at each stage of removal of your protective gear before it is taken away and incinerated.
Within five minutes of putting on the suit you are pouring sweat and mist is forming inside the goggles and on your glasses. Within ten minutes you can see nothing but a blur in front of you. In 30 minutes you are soaked and your boots are literally filling up with sweat. Médecins Sans Frontières (MSF) say that no-one should try to stay in their suit for more than 45 minutes, and I would be surprised if you are safe beyond 15 minutes in the tropics. There is not a lot that you can do in that time. If you overheat and collapse in the infected zone of the hospital, rescue will be difficult and very dangerous . The fear of staff developing Ebola has driven MSF to recommend ever more draconian protective measures for staff, which are now becoming so complex as to make the risk of contamination greater, not less than before, and the work of caring for patients well nigh impossible. Metaphorically we are shooting ourselves in the foot! We did exactly the same thing in Afghanistan, providing heavier and heavier body armour for our soldiers and their vehicles until they were almost unable to move. Paradoxically they were then probably at greater risk of being injured than if they were only lightly protected and mobile, a sort of ‘protection paralysis’ I suppose.
I am to be the clinical director of one of the Ebola Management Centres for the next 9 months. We will open with ten beds then rise to 100. My primary job will be to make sure that not one member of staff gets Ebola. If they do, it will be because a mistake has been made and I wilI hold myself to blame. Volunteers are not famous for being keen on mindlessly obeying orders and my task may be something close to herding rabid cats.
I will also try to ensure that patients are cared for with as much dignity and kindness as possible, but this is not going to be easy when working in Cosmonaut suits.
The logistics behind providing enough isolation beds to bring this epidemic under control are quite awesome. We are only one of seven centres being built by The Royal Engineers who have come in to design and build the Centres. Everything has done as quickly as possible but be right first time, because once the centres are open, no-one can enter the contaminated areas except in suits. The Army have done all this from scratch incredibly quickly. That doesn’t stop some people complaining that the ‘International response is woefully slow and inadequate’. That is the sort of soundbite that the media love.
In Haiti it was a bit galling to see footage of the reporters standing amongst the devastation, demanding to know where the aid workers were. Well we were ready but waiting for the helicopters. There weren’t any spare because the media had chartered them all!
Today the Royal Air Maroc flight to Casablanca and then Freetown is filled with fifty British doctors and nurses heading out to staff the Ebola Management Centres. At last we are in action.
Lots of bright T-shirts with NGO logos clothe some very excited and apprehensive people. To my amazement a high proportion are first timers to the aid world. It is really difficult to get work in Humanitarian aid. No-one wants to take you on until you have experience ‘in the field’, and you can’t get that work until you already have experience, a chicken and egg situation. This time the sheer numbers being deployed have meant that lots of new faces have been recruited, and I think that is great news. Within a few weeks all will have confronted the reality rather than the dream of working in the third world. Most I hope will find the experience exceeds their wildest expectations, but some are in for a major shock. Living conditions will be difficult. But one the most upsetting part will involve ethical dilemmas, where we have to turn patients away or leave orphaned children to fend for themselves. It may be that putting up drips and inserting naso-gastric tubes for rehydration will be too risky so that ‘treatment’ will be reduced to ‘all nursing care’. This will be very frustrating when these patients could be saved if we just did a little more. Africa will take everything you have to offer and then hope for more. Demand for health care can appear limitless.
An aid charity is not dissimilar to an ordinary commercial company which is doing business to make money. It is just that all the staff passionately believe in what they are doing and are a woefully lowly paid compared with their colleagues in the commercial sector.
We doctors and nurses working in the NHS often perceive ourselves to be in the same position. Most of us work because we love what we do, not to make our fortune. Paradoxically that makes us, and the staff in NGOs quite tricky to manage. The productivity of workers in the commercial sector is fairly closely related to how well you pay them, so a manager has a simple lever if he wants to improve productivity. But staff in the charitable sector will give 110% if they believe in what they are doing and walk away if they don’t. If what they like doing fits with the goals of the NGO, productivity is good, but if the goals of the organisation and the ‘volunteers’ working for it do not coincide, then that charity is doomed. It is even more complicated than that. Those working in head-office may have little insight into what workers are doing in the ‘field’ and vice-versa. If communication is not good, and it usually isn’t in the 3rd world, then lack of understanding can rapidly morph into lack of respect and then the trouble starts. One of my jobs is to keep those communication lines open and clear.
Today we were meeting and greeting the various organisations that we will work with. DfID seems to be staffed by incredibly young people who are all fantastically bright. This is very scary for an old buffer like me.
There is a ground swell of frustration in Sierra Leone amongst the Leonians at how slow our response to Ebola has been. If they but knew how hard everyone has been working to get things going as quickly as possible. But one of the hurdles seems to be safety. The Sierra Leonians are living with Ebola in their community and every day that goes by means the loss of more of their family and friends. In contrast our volunteers have agreed to come to Sierra Leone and are putting themselves into hazard. They are not soldiers who have taken the ‘Queen’ shilling’ and must obey orders. Nor are they employees of a multinational company receiving a hefty hardship allowance They are volunteers and the NGOs employing them are quite rightly really worried about their safety. So, we have become embroiled in what can only be describes as a ‘super-safety’ culture where any suggestion that could possibly make things safer for the team is adopted and sanctified in standard operating procedures (SOPs). Each one means more equipment being ordered, more training being needed and more delay.
As we drive round Sierra Leone from meeting to meeting, we are met by closed gates. Once open we must first wash our hands in Chlorinated water, and then have our temperatures taken. I am not sure what happens to us if we are found to be febrile. It does create a siege culture, with a stark contrast between the ordinary people haunted by Ebola and the expatriates secure in their gated compounds.
The other job today has been to recruit staff. I had no idea that an Ebola centre opening 50 beds needs more than 200 staff, and they all need to be recruited within the next week. Sadly there are lots of teachers in the pile of applicants. The schools are all closed so they have no work. Now we are going to train them up to clear up vomit and diahorrhea, a miserable job but one that requires the most careful training because it is so dangerous. How do you interview someone to discover whether they will obey the rules that protect us all? How can we be sure that they will care for patients. Will they get claustrophobic in the Cosmonaut suits?
The staff at the Old Ebola Centre in Moyamba. They are in flip-flops, have no aprons, and the gloves that they are wearing are the only ones they have. There are not enough face masks to go around. So, how come they didn’t get Ebola?
An aerial view of the Ebola center built in 8 weeks, designed to house 200 patients. But actually ended up holding the same number as the old one
25th Nov 2014: First sight of the Ebola Centre
We were supposed to leave Sierra Leone very early this morning to head up country to Moyamba, but there were signals from Headquarters to reply to. It was ten o’clock before we finally set off up over the hills out of the city and into the country.
Sierra Leone unwound for hours – empty country, small villages, and then checkpoints. Lots of them. At every one, a boy with an infrared camera took our temperatures. If we are febrile they are supposed to turn us back, but when we asked them what number on the thermometer meant ‘turn back’ they looked bewildered. One said 40 or 41 C maybe! On top of that, it was clear that the thermometers could not have been calibrated so they gave all sorts of crazy readings mostly in the low 30s.
When we got to Moyamba we could not miss the Ebola building site. It is huge! 15 Royal Engineers are supervising a team of over 300 local labourers milling around some very heavy digging machinery. The scene was like something out of a Breugel painting, dozens of figures clambering up, and then scrambling down, carrying great piles of stones, cement, wood, and steel. A David Attenborough voice over of how a colony of ants work would have completed the documentary. They have only been at work for 4 weeks but the Centre is nearly finished, complete with wards, generators, incinerators, soak-aways and massive water storage tanks. The exclusion fences will be last to go up so we had to imagine the double barriers between the red (infected) zone, and the green area, where we don’t have to wear Cosmonaut suits. The villagers of Moyamba didn’t want the facility built too near to the town, so it is placed in the open bush with scrub and jungle all around, except on the side where it borders on the main road. Opposite the entrance was a line of little grass hut shops. We were told that within 48 hours of the site work starting this small village of stores had appeared. Maybe we are creating a new town.
Rumours are flying everywhere even far up country. Another doctor has tested positive for Ebola far away from us, but it is the same disease. We need to start some major incident investigations. Too many staff are catching this. They always say that the difference between errors made by medics and those made by pilots is that with medical mistakes, only the patient dies while mistakes made by pilots kill the pilot as well. In that case Ebola is more like flying than medicine because it is the medical staff who risk being killed if a mistake is made.
One of the important people we met today was the Paramount Chief of the Moyamba district. I would really like to be a Paramount Chief and he quite lived up to his august title. Elderly but quite upright, he had sparkling eyes and a quick sense of humor. But his best feature to me was his solar topee which was dark brown and woven from thin reeds. It perfectly complemented his noble appearance.
The Paramount Chief
Last night I realized that I am really too old for this lark. We could not find any accommodation in Moyamba so the Royal Engineers lent us some camp beds and mosquito nets which we put up in the middle of the local (derelict since Ebola started) football stadium. Leaving aside the eerie feeling of being in a place so famous in many countries for executions and massacres, there were no blankets, sheets or sleeping bags. At first it was drippingly hot, the village dogs howled and the mosquitos buzzed round the net. Then came the chill of the night, a fog rolled in and by three am I was so cold that I was happier walking up and down than tossing around on a hard canvas.
The Norwegian aid workers are providing us with lovely tents as soon as they have built the staff camp but just for now we are going to have to sleep where we can.
26th Nov 2014: Opening up and shutting down
You can tell what a third world country is about by the goods for sale at the roadside. That is not completely true in Sierra Leone because tucked away up long tracks off the main road there are the mines, – gold, diamonds and bauxite, which should boost the country’s economy. At the road-side there are sacks of charcoal where the forest is being cut down. Then there are the one litre bottles of diesel for running the ubiquitous motorbikes. These stand alongside piles of oranges, grapefruit, and pineapples. Oranges are 50p a dozen but a motorbike costs over £1000 pounds, so you have to sell a lot of oranges to get a motorbike. Nevertheless, it is the ‘must have’ for every young man, along with his mobile phone.
This country has been decimated by Aids, then by a civil war of unparalleled brutality and now Ebola. It all seems a bit unfair. But the Leonians are bouncing back. Alongside the road from Freetown to Bo (Sierra Leone’s second city) a trench is being dug into which a set of fibre-optic cables are being dropped, right beside girls selling oranges for 4p each. We have only just got fibre-optic cable in our village in central Oxford. I don’t know who is paying for Sierra Leone’s leap into high technology: perhaps it is those hidden mining companies. In that case I wonder how much of the benefits of high speed communication will percolate down to ordinary people.
The Ebola Management Centre is nearly ready and the tents we will live are going up too, so now it is time for the final training and quality checking. Médecins sans Frontières are going to help us with that. First, we will go to their centre in Bo two hours up the road from Moyamba where we will work alongside them on real patients. Then we have a final week practicing our routines in Moyamba and then the hospital will open. The co-ordinator keeps reminding us that we need to build in some time for relaxation, but the clock is against us now and anyhow she can’t talk. She is a cross between a Cray computer and a whirling dervish, with emails still going out long after midnight and starting again at 6am. There are no limits to hours of work out here and anyhow there is little to do when off duty so the temptation is to work-eat-sleep-eat-work. Anyhow it is such interesting work that, at least in the short term, this feels fine.
But just as things are opening up, things are shutting down too. All the schools and hospitals in Moyamba district have closed for the foreseeable future. We are employing teachers as nursing aides because they have had no work for months. Just imagine if all hospitals and schools in your area closed. I suspect that for most of us it wouldn’t make much difference, unless you actually worked there, but if you fell ill or went into labour you really are on your own. There are apocryphal stories that when the French doctors went on strike the overall death rate fell. All very droll, until your child is sick and there is no hospital to take him to. Maybe, once this epidemic is over, all the effort that has gone into teaching universal precautions will act as a springboard for building a better health service than there was before these disasters struck.
Yesterday was the big meeting at the WHO headquarters in Freetown when they wanted to present to us the new Ebola monitoring tool. There must have been over 40 people present from all the organisations involved in fighting Ebola. It was a very long presentation of a very sophisticated system which works on paper, iPhone, or computer. It will give the WHO daily updates on the progress of Ebola or more accurately our progress against it. The form takes over an hour to fill in and is sent off each day, from every centre handling Ebola. It is very cleverly designed and has clearly taken hours to write, but I fell to wondering who it actually helped. Certainly, it will give the staff in Geneva data on which to base reports and recommendations but it relies on all the work being done by the workers in the field who are busy enough as it is. It also relies on every Ebola team religiously filling in these forms as otherwise the information will be flawed because it is incomplete. At the back of the room a restless man in too much of a hurry to sit down, broke in and introduced himself as the coordinator of haemorrhagic disease outbreaks, explaining that he had been in charge of 19 of the last twenty outbreaks worldwide . He spoke quickly, passionately and clearly. He damned the WHO efforts with swift and faint praise and then moved on to what we clinicians needed to know.
He explained that if you bring cases together into holding areas but fail to observe strict protection of staff you can actually spread the disease to more people rather than slowing it. He called this effect disease amplification. I had never heard of this concept before but it made sense. He then gave a message that he had clearly given one hundred times before. We need to rehydrate the patients quickly and not delay while they were moved from holding centres to the main Ebola Management Centres like Moyamba. In a few short minutes he cut through to the chase pointing out that this disease needs handling from the bottom up not the top down and does not need a super sophisticated measuring tool. Then he swept out of the meeting to catch a flight to deal with polio in Pakistan. The WHO staff had glazed over as soon as he started to speak. Now the thunder had been stolen from their meeting, and the momentum of the meeting was gone. I felt rather sorry for them. They had obviously put a huge amount of work into this but I am not sure whether it would help eradicate or Ebola or just provide a rich source of data (food) for the WHO data analysts in Geneva.
Today we visited Kerrytown Ebola Centre, which was opened by Save the Children some weeks ago. They lost three patients last night and have only 16 of their 90 beds open because they have learnt so much about design that they have only been able to open a small part of the centre while the rest is modified.
This disease is extraordinary. They have in the centre a two year old breast fed child whose father died of Ebola some weeks ago and whose mother died shortly after admission two weeks ago. The child is fit and well and testing negative for Ebola despite the closest possible contact for a long period of time. In contrast one slip with your full protective gear and another staff member goes down with this strange disease. The numbers of staff at Kerrytown are enormous, and yet they can service just 16 beds. Nurses and doctors work 6 hour shifts but during that time are only able to enter the red zone for around one hour twice in the shift. In between they need to rest and rehydrate. Kerrytown is currently only accepting proven cases of Ebola so their mortality rate is high. They are real pioneers as far as we are concerned so we were there to learn the lessons they had learnt the hard way. We have a huge amount of work to do if we are to be ready in two weeks.
One week in and I am a worried man. We are past that first blur of the new colours and sounds of an African country. Now the nuts and bolts of the job are the focus of our attention from dawn to dusk and beyond. It is 15 days until we open a 20 acre-200 bed centre which will employ over 300 staff and deal with a most lethal disease.
300 cubic metres of medical stores are on their way to us. That is six large lorry loads. They will arrive (we hope) 5 days before we open, and then they must be unpacked and made operational in those last few days while we are rehearsing safety techniques of entering and leaving the red zone (where the infected patients are being treated).
Don’t let anyone say we have been tardy. They have no idea of the mountain of hidden work this project involves, if staff are to be kept safe, and patients treated with dignity.
There was lots of new building work going on in Sierra Leone. Most of it is now at a standstill. Ebola may not have killed many people yet (although we don’t actually know) but it has certainly killed investment and development. Thousands and thousands of teachers, builders and other workers have been thrown out of work. The social cost to Sierra Leone must already be huge.
Britain has now spent £230 million on aid to bring Ebola under control and so far there is precious little to show for it. This is very frustrating for everyone. It takes time to build facilities and train staff, but for the Leonians every week that goes by allows the disease to get a deeper and deeper hold on society. In Liberia, the Americans have simply poured in the military staff and run this as a war. Whether because of that, or because of the nature of the disease, it seems to be coming under control. But in Sierra Leone that is not the case. As one infectious diseases doctor described it to me, “Influenza rolls across a population like a tidal wave, but Ebola creeps along under the carpet silently spreading, we are not sure how, then suddenly pops up like a fire cracker going off and decimates a cluster of people”.
If the centres that we are building are not seen to help people the local population will not bring their sick to us and the disease will continue to creep on unchecked. If we try to help too many too quickly we will cut corners on safety, and staff who have volunteered to help, will be struck down themselves. The local Sierra Leonian solution has been to set up holding centres all over the country for patients who may have Ebola. They are in quarantine, and are given as much care as is possible in an isolated tent with staff doing their best in Personal Protective Equipment.
When we first open we will hope to take patients from these holding centres who are proven to have Ebola. Then once we are up and running safely we will open our own reception for patients. This triage or screening area has a double fence across it separating the patients from the staff by a full two metres. No person or thing may cross that gap. To make a diagnosis you cannot look closely at or examine the patient, you can only call questions across and decide from the answers what to do. If you bring in a patient with fever who has not got Ebola they may easily become infected by a patient next to them who has. If you send away a patient by mistake who has got Ebola then you are re-introducing the disease into the community. Obviously, sensitivity and specificity is poor if all you do is base your decision on questions called across a 6 foot gap. It is almost the opposite of veterinary medicine. Your patient can talk (sometimes) but you cannot examine them.
Little things have blown into great storms. There is a passionate debate currently about whether we should wear goggles or face visors when working in the cosmonaut suits. Goggles can be fitted to make sure that no skin whatsoever is exposed, but they have a horrid tendency to mist up and they make your double face mask fill with fluid. Then the mask becomes difficult to breathe through and causes panic in staff, a sort of waterboarding. One doctor who became infected is believed to have done so because he could not breathe and pulled at his mask with contaminated gloves. Médecins Sans Frontières, who set the standards in Ebola care, direct that goggles will be worn. Our doctors and nurses were trained by the Army in Britain to use visors. They don’t mist up, and the face masks don’t block, but there is skin exposure under the visor and in theory vomit or other fluids could get round the side and onto your skin. Both systems are so safe that no trial could show a difference so it is personal preference. Except that it is personal preference based on concern about your life, so feelings run very high. Because we are going to have our final training by MSF, we are going to have to change to goggles, despite our original training taking place on visors. No-one is happy about that!
We have now visited two hospitals treating Ebola. One, brand new like ours has one hundred beds but weeks after they have opened they still have less than twenty beds occupied, and feel unable to expand safely. The other is a beaten-up old hospital with lines of string in place of fences. They are full to the brim with Ebola patients and seem quite comfortable with what they are doing. They are just about to open another 100 beds and expect to have them full within a week. The staff are quietly confident and assure us that managing this disease just requires common sense. I had decided with my colleague John Wright that any intervention, such as putting up a drip would create far too much risk for the staff for a relatively meager benefit, so we were going to focus on being a simple ‘care’ centre. However, that second hospital is putting their Ebola patients on their ITU and managing them with central, arterial and peripheral lines. The community around them think they are marvelous and a steady stream of patients are being treated.
John is a physician/public health doctor and I am a retired surgeon. The meeting of these opposite approaches to medicine is really interesting and we debate hour after hour the pros and cons on how our centre should be managed. Moyamba district, where we are going, is a donut. As a result of good public health practice, the incidence of Ebola appears to be quite low where the centre is being built but in the countryside around it is high. By the time patients reach us from the remote areas, they will be dehydrated and the disease will be well advanced. If we don’t put up drips then their chances of survival will be minimal. If we do, we are putting our staff at risk of blood splash or even needle stick. It is difficult to compare success rates between those two hospitals that we visited, because the earlier that you get the cases the better the survival: but importantly there is no clear difference in the staff infection rates despite their approach to patients being diametrically opposed. It is difficult for me to get my head round all this risk. One minute we are discussing heatedly whether goggles or visors should be used, the next we are walking through the streets of Freetown mingling with the crowds of people in the market, knowing that this is currently a hotbed for Ebola.
Yesterday was Sunday and the town throbbed with singing and mighty sermons calling down fire and brimstone on the congregations who moaned for forgiveness. Between the services everyone was out in the street strolling along in their Sunday best clothes and looking quite magnificent. Religion is clearly big here and is probably even bigger with the shadow of Ebola hanging over the town. There is a large Muslim community too but they seem very quiet and restrained in comparison the ostentatious behavior of the Christians. Most importantly everyone seems to rub along together quite amicably.
At last we have finished all the meetings and planning in Freetown. The Army have announced that the hospital is ready today (built from scratch in four weeks)
Day 1
Week 2
Week 2
Picture from the site one week ago. The Centre is finished today!
The Centre exists but was not quite ready for handover yesterday!
“There is no way that we are doing that. It is not in the spec.”
Testing a live wire. “Safety at work’
Now it is time to give the teams their final training up the road in Bo where MSF work. This will include ‘wet’ training so we will enter the red zone. Then it is back to Moyamba to start rehearsals. At first each team will rehearse on its own, then we will bring the teams together and finally there will be dress rehearsals before the first patients arrive.
Tensions are now running high. No one has had a day off since this project began. Each day starts at 7am and finishes after 10pm. No one in the other teams answers their emails or their phones: then at meetings blames us for a cock-up because they claim that we do not communicate. It is hot. It is humid. We are tired and the day of the Centre opening looms closer and closer. Last night a merry old row exploded into the open. I am not even sure what it was about. It was more a symbol of how tired everyone is than the issue being argued about. This morning a whole set of new issues have arisen but the row has shown us how easy it would be to break up as a team.
The Sierra Leonian government is going to have a push on Ebola. They are sending health care workers from house to house to search for cases being hidden from the authorities. It is expected to flush out a lot of cases. The question is whether we will be ready to take them. We were supposed to accept the hospital yesterday but it was ‘not quite’ ready. They have put in fenced off walk ways to separate our red(infected) zone from the rest, but have done it in local hard woods, which in Britain would cost a King’s ransom.
Ebola initially spread from Liberia into the Eastern Mountains of Sierra Leone, and then westwards across the country. Médecins sans Frontière (MSF) had a large hospital in the centre of the country and converted this into a barrier to Ebola preventing it from spreading west to Freetown and the sea. This seems to have worked for a while but now Ebola has marched around the castle in the plain and is very active in Port Loco and Freetown down on the coast. Now it seems to be spreading South and East again threatening to increase further in Moyamba where we will be working. It looks as if the weapon which works best against Ebola is education and changing burial practices.
John Wright our Public Health advisor is going to be spending part of his time out in the community helping with education, and tracing. Once we open the Centre we should have a safe place for families to bring their sick. These are the measures that will control this disease if we can persuade people to bring us their sick family members. We need to provide good treatment at the centre so that people falling sick will decide that their chances of survival are better if they come to us than if they hide at home. What we cannot be is charnel houses staffed by space suited aliens. If we provide no active treatment apart from oral rehydration the local population will see most of their relatives die at the Centre (especially if they arrive in the late stages of the disease). They will then hide them at home and the disease will continue to spread unchecked. Some centres are treating Ebola just like any other disease and claim good results. If we do the same, putting up iv lines, catheterizing and closely monitoring our patients, then we must assume that their chances of survival will go up, and with that the trust of the local population will rise too. We will then start to become an effective additional tool in the battle against Ebola, not by saving the odd life, more by encouraging the people to change their behavior.
The down side of course is risk to staff. We don’t know how much aggressive intervention increases the risk to staff but at first I felt that minimizing risk to our staff must be our first priority. Now, I am not so sure, because it looks to me a little like a form of racism. Why should the life of one of our staff members be any more valuable than that of someone in the local population. Well, I can think of a dozen reasons but all of them appear to mask the truth that all us believe that we are worth more than anyone else. We can argue that we are more highly trained, or that we have come here as volunteers, but I fear that at the end of the day these arguments are a smoke screen for what we dare not admit. I have spent hours poring over contingency treatment plans for expatriate staff who develop a fever. From minute one we are treated differently. The British Army has a special unit reserved for staff only . Contracts have been organized to fly us out to our home countries at vast expense, and there we will be treated with everything that Western Medicine can provide, but here we are deciding whether to put up iv lines or not. The what about the gated compounds with guards, the new white vehicles, with drivers, the helicopters, the super sterilized water. From the Sierra Leonian side the whole thing must look a bit like apartheid.
Transport for staff compared with local transport.
Donning and doffing
It is eight o’clock in the evening and the rain is pouring down, drumming onto the corrugated iron roof of the guest house where we are staying while we do our final training. In the background thunder rumbles away. It is pitch dark, apart from my lap-top screen and the occasional low flicker of lightning. It has been a long day of training and this afternoon we put on PPE (Personal Protection Equipment) again and were asked to stay in it as long as we could, while we continued to be lectured and hectored.
Gowning up
The last time that I put on PPE was on the shores of Lake Geneva on a cool autumn day. It was grim. This time the temperature was over 30 degrees with 100% humidity, so we knew this was going to be uncomfortable.
I think it is worth describing in detail how you don and doff the PPE, because it may give you some idea of the working conditions we face for the next weeks. Each shift you will put on PPE three or four times and then enter the red zone for around one hour to look after the patients. You always work in pairs and your partner dresses beside you so that you can check each other as you don the various layers of protection and make sure that there are no gaps. You start in surgical scrubs with heavy white gumboots, and put on your inner thin blue rubber gloves. Then comes your heavy yellow plastic air-tight boiler suit with a front zip covered in a double overlapping layer of Velcro and a high collar that seals your throat. Now you really start to feel hot and the sweat starts to run. The next stage is a heavy-duty face mask called a duck-bill. It sticks right out from your face and is supposed to give the maximum surface area for breathing. You are going to need that. It is pinched tightly over the bridge of your nose and has double elastics on the back of your head to keep it tightly in place on your face. Now the white hood with integral face-mask goes over the top. The face-mask on this hood is split so that your duck-bill mask sticks out through it. The hood fits tightly around your eyes like a Burka and has six ties holding it tightly onto your face while the chest and back flaps fit snug against your body. You are already feeling hot but now, added to this, is a slight feeling of claustrophobic suffocation. Breathing through the double mask requires a conscious effort, and if any air escapes from your nose your glasses mist up at once. But you are not finished yet. You must fit on a heavy-duty butcher’s apron with a bow tied at the back one end short, so that you know without seeing which one to pull when taking your suit off. Next the ski goggles go on. They must fit tightly over the hood so that no skin is exposed. Then last of all you don your second
pair of outer gloves. It now feels like being underwater with a dry suit, weight belt, and aqualung on, except that there is none of the feeling of freedom that diving gives you. Your breathing is loud as you strain to drive air through the mask. Your vision is limited to the field of the goggles and your hearing is muffled by the hood. And you are hot, really hot. Sweat is now running down into your boots in little rivulets. After an hour we were allowed to go and doff our suits, but there was a queue for the undressing stations so most of us waited another 30 minutes more to be released. That was purgatory.
Undressing is far more complicated than dressing. The outside of your suit is now contaminated and you must not touch any of it. If you do get contaminated, the least serious consequence will be that you will be evacuated by charter plane. The plane alone costs $250,000 leaving aside all the other expenses. The worst consequence is that you get Ebola. I suppose the nearest equivalent to this is doing bomb disposal.
Undressing
This time a dresser stands in front of you calling out orders. You must obey him/her exactly, step by step and very, very slowly so that you do not make a mistake. The dresser works beside a sprayer who has a pressurised container of chlorine solution on the floor in front of him, fitted with a long wand. They stand in the safe zone. You stand at the barrier close to the edge of the red zone. First you face the sprayer in the crucifix position while he sprays your front from head to toe. On the dresser’s orders, you turn and your back is sprayed. Finally standing sideways on like an Egyptian hieroglyphic, the left and then the right side of your boots are decontaminated. Now, the dresser calls again, and slowly and very carefully you remove your outer gloves using the outside/inside technique, a routine that means that only outside touches outside and inside contacts the inside. The gloves go in the red bin for burning. Immediately after this you hold out your hands and your inner gloves are sprayed with chlorine. The dresser calls again and you reach behind you and release your apron bow. Then leaning forward, you draw the apron over your head. It must not touch your face! Then you roll it up touching only its inner surface. It goes into a chlorine bucket for washing and re-using. Again your hands are sprayed. When the dresser is satisfied that your hands are completely decontaminated, you lean forward and with eyes tight shut (to avoid splash) you remove your goggles, rinse them three times in a bucket of chlorine solution and drop them on the floor on the safe zone side of the barrier. Again your hands are sprayed and you await orders from the dresser. This time your hood comes off. The ties are ripped and once again, leaning forward with your eyes tight shut, the hood is drawn over your head and dropped into the incinerator bucket. Your hands are sprayed again and you remove your duck mask. Hands are sprayed again and you undo the Velcro and zip at the front of your suit and touching only the inside of the suit, but not the skin, shuck it off your shoulders and roll it down your body. It is very difficult to get your boots out of the trouser legs, so there follows a strange slow-motion dance as you trap the suit under one boot and try to lift the other boot out of its trousers, just like I used to do as a student trying to get to bed quickly after too much beer. The suit is then kicked towards the barrier where it is sprayed where it lies on the ground, then rolled up. and put in the incinerator bin. One final glove spray and then you remove your inner gloves very slowly again using the inside/out technique (they are full of sweat which must not spray around). Then your bare hands are sprayed with dilute chlorine. The last action is to step backwards out of the red zone holding up the soles of your boots one at a time to be sprayed. Once you have practiced this for a while, the whole doffing process takes around 15 minutes. During that time you must concentrate really hard and listen carefully to your dresser to make sure everything is done slowly, correctly and in the right order. Once the suit is off you can relax but you are soaked to the skin and for a moment you feel quite cool.
Ebola diary. Still not operational! Why not?
I sense that there is increasing anger and frustration here in Sierra Leone at how slow we have been in getting our support organised to bring Ebola under control. The media always enjoys running the ‘Where are the cavalry?’ stories, and it is a good question, but it is so easy to be wise after the event. Some of the sniping is justified, but some of it is not.
The first case of Ebola in this epidemic was October last year, just fourteen months ago, in one of the poorest and remotest parts of Africa. Superficially the disease mimics several other diseases, which are common in this area. Lassa fever kills five thousand people a year. Malaria and typhoid even more. Ebola did not appear with a fanfare of horrible deaths. It crept in under the cover of other similar endemic diseases. Even so, Médecins sans Frontières (MSF), who had a hospital in the area and have also seen many Ebola epidemics elsewhere in Africa were quick to spot a new outbreak. The problem is that Ebola has appeared and then died out many times over the past few years. So, at first, no-one worried too much. But this time it seemed to be different, and again MSF were quick to spot this. The WHO just did not accept MSFs assessment and made soothing noises based on previous experience of Ebola. They were wrong and have very honestly admitted as much. Most of us, who work in the field spend a lot of time grumbling about big Geneva based UN type organisations like the WHO. Their staff can appear arrogant and remote, flying here and there in big helicopters. Their massive salaries (certainly by NGO standards) are tax free, so they are a perfect target for the ‘politics of envy’. But this time, even I felt a little sorry for them. They were caught out and had the grace to admit it. Meanwhile Ebola continued to spread, creeping along under the carpet, and then exploding like a fire-cracker in a cluster of cases often centered around a hospital, and its staff. But the important thing was that it was not killing Westerners apart from the odd missionary. It did make the bottom of the foreign news pages because it involved lots of the features that make an ‘Africa shock-horror story’ so attractive. The disease reservoir is a wild animal. Better than that, it probably involves the fruit bat, an enormous creature, that looks like a vampire in a horror movie but is actually a rather benign social fruit eater. The second feature that makes the article attractive to the Red-tops is that the local people hunt and eat these bats. Really it is no different from rich bankers shooting and eating pheasants but it has that little frisson of darkest Africa and a paradox, people eating vampires, instead of vampires eating people.
Then Ebola is a little different from other diseases. Despite our in-built anxiety about touching dead bodies, they are usually quite safe to handle. Patients who die of an infectious disease are not usually infectious once they are dead, but in Ebola they are. The corpse remains highly infectious, and we don’t know for how long. I can only think of Anthrax doing anything similar and that is only from spores. The Leonians show great respect for their dead. They wash the body carefully and only allow burial not cremation. At the funeral I understand that it is usual to say goodbye to the person by touching them, or even kissing them, so now we have the final element of a ‘good’ news story, respect for the dead converted into a hint of necrophilia.
Even so, a good Red-top story does not spur governments into action until people in the developed world feel threatened. At the end of July an American doctor died after returning to the USA from Liberia, and suddenly the world woke up. This was no longer an African disease, it was a plague threatening the developed world. By the September the Royal Engineers were ordered to mobilise at 24 hours notice to design and build six Ebola Treatment Centres in Sierra Leone. Today at the beginning of December, most of these centres are open. Now that is what I call fast work. Not fast enough for the media or the Leonians, sure, but nevertheless very, very fast for a complex aid project in a third world country.
A 200 bed hospital built in 8 weeks flat
One of the four stores tents starting to fill
John Wright and the drying area for boots and scrubs
Could we have moved more quickly? Of course we could – in retrospect. In August I suggested to DfID that we should follow the model being pioneered by the King’s Hospital team in the Connaught Hospital in Freetown. Dr Oliver Johnson and his team just took over a ward, put up polythene sheets to isolate patients and got on with it. Awesome! But they have had staff infected, and in retrospect I think I was wrong to suggest that the approach taken by King’s was the right one to expand to the rest of the country. As soon as the big guns like DfID became involved, staff safety became a dominant and almost paralysing influence. The design of the Ebola treatment centres each of which cost millions of pounds to build is all focused on staff safety, not patient dignity or comfort.
The World Health Organisation have now arranged to charter a special aircraft at $250,000 a flight to repatriate international staff who MAY have Ebola. They claim that they had to do this because no International staff would volunteer to come out to help, if this rescue route was not in place. I don’t think that is true. UK-Med were swamped with volunteers the moment they launched their appeal for help. It is nice to know that there is an extra safety net for us here, but it is also another punch on the nose for all the National staff here in Sierra Leone, who have volunteered to help, are at much higher risk of contracting Ebola than expatriate staff, but who have no special arrangements made for them if they fall ill.
On the training courses our instructors are forever thinking of more abstruse and complex ways of catching Ebola, which lead to ever more constrictive protective measures being formulated to reduce risk to staff.
If you watch the news from Iraq, Syria, Gaza or indeed Sierra-Leone, you will see patients and refugees being herded along by NGO workers with face-masks on: so why are they wearing them? It certainly can’t be anything to do with infection control. Paper face-masks are supposed to stop you spreading aerosol-based infection to other people, although I very much doubt that they do. I have never seen any evidence that wearing a face-mask prevents you from catching an infection from someone else. Even so, it seems to be becoming part of the uniform of the health care workers just as dark glasses are part of the uniform of a dictator. Both have the effect of reducing contact between people. I can understand that a dictator might not want his people to see the fear in his eyes, but why would a health care worker want to wear a ‘face Burka’?
I just wonder whether it is something to do with power and control. As soon as you put on a face-mask you become a little less of a human being, and more of an object, an automaton. Perhaps it is only a label to say that you are ‘staff’ not a ‘patient’ or ‘refugee’. But, to me, it carries some heavier connotations, such as “I am clean, and you are dirty” or “I want to minimize any contact with you”. It certainly does not help build trust and confidence between staff and the people that we are supposed to be helping. But if I am to persuade my health workers to remove their masks and interact properly with the people that they are supposed to be helping, how am I going to give them a badge of authority and the sense of security which seems to be provided by the face-mask.
With Ebola, the measures taken to ensure cleanliness and protection have risen to new heights. Obviously there is a no-touch policy. The Mediterranean staff now ‘air-hug’ each other instead of embracing, while us cold-blooded Northerners merely lay our right hand on our heart, instead of shaking hands.
Rescue team going out to collect a patient who has collapsed outside the gates of the centre
Yesterday we worked through complex scenarios, so that we would know what to do when confronted by them. The one that caused most furore was apparently a true one. An ambulance arrived from a holding centre with four Ebola positive patients in the back. They were expected by the Centre, and were admitted. But what was not expected was that in the vehicle also was a mother with two young children (aged five and ten). The children had tested positive but were not expected, and the mother had tested negative but been told that she could come to look after her children. They had all been in the back of the ambulance for four hours with a patient who was terminal and bleeding, so they had been in the closest contact with Ebola that is possible. The rules are that only Ebola positive patients can be admitted to the inner sanctum of the ETC ‘Confirmed patient’ ward. Clearly that was where the children should go, but what about the mother. By the rules, she should now be turned away (four hours away from home, darkness falling, without any money and with Ebola contaminated clothes) and separated from her children. Humanity dictated otherwise. The room polarized swiftly into “the rules must be obeyed or we are setting a precedent” and the “you have got to discuss this with the mother and if she wants to take the (? increased) risk of going into the confirmed ward to look after her children, that is her choice.”
Like Middle-East peace talks the argument ground to deadlock. Then someone had the sense to ask the facilitator what had actually happened, seeing as this was a true story. The answer was that the mother had been turned away after being given clean clothes and some money. During the following week her daughter died but her son survived. But the most extra-ordinary part of the story was that the mother did not contract Ebola! So here we are dressing up in space suits, and tip-toeing around this disease, and this mother who has had close contact with two disease positive children and a dying passenger does not. This disease gets stranger and stranger.
For weeks now, day and night I have lived and breathed Ebola. I have read newspaper articles, scientific papers, and WHO reports. I have attended medical grand rounds where the great and the good discuss the possibility of vaccines. We have trained again and again to put on our space suits, and today for the first time I faced Ebola in the red zone. This time, donning the PPE was for real, so I checked each step twice. It seemed to take an age before my partner and I were ready to trudge through the foot-baths into the confirmed zone. We had already been given our tasks. One patient was bleeding from an intra-venous cannula. She was confused and rolling around in pain, and the needle had pulled out of her arm. Another, we were told, needed a dressing for a bed-sore. So before we even got dressed-up we rehearsed what equipment we needed and how we were going to do things. The young woman whose drip had come out was half off her cot when we got to her. She was clearly terrified and in pain, her eyes staring wildly around her. I am not sure that she knew where she was or who these suited figures were. Her drip site was no longer leaking so we tried to give her some water. She drank avidly from the bottle we held to her lips even though swallowing was clearly hurting her. Then she rolled onto her side in a spasm of pain and vomited up blood all over her bed and the floor beside her. Everything happens in slow motion in an Ebola ward. You cannot move quickly in your PPE suit and nor should you, in case you tear it on something. We fetched a bowl of water and absorbent pads and started to mop up the highly infected blood, but it was everywhere. The effort of lifting the patient was making my goggles mist up, so my connection with this world became ever more remote. Within twenty minutes of putting on PPE a pounding headache starts which builds in intensity until it dominates everything that you do. I suppose it is your body overheating, and it is very unpleasant.
The next patient was again a young woman and needed a bed sore dressing. This was no ordinary bed sore. It was the size of the palm of my hand on her sacrum. Its walls were deeply undermined so it was actually twice as big as it looked from the outside. The bones of her sacrum were clearly exposed. I have seen sores like that on patients with spinal cord transection or in elderly patients who have been neglected, but never in a fit young women. Even though we gave her morphine, washing and then dressing the wound was obviously agony for her. The proper treatment for such a huge deep sore would be complex plastic surgery, but there is currently no surgery in Sierra Leone and certainly no one would operate on an Ebola positive case anyway. That bed-sore is a death sentence for her. In Britain I worked on bed-sores as a junior doctor. I learnt that they are a primary indicator of neglect, a sign that patients are not being turned properly and/or are not being given food and water. Here, I am afraid they may be inevitable. All the patients coming in with Ebola are already dehydrated. They may have been some days in a local holding centre where there is minimal nursing care. Then they will have travelled in the heat of the day for many hours in an ambulance to get to our centres. They also have terrible pain when they swallow and they may have diahorrhea and vomiting. Their situation is a perfect storm of dehydration. “Why don’t you put up a drip?” I hear you ask. Well, firstly it is hard to do in PPE, with goggles and double gloves, and potentially dangerous with an uncooperative patient. Then you have to work-out how you are going to change the bottles each time they finish; then how are you going to adjust the flow-rate? I think that what we are going to try in Moyamba is a new kind staff member – a hydrator. They will simply go from patient to patient giving each of them sips of water, as much as they can tolerate. Just like the painters of the Forth Road Bridge they will never stop revisiting every patient until their shift in PPE is finished. They will then be replaced by another team. We will certainly need drips on some patients but perhaps we can avoid that need in others and make them more comfortable.
Today I was allowed to attend the morning ward-round. We have to be quick seeing the patients because we will only last one hour in our space suits and there are over 50 patients to see. The first thing the team does is identify every patient who can stand. They are then told to get up and move to a chair outside the ward near to the exclusion fence. There are several advantages to this strategy. First, it is a good test of how ill they are and gets them moving a little. But the big advantage is that it also means that they can then be seen and talked to by a doctor and nurse outside the fence who do not need to be in space suits. This means that we can simply focus on the sickest patients in our full protective gear. The lady who vomited blood yesterday is now quiet and in a coma. One of the children who is only two years old is having an epileptic fit. She is very hot and while we go to the fence to ask for some midazolam, I ask one of the nurses to cool her down with cold water sponging. She fills a large tub with cold water and lays it by the child’s cot. Then without further ado she hoists the child up by her wrists, her head lolling to one side, and unceremoniously dumps her into the tub, where she starts sponging her down. She is obviously a mother herself because she has none of that cautious hesitancy that people who have had no children show to these apparently fragile creatures. To my delight the child’s fit stops but I fear that it will start again as the temperature in the ward is over thirty degrees and the child is feverish too. She is so weak that even her fitting is just a shake. All the patients are thirsty but some are simply too weak to lift their water bottles. I stop to help and am told off by my fellow doctor on the ward round. There are still more patients to see and our time is running out. My goggles have misted over but I notice that when I lean forward, sweat from my face pours onto the inside of the goggles. If I then roll my head about I can use the small pool of sweat inside my goggles to mop up the misting.
I managed to last a full hour today in my protective suit before I found myself swaying on my feet, so I missed the final stages of the ward-round. After the last patient has been seen the doctor walks to the fence and shouts across the no-mans land between the fences the findings for each patient and actions needed. It is the only way to get the information to the outside world, as nothing (not even paper) is allowed to come out of the red zone. This time the transcription was not very good so we then spent the next hour trying to remember which comment belonged to which patient.
The staff at the Ebola centre are kind, cheerful and happy until you scratch the surface and then the stories pour out. One nurse has not dared tell his mother what he does. He knows that if she finds out she will forbid him to continue. Another told me how her neighbours call their children back if
they play close to her house, and who drive her children away if they go near to her neighbour’s house. There is a huge stigma against anyone who gets Ebola. It is seen as judgment from God for sinfulness. This prejudice rubs off onto those who work with the disease too. I wonder how open minded we would be if we knew that our next door neighbour worked in an Ebola centre and might contract the disease at any time.
I am still trying to understand how this disease spreads, or equally importantly why on some occasions it does not spread at all. There is an obsession amongst everyone I ask that it is something to do with the burial rites of the secret societies which exist in Sierra Leone. There is talk of unborn fetuses being removed from the dead mother, so that the family line is not buried, and other strange customs. The stories about the ceremonies become ever more lurid, but the anthropology articles which I can find on the web make all this seem very unlikely. The Sierra Leonians certainly wash and lay-out the dead body and show great respect for it, but it seems that beyond that, there is precious little evidence of customs which could spread Ebola. What is now very clear to me is that it is a cruel disease, and the sooner we bring it under control the better. We are now one week away from opening our own centre. The Royal Engineers make the final hand over today. The countdown has started.
Coming out of PPE is like coming up from the bottom of the sea. I only lasted forty minutes before I felt myself swaying and knew that I was unsafe. The un-dressers are very strict. They have to be. You must not make a mistake undressing. Your suit is contaminated and it would be only too easy to get bare skin in contact with contaminated suit. So, they bark out the orders, and if you look as if you may be about to do something wrong they shout “Stop!” and repeat their order. There is a sort of desperation to get the PPE off, and to get fresh-air on your face. It is their job to keep you steady and under control, however bad you are feeling. The relief as you step away from the red barrier is huge, but then you start thinking about those poor patients back in the ‘confirmed’ ward. For them there is no simple escape.
The hospital has been handed over 8th Dec 2014
The Ebola Treatment Centre was formally handed over by the Royal Engineers to Medicos del Mundo today. It is very nearly finished and the question now is whether we are ready to open in six days time. We have recruited 20 local nurses on top of the eight Norwegian doctors and nurses who arrived today. Then there are 160 Water and Sanitation workers (WATSANS) who will do the spraying, the cleaning, the cooking, and the washing needed to run this huge centre out in the middle of the jungle. But we have problems. The 17 lorry loads of stores that we have been allocated have not been unpacked or inventoried. Although I begged them not to send all the supplies and gave them a skeleton list of what I needed first, there was no-one with time to separate out what we asked for. So we have X-Ray plates and inotropic drugs, ECG machines and hospital beds all stacked in together. I have listened to each team leader describe what they need to do before we can open. Long speeches have been delivered describing problems not plans or solutions. The Head of Mission in Sierra Leone who chaired the first meeting tried to bring each speaker to order, but they had to have their say.
All the old management truisms now come into play. “We are only as strong as our weakest link”. Our head of the water and sanitation team is really worried. He has only three trainers and feels that he needs at least another eight days to draw up rotas and to train the hundred staff he needs to open. I have to say that I am a little bewildered as I cannot understand why rotas have not been drawn up in advance. You don’t need the names of people to decide how many staff you need in each position. However, it is one of those issues which is best avoided in an open meeting. The Norwegians in the meeting fall silent, the Mediterraneans repeat over and over again principles that we already know but give us no idea of how to take things forward. Minutes tick away while the chair tries to bring things to order, but eventually the meeting breaks up. There is now a meeting with the team doing community support work, and another with the NGO who is managing the burial teams, so everyone sets off to attend these.
I am really disappointed and frustrated as I cannot see the solution if I cannot understand the problem. Two miles away from the main base across the other side of Moyamba town the Norwegians have created a camp for the expatriate staff. It is how I imagine the Norwegian state oil company would build a camp for an oil prospecting team. It has air-conditioned tents, hot showers, and five chefs producing three wholesome European meals a day. There are washing machines and dishwashers, a floodlight fence and guards patrolling continuously. It is certainly not what I am used to in Africa, and although it is very comfortable it has split our team down the middle. The Norwegian doctors and nurses are in their camp. The MdM Spanish staff have rented a large house in Moyamba town and are staying there. So, in the evening just when we all need to meet and talk, we are divided into two camps. I find myself withdrawing into my zone of responsibility. The Project co-ordinator is responsible for supplies and Watsan. My responsibility is medical staff training and patient care. I sit down with the Norwegian nurses and go over with them the main impressions that John Wright and I have gained from the time we have now spent in three Ebola centres. The overwhelming need of the patients is hydration and nutrition. If we can get the patients to take fluids and to eat, then their bodies will have time to overcome the virus. If we can get oral fluids in early, then we won’t need drips so often. We have noticed that drips are really hard to manage in the red zone. John Wright, our public health physician is staying at the Norwegian camp, as am I. We mull over what has happened today, and he too cannot understand why it looks as if we are going to have to delay the opening of the Ebola Centre. It is now 3am and I am trying to draw up a plan on how to galvanise this project into action. At 8.30am tomorrow morning the local staff will be welcomed to the centre. I am hoping then to hit the ground running. Surely we are not going to be delayed now after everyone has worked so hard to get here so quickly.
The Norwegian camp is flood-lit all night, a great beacon in the jungle. Moths gather round the lights, some of them as big as my hand. As dawn broke this morning there was a thick mist and the Pied Crows quietly swept in to hoover up the crop of insects lying stunned under the lights.
The Norwegian camp where we are now sleep is Very comfortable!
Staff Queueing To start work
We arranged to meet the local staff this morning at 08:30. I went in at 7 am because it is the best time of day and because I wanted to understand where we now are in terms of being ready to equip the ETC. As I arrived at the gates of the compound there were already dozens of Sierra Leonians queueing up in their best clothes quietly chatting. By 08:00 there were more that 200!
The ETC lay quiet, its great empty tents and wooden walkways waiting for us to start.
The local staff are all so eager to work. They want to help their country and they want to stamp out Ebola. It is quite humbling how keen and cheerful they are knowing that they are putting themselves in danger and risking rejection by their family and neighbours.
At the same time we spent the day, at the insistence of one member of staff, reviewing complex and interminable protocols for handling patients with Ebola. They are all focused around doctor orientated subjects like taking blood which we are not going to do initially. They really should have focused on giving patients oral fluids and clearing up diahorrhea and vomit. As we get closer to handling our own Ebola patients those who have not dealt with them before are spiraling into a paroxysm of complex rules about what you can and cannot do when in the Red Zone. The Norwegian nurses were getting very frustrated with the continuous harping on about protocols which the hygienists write, where it is defined which hand touches the bucket John and I are the only ones who have worked in there and we both know that once you are in the confirmed ward, you have to use your head not protocols. No situation is ever the same. Each must be approached using some simple and obvious precautions. The latest height of lunacy is a directive that if you get a needle stick injury you should remove the inner and outer glove and plunge the whole hand in 0.5% chlorine for three minutes. That strength of chlorine burns the skin, and certainly won’t penetrate down the needle track. It seems to me that we are getting into the mind-set of ritual purification through suffering. I thought that died out in the Middle Ages.
It is clear that the pressure is getting to everyone in different ways. Some, like me, are simply not sleeping. Others are spending long hours writing out these long boring protocols and then searching the camp for anyone to read them! Meanwhile the number of cases in the community continues to rise and we are still not open. I am afraid that I have liberated the Norwegians from this protocol mania. They are too senior for this so I have just asked them to apply the basic principles of sterility. They can then work out for themselves how they are going to do things and avoid the risk of infection. The result has been like knocking the top off a bottle of champagne and now there are clusters of nurses muttering away in Norwegian working out how to get someone off the floor or how to feed a patient local food. Meanwhile the politics of the NGOs rages away like a thunder storm in the sky above us. If we don’t say anything about the problems that we are having we are accused of hiding things from our Head Office. If we do, we are told that we just have to make do, as this is an emergency situation. But then our Head Office uses the information they have got from us to accuse another head office who have not heard anything from their staff, of neglecting them and the mission. That really does make everyone cross.
Today we found that there were no gloves in the first consignment of thirty seven lorry loads of equipment that arrived, so we still cannot practice dressing and undressing from our space-suits. Some of the more obsessional want us all to practice putting on and removing PPE at least ten times before we see real patients. The kit is disposable and can’t cost much less than £100 per time. This is fast becoming an expensive exercise in Obsessional Compulsive Disorder. The local Sierra Leonians must wonder what on earth we think we are up to. They are living with Ebola in their communities.
Management issues
We have no internet here in Moyamba. It is not a ‘priority issue’, so it will have to wait until everything else is sorted and the Treatment Centre has opened. Thirty Nine lorry loads of supplies have now come up from Freetown, but no modems. And we still do not have any gloves or masks
so cannot practice the dressing and undressing in PPE which is so important to our safety. This is now getting serious as we open in three or four days.
Building and opening a 100 bed centre in 8 weeks is a hugely complex project, and it requires superb site management control. Like all doctors I admit that I have sometimes been a little less than complimentary about hospital managers. Never again! I had absolutely no idea how complex their job is at every level. We don’t actually have a manager to co-ordinate tasks so each person is finding things to do and throwing themselves into it. Lots of times that works, but on other occasions we find two teams tripping over each other. It is hot and dusty here, so tempers are fraying especially as everyone is so stressed by the start date, and all the safety issues which will then come into play. One of the main water pumps has broken 48 hours after the contractor handed over the keys to the hospital. We have a back-up system but spares for the main one may take ten days to arrive. I can’t believe that it is a good idea to open a 100 bed centre on a reserve pump only. If that fails then we can’t just decant patients into another hospital or send them home. These are Ebola cases.
Yesterday once again, all the staff that we had recruited turned up for training. We had nothing we could give them to do, as we still have not unpacked all the stores and cannot find critical equipment. So, they sat around in the hot sun without any water. I was really cross as it was both rude to them and made us appear disorganized, which we were! There is just so much to do, finding equipment and unpacking it, searching for things that have not yet arrived, and these are jobs you cannot delegate. There are still several lorry loads of supplies which have not yet arrived and we open in four days. In this frenzy of activity, it is very easy to get drawn into sorting out a single problem. I really should be standing back and working out priorities and delegating tasks. John Wright the public health professor from Bradford who is working along side me has taken the bull by the horns and turned into a whirl-wind of ideas, plans, actions. So today we really moved things forward a lot. The wards are now recognizable with beds and buckets, and the operations room looks really good. The kitchen however has no cookers and so there are still many other gaps to be filled.
What next? Opening Day minus three
Yesterday all of us contacted our parent organisations to warn them that the opening of the ETC was likely to be delayed for the forseeable future unless we had a manager on the ground to bring all the different teams together. We have one logistician with four assistants to unload and catalogue all 39 lorry loads of the stores. There is no fork-lift truck and on top of that she also has to organize the vehicles and the drivers, and the meals for everyone. Then there is a mechanic who arrived today at last to look after the generators, the water pumps and the sewage. The Ebola centre was handed over 4 days ago, and already one water pump has failed. He only has the manuals to work out what the Army has fitted. Very kindly one of the Gurkas agreed to come across and give advice out of the kindness of his heart. The ETC itself looked like an ants nest that has been kicked by an elephant. Large numbers of carpenters were running around putting up shelves, painting doors and building gates. Even more labourers were carrying beds and mattresses to wards then assembling wonderful old King’s Fund beds. I was almost expecting a large American with a cigar and megaphone to shout “Cut – we’ll do the Tower of Babel scene again”. Huge amounts of activity – but it was unclear whether we were actually doing the right things in the right order. Most importantly there was no line of command. One unusual individual has insisted that he in charge of everything but could not have organized a piss-up in a brewery. His micro-management skills were awesome but his ability to look at the big picture and prioritise the key issues was nil.
Overnight Angeles, the in-country Head of Mission appeared from Freetown and quite suddenly everything changed. Within an hour she had identified the time critical jobs which needed doing, cut out the rest, and set everyone to work again. Now the ants nest is more like a beehive, humming with productive activity. Cells of people are focused on the tasks which need to be completed before we can open. The lorry load of gloves and masks, which had apparently been sent up to us on December 1st, arrived – eleven days late. Now we can start training properly, as at last we have all the component parts of the PPE space suits. A delightful logistician called Charlie arrived from DfID to help. He admitted that it was he who had unloaded all the planes and loaded the lorries. He was expecting us to shout at him because so much of the stuff that we have received is wrong. But he is much too nice for that, and when I asked him, he also admitted that he had not slept for days as the 747s flew in (up to three in one day), and he had to unload them all.
We are back on course again and I just need some sleep, as the last few nights have been spent puzzling how to get things moving. It is so simple when you see it done by a real expert, who has the authority to tell people to do things rather than discuss their innermost feelings about how things might be done. Our Spanish colleagues clearly have a different way of communicating information in committee. They present their idea, and then give a concrete example of how this might apply, then present the idea again and give another example. This is repeated no less than four times. If you dare to interrupt this ‘perseveration’ with a “so if I could just summarise” there is complete outrage. “Please let me finish!” they cry as if their point has not yet been made. At the other extreme the Norwegians quietly mumble out an excellent idea in impeccable English and because they have not repeated it four times embellished with examples, the Mediterraneans think they are merely clearing their throats and completely ignore what has been said. The team is irrevocably divided. The Norwegians and Brits are staying in a purpose built camp in the forest with meals all laid on. The Mediterraneans have said they prefer to live in their headquarters building in Moyamba, which is much more difficult living conditions but gives them independence. While this continues every effort to get us to work as a coherent team is going to be undermined. A minor issue on paper but probably critically important.
Ebola is on the move again. The dragon is stalking the dragon-slayer. We have a rash of deaths in Moyamba and on Monday there is going to be a lock-down in Moyamba for three days. All access in and out of the town will be closed (apart from supplies), and search parties will go from house to house looking for suspects. We have no idea how many cases this will flush out and we are not yet ready. Ebola waits for no man.
Team building? Day minus two to opening
Everyone is now working flat out and doing what is needed to get this centre open. There is tons to do, but more and more people are arriving to help. I am not sure why they were not here a week ago, but they are now diving in with panache. They are all French with Goatee beards, glinting eyes and cigarettes hanging from the sides of their mouths. The place is beginning to look like pirates of the Caribbean!
We have finally had a response from our head quarters about our slight problem with management. The problem has gone, but the ripples are still spreading out. Apparently they convened a Board meeting and after careful consideration have decided that we need to have a series of team building exercises to recover from this. They are sending someone from Madrid to facilitate these and have ordered that we are not to open to patients until we have completed the bonding to her satisfaction. The facilitator is due to arrive the day after we are meant to open. I think this is probably the finest example to date of dissociation between an HQ and its field team. We are surrounded by Ebola. The district is fighting a desperate battle to stop any more lives being
lost, and HQ in Europe wants us to do a team building exercise for something which we solved two days ago.
We have a direct line to the head of DfID here who is providing us with all the support he can. John decided to use the hot-line and came back from the call wreathed in smiles. DfIDs response to this proposed delay had been unprintable, and I suspect that we will not be doing any team building exercises after all. We will just get on with this job as fast as we can.
But as soon as one problem is solved another one appears. The white space suits that we have been sent, all 31,700 of them, and which finally arrived yesterday on a special delivery lorry are made of the wrong material. They tear far too easily, so they will have to be replaced in 48 hours. Even the unflappable Charlie looked a tiny bit flummoxed by that one. Apparently each NGO specified what equipment they needed and then it was ordered by DfID. It may be that some of the specifications were the wrong ones. Anyhow there is no point in trying to blame anyone. What is done is done, and doubtless there will be a report afterwards about the lessons to be learnt which will then gather dust un-read. No-one learns lessons from exercises like this. Each one appears to be unique but they are not. We had exactly the same problems in Haiti and in Gaza, and each time we have had to re-invent the solution.
One of the teams that arrived today to help were four smiling Gurkhas from the Army. They had just been told to report here for a week to help us with our stores. Quietly they set to and began moving stores around so that we could get at everything. They are the most extraordinary people. Nothing is too much trouble. Always polite, and cheerful. Always trying to anticipate what needs to be done. It is quite humbling working alongside them.
This is Africa-15th Dec 2014
Working in Africa is all about two steps forward and then one, two, or even three steps backwards. The washing machines have arrived but we cannot plumb them in. So, we are hand washing the surgical scrubs (there is no shortage of labour here) and the boots have to be hand washed anyway.
There is no equipment in the kitchen, neither stoves nor pans, but we will arrange for food to be brought in from locally.
The training of medical staff is going really well. Or at least we thought it was until two very experienced staff came over from the Médecins san Frontières base in Bo to help us with our rehearsals. Instead of us discussing in abstract terms how we are going to manage a new patient arriving by ambulance, she grabbed our attention by taking us out to the gate and calling ‘ “The ambulance has arrived with your expected patient, but there is not just one patient inside: there are four. One is dead. They have been travelling for four hours and are severely dehydrated. You do not know if they have Ebola or not. Now take it from there” .
That put the cat amongst the pigeons. All our well-laid plans collapsed and we stood in a huddle in the sun looking foolish. We have had to make contingency plans, and then contingency plans, for failed contingency plans. Everything revolves around whether we are in the ‘Red Zone’, the ‘Green Zone’ or the ‘White Zone’, and whether we are wearing the correct protective gear. Finally, are we making sure that we only move from areas where patients are suspects through towards the confirmed zone area (low risk to high risk)? Otherwise we may be carrying disease back to patients who are not infected, and actually start causing infections, rather than isolating confirmed ones.
And one step back. It appears that while trying to sort out the failed water pump, it has been found that the local contractor doing the pipe laying has used cheap fittings to save money but that these are now blowing off under the pressure of the system. This is not the end of the world. A pressure reducing valve must be found and fitted. But where in Sierra Leone is the right size of pressure reducing valve?
And a second step back. The protective overalls that we need for the PPE suits are very fragile and tear. Of course they do, we are not wearing body armour. The Watsan claim that they are not safe to use. Yesterday a new batch of a different type arrived by lorry direct from Freetown airport where they had been flown in from Europe. I was called over to the lorry to find our senior Watsan and the senior Spanish doctor in a frenzy of excitement and rage, tearing holes in the newly arrived suits, and accusing the British DfID of sending sub-standard equipment. Certainly they are not much stronger than the last ones but the frenzy of tearing and belly-aching was, I felt, unhelpful in front of all the staff, especially as there are now no more suits available anywhere in the world. We are now stymied. John calls it a ‘paralysis of risk analysis’. Nothing is good enough, and some of the staff are vying with one another to find more and more problems, which could prevent us from opening. I spoke quietly with the doctor from Bo who has now worked in four different MSF Ebola Hospitals. She said that quite frankly, if you observe universal precautions, you do not need a PPE suit or goggles at all. You just need to move slowly and carefully. The situation would be funny if it was not tragic. The ‘I am safer than you brigade’ rule the roost and until this phase of the cultural revolution dies down there is little that commonsense can do.
The third step backwards is Public Health England, who up until now have been quite sensible. They have now joined the merry throng of ‘My people are safer than yours’ and announced that when those of my team return to the UK , they are not allowed to travel more than an hour from their local hospital and not allowed more than one hour on public transport. So, John who wants to travel from Heathrow home to Bradford is supposed to get off the train every hour, wait on the platform for the next train and then hop on for another hour. I had thought that the team-building directive from HQ held the record for daffiness, but Public Health England now moves smoothly into the lead. All this is happening just when I am trying to build up the confidence of the staff. Thank you Public Health England. It is nice to know that you are right behind what we are trying to do. Have a great Christmas!
We medics will be ready for the centre to open on the 15th, but I fear that other parts of the centre will not, so it looks now like the 16th is the date when we will finally open. Frankly I would just like to get on with things now. The wait seems interminable.
I think we are all getting tired now. John and I have worked non-stop for over a month, and I suspect that it is adrenaline that is pushing us on.
Job’s Worths: 16th Dec 2014
The Job’s Worths have returned to the attack. They managed to get internet contact last night and found that the overalls that have been issued to us are not specifically recommended for use with Ebola and hinted that anyway they are probably fakes because they lack finger loops. They went on to point out if any staff member now contracted Ebola our NGO would be held liable. When asked what they proposed to do in the face of no more Ebola suits being ready for six weeks, they shrugged their shoulders. It is a pity that they could not have devoted as much energy to finding a solution as they have clearly devoted to creating the problem.
The most extraordinary part of this charade was the way that the chief job’s worth delivered the news with an assurance that no-one more than him wants to see the Ebola centre open as soon as possible. Talk about saying the opposite of what you mean!
One mile down the road from us, four Sierra Leonian nurses are working in an Ebola holding centre, a tent in the woods far from the village. They have now treated 120 Ebola patients without a single staff infection. What equipment are they using? No – not the latest anti-Ebola boots and suits – just Flip-flops and gloves, and no protective overalls. This simply cannot be right.
On the previous day I had held an emergency meeting when the issue of the suits had started to surface. Staff were worried that they might tear. After a long debate we had all agreed to use the suits that had been issued to us despite the concerns that they were not ideal. They are good. They are used by other Ebola centres, and our MSF mentors say our suits are more than adequate. But the cultural revolution led by the BWA’s (But What Abouts?) has scuppered us with fear, rumour and innuendo.
We were so close to opening tomorrow. Now the future is very uncertain.
Our brilliant in-country chief managed to drag a compromise from the meeting. We would use the better of the two suits that we have, if we could get enough stock for three weeks running. I rang everyone I know in the country and Kerrytown came up trumps. Thank you Rachel Cummings! She lent us the suit design that our staff originally decided to use. But they were only able to lend us 400 suits. That will last us only five days and it had been agreed that we need three weeks supplies before we can open safely. That means 1700 suits. Then the BWAs dropped in their final grenade suggesting that all the suits were potentially unsafe (even though they are being successfully used in other centres) so we are back to square one.
When I reported the results of the meetings to the nurses, they revolted too and suddenly decided that they wanted more time to practice the protocols of handling patients in PPE. I had given them free rein to work things out for themselves, it is only common sense after all, but fear and uncertainty has led to them reverting to didactic protocols. Damn! Damn! Damn! If we had just managed to open tomorrow with one patient, I am certain that all these anxieties would have melted away and we could have used common sense to get on with the job. Now we have lost the momentum, and it is going to be really hard to regain.
So, now we move into a blame orgy. Everyone of the BWAs insists that they are only trying to help and keep people safe, while implying that others do not share their high standards. A few years ago I found a quote by Sir Christopher Bland, Chairman of BT. It read “the amount of back-biting, in-fighting and general skullduggery in an organisation is in direct proportion to the nobility of its goals”. Clearly we have very noble goals because, just at the moment, skullduggery is rampant. It is difficult to resist responding to the claims and counter claims, by joining the fray, but the only thing that really matters to the people of Sierra Leone is that we should open the centre without any unnecessary delay. But while the BWAs denounce us as ‘enemies of the staff’ we are in a tricky position. The sheer size, speed and potential danger involved in this project has clearly blown the organizational structure of some of the NGOs. This is not a ‘let’s try and provide some gentle sustained assistance to a less well developed country’. This is supposed to be a swift military campaign overwhelming a nasty disease which is causing untold damage. It should be very similar to the goals of the British Army when they put an end to the revolution in this country a few years ago. I wonder how they swept aside the BWAs and brought back common-sense.
The Official opening 17th December 2014
We must not delay any longer. The local people of Moyamba are desperate for us to open the Ebola Centre. Our bosses keep on emphasizing that we should not let ourselves be rushed. But we aren’t. We are dithering over final details instead of getting started. We can perfectly well do some jobs once the centre is open.
If you are training children or soldiers you practice and drill until they are faultless. This works really well when the situation is the same every time and people are in no mood to think things out. If you are training top professionals then you don’t need to teach what you want them to do, you teach them how to approach the problem and what the outcome should be. That way it doesn’t matter if the situation changes slightly, they can still apply first principles and come up with a good solution.
I had trained the Norwegian nurses using the professional technique and was quite happy that they were ready to take their first Ebola patients several days ago. Then came the wobble about whether the PPE suits were virus proof or not, and they morphed straight out of professional mode and into technical mode… ..If A then B and so on. So yesterday and today we have been training by numbers, practising again and again admitting patients, cleaning, feeding and removing bodies. Maybe later when the initial worries are over we can move back to professional mode again.
We are supposed to be ready to open on Friday (tomorrow), but we don’t have enough of the overalls that the WATSAN have insisted that they need. We now have instructions from HQ that if we do not have six weeks supply of “the right” suits, we must not open. At a rough guess that is 3000 suits. I spent yesterday phoning every other centre in Sierra Leone, the WHO, and DfID searching for any spare supplies. I got 800 suits.
Although we have no idea when we are actually going to open we decided to hold an official opening this morning with a tape cutting exercise. All the local chiefs and the minister wanted to come and they all wanted to make long speeches. Really long speeches! We were in the big dining tent, all 120 of us, and the heat was brutal. They were dressed in three-piece suits specially for the occasion. We were sweating in scrubs. Two hours after the start of what should have been a 15 minute exercise we were finally onto the last speech. Every one had the same message. “Great building, now open it and start treating Ebola patients”.
The Real opening 19th December 2014
We did it! We took our first three patients today and, I hope, closed down the local holding centre, where it has been impossible to give patients proper care. People suspected of having Ebola will now come directly to us. It was touch and go right up until the moment we opened. The last ditch attempt by the Jobsworths was that the kitchens had not yet opened (the cookers only arrived this morning) and so we could not feed the patients. We were only admitting three patients to start with, and they were so ill that they could not have cared less whether we were able to serve lunch or not. When this was pointed it, it was explained that we might not be able to give our staff lunch. Well, we have given them lunch for the past week by buying it in from Moyamba town so I failed to see how today was any different. This sterile debate was brought to a timely end, by John announcing that the ambulance with three patients in it was on its way. It wasn’t, but this was an inspired move and timed perfectly. It effectively silenced any further debate, and we all moved to ‘action stations’.
For me the next couple of hours were the most harrowing of my life. All the training and preparation we have done over the past months was finally going to be put to the test. I had decided that the Norwegian nursing staff should be allowed to handle this all their own way. So, I was going to lead from behind rather than in front. To my chagrin they decided to manage the patients themselves and did not ask John or myself to change into PPE. It was a correct call. They knew what they were doing and admission of patients specifically does not require a doctor. They had thought things through and were behaving as professionals not technicians.
Even so, my heart was in my mouth, watching through the fence the slow movement of the team as they shuffled down the corridors and into the receiving area. It was a huge relief when the first member of the team re-appeared at the undressing station with the patient’s notes. He announced that the patients had been successfully admitted and that there had been no breaches in protocol. He also told us that the patients were comfortable, and that one was even taking a shower. Shortly afterwards one of the Hygienists came out as his face mask had blocked with moisture and he could not breath. Each breath feels like it is your last. However, he kept his head and undressed slowly and in the correct order. The look on his face as he finally removed his mask was one of pure relief.
As soon as the patients were settled in, the notes on them were held up at the barrier and photographed so that we had sterile copies outside the red zone. Then it was time for the first ward round. Again the Norwegian team did not choose John or myself (the only ones who have been into a red zone before). They chose their own senior consultant Cindra, a very steady pair of hands. When he came out, he announced calmly that one patient was now semi-comatose and quite unable to drink. He had therefore put up a drip and started iv fluids just as we would do with a case like this in an ED in Europe. I was so proud of him. A good sensible decision made at the right time and we had slain yet another demon. MSF had been advising that no drips should be put up as they were too dangerous for the staff, so patients who were severely dehydrated and who could not drink were unfortunately being allowed to die.
Interestingly Médecins sans Frontière have produced an absolutely fascinating document relating to Ebola. Four of their own senior staff have criticized their own organization for its failure to manage Ebola patients properly. I have never before come across an organization with members who have the intelligence and courage to do such a thing, and my admiration for MSF has soared. I have only quickly glanced at it and must read it carefully but they accuse themselves of allowing dogmatism to cover up for ignorance, and focusing so much on the safety of their own staff that they have neglected the care of their patients. That is a really tough charge to make against yourself but it goes right back to John Wright’s lovely aphorism a few days ago where he accused us of suffering from ‘paralysis by risk analysis’. It is also an occult form of racism where we value our health and lives so highly that we are prepared to compromise the care of our patients because they are not from our part of the world. I realise that I am putting my head on the chopping block by saying this. If, heaven forfend, one of our staff contracts Ebola then this will be quoted against me, but perhaps this is the first light of a turning tide against the jobsworths. I do wonder whether it has not been in the interests of the media and of the health care officials managing this epidemic to hype-up the infectivity of this disease, and that now is the time for a balanced re-appraisal of how this condition can be managed so that patients are given good care and are treated with dignity, while staff are well protected.
And now we are only two 21st December 2014
We were so excited admitting our first three patients. Now we are not so chipper. The youngest, fittest, and strongest of our patients who sauntered into the ward 48 hours ago, is dead. This disease is amazingly quick! Our elderly lady who was comatose when brought in has picked up wonderfully on fluids. Now all we need to do is settle her oesophagitis so that she can eat, as she is already skin and bones. She is talking now, washing herself, and drinking, so we have high hopes. Our third patient, however, is a real problem. Just before she caught Ebola at her sister’s funeral, her husband left her. She had eleven children but the youngest, 5 ½ months old, died last week. She was the bread-winner for the family, and now says that she does not want to live anymore. Physically she seems to be slowly getting better but we have some support work to do here before she can go home. For a start, we need to find out who is looking after all her children now.
There have been some critical staff changes over the last couple of days, and despite the sad news, the team spirit amongst the staff is building well. The gulf between the expatriate and national staff is steadily narrowing, as trust and respect builds, but the next few days will be a little tricky with everyone far from home over Christmas. The rhythms and routines of the centre are settling down. We are now divided into three completely separate areas by high fences. The outer white area contains stores, logistics, admin, the dining room and pharmacy. There, the staff are in normal clothes. To come into the green zone you have to change into surgical scrubs and white boots. It is a real palaver for me as I may have to cross five or six times a day to talk to admin.
Just some of the scrubs and boots drying after soaking in chlorine and then scrubbing each day
Then the real barrier is from the green zone to the red zone through the dressing area. In green we have our medics office, rest area and inner stores. Once you dress up in PPE and enter the red zone, nothing can now come out again unless it is in a body bag or sealed sacs sprayed with chlorine and ready for burning. Undressing takes over 15 minutes as each layer is either discarded or dumped into a tub of chlorine. One of the most difficult problems is getting information out of the red zone. Within 15 minutes of entry your goggles are so misted that it is almost impossible to see. The trick is to peer out of a crack at the edge of the goggles where the mist is not so thick. Your voice is muffled by a double face-mask; your hands made clumsy by double gloves, and you have to stay at least two metres away from anyone in the green zone just over the fence. Just at the moment we are trying to photograph notes made in the Red Zone using a telephoto lens and a pre-prepared sheet which just requires crosses on it. If we were to use a tablet it would have to work after being sprayed with chlorine and tolerate our fat fingers in double gloves.
One of the nurses trying to communicate with the outside world. His head is up because he cannot see out of his misted goggles. We are about to photograph the sheet he is holding
Little by little we are learning tricks for dressing up in PPE more quickly and for avoiding misting of our goggles. The best seems to be to cover them in shampoo and not wipe it off. It makes for a blurred view from the start but it doesn’t get any worse. Even so we can only stay in the red zone for less than an hour, before you are so soaked that your boots are squelching with the amount of sweat that has dripped down into them.
Undressing in front of the dresser who barks out the commands.
You are exhausted and it is soooo slow
Any minute now our area of Sierra Leone is to be locked down by the police and army and a house to house search is to be performed to try to find patients with Ebola who are being hidden at home. If they find a lot we will move into a whole new gear. The discussion about this expansion has once again brought the ‘Jobsworths’ to the fore. They feel that we can only safely expand by three patients a week. I am afraid that I very nearly lost it when this figure was put forward. This is a 100 bed facility costing millions of pounds with nearly 200 staff. It is trying to bring an Epidemic under control. If an increase of three patients a week is the best that we can do then we don’t deserve to be here. And so my next struggle begins. Hanging over me is the sword of Damocles wielded by the Jobsworths. If any member of staff gets infected I am certain that all the blame will fall on me, for rushing things. It will make for an interesting Christmas.
The Fun starts 23rd December 2014
Early this week I drove down to Freetown for a meeting of all the team leaders in the DfID initiative. It was only a two hour meeting and I had to leave after an hour to get back before curfew. So it was 11 hours on the road for an hour in a meeting. It was the first time I had set foot out of Moyamba since the Centre opened, and I am afraid that I slept most of the way. At first the roads were clear, not a vehicle to be seen until we got to the first Ebola check point. There hundreds of people and dozens of lorries and cars were waiting patiently to have their temperature checked and feet sprayed before they are allowed through. Sierra Leone is in lock-down to try to stop the spread of this strange disease. No vehicles may move at all between 7pm and 7am and everywhere there road blocks through the day where every person has their temperature taken and are turned back if it is raised.
I was being driven in a brand new white MdM truck with a special pass on its windscreen so we swept through the increasingly frequent barricades, as if we were royalty. I felt thoroughly uncomfortable sitting in air-conditioned comfort while the people who own this country stand in the sun and dust patiently waiting to be let through.
The meeting itself was important if only to know that we were facing the same problems as everyone else, burst water pipes, failing pumps, shortage of PPE suits, worries about face masks that water-board you, and gloves that split. More important was the fact that the number of cases of Ebola seems to be falling all over Sierra Leone. This does not fit with the news reports, or what we are expecting. I wish we could claim some glory for this success, if success it is, but we came on line far too late to have made any difference. The survival rate of infected cases, however well treated, remains stubbornly low, at under half. So, this disease is still a killer.
While I was away the unit admitted three new patients. Once again we had a young man who seemed quite well, but thankfully he has not deteriorated and his Ebola test is negative, so he has now crossed back from the red zone back into life in the green zone. When he arrived back in his village there was much cheering especially when our field worker walked up to him and embraced him to prove that he was safe to return into his society.
We also had a two year old brought in without any warning by an ambulance. She had been sent by the orphanage and had diarrhea but no other symptoms. She should never have been brought to an Ebola centre and created pandemonium for us. How can you look after a two year old dressed in space suits and only able to stay in the ward for 45 mins at a time? The poor thing was absolutely petrified, but we have now managed to discharge her too.
A very frightened child heading back to her orphanage
The third lady who came in is only in her early fifties but has diabetes and was grossly dehydrated with a gangrenous foot. She has responded to fluids and clearly does not have Ebola. But nor does she have any treatment for her diabetes either. She has been seen at the government hospital but they do have any insulin or oral treatment: nor do we, so I am afraid she will go home to die from a condition which is eminently treatable. It just reminds me how lucky we are in the first world.
Gangrene of the foot in a young untreated diabetic
The Lockdown of our region of Sierra Leone and the house to house search has not yielded many patients so it really does look as if Ebola might be on the wane. However, it has done this before and then suddenly exploded again so we need to be careful.
The teams in the centre are all settling down and working better and better together. We are all unusual personalities but thankfully at the moment everyone is playing to their strengths so the whole enterprise is thriving. The Norwegian camp has erected a small Christmas tree in the middle of the camp. The temperature is 35 degrees and the decorations and artificial snow glitters in the blinding sun. The Norwegians seem to take Christmas eve very seriously and keep on jumping up and singing wild Nordic songs. Christmas day has dawned with the crows coming in to hoover up the insects attracted to the security lights during the night, and we will now start building numbers as quickly as we can.
Wind-down 27th December 2014
I like to pride myself that I am not superstitious but I find myself hesitating before I say this fateful phrase ‘Ebola is dying away’. There, I have said it, and now I will doubtless receive some divine punishment for tempting the fates.
The number of cases reported in Sierra Leone is falling steadily now, and the proportion of people testing positive who have an unexplained fever is falling too. There are still dire stories of cases being nursed at home, and of secret burials, but the tide of evidence is turning against the doom-mongers. The cynics will say, I am sure, that Ebola was never very infectious, and that it is simply dying out of its own accord, as it has doubtless done in the past. The realists will probably recognize the huge efforts that the Sierra Leonian army have put into finding cases and bringing them in for isolation. What no-one can claim, for sure, is that we ex-patriate doctors and nurses have made the slightest difference. We were six months too late and our gigantic white elephant Ebola centres have hardly been used. We spent so long and so much money on building a system that protected us, rather than helping the patients that we missed the boat completely.
That is not true of Médecins Sans Frontières who have led the campaign against Ebola from the start. They recognized that this epidemic was something different, but no-one listened. They went ahead and developed safe ways of handling cases, and we trudged reluctantly along behind, mindlessly following their protocols.
I suppose that this is ever the story of Emergency Humanitarian aid. We were late into Haiti, far too late into the Phillipines and completely irrelevant in Gaza. And the bigger the organization providing aid the more cumbersome the response.
So here we are five weeks on, and I have just been told by my organization that I must return to the UK next week because ex-patriates cannot last more than six weeks in the field! I am just starting to understand how things work here, and I have to go on leave, passing the baton to a new person who has to start from scratch. “It is for my own good” they are saying. I never liked that phrase when my mother used it on me as a child, and I like it even less now!
But I still don’t understand Ebola. I realise that I am risking being vilified by my readership, but there are a few questions about this disease that simply will not go away. What other disease is caught from dead bodies? I know we have a natural aversion to cadavers, and perhaps there is some evolutionary reason for that, but I cannot think of any disease primarily transmitted this way. Sure, cholera can be caught from handling an infected body (I think) and I suppose Anthrax could be caught from spores on a cadaver but I know of no other disease particularly a fragile virus which
does this. I am not a public health doctor, nor am I a pathologist but surely I would remember something of this form of transmission from those long summer afternoons when I dozed through another pathology lecture. Oh how I wish now that I had listened more carefully. So, have we really got the mode of transmission here, or is this yet another myth? I have searched the internet for evidence of strange burial practices in West Africa and found plenty of speculation but no evidence. Could washing the body after death really lead to the infection of someone who was only at the funeral twenty four hours later? I find that implausible.
Our wonderful Ebola Treatment Centre stocked with 100 beds, nearly 200 staff and tens of thousands of PPE suits will reach the giddying heights of SIX patients today and I expect that will be our peak. Surely these will be some of the most expensive patients ever treated, and all we can do is provide good nursing care!
The heartbreak for me is the young children. If a mother tests positive and the child has no symptoms, then the mother is taken away and the child put into an orphanage. Worse still are the positive children with negative mothers who are quite literally dragged away by aliens in space suits and isolated in pens in our huge tents. I cannot imagine anything more psychologically traumatizing than this ‘treatment’. It is worse than anything that Roald Dahl ever thought up in his terrifying children’s stories. The BFG has nothing on us when we stride down our huge tents in full PPE to see a solitary child trapped in a pen.
Take one of these children. Put her alone in this ward, then send in a team of these ‘Star wars’ characters and tell me she won’t be traumatised!
Our current patients seem to be improving. They are now drinking and say that they are hungry, although the pain of swallowing makes things very difficult for them.
The Norwegian camp where we stay when off duty remains a freakish bubble in the heart of Africa. It is surrounded by a floodlit fence, patrolled day and night by guards. There are air-conditioned tents, food imported from Norway, and ground scraped clean of every shred of vegetation. It feels as if we have landed from a flying saucer. Heaven only knows what it must look like to Sierra Leonians peering in from outside.
Our accommodation by day and by night. It doesn’t relate very closely to Africa
So much for the wind down 31st December 2014
Well, So much for the wind-down. The hospital is now heaving with patients. We have over 20, and the teams are busy at last.
The/Ebola treatment centre Mgygogégfrom the air. Millions of pounds of kit in a clearing in the jungle that can never be used for anything else once this is over.
Just down the road is the old holding centre where all Ebola patients went before this smart new building was put up. It is a set of ramshackle old one storey sheds next to the grave-yard. It contained a mix of Ebola cases and cases that no-one was sure about.
However, it is proving stubborn. My dear bosses at headquarters in Europe keep sending arbitrary and illogical orders, saying that we must not have more than ten patients in our new 100 bed centre or that we must turn away patients who do not fit their entry criteria. So, time and time again patients are diverted back to the holding centre just when we think that we have seen the last of it. The second edict about criteria seems superficially logical but when you look at the situation more carefully it all unravels. Moyamba district is huge and the roads are terrible. Some of the more remote villages are more than six hours away in a jeep and that is when the weather is good! There are over 200 trained volunteers who go out in response to a call that there is someone sick or that there is a corpse. They do not have proper protective gear and have to do their best to assess the patient and report back to their Supervisor from the field making best use of the limited training that they have received. If the surveillance officer thinks that the history and very very limited examinations suggests that this might be an Ebola case they have to load the patient(s) into the ambulance and set off back to us. We then check the patient and if we think the criteria do not indicate a risk of Ebola we send the patient away. This is a political disaster. The patient has nowhere to go and the surveillance officer is made to look a fool. So, one of the first questions I had to address was why was there a difference in assessment when we were using the same criteria? Simple. One of the main criteria for suspicion of Ebola is the presence of fever. If the patient is feverish then they need further investigation. If not they don’t. It transpires that the surveillance officers have been asking “Have you had any fever recently”. We have been asking “have you got fever now”. We also use long range infra-red thermometers to check the patients temperature. They are hopelessly inaccurate so if they read normal or low we record ‘No fever’ not allowing for the fact that it could be wrong and that the patient might have been having rigors two hours before. It is interesting that the same problem arose at Heathrow with Pauline. She had no fever NOW but had fever on the flight. The surveillance people foolishly relied on their thermometers and that ‘now’ question. It is not reliable.
Everything came to a head the night before last, when the ambulance started back from a very remote village with four suspects in the back. Nothing could be better guaranteed to spread Ebola than to pack four possible Ebola cases into one ambulance. We had already decided to close the holding centre that day and I suspect that in revenge for our treatment of the surveillance officers someone decided to empty the rest of the holding centre patients into the same ambulance and deliver them as one big Christmas surprise. So it arrived with seven patients crammed in the back.
The team setting off to unload seven patients thinking there were only four
There was no panic but it was a tricky couple of hours as we unloaded the patients one by one. In the middle was a beautiful little three year old girl. She was obviously unwell but was in her best party dress. For an hour she sat bolt upright on a chair never making a sound, obviously on her best behavior but at the same time simply terrified by the gowned and masked figures moving around her.
None of her family was with her so I sent the ambulance back to bring in her older sister to look after her. But by the time she arrived, the little girl was catatonic, urine and diarrhea spreading across the white seat beneath her. We tucked her into bed but she was sickening by the minute and we had to put up an inter-osseous line right away. She rallied a little as she received the fluids but then slipped away this morning. It was heartbreaking for all of us. She was such a sweet brave child, but even worse, everyone in that ambulance had taken turns to carry her during the journey to the center so all the patients who have now tested negative for Ebola have been exposed at the highest level to the Ebola virus. How on earth did we manage to do that?
So now we have had a baptism of fire. Eight patients arriving in the middle of the night. It was heartening to see how everyone worked quietly as a team doing something far beyond our training when ambulances arrived in daylight with one patient at a time.
At last the centre is starting to be used properly. We are going to need a lot more staff if we are to expand further, and just at the moment we are gambling that we are scraping the barrel, and that once this bulge is over the numbers of inpatients will fall again. I hope we are right! Meanwhile headquarters have queried why I have not done an audit of the pharmacy stock yet! Ah! The joys of remote-control micro-management. A great way to get a reality check on what we are doing.
Pack your bags 4th Jan 2015
It is 3 am. The night has become quite my favourite time. I cannot sleep after 2am now, and just end up tossing and turning reviewing the previous day and planning the next. “Ah! Acute anxiety” I hear the doctors amongst you muttering. Well not really. This is a tense situation, and it does need some careful thinking. The middle of the night is a wonderful peaceful time. The day, from 7am to 7pm, is a blur of Walkie-talkie radios, mobile phones, high level discussions with your colleagues and a stream of National staff wanting T-shirts, pay rises, extra food, and new working conditions. I fear that I am getting a reputation for an oft repeated phase “Solutions please – not problems” as I pack them off to seek their own salvation. But just now it is peaceful. The cicadas are chirping over the soft hum of the generators. The flood lights are working as moth traps: bats and nightjars flutter in and out of the great pools of light having the feast of a life-time.
The Norwegian camp at night drawing in moths and nightjars
Yesterday was brutal. I am going on leave and handing over to my replacement. I have lived and breathed this place and Ebola for over six weeks, 24 hours a day, seven days a week. I haven’t read a book and when occasionally I manage to download a copy of the Guardian, it all seems a little trite. Do I really care what Ed Balls thinks about the Tory public service policy? Not a lot just at the moment.
So, when a new director arrived to replace me I felt my hackles rising. Unfortunately, he started off badly, telling me how I should manage the problem I was tackling at that moment. I am sure that he was only trying to help, but he had only been there for five minutes and had not a clue about the complexities lying behind this simple looking decision. Apparently this behaviour is called E.O.A. (expert on arrival) syndrome and is wildly irritating. I now so hope I didn’t do that when I first arrived. Those of you who know me well will be shaking your heads and muttering “I am sure that you did!”
Once again an ambulance stuffed with patients from far away Ribbi piled in without any warning. Two mothers sick and exhausted by the journey with three very young children, and a grandmother who now realized that her answers about fever and vomiting were going to lead to incarceration. So, her story had now changed. No fever. No joint pain. No vomiting, and ‘No’ she was not going to be admitted into this terrifying place where everyone wears space suits and sprays chlorine onto every surface.
You don’t have to be an infectious diseases consultant to realise that packing four Ebola suspects into the back of one ambulance makes absolutely sure that if one of them has Ebola, the rest will too by the end of a four hour journey over atrocious roads. My headquarters have told me that I have to stop this practice. That is a marvellous idea and I absolutely agree. The only problem is: there is only one ambulance. It is four hours to Ribbi and a whole tank of fuel, so if the surveillance team send them up one by one it will take four days. Meanwhile they will be contaminating the local population. Secondly, I have absolutely no authority or control over the ambulances. They belong to the surveillance team and each time I have brought up the problem with them I have received the same response. Sierra Leonians are astoundingly kind and courteous so they don’t say “don’t be so bloody stupid, don’t you realise…..” which is clearly what they are thinking. They begin a long rambling speech which is inevitably interrupted by my phone ringing, my radio blaring, or another metaphorical tap on the shoulder (we are not allowed to touch).
We had to bury a sixteen year old girl yesterday. She wasn’t very ill when she first came in but she was very, very frightened and kept on trying to climb the fence and escape. The Norwegian nurses were very kind with her but it gradually became clear that she was not just frightened, she was hallucinating, although how you could have a worse hallucination than what is going on around you in an Ebola centre, I do not know. Then she could not swallow, and was in terrible pain. Finally she started to bleed everywhere. She hung onto life for a long time. If I close my eyes, I can still see her terrified face when she first arrived. I just so wish that we could have saved her.
The Norwegian nurses and doctors who make up the bulk of the medical team have gone from strength to strength. I have tried to delegate everything medical to them and they have risen to the challenge magnificently. My dad used to talk fondly about the Norwegians he met during the war. He was absolutely right. They are very competent, quietly outspoken, utterly loyal and very good fun. What more could you want? That has freed me up to deal with the interface between the Treatment centre and the rest of Moyamba district, which has been a really thorny problem. We, in our multi-million pound bubble can pontificate on how things should be done outside the fence.
The daily briefing at the Command and Control centre where the fight against Ebola is managed in Moyamba district
The Sierra Leonians who run the contact tracing, the surveillance and the quarantine work have only minimal resources. Ribbi the current hot-spot village in our catchment is over four hours away over rough roads. I am told that the people there are stubborn traditionalists, the kind of people we sort of admire in Europe when they wear funny clothes and dance, but here they have signed their own death warrant, by hiding their sick, and burying their dead according to old traditions. This area was trashed in the civil war and I suspect that they are also pretty fearful of the Army, and completely reject our model of how Ebola is spread. In Europe we could bring this little outbreak under control in days. Here it is going to take months, and every day that it sputters on risks it spreading out to the other villages nearby. There is also the problem that a violent civil war has just finished in Sierra Leone and everyone is terrified of anyone in an Army Uniform. The responsibility for Ebola surveillance has been taken over by the Army (Public Health were not up to it), so now when a village is being checked it is the Army who charge in. The result is that everyone runs for their lives and hides in the bush. They are not to know that the Army is now coming to help not slaughter.
What the civil war did to Sierra Leone
Ebola bog 29: Decompression
I have just awarded myself some decompression. The overlap with my replacement was set at four days but within two I got the first sniff that I might now be getting in the way, so I have fled to Freetown to have 48 hours in a seedy hotel before boarding my flight out to Casablanca at 5.00am. The airport is on a peninsula that can only be reached by ferry. And guess what: the last ferry goes at 9pm so there is no danger of being late for the flight. We are going to be spending a jolly night on a concrete floor!
I have a secret admission. I now travel everywhere with my own pillow. Some people sneer at my ‘softness’, but the boot (or pillow) will be on the other foot tonight. At Casablanca we change for Heathrow. This airport loses more luggage than any other in the world so I am not expecting to get back with anything except hand luggage.
It was very hard leaving Moyamba. I have lived and breathed that place for what seems like an eternity and it felt like watching a teenage child going off to University, when I climbed into the truck and was driven away. As I left, our score was only two survivors and five deaths with one more expected to die at any minute so I was pretty depressed by our stats. Today, 48 hours later, I took courage in both hands and phoned. We now have seven deaths and seven survivors so our stats are now acceptable if not exceptional. We just needed the results of the blood tests back!
The drive down to Freetown was eerie. The roads were completely empty apart from white land-cruisers with NGO insignia carrying solitary ex-pats about their Ebola business. Sierra Leone has been closed down to all traffic until January 13th to try to slow the spread of the disease. Try to imagine that in Great Britain. Two weeks of nothing!
At the police road-blocks on the edge of each town, lines of lorries loaded with wood and charcoal wait to be released. Blocking the road are dozens of young men begging for food. I assume that they are the drivers stranded without money. The price of charcoal and food has off course rocketed, and fruit is rotting at the roadside. I bought some oranges and pineapples but could not face bargaining. Everyone just looked so desperate so I paid top wack to my driver’s disgust.
On one of the stretches of open road Mohammed, the driver asked if he could stop to relieve himself. As the car stopped I noticed a young woman walking along the opposite hard shoulder carrying a basket of yams on her head. As soon as Mohammed got out of the car, she turned and the look on her face was pure terror. She literally dumped the basket and started running up the road as if her life depended on it. When Mohammed got back I asked him what was going on. He laughed and explained that Christmas was a big time for rituals and secret ceremonies, and that cannibalism occurred in this area. She had run because she thought we were going to kill and eat her. I looked across to see if he was joking. He was not. In fact Mohammed just doesn’t joke. I know he doesn’t think much of his rural countrymen but this was a quite extraordinary accusation.
Almost as soon as I arrived in Freetown the BBC World Health Correspondent wanted an interview. So, I went to the Radisson hotel to meet the crew. The hotel is as smart as any in world and walking through its door is a temperature and culture shock. Inside there are suave ex-pats in safari jackets mixing with top-level Sierra Leonians dripping with gold jewellery. The swimming pool is open and there were lots of people frolicking in it. Yikes! Imagine swimming with other people who might have Ebola, or have I just become paranoic? I thought of popping in for a dip, and then as I got out casually mentioning that I had just come from an Ebola centre. I wonder how quickly the pool would have cleared. Amazing how a little air-conditioning and butler service can isolate you from the real world.
The BBC team were very well informed, and I felt a bit of a country bumpkin, but clearly they were amused by this bearded ‘thing’ which had just come out of the bush! They were working flat out as the light was failing. It is so difficult to know what to say. They want you to be spontaneous but this is no subject for spontaneity especially with the situation as politically delicate as it is. I felt myself tip-toeing along a tight-rope cursing myself for having a beer while waiting for them to arrive. I was so tired that as I drove back to my crumbling hotel I could not recall a word of what I had said.
Just to add to the stress at the moment I am trying to get my GMC five year revalidation. The chickens really have come home to roost here. I was on the GMC when revalidation was being designed and it was quite clear from the start that it could not and would not be fit for purpose without taking up massive amounts of good clinicians time. Now, because of my unusual career path no-one has the courage to decide whether I should be allowed to revalidate or not. It is interesting because every doctor from Britain that I talk to, and who is working in the field, is having the same trouble. Pretty soon there will be no-one who can work for an NGO. Doctors from other developed countries do not realise that it will happen to them soon enough too. I feel an editorial in the BMJ coming on, but I gather that the problems of revalidation will pale into insignificance beside the stigmatization that we are experiencing back in the UK if anyone gets wind that we have been working with Ebola patients. The media have played their Hammer Horror movie card and we are in for a rough time.
Furlough
I am on leave at last. The journey home was a brute. The flight from Freetown to Casablanca left at 5am but the last ferry across the creek from the town centre to the Airport was at 11.30pm. So the journey started after check-in with a long uncomfortable wait stretched across metal chairs at the airport, trying to get some sleep but daring only to doze in case I missed the call for my flight (not that there were any others!).
At Casablanca we were met by immigration officers wearing PPE suits. My practiced eye noted that they were not being worn properly so were completely useless. Most of the airport staff were also wearing paper face masks. These are one of my pet hates. They do nothing for cross-infection: they just label authority figures as faceless people who feel that they are dealing with ‘dirty’ public.
As we descended to land at Heathrow I reminded myself not to get cross with Public Health England. They only have a job to do, and I was tired and frustrated with the misunderstandings that have surrounded Ebola transmission. At immigration I put my passport into the automatic reader. It was promptly rejected and as I tried again there was a gentle tap on my shoulder and the not un-expected question “Are you flying in from Sierra Leone via Casablanca?”. I admitted my crime, and was led away through the queues, the inquisitive eyes of other passengers wondering whether I was a drug dealer or an asylum seeker. Public Health England have their own little area for checking us out and they could not have been kinder or more courteous. Dr. Matt Alfonso, the public health doctor on call at Heathrow, had worked for the same NGOs as me, and spotted at once that I was tired and a little brittle. Quickly he led me through all the paperwork, explaining at each stage what was necessary and why. I felt my anxiety and frustration ebb away and an apology forming for all hard things I said about PHE in a previous blog. Thanks Matt – outstanding patient management! And please put that plaudit in your appraisal folder.
Then my wife is waiting and I am whisked home. No hug allowed when we meet. It feels strange and worrying. Vicky probes gently to find out what I can and cannot do. Should we have separate crockery? Can we sleep in the same bed? It is not a comfortable home coming, but that first cup of
tea is a delight. It is difficult to focus, as I have entered another world, but my mind remains locked in Moyamba. Surely it is time for the Command and Control meeting. Am I up to date on our stats? Who is now in the Red Zone? How long have they been there? And what are they doing?
Today is a lovely cold, wet, windy English winter day, and I walk out into the village main street relishing the fresh air on my face. One of my neighbors spots me. I greet her but she is already turning and half running away dragging her dog with her. I wonder what on earth I could have said or done wrong so soon after my return. Then I remember. I am a leper. I might just as well hang a sign round my neck and ring a bell. I am tempted to follow her and confront her with her unkind behaviour, but luckily I decide to leave it.
The first thing I need to sort out on my return is my revalidation, the deadline for which is only a week away. For months I have pestered and checked what I need to do so that my final appraisal can be signed off. In fact it was all completed before I left for Sierra Leone, by dint of my appraiser putting in hours of extra work on my behalf. It was complicated because I had been working in New Zealand as well as for Save the Children in Gaza. On paper it is such a simple exercise. Evidence on a set of domains to complete, and if you are a normal hospital doctor they almost fill themselves in. But I am not, and have not been for some years, so each section has to be checked and double-checked. The GMC have rightly been vague about what is required, but the arbiter is my Medical Director alias Responsible Officer. It appears that there is only one thing you can do wrong as a Medical Director, and that is sign off something that you should not have signed off. You don’t have to show inspiration, flair, leadership or empathy, you just have to make sure your name is not on anything that might come back and bite you, so the deadline draws closer but still no decision. This procrastination is incredibly stressful for me, because however rational I try to be about this delay, it suggests that there are doubts about my competence as a doctor, and I feel hurt by that.
Revalidation is a big problem for all of us working for NGOs far away from the UK, and unless someone addresses this quickly we will all be stopped. I wonder about setting up an NGO subsidiary to appraise and revalidate doctors with unusual career paths.
And what about the future for Sierra Leone? It is a lovely country, rich in resources and with some of the nicest people I have ever met. However, it has been hammered by AIDS, mutilated by a civil war over blood diamonds, and is now trashed by Ebola. The schools are shut, hospitals are without staff, immunization programs have stopped and family planning is no more. Food has doubled in price and the roads are all barricaded off. There are people begging for food at the road side.
Once this Ebola epidemic is over, and it shouldn’t be long now, the trouble really will start. There is no work, and business confidence is zero. That is the time when this lovely country really will need all the help it can get. It will need political stability and inward investment, after which I hope we can help them to rebuild their health care system. If there was ever a country with so much hope, then this is it. It will just need a little help to get them there. The alternative is Richard Collier’s ‘Bottom Billion’ and a spiral into anarchy.
And for me? Someone did notice what I was doing, and with Vicky’s help with the paper-work, I found myself awarded a CBE at Buckingham Palace and an invitation to drinks at No 10 with the Prime Minister. It is nice to get a ‘thank you’ for what was the most difficult and dangerous humanitarian mission I had ever done.
CBE
The mission to Sierra Leone was dreadful. It was very high risk and we had a completely dysfunctional team. The Spaniards were notionally in charge but had sent out an A&E consultant to run things, who was completely mad. Apparently, this was not the first time that he had got into trouble so it was very naughty of them to use him again. The staff were mainly Norwegian and they were culturally totally at odds with the shouting and ranting that dominated the Spanish way of doing things. Anyhow, by the end of the mission I was exhausted. Thank heavens John Wright was there and the Norwegian nurses and doctors really appreciated being allowed to organize their own way of doing things, as it was they who were in the front-line, and who were most at risk. None of the staff died, so that at least was a success, but like all the other missions there was a feeling that we were a band-aid on a massive wound and that we were serving to avoid governments having to face up to the real issues.
Shortly after I got back Vicky organized a small party to announce that I had been awarded the CBE (the award one below a knighthood). It had all been organized by Vicky. I was hugely proud, although I suspect that most of these awards cause more jealousy than joy. As John Goodfellow (one of my colleagues at the NOC) once said. “Would that we could bask in each other’s reflected glory”. It is a lovely pithy expression expressing a forlorn hope.
I duly went to the palace with Vicky, her son Adam, and the head of Doctors of the World. It was a magnificent ceremony, lots of pageantries and beautifully organized. Prince Charles was representing the crown and you are not supposed to speak to him. When you go forward, an ADC whispers into the prince’s ear the service for which you are being honoured. Mine was humanitarian work. But, when I got to him, I could not resist a quick comment. I reminded him that we were in the same geography class at Cheam School and that he used to hide behind me because he was terrified (as were we all) of the geography teacher, Colonel Shipway. He grinned and admitted that he remembered it well. The next day I got a letter from his ADC saying how amused Charles had been by this small breach of protocol.
Early retirement from the NHS
When I retired I made a bucket list of things that I wanted to do. Most of it was of places I wanted to visit. I didn’t do private practice so did not have a pot of gold to spend. My motives for not doing private were, I am sure, not so altruistic as I would like to think. I just have never liked being ‘owned’ by patients. I would also rather make clinical decisions based on the ‘needs’ of the patient not their ‘wants’. This new scandal about retinopexy with nylon tapes seems to fit into that category.
So, the only way to travel was to use my medicine and work as a ship, base, or repatriation doctor, all unpaid but taking me to parts of the world I could only dream about otherwise.
After stopping surgery I did work initially for a repatriation airline company who were working to the highest standards. Unfortunately, they went bankrupt and were taken over by a company mainly concerned with chartering small jets not doing medical work. Slowly but surely the safety standards were eroded to save money and increase profit. At first I grumbled under my breath, but knew in my heart of hearts that if something did go wrong, there would be justifiable awkward questions as to why I did not change things or resign. I resigned.
A similar thing happened in the Emergency Department. I arrived to do a locum shift at the Horton Hospital one morning. There are supposed to be four doctors on duty, but they had not been able to find any others, so I was on my own. A little bit of me felt proud that they trusted me to carry this load, but another side of me coldly warned me that this was dangerous and if anything went amiss, the coroner would take a very dim view of what I thought I was doing trying to work single-handedly. All Emergency Departments are under terrific pressure now but making yourself a martyr is not the answer. Almost immediately three blue light ambulances arrived. Luckily, when I called the medical registrar he appreciated my position and came straight down to help. But the damage was done. I couldn’t go on like this.
A&E shouldn’t even be called the ‘Emergency Department’. It should be called the department for PNEWS (Patients No-one Else Wants). If the police can’t cope with a mentally disturbed patient they bring them to ED. If a GP can’t get an urgent outpatient appointment they send them to ED. If a school has a child with a scratch on their knee and is worried about litigious parents, they send them to ED. If a family can’t cope with an elderly relative, they bring them to the ED. The list is endless.
It is a cruel specialty for the doctors too as you get older. Day and night, weekends and bank holidays – it never stops. You come on shift and there are fifteen patients waiting to be seen. You get your head down and start trying to clear the backlog, chivvied by managers worrying about the four-hour wait times. Nine hours later (with no time for a meal break) you slip out of your scrubs, and there are now twenty waiting to be seen. You had been running to stand still, but actually, you were slipping backward. So, there is none of the satisfaction of finally sitting back and having seen the last patient in a clinic, just a sense that if you dropped dead tomorrow no one would even notice. That is not quite true. There would be a flurry of emails from medical staffing trying to find a locum to stand in for your shifts.
No wonder juniors do their 6 months and then shake the dust from their feet heading for specialties where there is no night or weekend work, and they can see their families.
But there is a real pleasure in the job too. The variety of patients is a cornucopia of training opportunities for medical students and junior doctors. You can lead them through this fascinating world building their confidence and competence, and patching up their fragile egos after another ‘gumming’ from a specialty registrar trying to block a referral. At the end of each shift I wrote a thank you note (copy to consultant) to any specialty registrars who had been constructive and helpful when taking a referral. I didn’t have to write many letters, certainly fewer than the letters of complaint I would like to have written to all those who don’t answer their bleeps and, when they finally did were rude and unhelpful. One staff grade, who received one of my ‘thank you’ letters said it was the first and only nice letter she had received in fifteen years working in our august teaching hospital.
Something has to give. Attendances are up again. We have a public now well attuned to the Amazon culture. They want 24/7 service, and they don’t want to be kept waiting. I don’t blame them. I wouldn’t want to wait a fortnight for a GP appointment and then another week for my blood results, but it doesn’t half put a load on the system. They certainly don’t want to be told that their attendance on a Sunday evening for a trivial and chronic problem was not appropriate. When I started in the NHS we were encouraged to see ourselves as guardians of an extraordinary social experiment – free health care. We did not hesitate to ‘educate’ patients in the importance of not abusing this great service. Now, no more, – the customer is always right. Viva Amazon, and indeed those doctors who get a buzz out of making martyrs of themselves!
Then there is the antediluvian way in which we still process Emergency patients. Para-medics now do superb ‘clerking’ as they bring the patients in by ambulance, but as soon as the patient arrives, the process is repeated by a triage nurse who again does a great job. Then it is the turn of the casualty officer to perform another clerking and then present the case to their senior who may choose to clerk the patient again. Now it is time to call the specialist team who send their most junior doctor to repeat the process, and present to their registrar. Finally, the case is presented to the consultant on duty for that specialty. The patient has been poly-clerked half to death, darkness has fallen, and if it might have been safe to send the patient home earlier, it certainly isn’t now.
All this has been done without sight or access to the GP notes which may be a gold-mine of information on the patient’s illness and attitude to it. All the information we gather is entered on the hospital computer. Our system requires more than 50 separate clicks on tiny boxes on many screens just to progress through the system. That does not include any notes written. So the C/P ratio, (the time spent working the computer compared to interacting with the patient) is well below 30%. The health service doesn’t need more money it needs to streamline its working practices. It cannot be appropriate to have each patient clerked 5 or 6 times before a decision is made on admission, nor a computer system which wastes 15 minutes of doctor’s time on each patient however trivial the complaint. Providing life-long job satisfaction in a career of night and weekend shifts will be the most difficult problem of all. But if we don’t do something radical soon, I fear that ED may collapse and bring the whole NHS system down with it. I can imagine a history lesson in a school in one hundred year’s time. Children will be taught that in 1948 a small island off the west of Europe created a staggering advance in civilization, which was the talk of the rest of the world. It was free health care which was universally available 24/7. My fear is that the next sentence will be that it then collapsed in the year 202….
Southern New Zealand Fjordland and Stewart Island
We arrived in Bluff, at the Southern tip of New Zealand, from Dunedin via a cruise through the many sounds that make up Fjordland. I had the day off while the ship re-provisioned and the passengers changed. Vicky and I met up with Neil Waldman from the A&E department at Invercargill Hospital, where I worked earlier this year, and popped into the hospital to see who was on duty. Everyone was even nicer than I remember. What an extraordinary department – staffed with some of the kindest people I have ever met, committed to doing a really good job. We had a splendid lunch with some of the team and then we were off back to the ship.
With new passengers aboard the ship headed back to Fjordland doing it the other way round this time. There is no real sense of deja vu. The weather is so extreme and so changeable that every visit to this area is a new experience.
The mountains of Fjordland tipped with snow and cloud in mid-summer
Then in sun a couple of hours later
There are three major Sounds each with their own charm. Millford sound is steep and dark with huge waterfalls tumbling down from hanging valleys, while Dusky is remote and Doubtful is silent.
Over 9 metres of rain falls here every year on the mountains around Milford Sound producing a lace of waterfalls down the precipitous sides
At Dusky Sound we landed the zodiacs at the spot where Cook had landed over 200 years before. He describes tying his ship to a horizontal branch and walking ashore. There is a horizontal branch at the landing site. I wonder if it is the same one that he used!
Cooks landing site at Dusky Sound with the horizontal branch hanging over the Zodiac
Dusky Sound has a magic all of its own.
All aboard again and the ship weaved through the Sounds as we admired the scenery, the violent changes in weather, and the wealth of wildlife – rare Fjordland penguins, fur seals, Dusky dolphins, shags and terns. The only thing we missed was the experience we had in Doubtful Sound earlier this year, when the ship switched off all its engines and we drifted in complete silence for ten minutes. It was so utterly quiet that it made your ears ring, or maybe I am getting tinnitus earlier than I thought. As we sailed through the sounds, the Zodiacs were launched again and again to explore coves and search out wildlife.
As soon as the passengers are away on a shore expedition, the chief officer calls a General Crew Alert. This is practice for an emergency and could be a fire on the ship or a man overboard. The purpose is to make sure that we have practiced the drill so many times that it would be second nature in a real emergency.
Towing the mannikin out ready for MOB drill
Launching the rescue boat
Then off we go, like a dog fetching a stick, and haul the patient onboard.
Immersion suits all round for the rescue team in Antarctic waters. Back we come with the casualty. Rescue time less than 10 minutes. The mannikin survived!!
Once again we visited Stewart Island and my favourite island of all – Ulva – where they have eradicated all predators and re-introduced the Stewart Island Robin. He is thriving, but remains as tame and trusting as ever. His numbers fell to less than 40 pairs before New Zealand woke up to what was happening to many of their wild birds (they have no indiginous mammals). They cleared several off-lying islands of all the rats, cats, stoats and mice that were eating the young of the ground nesting birds, and then re-introduced endangered species like the Robin. The result was that many indigenous species have been saved from extinction, and will be re-introduced to more and more areas as they are cleared of predators. The programme to eradicate all mammals including pigs, deer, cows and goats from these islands has now spread to a world-wide campaign to clear islands all over the world where nativa fauna and flora is threatened. New Zealanders and now Australians are leading projects in the Seychelles, South Georgia, the Glapagos and other places where the arrival of ships led to invasion by rats, and sometimes the deliberate introduction of harmful species for farming or to act as a foodsupply for shipwrecked sailors. Each of these islands then returns to its former glory as a haven for birds and a garden of indigenous plants.
The incomparable Stewart Island Robin whose numbers fell to only 40 pairs a few years ago. If you scrape your foot on the ground he will now come down to search for insects and perch on your foot! A very strange feeling when it is one of the rarest birds in the world
After Stewart Island we turn south towards Antarctica visiting the sub-antarctic islands. The weather looks very doubtful as we leave the roaring forties and head into the screaming fifties. Extra watertight doors are now closed on the ship, and we have been issued with polar gear. We are battened down for action!
New Zealand May/June
Day by day the weather is getting colder, as we move into the heart of winter here in New Zealand. The weather oscillates (sometimes within minutes) between clear skies and then blustery rain. From my living room window the rain squalls look like a scene created for a B movie. It is as if an extra has been ordered to throw bucket after bucket of water across the garden to create the background for one of those tragic scenes which always occur in a rainstorm.
A Burbling Old V8
When the sun comes out, the old cars come out too. There is clearly a love affair here in New Zealand with V8 engines and old American cars. The results are glorious. Big old 1960s Chevvies rumble down the main drag of Invercargill gleaming with the passion of their owners. Jeremy Clarkson would be in seventh heaven as these old cast-iron engines burble away. I cant think when I last heard a V8 in England, but here they are common, new and old. Of course, the ultimate statement of style here, as in rural Australia, is the ‘Ute’, half truck, half car. It defines the schizoid nature of the New Zealander, half city sophisticate, half rural cow-boy.
An urban Ute. Every young man’s dream
This is a very young frontier country. There are still plenty of new fields with what look like giant Guy Fawkes bonfires pyres standing in them. The bulldozers have cleared the scrub and simply piled the remains into enormous heaps and left them there to rot.
A field recently cleared from the bush with the remains of trees piled up to rot.
Dairy farming is booming here in New Zealand. South East Asia is discovering dairy products and the farmers need more and more grassland to fed their enormous herds of dairy cows. In Guernsey where I grew up each herd was around 20 cows, and the milk collection for the whole island was performed by a single 5 ton lorry fitted with an oval tank on the back. Here each farm may have a herd of over 400 cows. The milk-collection lorries are 40 ton stainless steel leviathans, with another 40 ton trailer towed behind. When you get close to the huge milk processing plants like Edendale, you will see convoys of up to eight rigs pounding down the main road one behind the other.
Those lorries which are not carrying milk are carrying loads of sheep to slaughter packed into trailers three decks high, or logs down to the chipping plants in Bluff. Forestry and farming is big business here and it is thriving.
However, there is always a down-side. The dairy industry now relies on irrigation, nitrate fertilizers and supplementary feed-stuffs for intensive production, and the rivers that were famous for their clarity and their trout are now choking with a torrent of manure.
This industrialisation of the countryside is being opposed by a strong hunting lobby (including of course trout fishermen) and now perhaps an even stronger conservation movement. They want to rid New Zealand of all introduced species and return it to some kind of Moa-rich Garden of Eden. The introduced animals doing the most harm are rats, stoats, and of course Possums. Funnily enough, possums are rare and protected in Australia where they originate, but are common as dirt in New Zealand and destroy the trees. No reserve is complete without its scattering of stoat traps and poisoned bait for rats and possums. As a result, New Zealanders are now famous all over the world as the experts in ridding islands of rats etc, which destroy the nest sites of sea-birds, and indeed all ground-nesting birds. Rat eradication is a national pastime here. Two of the poisons that they use are paracetamol (the common pain-killer) which is lethal to rats, and warfarin (the medicine which we use to reduce clotting). If rats are to take the poison, it needs to be odorless (as otherwise rats are put off tasting them), and paradoxically they should not kill quickly, nor even give any symptoms for some time after they are eaten. Otherwise, the rats learn to associate bait with illness and avoid it!
Luckily there are no indigenous mammals in New Zealand, so any poison that is specific to mammals is likely to work here. They have now cleared many off-lying islands of all rats and cats, and there they have re-introduced rare and endangered species of birds so that they can breed safely. The Stewart Island Robin which sat on my foot within a week of me arrival in New Zealand is the descendant of only forty birds introduced back to Ulva island when it was cleared of rats some twenty-odd years ago.
A Stewart Island Robin about to hop onto my foot. I was so surprised that I missed the key photograph
Now these delightfully tame birds are thriving. However, since then rats have managed to re-colonise the island twice. Nobody knows how. Did they swim from the main Stewart Island (it is not far away) or did they escape from visiting boats? Who knows? All they do know is that they have to continue baiting the traps all over the island ready for the next invasion.
To me the most under valued asset in New Zealand is its Railways. One single track line passes my house on its way to Bluff, but now only carries freight. If only they bought some old steam trains from India or China and got the passenger trains going again, I can think of no lovelier way of travelling this beautiful country, especially if the train actively encouraged cyclists, and at every station there was a youth hostel and a radiating web of cycle tracks to explore the surrounding countryside.
A good’s train passing through the centre of Invercargill
Corrugated iron, cupressus and Leylandii thrive here
The architecture in Invercargill is rather quaint. Corrugated iron and wooden clap-board dominate. Often there is a sofa out on the veranda as, however cold it is, the owners seem to like sitting out and watching the world go by. Garden fences are made of corrugated iron, Cupressus and Leylandii, all of which thrive in this climate.
A typical Invercargill traditional house with the sofa on the porch
Over here in New Zealand, I am having to cook for myself rather than rely on Vicky’s lovely food. However, she is trying to teach me from afar on Skype video. The process is pretty hopeless because many years ago I lost my sense of smell and so cannot taste food. This makes me a pretty poor pupil. It is a bit like trying to learn a musical instrument when you are deaf, but I suppose it also means that the result doesn’t matter much either!
The main problem seems to be this business of retro-timing in cooking. Everything has to be ready at the same time. So, time zero is at the end of cooking, not the beginning. I am having to learn that to achieve this you have to remember to start each part of the meal at a different time, depending on how long it takes to prepare. Last night I forgot to boil the water to cook the vegetables, and only remembered my mistake at the last minute. In my haste to get the greens into the boiling water I scooped them all up in one go, and dumped them in the pan. Unfortunately I included my hosptial notebook which happened to be lying on the table underneath them. Five minutes in boiling water cooked the beet perfectly but the notebook turned into a most unpleasant papier mache pulp which then blocked the sieve and coloured the beet blue. Never mind, I have no idea how it tasted. Vicky has now produced a series of one-pot meals that I can put in a slow cooker at the beginning of the day and by the time I get home, supper is waiting. Magic!
You never know how each day is going to be in the Emergency Department. We spend lots of time speculating in retrospect what external events could have made a day busy (the weather, no GPs at weekends, etc). However, we never speculate about the future, as everyone is surprisingly superstitious about what we might bring onto our own heads. As soon as anyone starts to say anything that might be a prediction of what the day may hold, everyone hisses, crosses their fingers and begs the person to stop. I find this all quite unexpected behavior in supposedly rational people.
Walking to work yesterday. Mid-winter Invercargil
Yesterday morning there was no time even to speculate. As we sat down to take hand-over from the night team, the phone went from a blue-light ambulance on its way to us. The crew were calling a category 1 casualty (the most serious) with an arrival time of one minute (a lot shorter than we like or expected). They were bringing a 23-year-old victim rescued from a house fire. We only had time to get our tabards on when the patient arrived with the fire and ambulance crew more upset than I have ever seen them. They were quite literally shaking.
In Afghanistan, the Chinook helicopter bringing in casualties would send ahead a radio message which was called a ‘Nine liner’. Each line defined the details of the event in a clear and logical manner. However, because of weird logistics, the Chinook could not contact Camp Bastion Hospital directly. So, the doctor supervising the casualty had to pass his 9-liner to the co-pilot, who then relayed it to the Apache helicopter flying cover above the Chinook. He then passed it to the helicopter control tower, who then called us in the hospital. Surprise, surprise, the resulting message bore little relation to what was sent out. It was just like the children’s game ‘Chinese Whispers’, and we, in the Emergency Department called the nine-liners nine-liars. I had not realised that this miscommunication occurred in the civilian world too. Our patient was a 23 month old child (not a 23 year old male) who had been dragged from a burning house where he was found by a fireman huddled behind his toy box cuddling his teddy bear and with the family dog beside him. The fireman had obviously left the dog behind and had only just got out with the child who was very badly burnt. His airway was deteriorating by the second and he was in a lot of pain.
Once again, in Afghanistan the problem with the early management of casualties was often too many people around the stretcher when only one or two casualities arrived (we were staffed for up to six at a time). So, we had a red-line drawn on the floor just inside the door of the Emergency department, and no-one who was not in the Emergency department team was allowed to cross this line without invitation.
Well I saw something similar in Invercargill. As soon as we got the Cat 1 call, I asked if we wanted to put out a general call for the medical registrar, the anaesthetist etc. The hospital has a system for doing this. I was smartly overruled by the ED consultant in charge, who said firmly “No. We manage the patient first and then decide who to call”. When to our horror this 23-month-old child was delivered onto the resus table struggling to breathe, I saw our shift boss hesitate and then order an immediate call for the paediatricians and for an anaesthetist.
It was clear that the child needed intubating immediately, but would need anaesthetising first. His airway was poor and deteriorating. By the time the paediatrician and anaesthetist arrived at the run, we were well into preparing to put a tube down. Using one of the new bone drills I had put up a drip directly into the child’s tibia. Both legs and arms were burnt so looking for veins was going to be even more fruitless than usual. I was happy to be doing this because the paediatricians take bone cannulation as an admission of failure and waste hours trying to find a peripheral vein to cannulate.
Spitfire burns on a two-year-old. His body had been protected by his teddy bear and the family dog (who died in the fire).
We were just injecting the general anaesthetic when the crash team arrived. As soon as they saw the situation they paniced. The paediatrician was cursing and demanding to know where his registrar was (that told me everything!). The anaesthetist was simply burbling, talking complete rubbish. Then I saw an interesting thing happen. Our ED doc in charge quietly but firmly asked them to move out of the resus bay to make space. They were way outside their comfort zone. She was not.
So, now I have seen first hand another unique area of expertise that ED consultants (not me!) have in their repertoire. Most specialists whether they are paediatricians or anaesthetists work in controlled environments and are in danger of losing the plot when things are really urgent. ED consultants thrive in this peculiar atmosphere. Within minutes the child was safe, stabilised and on his way up to the Intensive Care Unit. A fixed-wing aircraft then came down from Auckland to evacuate the patient to the National Burns Unit. A very anxious father had to be dissuaded from lighting a cigarette while standing beside the child. Obviously, this was his normal response to stress!
Waiting for the cardiac arrest to arrive.
We just had time for a debrief before a youngish patient was brought in on a blue light in cardiac arrest. We got his heart going but his pupils remained fixed, and he was transferred up to the ITU. Then we had a flush of minor musculoskeletal injuries and acute abdomens, including three patients in a row who claimed that they could not afford to go and see their GPs (the minimum charge for a visit is £30). Then I got a call from Dunedin labs (the main Southlands hospital some 80 miles away). The patient on whom I performed a lumbar puncture last week had positive signs of Varicella
Zoster in their cerebrospinal fluid. I didn’t know that you could get brain chicken pox! Anyhow, with my heart in my mouth, I rang the patient at home to check how she was. “Oh I am fine now thanks doc. That needle you put in my back did me a power of good!” she told me cheerfully.
It’s a rum place ED, and certainly provides you with plenty of variety. I am pretty sure that the patient with fixed pupils has not done well, but the burnt child is now off a ventilator and will be out of the hospital soon. The fire service has done an interesting thing (with the permission of the family). They have held an open day at the house, showing people how the fire started (a computer games console left on overnight) and how it spread (the smoke alarms were disabled).
New Zealand
Earlier this year John James and I cycled up the Outer Hebrides from South to North. Although it looked uphill on the map, it was absolutely the right decision as we were pursued by Southerly gales which drove us up the islands as if we were on electric bikes. We met lovely gentle people and the scenery was to die for.
Sealions on the beach just down from my house
New Zealand is just the Outer Hebrides transposed to the other side of the world and expanded a hundred thousand times. Lantern jawed Scotsmen with beetling brows and gleaming eyes stride down empty roads their knees wobbling in the breeze beneath mighty empire builder shorts. They look just like modern day characters out of ‘Kidnapped’ or ‘Treasure Island’. You almost expect them to stride up to you, glower into your eyes and then slap the ‘black dot’ into your hand. Instead, when you do speak to them, they turn out to be the kindest, most courteous and friendly people, for whom nothing is too much trouble. The women are always laughing and everyone is incredibly friendly. It is soooo rrurral that your rrrs rumble in your head. However, I suspect that the wind here can be similar to the outer Hebrides.
Trees on the south coast road of New Zealand showing possible signs of wind-blow!
The politically correct, who run all the politics and NGOs here in New Zealand worship the Maoris, despite the fact that just as in Australia, the Indigenous people have appalling rates of alcoholism and unemployment. All politcally correct truisms are credited to ‘ancient Maoris sayings’ such as ‘If you cut down a tree, you must plant one in its place”, or ‘Wish for what you need, not what you want”, or “if you chew gum, expect to have to swallow it”. It doesn’t really hold together for what were by all accounts a horribly war-like people, who started the deforestation of New Zealand, wiped out the Moas, and who are now struggling to cope with modern society in any meaningful way. It is a bit like us attributing all wisdom to the Celts as exemplified by the modern day Welsh.
I am in Invercargill on the very south tip of South Island to train as in an Emergency Department as a medic. When they interviewed me by phone they asked if I knew where Invercargill was. When I admitted that I wasn’t completely sure they said “Weell its not the end of the world, but we do think that we can see it from here!”. I have to do this because I want to work for NGOs in the Third World and disaster areas.
Invercargill Hospital across the road from my house
The hospital is only five years old and is lovely and airy. The have given me a house opposite the hospital and a car, and made me feel incredibly welcome. At the end of the road there is a nature reserve with more birds on it than I saw in the whole of south east asia in three months.
The nature reserve at the end of the road
Black swans, pied stilts, gulls, herons, and then old friends from Europe goldfinches, chaffinches and yellow hammers. It is summer here so it doesn’t get dark until 10pm. The reserve has no litter and is beautifully laid out with raised walkways over the flooded bits, and the rest of the track is a disused railway line. Everyone greets everyone else. I have always had this theory that the further you get from London the more courteous people are. Well we are a good 11,000 miles from London here and it certainly shows.
I am sure that they find my accent pricelessly funny but are much too polite to laugh at me. Some of the youngsters do ask, and when I explain ‘England’ you can see a look of delight mixed with understanding coming over their faces. I am ‘Fawlty Towers’ in real time! Thank you John Cleese!
I had to come through Wellington on the way down. It is a very lively young persons’ city with an open sea front coated in skate-boarders, protestors and people just promenading from restaurant to restaurant.
Meanwhile I am having night terrors that I will not be able to manage the patients in ED. I have medical textbooks on both sides of the bed and test myself on life threatening asthma, then on the early management of stroke. Aaarggh why did I decide to do this. It was so much easier as a ship’s doc.
They give you the first few days off while the paperwork clears, so I have been over to Stewart Island on the ferry and then onto a tiny island called Ulva where they have eradicated all rats and cats. On the way over there were Albatrosses (mollyhawks) and sooty Shearwaters. Then on to Ulva.
Moss, fern and beech tree forest
ED in Invercargilll
Yesterday was my baptism of fire. They have built me up to it slowly and I knew it was coming. Indeed my first day as a consultant in charge of an ED department went reasonably well. The pace was steady. There were no major problems and I was quietly and prematurely congratulating myself that I might have cracked the transition from Orthopaedics to Emergency Medicine. But Tom Hughes’ doom-laden forebodings came to haunt me yesterday, my second day in charge.
I had done all the Emergency courses before I came to New Zealand that are supposed to prepare you for medical or surgical emergencies in adults and children. But courses arent the same as the real thing and indeed these acute emergencies are not really about what happens in the ED 99.999% of the time.
In the Navy, they used to have a course called the Perishers for selecting future commanders of submarines. In the documentary about the course, the examiners focused on the ability of the candidates to cope with the stress of an attack. But when you think about it, the chances of you being attacked during your tenure as the commander of a submarine are infinitesimally small and the criteria as to whether you are going to make a good captain are probably much more to do with the humdrum everyday running of the submarine than whether you can take on two frigates simultaneously. Well the ED courses are the same. For a start the medical emergencies yesterday just sort of crept up on us. One of the nurses tapped me on the shoulder to say that one of the patients was just being moved across into the resus bay because he had dropped his blood pressure to 65/40 but was still chatting
away so they were just moving him to be on the safe side. Then we couldn’t get any lines in. As we struggled away, he explained with great glee how much difficulty other doctors had experienced finding his veins. Then another patient dropped her pressure and suddenly our forces were divided. I made the cardinal mistake of joining the merry throng trying to find a vein. I know, I should have stood back and assessed the situation and then decided on priorities. Well, I lost the plot for a bit. No-one died, but that was mainly due to the resilience of elderly New Zealanders, rather than a well oiled Emergency team. As I walked home at the end of my shift I found that every muscle in my body was aching from, I suppose, me being rigid with worry for the past four hours.
They speak New Zealand out here. In its broad South Island form it is really quite tricky to understand. I asked one elderly lady how many months she had her symptoms. “Sex!” she spat back at me. For a moment, I thought she was dementing and was preparing to fend off an unsavouray attack when I realised that she meant ‘Six’
The hours of work are embarrassing. I have to work 7 shifts a fortnight so I have lots of days off, and there is something beautiful in every direction. Milford Sound apparently gets on average nearly an Inch of rain every day (eat your hearts out South of England) but the day I went there was cloudless and the fur seals were basking on the rocks on each side.
Milford Sound on a ‘drought day’.
The tiny winding road to the Sound, which passes through a single-lane tunnel (you have to wait for hours for the lights to change) is the only road into this enormous national park called Fjordland. In the opposite direction from Invercargill is rolling farmland with empty surf beaches stretching as far as the eye can see. The only figures are seals frolicking in the surf.
Sunday afternoon, mid summer New Zealand.
I have joined the local library and can borrow up to 40 books at a time (far more than I can carry on my bicycle) but it does mean that if after ten pages the book doesn’t interest I just swop it for another. Very decadent.
In the absence of Vicky I am learning to become a master chef. Or at least I think that I am, but as I cannot taste anything and have not been able to for years I may be in for a rude shock when Vicky arrives next week. If she is wise she won’t even offer to sample anything that I have prepared.
It is strange being 11,000 miles away from England and yet being able to listen to Radio 4 on the internet. Very reassuring to know that the UK continues in what appears from here to be a wonderfully parochial way. Sandy Toksvig’s laugh gurgles away as merrily as ever and all is well with the world. But somehow the urgency of the crisis in Greece is dulled by distance and the ridiculous exposées of Dominic Strauss Khan (quite literally) just seem like pecadilloes rather than a criminal offence. How on earth did he think he was going to stand for President. So much for insight.
Top Gear: Travels in Nepal and up towards Tibet
Top Gear produces car journey stories from all over the world. This time it was to be the high mountains of Nepal and they decided that they needed a doctor with high altitude experience to accompany them. Lucky me!
CB in Mustang province Nepal close to the Tibetan border
A trip like this is quite an extraordinary logistical exercise. The BBC has to fly three old bangers, a team of 35 and a ton of camera equipment halfway around the world then get it through Indian customs and across the border into Nepal. Then they needed to hire 10 Land cruisers and two 4 wheel drive lorries to carry the team and their equipment along the planned route which has been recce’d twice before the actual filming trip. This journey was along the Annapurna trail. For those of you who are keen trekkers, this must be one of the most beautiful routes in the world. But go quickly; the road is being tarmacked and already the lorries are starting to pour out their diesel fumes as they thunder up the New Silk Road to Tibet. In 5 years it will be like walking along the hard shoulder of the M25
Heading towards the mountains
The shoot was supposed to take place just at the end of the monsoon, when the mountains are clothed in wild flowers, with clear blue skies. But, the monsoon started late this year and finished even later, so although the picture above looks just how it should, it was a rare sight. For much of the rest of the time we were in low cloud and rain.
We all mustered in the Shangri-La hotel in Kathmandu, taking up a whole ballroom with equipment being unpacked and set up ready for filming.
Vehicles and drivers lined up ready to go, all to film 3 celebrities and 3 bangers
Kathmandu is a typical Eastern city that has grown far too quickly, clogged with traffic, battered by noise and buried in a smog of diesel fumes.
The wiring in Kathmandu is ‘exciting’ to put it mildly
Even so there are havens of peace which give you a glimpse of how Kathmandu must have looked hundreds of years ago.
Cameramen setting up in a lovely temple area of Kathmandu
Buddhists like to feed animals so there are lots of cows, monkeys, and pigeons to contend with too
The local gods are not user friendly
The cars looked utterly incongruous in this peaceful Eastern scene.
Our first shoot was in the temple area which is usually (rightly) traffic-free. I don’t know how they got permission to bring the bangers in there.
Most of the time the bangers are driven by professional drivers, not the stars for very obvious reasons. They are a very nice bunch who belong in the team.
Phil – one of the professionals trying to get one of the cars started
The stars handing over the cars to the professional drivers
The next stage of the shoot was to cross Nepal from East (Kathmandu and Everest) to West Pokharra and Annapurna. It is a long drive and a wonderful opportunity to see a lot of Nepal. We drive in Convoy with each vehicle having a specific task (P1 & 2 & 3 = producers, C= cameras, MC =Micro cameras, D= drone M=Medical E= Engineers DTI= data, Luggage transport lorry and three bangers.
The convoy without the bangers and the luggage lorry. Our job was to be as close to the filming as possible in case we were needed but always out of sight. The public must think it is just three ordinary blokes having fun
The road was rough in places and sure enough on the first afternoon, one of the bangers ripped out the front of its chassis on a rock. No problems; the engineers took out the rear seat and rolled the car onto its side resting on the cushion. Then, beside the road, in the dark they welded up a replacement strut, and on we went.
Welding up a broken chassis
From Pokhara it is uphill North into the mountains and this is where the fun started. The road is being rebuilt as one of the New Silk Routes but the work has only just started and in my opinion will never finish. Earthquakes and monsoons will see to that. The two recces for this film had been done in the dry season. The road looked rugged enough to be fun but passable for the bangers. We were supposed to be filming just after the monsoon had finished. Well it had not, the rain poured down. The road was a deeply rutted mess of mud, difficult on the level, impossible on the steep hills.
Muddy road with deep ruts. Difficult in daylight on the flat. Lethal on steep hills in the dark
In the dark it was frankly terrifying. There was a steep drop off the edge and lorries and buses were jockeying to get past each other. The key was to keep moving so if a vehicle got stuck then you tried to pass it without slowing down. Woe betide anyone wading through the mud trying to push vehicles out. Our bangers had to be towed by the 4 wheel drive vehicles and that hindered them even further especially when the lights failed on two of the towing vehicles. No pictures I am afraid. I was just up to my knees in mud pushing. That day (and night) was thirteen solid hours of driving and when we finally reached our destination the engineers were straight back out repairing vehicles so that they would be drivable in the morning.
The wet side of the Himalayas facing the monsoon
Pedestrian bridge over river in spate
Building bridges for the new Silk road
Crossing a ford
Quite suddenly we came into the rain shadow of the Himalayas and instead of steep forests, crashing rivers and mud roads we were in a desert dotted with oases. Even though the roads were being washed away before our very eyes, armies of diggers were building bridges ditches and drains and clearing away the rockfalls.
Clearing away another landslip building the new road
Folded rock strata at sunset
Braided river and raised beach
Water eroded soft sandstone
An Oasis in Mustang province
Our driver was not the least bit phased by the unstable edge of the road in places but was very loath to stop under any overhangs because of rockfalls or even to go near the inside of the road. We were begging him not to drive so close to the edge while he was pointing out rock fall after rock fall on the inside of the road.
Stone-fall damage to the top of the Landcruiser
The part of the road where we were hit by stone-fall
In places we preferred to get out and walk
Andy and I decided to Walk this bit as it seemed a bit narrow and unstable
Vehicles working their way through this narrow gap with over a 1000 foot drop below
A fresh landslip being cleared while the convoy inches past. This is the main road from Nepal to China
Even on the simpler stretches of road our convoy caused enormous problems if we met a lorry or bus coming the other way. Goats were a problem too.
Convoy blocking the road. There was no way that we could back up
Goats and landslides blocking the road
Bringing in the hay to the walled town of Lo Man Tang
The welcoming ceremony in the central square of Lo Man Tang
It is a walled mediaeval city and will be completely ruined by tourists the moment that the road is opened.
A Completed bit of road
Presenters leaving by helicopter. We have three more days of driving to get back to Kathmandu
As soon as the filming was finished a helicopter whisked the presenters away, while we took one longing look into Tibet and then started the three-day journey back to Kathmandu
Rockfall in front of one of the convoy vehicles
Shrine high in Mustang near to the Tibetan border
Sunrise Mustang
Renault 4 at end of trip
Paddy celebrates winning hill climb
Travelling around South Island
A couple of duty days and then I had another 5 days free to travel around New Zealand with Vicky.
This time we wanted to concentrate on the Southern tip of New Zealand which is perhaps one of the most beautiful parts of all. But once again, bad weather can be a problem. We wanted to go to Stewart Island off the south end from Bluff, but the Foveaux Strait is notoriously rough. Indeed the night before last the house shook as the rescue helicopter brought in the only survivor of six fishermen whose boat had capsized in a freak wave in the strait. He had clung to an empty water barrel for 18 hours. They certainly make them tough here! But disasters like this are an annual event for the fishermen going out from Bluff, so although the ferry to Stewart Island is a modern 100 seat catamaran, we didn’t want to take any chances with rogue waves. East from Invercargill is the Catlins, a bulge of land on the way to nowhere, the landscape being rolling hills like the lake district. Then to the West there is Fjordland, with scenery to compete with Patagonia, the Pyrenees, or the Norwegian coast. With a forecast of zero wind we set off for Stewart island. Calm seas makes it easy to see birds, whales and dolphins and we were not disappointed.
Blue (fairy) penguins were everywhere floating in rafts on the sea. Albatrosses (Mollyhawks) soared right in beside the boat while Shearwaters (mutton birds) glided inches above the waves. They made the journey out to the islands a pure pleasure. Stewart Island is over 40 miles long but only has 400 inhabitants clustered in the small port of Oban. Just like everywhere in New Zealand there are lovely paths through the forest and the walking is a joy as there are no snakes, leeches, or scorpions. The lower canopy is mainly giant tree ferns and a giant species of Fuschia.The main upper forest canopy used to be a beautiful hardwood tree which takes 900 odd years to grow to full size. It was all removed for timber a hundred years ago, so now there are only scattered saplings of these great trees. However Ulva Island tucked away in one of the bays of Stewart Island was the home of the post-master. He loved plants and especially trees and refused to allow any felling on his island. So, here the original forest remains.
But, Ulva is even more interesting than that because it is one of the islands where they first erradicated cats, rats, deer and stoats and then re-introduced rare indigenous ground nesting birds which had been obliterated from the rest of New Zealand.
A Stewart Island Robin about to hop onto my toe
There were only 40 black Stewart Island Robins left in the world when a few were released on Ulva. They have thrived there, and remain as tame and trusting as ever. If you scrape the ground to expose grubs they will come to sit on the toe of your shoe checking for prey. It is difficult to take a picture when one of the rarest birds in the world is sitting on your toe!
On the way back from Stewart Island the sea was very very calm. Far away we saw a Humpback whale spout, then closer to us a pod of large bottle nosed dolphins were feeding in a long line. What happened next could only occur in New Zealand. The captain spotted the dolphins and then asked if anyone had any flights to catch or urgent appointment that could not be missed. No reply, and so he throttled back, turned towards the dolphins and stopped the engines. For ten minutes we wallowed amongst 200 Bottle Nosed Dolphins all trying to see how close to the ship they could get. As we started off again some of the younger dolphins raced along beside us, bursting with energy, determined to prove that they could go as fast as us.
The beaches in the Catlins are enormous and empty, with a surf pounding in from Antarctica. In the forests waterfalls pour down towards the sea
The following day we set off for the Catlins. The weather was poor so we didn’t see them at their best. The sealions and yellow crested penguins were nowhere to be found but the scenery was still magnificant, the trees bent down by the prevailing gales.
Our third trip in week two, this time to Fjordland, started provisionally as a day trip but got longer and longer. It was supposed to start with a visit to Te Anu the gateway to the National Park, but when we got there the weather was lovely, and the meat pies quite excellent, so we decided to stay on for two more days. The first evening we went on a boat trip up the lake to some limestone caves whose walls are lined with glow-worms. It all sounds very naff, but was in fact really impressive. Having crossed the lake and then climbed into the caves, we were put into small dinghies which travellled in complete darkness and silence with thousands and thousands of glow worms shining all over the walls. A most eerie experience.
The next day was again great weather and so we took a long trip to the rarely visited Doubtful Sound. To do this you have to cross one lake by ferry, then be delivered by coach over a pass to the Head of Doubtful sound. These coaches were brought here by boat and are the only transport available there.
Finally a rather lovely motor-sailing ferry cruised us down this beautiful sound, which must surely be one of the quietest places on earth.
As we came back up over the pass the driver suddenly decided to take a diversion and took us down a 2km spiral road dug deep into the heart of mountain to visit the huge hydro-electric plant which has been hollowed out inside the mountain (again this could only happen in New Zealand). It provides one seventh of New Zealand’s electricity in almost complete silence. Very paradoxical to find a huge power plant hidden deep beneath a wild national park.
The weather held, so the next morning we set off North to Milford Sound. The drive itself is quite beautiful up the Eglington valley and then through the Homer tunnel and down to the top of Milford Sound.
Having seen only six cars on the whole 100 km drive we suddenly found ourselves in a harbour busy with six ferries, two helicopters and a couple of planes ferrying visitors up and down this huge fjord All along the walls of the Sound there are soaring waterfalls. When it rains (as it often does) then the walls become sheets of water which are blown back up the mountain, so the cliffs are lined with bottomless waterfalls.
So now it is back to nights on duty in Invercargill. The department last night was full of worried mums with sickly babies and drunken men with horrible cuts and lacerations. Two extremes of our society. Precious infants mollycoddled by anxious mothers, side by side with men trashing their lives.
New Zealand two months in
Two months in the same place, and it is getting harder to write a blog. My sedate and solitary existence has been overshadowed by John James being in the middle of a revolution in Mali, Harry winning cycle races, and Jenny getting her teeth into History of Medicine.
I gather that Spring in the UK has been wonderful. Well the weather here too in South Island has been quite unexpected. We have had an indian summer, with day after day of no wind and warm sun despite us now being effectively in October! And this is a place famed for its winds and savage storms imported direct from the Antarctic.
Yesterday was my first day off for nearly a fortnight and a chance for a massive bike ride. I am trying to go out of Invercargill in every direction exploring what is there. I had been West twice but there was a peninsula jutting out South West on the far side of the river which looked interesting, and which I had only seen from afar on previous trips.
I now have a mirror fixed to my bike helmet (Helmets are compulsory in NZ) so I don’t have to turn my stiff arthritic neck to see what is coming behind me. I also have lovely earphones and an MP3 player so can travel long distances on my bike completely removed from the outside world. This is not nearly as dangerous as it sounds as there are very few cars and anyhow there are lots of cycle lanes too, so the most dangerous thing is a young New Zealander storming up behind you on a personal mission to climb Mt. Everest or the next best thing. I am sure that overtaking me gives them a lot of pleasure. I justify my slowness on the fact that I am doing really long journeys, and I am giving young New Zealand jocks pleasure in overtaking me.
My bike trips almost always start along the wooden walk way at the end of the road. It is such a pleasure to ride along, and it connects to cycle tracks in lots of directions.
The wooden walkway which is the start of most bike rides
I had to cross the main estuary mud flats to go West along a track originally built for a train which ran on wooden rails. It is also operates as a dyke as the airfield behind it is on reclaimed land and is actually below sea-level. Not far beyond that is the bridge crossing the big Oreti river. Suddenly traffic dwindles to almost nothing and to add a sense of wildness the road is part covered with little banks of sand blown in from the dunes around. Finally, the road cuts through one final dune and you are quite literally on the beach. Drive 50 yards further and you will be in the sea,
Oreti beach is one of the top surfing places in South Island and yes indeed, demonstrating its national importance as a surfing mecca there was one 4WD parked in the centre of the beach and a lonely surfer far out beyond the waves waiting for a big one. The beach here is 30 km long, so I really could not resent my solitude being invaded in this way.
Oreti beach packed with people
on a lovely sunny day
Roots of giant kelp make Tate
Modern scultures on the beach
The beach is covered in all sorts of flotsam and jetsam icluding the roots of the giant kelp which grows on the shores here, and which is ripped up by the storms. It makes the most wonderful ‘monsters’ peering out of the sand. Once around the headlang the beach turns in to form the edge of the estuary. Behind it are towering sand dunes, some of which are covered in pine forest. However, the pines are coming to the end of their useful lives and already they are starting to plant local trees to replace them Unfortunately Rimu and Totara are very slow growing but in some hundreds of years they should return the habitat to its old glory. On the beach there are sea-birds galore here and almost no litter, a wonderful contrast to the horrid beaches in south east asia which were devoid of wild life and banked up with litter.
On the way back up the peninsula the path weaves through sun-light dappled forest with the ground covered with glorious ferns.
Thé track back through the forest
Ferns cover the forest floor
In the hospital I am at last beginning to feel part of the team. The juniors are all from England escaping the NHS. They are cheerful, work hard and know lots of medicine. The seniors are from all over the world, the USA, Sweden, Sri Lanka, you name it. The nurses are all New Zealanders and to my surprise wear short trousers (well breeches really) as part of their work uniforms. Short trousers seem to be the National Dress of New Zealand for both men and women and jolly functional they are too.
In the department we seem to be having a rash of dog bites at the moment. Lots of people keep pit bulls and if you tangle with them they bite. No-one seems to mind too much. They seem very philosophical about the bites even when pieces of their arm or leg are missing.
There is no CT or Ultrasound after 5pm and no X-Ray (except in special circumstances) after 9pm. This certainly concentrates the diagnostic mind. Luckily the New Zealanders are not at all litigation conscious. The national Accident Insurance scheme means that you don’t have to prove anything to get compensation. It certainly makes it much easier to work with patients rather than against them, and the farmers at least are a stoical lot. One of them last week had been gored by a bull, which had lifted a great flap of skin off the front of his leg. I gingerly removed the dressing and was just trying to assess the damage when a hoary pair of manure covered fingers reached into the sterile field and hoisted the flap of skin and tissue into the air like a sail. “See, what I mean doc, his horn must have gone in and out right there!”
In two weeks I come back to the UK for a couple of weeks. It will be great to see the kids and Vicky and the changes in the garden. With luck she will come out for a third time towards the end of my stint, then we can visit North Island and travel home together. I will finish here in early August, when I will have completed my six month probation period in New Zealand and should be able to work here again as a consultant. It feels like a long road away from orthopaedics and into other areas with different perspectives and challenges.
A sail around NZ
Our trip was a circumnavigation of New Zealand. We visited the most wonderful wineries in North Island and the North of South Island and then headed down to South Island.
This time we entered Doubtful sound from the sea and landed on the very point where Cook first made landing in New Zealand.
Fjordland from the sea with Doubtful and Milford Sound.
Cooks landing site
Finally, we dropped down to Stewart Island one of my favourite places, because there lives the Stewart Island Robin which was down to only forty individuals when it was saved from extinction. Its fate is to be far too tame with no fear of terrestrial predators like cats.
Stewart Island Robin If you scratch the ground with your shoe he will land on
the toe looking for insects that you have disturbed
Sub Antarctic islands
The normal route for visitors to Antarctica is from Ushuaia in South America across the Drake Passage to Graham Land, a rough but short two-day journey into the Wedell Sea with the opportunity to visit South Georgia and the Falklands if you extend the cruise. Orion went down the opposite side of the world from New Zealand into the Ross Sea in Antarctica from the opposite side of the world. It is a much longer journey (10 days rather than two) and very few ships go that way.
The bonus of the New Zealand route to the Ross Sea is a chance to visit a string of islands on way down, each of which is teeming with wildlife. MacQuarie is on a par with South Georgia but then there is Campbell Island, Enderby and the Snares. Finally there is the bonus of the Ross Sea where both Scott and Shackleton had over-wintering huts.
We made two circuits down to the Ross Sea from Bluff on the southern tip of South Island New Zealand. The tour started with Stewart Island, and then we headed south to a small group of uninhabited islands – the Snares. Except that of course they are not uninhabited. They are heaving with birds, giant flocks of Sooty Shearwaters and thousands upon thousands of Snares penguins.
Huge flocks of Black Shearwaters (literally millions)
We are now travellling down the continent of Zealandia, the 8th continent of the world. The unique feature of this continent is that most of it is underwater. Only the tips of the highest mountains appear above the sea, usually as storm beaten rocks; magnets for all the sea life which feeds here.
Zealandia continent is 2000 miles by 2000 miles and almost all underwater! New Zealand is only the centre of it. The red flag at the bottom left is Macquarie Island, the next up is Campbell island, the green is Auckland and Enderby and the red flag just south of New Zealand is the Snares. These are the mountain tops that we will be visiting.
As soon as we turned South we hit the Antarctic convergence. This is where the cold polar currents meet the warm temperate ones. All at once the weather turned cold!.
Vicky modelling the Antarctic convergence
The ramp on the Snares with thousands of penguins commuting up and down
Penguins leapjng in towards the cliffs
and the highway in close-up
Penguins racing past the Zodiacs loaded with food
The sealions and fur seals were fascinated by our boats and determined to amuse us with antics like standing on their heads for long periods.
The Sealions almost seem to be showing off
The sea was so calm that we could follow fur seals through into caves
Fur seals guarding their harems on the rocks
The main vegetation is an extraordinary giant tree daisy (Olearia) and these were in flower. Beneath them the rocks were crowded with the Snares own crested penguin.
Tree daisies and Rata cover the land while penguins cover the cliffs
The penguins are acrobats in the water and astoundingly handsome on land
They all seem to be fascinated in the fate of the first to jump into the water- Great white sharks are common here!
Their breeding burrows are high up and deep in the forest of the island. On the cliff there is a veritable Highway 77 leading to the forest with Penguins busily marching up and down it. We could sit at the base of this cliff watching them swim in and set off up the cliffs
Apparently it is rare to get such good weather at the Snares and certainly when we ventured round the south end of the Islands we suddenly found ourselves exposed to the full force of the wind and the waves
Again the zodiacs were hoisted aboard and the Orion set off south out of the roaring forties into the screaming fifties. Sure enough the wind picked up and we started to feel the real strength of the waves
Then we set off South again until we reached the Enderby Islands, the location of some simply terrible ship-wrecks in the late 19th century. The crews struggled to survive for years before the survivors were rescued. Now the islands are again un-inhabitated, but are the breeding ground for Sea Lions,
Massive sea lions guarding their Harems
Inland the Enderbys are coated in thick forest which at least provides shelter from the wind
As we went deeper South the wind rose and the we were now surging across the huge waves that roll all the way aound the world. Enderby is another set of islands which was trashed by sealers and by whalers. Within twelve years they had stripped out all the wildlife. So far, not much different from many other mountain tops in Zealandia. Then came a series of shipwrecks, each a desperate tale of misery as sailors struggled ashore only to die of cold and starvation. In a couple of cases there were enough survivors to tell the tale of what happens when man sinks to his lowest ebb. The postion of the islands was incorrectly recorded on the Admiralty charts and lay directly in the path of sailing ships heading up from Melbourne to Britain. So, they were a deadly trap in the fog and storms which are the normal weather for this part of the world. Now the Islands have shelters for shipwrecked sailors with finger posts pointing to the nearest shelter. They are also havens for wildlife and the populations of some are starting to recover. Today, the most dangerous thing going ashore is sea-lions breeding on the beech.
The bull males with Harems were no problem. We just kept away from them. It was the young teenagers, stoked with testosterone who took our presence as a personal insult and mock charged us everywhere we turned.
The males with their harem and pups were just a delight to watch, snorting
and roaring at each other as they marked out their domains.
The youngsters were football hooligans, stoked with testosterone and rushing
out of the tussocks at us. A flag or stick held ‘en guarde’ temprarily stopped
the charge, while we ushered the passengers through the danger zone.
When they werent hassling us, they were beating each other up with tremendous roars and snorts.
Inland was the dense Rata forest which was impenetratble to the shipwrecked sailors and resulted in (at times) more than one group of ship-wrecked sailors living on the island unaware of the presence of the others.
On the tops there are meadows of sub-antarctic wild flowers dotted with Albatrosses nesting.
Meadows of Bulbinella
Bulbinella flowers
Carpets of gentians
On the far side of the island we came to the high cliffs which overhang the ocean and face the Westerly winds. It is here that the ships were dashed onto the rocks and the survivors scrambled ashore, then struggled to survive in the gales and driving rain and snow.
As we sailed away from Enderby wrapped in our thermal layers and Gortex jackets, I am sure all of us were wondering what it must have been like to be shipwrecked here for two years through winter and summer.
Campbell Island
South again to Campbell Island, a treeless island with beautiful mega-herbs dotted with Albatross nests. Its west coast are some of the most unforgiving cliffs that I have ever seen.
Albatrosses nesting amongst the strange megaherb vegetation
By the time we reached Campbell the wind was hurricane force. Extra weights had to be put into the zodiacs to stop them from being blown away in the gusts as we evacuated a guest with a broken leg. As we set off South again we were hit by a huge wave which stove in the rails in front of the bridge. The captain decided to turn back to take shelter in the lee of Campbell Island, but as we turned another wave hit the stern and stove in the railing there. That meant a lot of report writing for him.
The next bit of the journey south was spectacular with bigger seas than I have ever seen before. They were over 40 feet high but the length between each wave was so great that the ship managed most of them fine.
South from Campbell is Macquarie Island, which is equivalent to South Georgia in the quantity of wildlife.
You may not approach wildlife but they can approach you!
It is the Southernmost tip of Zealandia although it is administered by Australia. In the last few years the Australian wildlife service have managed to eradicate all rabbits and rodents, but there are still 10 teams of hunters with dogs who roam the island making sure that there is not one survivor. This has been an very expensive project but should yield huge benefits to the Antarctic Wildlife
There is no natural anchorage at Macquarie nor is there an easy beach on which to land.
Orion rolling in the swell waiting to unload Zodiacs
Orion stands off shore and waits for the Zodiacs. When we first loaded in the morning, the fog was so thick that we could not see land and had to set off blind using our GPSs. The first crew ashore must do their best, but can then help the subsequent boats negotiate the surf. Today the swell was good to start with, dampened even further by the kelp lining the shore.
The landing crew wear chest high neoprene waders to catch and hold the Zodiacs as they land
The passengers hardly need get their feet wet
The problem is the wild-life which has no fear of us and is quite inquisitive
Macquarie Island ain’t no tropical paradise but the wildlife is awesome, and
the passengers loved it apart from the one who dropped a brand new and
huge Canon telephoto lens into the sea while getting off a Zodiac to go
ashore! Vicky is in the foreground on the right.
When you first land it looks good, but it gets better from there
You are supposed to keep 10 metres distance from the wildlife, but if you sit still, baby sea-elephants crawl up to see you.
The Australians have a research station there but Wildlife clearly takes priority
All along the beach there is a constant roar of the male sea-elephants fighting
While young Gentoo penguins sit patiently waiting for their adult plumage
The colony of Royal Penguins is huge
The King Penguins on eggs look slightly uncomfortable
Royals heading out to sea
Sea-elephants frolicing in the river
The King Penguin colony is as big as that of the Royals. The chicks are at every level of maturity as the adults lay their eggs all the year round
On our return the sea was up and the marina deck was becoming a liability
One passenger mistimed their step and had to be dragged aboard as the
Zodiac sank away
Then a wave draining off the deck flooded the Zodiac. Luckily it did not have its passengers aboard
Our two day visit to Macquarie had been enhanced by the kindness and hospitality of the staff stationed on the base there. We brought them aboard for breakfast, lunch, hot showers and beer, but by the time it came for us to drop them back on their island the seas and the wind had risen. The parents of one of the young girls on the base were guests on the ship. As the conditions deteriorated their anxiety rose. One Zodiac swamped and I was now ready on deck with my medical kit. Finally, in a gap in the waves they embarked safely on the Zodiac. Then to our delight and their horror we saw a pod of Killer Whales appear beside the ship and follow their Zodiac into the shore. I have seldom seen such relieved looks on the faces of the girl’s parents when the Zodiac returned safely, all research team members safely landed. So, now back to New Zealand to pick up another group of passengers and then down to Antarctica proper.
Part of the reason why we were blocked by pack-ice is that there has been no westerly gale in the ‘furious fifties’ to drive the ice out to sea. On the slow two day journey back from the ice, the seas remained milky calm and the sun shone. North of us, gale after gale swept the sub-antarctic islands. During the journey, I used the opportunity to get some practice shooting the sun with the ship’s sextant, and finally got our positon to within five miles of the ‘correct’ one, which is continuously read off the GPS systems of which the ship has three! Of course THEY are all wrong! Now I have embarked on the even more arcane business of plotting our position by the stars. Not only are they difficult to identify, they are even more difficult to hold in the sextant’s mirror, and are absolute pigs to use for calculation from the Nautical Alamanac. So this will keep me busy for a bit.
Orion anchored off shore.
When we arrived at Macquarie Island the southernmost of the sub-antarctic islands the sun decided to continue to shine, and the huge penguin colonies just glistened in the beautiful light.
Quite a contrast when on our last visit there had been normal Macquarie weather, gale force winds, fog and driving sleet.
The base welcomed us very kindly as before, and we tried to repay some of their hospitality with the offer of showers, meals, and beer. Their new doctor has arrived, a GP of my vintage. He showed me around their lovely hospital with dental chairs, operating tables, X-Rays and anaesthetic equipment. His equipment and drug store is a veritable Alladin’s cave. To cap it all he was a huge help over a difficult patient we had on board.
The weather was balmy and so to demonstrate the ‘true grit’ underlying the formation of the British Empire I was obliged to go ashore in shorts to the horror of the guests who had so much polar kit on, they could hardly move.
CB steps ahore in Kiwi dinner dress’ (gumboots and shorts)
Don Macintyre the expedition team leader with Macquarie base in the background
The wild life were even tamer and inquisitive than before. We are not allowed to approach closer than 10 metres, but if they choose to approach us then that is fine!
King penguins of every age occupied one rookery standing aloof in their thousands while a quarter of a mile away even larger colonies of the smaller Royal penguins showed off their glorious crests.
The wonderful light and the tameness of the wildlife made close-up pictures too easy.
Then we headed North again to Campbell Island, notorious for only 16 days of sun a year. When we were last there, two weeks before, the ship’s anemometer recorded 54 knots in the shelter of the land. This time all was still, and we were able to walk up and over to the notorious west coast of the island where so many ships have been wrecked.
King penguins of every age occupied one rookery standing aloof in their thousands while a quarter of a mile away even larger colonies of the smaller Royal penguins showed off their glorious crests.
Two King penguins courting
A Royal shows off his crest
One of the Royal Penguin rookeries
Looking into the King Penguin colony
A sea-elephant offers himself up for dental inspection
A Royal Penguins poses for a profile view
Such handsome birds
and watching the world go by
The seas were rough and the Zodiacs could get swamped while trying to load
Then we headed North again to Campbell Island, notorious for only 16 days of sun a year. When we were last there, two weeks before, the ship’s anemometer recorded 54 knots in the shelter of the land. This time all was still, and we were able to walk up and over to the notorious west coast of the island where so many ships have been wrecked.
The final part of the trip was into the Ross sea to visit Shackleton’s and Scott’s Huts on the ice shelf.
We are now heading down to the coast of Antarctica. Last night the ship’s engines slowed, and because my cabin is next to the engine room I woke at once. I peered out of my porthole and in the gloaming (now it doesn’t get dark at all) an iceberg sailed serenely past and vanished into the fog. Apparently we had to slow down because there may be ‘growlers’ around it (fragments which have broken off and which are mainly submerged).
Antarctica and Patriot Hills
I have always wanted to go to Antarctica, and in Afghanistan I met a man who went there regularly. John is a GP who works in a remote part of New Zealand and clearly has the bug for adventure.
All trips to wild places are organized on the old boy network, and so he kindly wrote to Antarctic Logistics and Expeditions (ALE) on my behalf to ask if they had a vacancy for a doctor. The answer was brief and negative. They did not. They had enough doctors for the next season, and all that they needed was a nurse. I suppose that one of the things that I have learnt over the years ‘Never to take ‘no’ for an answer’. If it is something that you really want then persevere. I really wanted to go to Antarctica and they wanted a nurse, so I offered to go as a nurse. They said that they would let me know, but they didn’t. Once again, that is not enough, so every couple of weeks I dropped a short and friendly note just checking that no vacancy had arisen, and then it did. They had no cover for the second half of the season. Could I go for six weeks at short notice?
My favourite book was and is Shackleton’s ‘South’ and now I was to have a chance to see the real thing. Except that I didn’t. ALE is a company which flies tourists into Antarctica, who want to climb, sledge or visit the pole. It also provides Logistical support to various small government programmes which cannot justify having their own planes down in Antarctica. At that time they had a tented camp at the foot of the Patriot Hills just off to one side of the Ellington Mountains. It is in the middle of nowhere. You can travel in any direction for at least 300 miles and there will be no trace of life, human, mammal or bird. You are in an ice desert. It was a tented camp, which was dismantled every February at the end of the season, and buried until the end of November, the start of the next season.
All the tents were then re-erected and the camp ran flat out day and night for 10 weeks before closing down again in the Antarctic autumn. ALE had their base head quarters in Punta Arenas in southern Chile, a town of ferocious winds and plastic bags plastered on everything, fences, bushes and telephone wires.
Punta Arenas. A land of ferocious winds, a million plastic bags and dustbins up on poles to stop the packs of feral dogs from looting them
The flight down to the southern tip of South America was a long one, and I was much more worried than usual that I might not have the right gear with me. After all we were going to be high on the Antarctic plateau less than 600 miles from the South Pole. John had warned me that I needed at least four pairs of gloves as they blow away in the howling wind, and if a client loses a glove you may have to give them one of yours. I also had huge difficulty getting hold of insulated boots. They only seemed to be made in Canada and were ferociously expensive even before postage. There were also very heavy so I had to travel in them.
When I arrived in Punta it was to find that a private house had been converted into offices for ALE and that each year a team of Chileans and ex-patriates gathered there to support the workers on the ice, ordering supplies, clearing customs, repacking and sending on to Patriot Hills. Almost everyone there had worked for the company for years and were climbers, and explorers in their own right, who had decided to make a profession of their passion. None of them talked much about their previous exploits but gradually, as you got to know them, fascinating stories would start to come out of ship-wreck on remote Antarctic Islands, aircraft crash landing on the ice, and falls down crevasses. And we had plenty of time to talk.
The weather was no good, so we could not fly into Patriot Hills for ten days. We hung around the office in the day, driving the base logistical staff crazy, as they had tons of work to do and we had none. Then in the evening we would remove ourselves to one of the pubs and continue our enforced leisure there. Just North of us was a wonderful National Park , Torres del Paine, with some of the most spectacular mountains in the world, but we were always on short notice for take-off so could not go up there in case the flight was called. So near and yet so far. Even so, I walked all over Punta Arenas and into the hills behind. It is a real frontier town, and the delay just made Antarctica even more interesting.
Getting into Patriot Hills at the beginning of the season was a fascinating exercise in logistics. The first aircraft in were two Twin Otters, a small twin engine aircraft loaded to the gills with fuel, and fitted with skis.
Twin otter coming in to land
They would have to wait until the satellite photos suggested that the weather was OK, and when there was no head-wind they would fly across the Drake passage, a very dangerous crossing indeed, and then up the Antarctic peninsula until they were deep in the Heritage Range. Once they had landed on the ice, the engineers on board would uncover the snow-ploughs and piste bullies and try to warm them up before starting them. Once they were started they could push the snow off the trench where the tents were buried and start erecting somewhere to live. Slowly but surely the camp would come out of hibernation and start to hum again.
The camp being erected. Mess tent and crew accommodation tents
Their next job was to try to clear the snow off the main blue ice runway. There is very little snow fall in Antarctica because most of it is a desert, but snow drifts all the time, pushed along by the fierce catabatic winds that pour down from the South Pole. The blue runway at Patriot Hills is a natural formation created by the vortex in the lee of the Patriot Hills. If the wind is strong enough it blows all the snow clear and exposes the smooth ice below. However if the wind is too strong then aircraft cannot land on the blue ice because it is aligned across the wind and planes would be blown off the runway.
The window between the wind being too light and it being too strong was very narrow indeed. What the start of season crew hoped was that initially the wind would be strong so that there would not be much snow to clear. Then they would hope for light winds so that the main aircraft could land. This year the delay was more than 10 days before the runway was clear, and then it got blocked again.
Snow blower clearing the runway
Russian IL76 on the ice. It takes miles for them to stop as they can’t use their brakes on the ice.
It is specially designed to land on rough surfaces. This aircraft has wheels not skis so can only land on hard ice not snow. It then cannot brake normally as there is no grip on the ice, so it needs an enormous length of runway to stop, as it only has its reverse thrust to slow it down. The decision when to fly is a huge gamble as the weather may change during the 4 ½ hour flight down there, and if it does then they have to turn back. The aircraft must also land heavy as it has to have enough fuel to fly all the way back.
The Russian crew who fly the plane are quite delightful. They fly all over the world, always into dangerous places and work very closely as a team. The aircraft itself is astoundingly old (1960s) with valve sets rather than transistors, but everything is so over-engineered that very little seems to break. Even so they fly in from Kazakstan with a spare engine and several spare wheels on board. The plane itself is enormous so it can take tons of fuel in drums, Snow-mobiles and then a hundred passengers on top of that. The crew are very relaxed about flight safety so you can wander up onto the flight deck (it is up an iron ladder) or into the nose cone where the bomber aimer would have lain.
Inside an IL76. Valve sets and everything built ten times stronger than it needs to be.
My first sight of Antarctica took my breath away. It is so big, so still and utterly beautiful. It is eerie to look out over a range of mountains on which no man has ever set foot.
The landing seems to go on for ever, as the aircraft travels nearly three kilometers before it stops. During that time the aircraft is vulnerable to a gust or even to the slope of the ice, as the glacier is not completely flat, so everyone is holding their breath. Once we stopped, we taxied back up to the initial landing site while all of us pulled on gloves, puffer jackets, hats and goggles so that by the time that the doors opened we were all boiling in our polar gear. The light outside was blinding. It was bright sunshine on white snow and blue ice. I clambered down the steps onto the ice and before I had taken the first step I had slipped and landed flat on the back of my head. I was conscious enough to realize that if I had a serious head injury here, I could not be in a worse place. I staggered to my feet and tried to take in my surroundings. Piste-bullies with trailers on skids were already manoeuvring into the back of the aircraft to start unloading all the freight. The aircraft has to keep its engines running so that they don’t freeze up and the noise of huge howling jet engines right beside us was terrible. Almost at once barrels of fuel starting rolling down the rear ramp straight onto the trailers.
Stacking fuel barrels in a blizzard
These barrels are big and heavy and can crush a hand in a moment. Although everyone was working fast, no-one was taking any risks and in minutes all the barrels were off and the trailer loaded with them was moving away. Now they started to unload heavy machinery, a Piste-bully snow grader, some skidoos and crates of food. These two were moved away from the aircraft, crates being slid along the ice. Very quickly the plane was unloaded, and more trailers were being backed into place. Now all the urine (in drums) , faeces (in bags) and rubbish (on pallets) was loaded onto the aircraft. The rules for ALE to be allowed to operate in Antarctica is that all rubbish must be removed from the continent. As soon as this was complete, the ramp was raised and we all moved well away clear of the jet-wash; then the Ilyushin taxied away to take-off. The noise of the engines at full power boomed back from the hills then she climbed and vanished away to the North. Suddenly there was silence, deep Antarctic Silence compared with what had been going on before.
The snowcats were already nearly a mile away heading towards the camp. The skidoos were also far away and this was my first chance to drink in the immensity of the place. It wasn’t cold. The air temperature was probably around minus ten, but the air was dry and the sun beating down made it far too hot to wear a hat and gloves. I started trudging off on the two kilometre walk to the camp, crunching over the ripples of snow (sastrugi) and enjoying the will-o-wisps of snow drift running between these frozen waves. Within minutes I was so hot that I had to take my puffer jacket off too. So much for Antarctica being cold. That was something I would see later. I was just overwhelmed by the beauty of the place.
Patriot Hills camp from the hills above, truly in the middle of nowhere
The camp is serried rows of multi-coloured tents, large ones for the guests, small ones for the staff. In the middle there are big tents for the dining area and a hut with aerials for the communications. In the distance is the secondary snow runway with the twin otters parked on it, all fitted with skis. Beside that is the workshop full of snow-blowers, tractors and skidoos. One of the piste-bullies (those vehicles which groom the ski pistes in the alps) is inching its way between the tents removing all the snow accumulated during the last blizzard. Although it rarely snows in Antarctica the wind blows all the time, driving spin-drift snow along the ground. If there is any obstruction however small, a tent or even a pair of climbing boots a wall of snow builds up on the windward side and slowly buries it.
Blizzard in the camp
Five miles outside the camp there is the remains of an aircraft which got lost in a blizzard and came down just short of the runway. That was twenty years ago and now just the tip of the tail-plane pokes through the snow. The rest of this large aircraft is buried deep in the ice.
The tip of the tail of an aircraft that got it wrong a few years ago! The aircraft is now buried 30 feet deep in drifting snow
The mountains to the south of us are just the same. They present rocky cliffs to us, but over their shoulders ice is pouring like a shawl. It has built up behind these mountains and is now spilling thousands of feet down the sides. Looking north there is nothing.
The Ice wall looking South up to the plateau around the pole
The glacier is flat and pours slowly, ever so slowly to the edge of the sea some 100 miles away. Nothing blocks your view, no pylons, no radio masts, no chimneys, just a clean white line between snow and sky.
The medical tent is absolutely packed with kit. It has to be geared-up to deal with a major disaster, such as a fire or the Ilyushin crashing, through to an outbreak of food-poisoning. Then it has to cope with the whims of 100 wealthy guests who make the word ‘demanding’ take on a completely new meaning. You can spot the guests immediately. They have very dark glasses, and incredibly bright, very expensive jackets covered in badges. The staff are all in dungarees with no jackets as they are always working so hard it is too hot to wear anything else.
My fellow doctor is a very pleasant Swedish anaesthetist who has done a lot of mountain rescue courses. However, he looks a worried man and pretty quickly admits to me that he has got a girl pregnant back home and will be heading back from this trip to marry her. It transpires that she is a model who is reputed to have had an affair with David Beckham (she turns out to be Rebecca Loos). Sven is moving in exalted circles, certainly as far as the fashion magazines are concerned. However, he is well aware that this is his last trip away and he looks a little sad about that.
The medical tent has its own solar panel so we have plenty of electricity and as the sun shines day and night and there is never any cloud, a small panel and two batteries is enough for all our needs. Contact with the outside world is very difficult as the geo-stationary satellites are too low on the horizon, and even the oblique orbiting satellites only come over the horizon for a few minutes at a time. However we can buy expensive phone cards and they do work sometimes providing that there aren’t too many solar flares. I like to call Vicky every day – and have even from Afghanistan and Antarctica – and I discovered that I can do that even from here.
The operations room is a tiny box of an office with the metereologist packed in one corner with his computer screens. His input is crucial to everyone but most especially to the decision as to whether it is safe for the Ilyushin (IL76) to fly. The camp manager is working closely with Mark the meteorologist but he is also working with the pilots of the two twin otters which are used for ferrying clients around on the ice. A new plane has arrived this year, called a Baslar. It is an old DC3 (Dakota) fitted with new turbo-prop engines. The airframe dates back to the early 1950s and it is strange to see a plane still in action that used to ferry me from the Channel Islands to school when I was only eight years old.
A Baslar refueling on its way to the South Pole
The radio operator is a real eccentric. He is a ham radio operator and is determined to lay out a huge aerial and try to contact his other hams in New York. He talks of little else, and this seems to be driving the base manager and the metereologist completely crazy. His job is to keep in contact with base in Punta Arenas and with the guides out in the field and to log all the calls.
So, what are all the clients doing? Well, some of them are doing the seven summits. They are climbing the highest mountain on every continent. In Antarctica this is Mt Vincent some sixty miles away from the Patriot Hills base. ALE have an advanced camp at the base of this mountain and the twin otters fly the clients to and from this camp. From there alpine guides lead them up the mountain. It is not an especially high mountain, nor is the climbing difficult. It is just very remote and when the weather does get bad, it gets simply horrible. The flight in to the mountain must be one of the most beautiful in the world. You fly along glaciers between unnamed and unclimbed mountains, and finally fly straight at the mountain where a glacier tips vertically over a cliff. Above the cliff the glacier is a steep snow slope and the plane literally climbs and stalls onto the landing strip. The advance camp is perched at the end and to one side of this very short strip. The wheels are chocked as soon as the plane stops to prevent it sliding back, then when it is ready to take off again, it pirouettes on one wheel rushes off down the slope and takes off only because the runway drops away beneath it as the glacier tumbles over the cliff. After a lot of begging and cajoling they let me fly out with one of the groups of climbers. The flight was marvelous, the landing breath-taking but the cream on the cake was a marvelous ‘ice-dog’ around the sun when we were there. Ice crystal in the air were creating the frozen equivalent of a rainbow, which comes out as a beautiful circle with four small suns arranged north, south, east, and west.
Ice dog on Mt Vinson
Just like the Himalayas there were any number of unclimbed challenging peaks in the Ellington Range but the clients just wanted to climb Mt Vinson because it was the highest. The rest of the range was empty and pristine.
There was always a bit of a panic when the clients left the main camp to do whatever they had come to Antarctica to do, climb Mt Vinson, visit the Emperor penguin colony, sledge to the pole or even fly to the pole. All of them had to fill in very comprehensive questionnaires on their health before they were allowed to come, but there was always one individual who would come to me just before they left and ask me about their Prinklewitz syndrome or some other condition which they had omitted to mention on their medical form but which was now filling them with foreboding. Luckily I had never heard of any of the conditions which they mentioned. I must have slept through those lectures, so I would simply slap them on the back and explain that ‘No-one ever leaves this world alive’ and then bundle them into the aircraft. Inside me a furious voice would be saying “Why, oh why, are you telling me this now?”. They all came back alive so I must have said and done the right thing.
Some hardy folk want to sledge from the sea(ice) at Hercules inlet to the South pole. That is a long slog and takes around 30 days. Others want to be able to say that they have sledged to the pole, but have not got the time. So they are taken to one degree (sixty miles) from the pole and sledge the last bit in. The eldest and most frail just want to be flown to the South Pole. One of the doctor’s jobs is to accompany these elderly clients, as the flight is a long one and the Pole is at an altitude of 10,000 feet, so we need to carry oxygen ready for anyone who gets into trouble. The Baslar that we use to fly to the pole is not heated nor is it pressurized. Although we had hot-water bottles tucked under our puffer jackets the cold was bone-chilling. Half way to the Pole the plane has to land to refuel from a depot of drums towed up there for that purpose. The clients have to be taken off one by one to have a pee while the pilots pump fuel as hard as they can to stay warm.
The South Pole is a dreary place. It was dreary when Scott arrived there to find Amundsen’s flag. It is a high flat windblown plateau but it is even worse now that the Americans have built a base right on it. Their first base is now almost buried by driving spindrift, but to avoid that happening a second time they have built a huge ugly Hilton hotel on stilts, slap on the South pole. In fact, the Pole is in their front yard. There was no need for them to build at the Pole, they could have put their base 10km away and left the site itself authentically bare, but I suspect this was a political gesture to the rest of the world who declined to contribute to the cost of building or running this huge base in the most remote part of the world.
The American Base ON the South pole. It won’t win any architectural awards
The camp commander of the Pole base was the biggest woman I have ever seen. She must have been 6ft 4in tall and weighed around 200 lbs and she did not like visitors to her base. We were ushered in to the amazingly warm interior which was sterile clean and characterless. With great pride they showed us their hydroponics greenhouse where they were growing vegetables under artificial light. I dared not ask why they were doing this, when the sun was shining continuously outside. I dread to think what the electricity cost to generate to produce this light as all their diesel had to be dragged up in bowsers behind tractors all the way from McMurdo base on the coast.
To my amazement there were staff working in the base who had never been outside except when they transferred from the aircraft to the base and had no intention of doing so again until they went home. There was clearly an atmosphere and it was something to do with ALS bringing tourists to the Pole, but as I was new I could take no responsibility for that. Having done our tour of the base we went outside to take pictures of ourselves around the South Pole. Before we left I was ordered in the strictest terms not on any account to touch the American flag. I had no idea what the base commander was talking about, until I got to the South Pole, when I found that the USA had planted a flag pole right next to the brass dome which marks the exact position of the Pole. It is set so close that it is impossible to have a picture taken of yourself at the pole without being continuously slapped in the face by a very stiff Stars and stripes at -30 degrees. Now I understood the problem.
South Pole with old base in background and the American flag very much in the foreground.
I looked up at the Building and there in one of the central windows stood the base commander arms akimbo, checking that we did not touch her ill-placed flag. There was only one solution. I pulled up the South Pole and marched off with it and planted in the snow in a clear space. We were now able to take all the pictures we wanted. When we had finished I put the pole back where I found it. The base commander might own her miserable American flag but she did not own the South Pole.
Kidnapping the South Pole – If we can’t touch the American flag well then we can move the Pole
Flying back we had the catabatic winds pushing us away from the pole. The winds are paradoxically strongest closest to the ground, so the pilot dropped the plane to 50 feet and flew as fast as he could in the tail wind, savings gallons of fuel in the process. Even so we had to stop half way and refuel in some pretty horrible conditions.
On my birthday we climbed the Patriot Hills behind the camp. It was a great scramble up an ice and rock ridge, which brought us out several thousand feet above the camp on the glacier below. It was worth it for the view from the top, which was spectacular. There are very few places in the world where you can stand on the top of a mountain and see one hundred miles in every direction and for there to be no sign of human interference except our tiny camp far below on the glacier.
View from the top of Patriot Hills – the camp is below us. Otherwise nothing human to be seen for 100 miles in every direction
My stint at Patriot Hills was for the second part of the season. It had been decided that next year we were moving to a new base ‘Union Glacier’ which did not suffer from the problem of cross winds. So, towards the end of the season a team set off to prospect the route to Union glacier and to prepare the glacier for its first landing by an Ilyushin. Despite every precaution one of the snowcats fell down a crevasse on the way and an epic rescue had to be organized to get it out again. Finally, they got to Union, cleared a blue ice runway, and the Ilyushin landed successfully. I must say I take my hat off to the pilot who was prepared to be the first to land there.
Hidden crevasses. This one was hundreds of feet deep.
Then it was time to close the camp down. The last guests flew out and we went into hyperdrive dismantling the tents, packing them up and rolling them into a trench which the bulldozers had prepared for them. On the last day the sun was actually starting to set behind the Patriot Hills and as soon as the sun vanished the cold was numbing. Finally we had every tent down and we were sitting on the ground drinking beer waiting for the Ilyushin.
Tents buried ready for the next season
As we waited the talk went round to what it would be like to winter here, and then on to the best books any of us had read on adventure, mountaineering or exploration. I noticed the chef in the corner scribbling the names as fast as he could and sure enough he came over to ask me to check them for him. I couldn’t help with them all but suggested that when we got back to Punta Arenas I would look them up on Abebooks which has a good fuzzy search engine. That way we could find the names which we had not got quite right. When I got back to Punta I did as I promised, and as I found each book I popped it into the basket to get it out of way.
At the end I had a lot of books in the basket none of which were going to cost more than a couple of pounds. On an impulse I pressed ‘Buy all’ and thought no more about it. When I finally got back to the UK several days later, Vicky was puzzled. She had just had a phone call from the Post Office who were sending an extra large van just to deliver our mail. I had to build a whole new book case for them all. They are a wonderful set of books and I still have not read them all.
Ilyushin ready to take us away. The sun is slipping below the horizon.
I try not to do anything twice but the chance to go back and see Union glacier was too hard to resist, so I found myself going out at the start of the next season. This time we were the first in and had to work like beavers erecting all the tents before the clients could start flying in. This time it was much colder and the clients coming out were even stranger than ever. One group wanted to drive to the South pole, with one of the vehicles driven by a propeller. They had modified transit vans with 4 wheel drive which were completely useless, but then that is half the fun of Antarctica. What was much more interesting to me was the kite skiers. Ronnie, the camp cook, was a dour Norwegian who only really came to life when he was in a harness attached to a kite. He took no salary for being chef for the whole season but in lieu cadged one flight to the South Pole and a pick-up from the edge of the sea at Hercules Inlet. He skied with a sledge palk) behind him and used a kite to pull him. He could move at up to 80kph. So a journey which usually takes 30 days on foot took him only three. Apparently when he sees a crevasse he jumps and then hopes that his palk will follow him. I think that until kite surfers can ride the Southern Oceans with the albatrosses, that will have to remain the ultimate sport.
Kite skiing in Antarctica — the ultimate sport
On my second trip out I took a kite with me. Then on a light wind day I got out my kite, put on my skis and started. Lots of people in the camp knew how to kite-ski and all of them wanted to coach me simultaneously. The result was that I lost control of the kite and was yanked into the air while my legs were hung onto by one of the girls shrieking with glee. When I landed I twisted my knee and that was the end of my kite skiing. If I had just gone at it a bit more gently I too might have been gliding across the sastrugi lifting effortlessly over crevasses.
Union Glacier was much more picturesque than Patriot Hills, nestled in a cirque of mountains. Now that I knew the ropes I was given much more responsibility and could take the clients out to explore the rock formations all around. There were canyons and caves to be seen as well as hidden valleys where there was no radio contact and so we should not go. But it was fun to be allowed to wander over to the workshops, pick up a skidoo and a radio and head out into the great unknown.
The light changed all the time depending whether you were looking at mountains into the sun or when the sun was behind you. There was also the frisson of knowing that we did not yet know where the crevasses might be. This was all brought sharply home the next season when John showed me a short clip of a video taken of one of the Piste-bullies working along between the tents clearing the snow. One minute it was there, the next minute it had vanished down a massive crevasse which lay right under the centre of the camp. The drivers got out safely and they even got the machine out the next season, but I think everyone was pretty shaken, by the thought that they had been sleeping on the thin roof of a huge cavern.
Because the tents were bright orange they absorbed heat from the sun and were quite hot inside all day (there was no night). This meant that they slowly melted into the ice, so every couple of weeks we would have to take-down our tents and move them to a new flat site. Then we would shovel snow onto the sides (valance sheets) so that when the gales did come they didn’t blow away.
I made a couple more trips to the South Pole itself with Chinese clients and my feelings about that dismal place did not change at all. When we had Chinese clients we had a translator/travel agent with them, and he and I worked closely together. However when we got to the Pole we still had the same difficult base commander. Now she was adamant that no-one should walk on her runway, and most especially that no-one should go near the canvas pipe which brought oil from the storage tanks to the base. I could see her point about the latter but as there was only one flight a week, I could see little point in the former. However I duly passed the message on to the Chinese guide who told the guests. They all wanted to ski the last 200 metres to the Pole and take photos of each other as if they were intrepid explorers, so we parked the aircraft 200 metres up the airstrip fitted them with big flat skis and explained that they must go along the edge of the runway not across the middle. They promptly set off to the middle of the runway. I was mortified and checked with the guide that he had understood what I had said and translated it correctly. He assured me that he had. My amazement was compounded when they arrived at the base and promptly went over to stand ON the oil feed pipe. The base commander came out shouting. I was shouting too. When the dust had settled the translator explained that his clients are so suspicious of Westerners that whenever they are told by them that they must not do something, they promptly do it, because they assume that we are hiding something from them.
It was a real paradox but the weather in Britain those two winters was often colder than the weather in Antarctica.
Union Glacier was a challenge for safe landing. We knew very little about the conditions there but discovered that it tended to form banks of fog in the deep valley, so flares were needed frequently and the take off towards the mountains always had our hearts in our mouths.
Trying to give the pilots a ground line in the fine fog, I am standing by with the
medical skidoo to follow them down the runway in case they crash.
Climbing fast to get over the mountains ahead
Union glacier camp tucked in the mountains
My second tour in Antarctica finished just before Christmas in a year when Heathrow was closed because of ice on the runway. I found myself stuck with thousands of others at Orly airport in Paris waiting to hear if we were going to get a flight or not. The hours went by and as each staff member at a desk got up to go home they were whistled at and jeered by the crowd. Poor things it was not their fault that no one was being given any information. The monotony was relieved by an extraordinary sight. A middle aged Chinese couple were down on their hands and knees trying to crawl to the front of the queue. I saw them crawl past and lacked the gumption to do anything. Not so, a large bucolic Englishman a couple of rows ahead of me. He spotted them and with a roar dragged them to the surface quite literally by the scruffs of the necks. He shouted at them that they were cheats and a disgrace (to the cheers of everyone around) and ordered them back to their place in the queue. Smiling meekly they went back to their original position, and then to my amazement they dropped down and started again!
Finally we were sent off to hotels but our luggage was lost. I decided that I wasn’t having that, so, having found that no luggage was coming out on the carousels I decided to take a risk. I slipped into the tunnel that the luggage comes out of and found myself in the hall where it is piled up when it arrives on the in-coming aircraft. There were about forty piles but after a quick search I saw the characteristic black and red end of my kit bag sticking out of one of the heaps of luggage. My ruck-sac was in the same pile so I grabbed both and headed off. The next morning I got home, with my luggage. I was exceedingly chuffed.
My time at Patriot Hills and at Union Glacier had whetted my appetite, and now I wanted to see Shackleton’s Antarctica. That came next.
The Falklands
My time as a ship’s doctor was coming to an end. The company had discovered that they could use Eastern European doctors who would accept a much lower salary, would accept contracts of 6 months at sea, 3 months unpaid leave, did not have their wives with them and who didn’t care where they went.
Vicky and I had travelled the world from Papua New Guinea to Antarctica, wine tasting in the Mediterranean to trips to see the Aurora Borealis. We had circumnavigated New Zealand (including landing on White Island volcano – before it erupted) and cruised up the Baltic to St Petersburgh. All through these trips we had been treated as guests and I had been allowed to bring Vicky along in return for my services. But now everything was changing. However there was one very special trip that I still wanted to do. I had been to Antarctica four times but never to the Weddell Sea, Elephant Island and South Georgia, the route Shackleton and his men took in their epic escape when the Endurance was trapped in the pack ice and crushed. The story is a legend of survival (‘South’ by Sir Ernest Shackleton) and is my favourite book.
I was to join the Silver Explorer in Ushaia the southernmost port of South America. The flight down involved two changes with minimum time at each and I had to re-check in my baggage at Buenos Aires. Somewhere along the line I left my lap-top and lovely new iPad in a security check. Vicky did what she could to trace them then ordered Apple to obliterate their contents. I was very upset by the loss, but forgetfulness is part of Parkinson’s and now it was biting although I didn’t realise it at the time.
I wasn’t expecting to like the Falkland Islands. Remote, bleak, covered in sheep and populated by a tiny number of madly patriotic British. But nothing could be further from the truth. On our first cruise we went there at the end of our trip, as the dread Drake Passage was calm on day 1, so the captain took the opportunity to reverse the itinerary and head for the Antarctic Peninsula first. On this second time round the circuit, we are visiting the Falklands first, and then heading on to South Georgia next.
Port Stanley is tiny sleepy, and delightful. If New Zealand (South Island) is 50 years behind Britain, well this is 50 years behind South Island. There was no sign of or even mention of the Falklands war, but instead there was a thriving fishing and eco-tourism industry. On some of the Falkland islands the sheep (hill lice) have been removed altogether. Instead there are walks to the most beautiful bird colonies packed with cormorants, albatrosses, penguins and gulls, who allowed us to come within yards of them.
Port Arthur in the Falklands: 2 humans 4,600 sheep and hundreds of thousands of birds
Albatrosses and penguins tucked in side by side
At the end of the day’s walk we were invited into the home of the farmer home who runs this huge island with his wife as his only help. We are given lovely cups of tea and delicious cakes. I thought it was extraordinary and touchingly intimate. I asked the famers wife slaving over the Aga how often she had to entertain cruise ship guests. “Oh, in season” she said ”it is two or three times a week.” This is eco-tourism on an industrial scale without any loss of the personal touch. They are obviously making a go of things and I am delighted. On top of that the farmer tells me he has 4.600 sheep, pigs and chickens, but the island is so huge that we saw none of them.
The bird colonies are densely clustered in steep narrow stony gorges on the cliffs facing the wind. I suppose they are so densely packed to protect their young from the skuas and giant petrels patrolling overhead, waiting for a gap so that they can steal an egg or chick. They face the wind so that the Albatrosses can take off and land.
We were lucky with the weather. The wind blew but the sun shone and the sweeping sandy beaches curving between rocky headlands were like a painting.
Penguins admiring the iron trypot in which they used to be melted down
Guests admiring the nesting Albatrosses and penguins in a stony gulley amongst the tussock grass
Some of you have asked what it is like working on the ship.
I have a tiny cabin with a bed, wardrobe, desk and chair and a bathroom en suite. It is at or below sea level so the port hole is bolted shut and cannot be opened (it is too small to photograph). There is a television at the end of the bed but it only works now and then, and the remote control does not work at all. I believe that it is the smallest room into which you can put a human being for any length of time.
I wake at 5am and put on the BBC world news (if it works), shave and shower and then put on a clean uniform with shoulder flashes. My laundry is done daily so it is a clean white shirt every day. I take my scrubs and night medical bag (in case I am called at night) up to the office, and I check my emails (three hours behind the UK). Then I head off to the crew mess for my All Bran. It is just down the corridor and by 6.00am it is humming with life. A huge TV will be playing a Pilipino soap opera drowning out any chance of conversation which is in Tugalog anyway. There is a good variety of food from porridge through bacon and eggs to tons of rice and Phillipino soups which they mix into their rice.
After that I take a cup of tea up to the top deck where the Panorama Lounge gives me a great view of the weather, the sea state and any land in sight.
View of Ushuaia from the Panorama deck
Leaving Ushuaia
By 8am I am in the clinic. It does not officially open until 9 but the night staff and all sorts of bods start appearing around then. Skin rashes, insomnia, tooth ache, indigestion. The paper work for each case is enormous. I know that no one reads it so I wonder why I bother. We work with Windows 7. Forms have to be filled in on the computer, printed, signed and then scanned back into the computer as pdf files while the paper copies are also filed. Lunacy! Computerisation has doubled the work.
If there are Zodiac trips ashore for the guests then I try to finish the clinic early and get on these. By the time I get back at midday there is a pile of paperwork to sign, oxygen cylinder checks, water purity testing, Defibrillator testing. I now have a nurse working with me so she checks and prepares the papers for signing. Before she arrived I am afraid the tests just were not done. No-one seemed to care.
Zodiacs taking passengers ashore and then back to the ship
Today we had a lovely Zodiac trip to shore at West Point Island. There was then a walk (or lift in the back of a Land Rover) 1.5miles to a lovely albatross colony which has Penguins, Shags, and gulls all breeding together. On the walk back there were Falkland geese and Steamer ducks before a cup of tea in the kitchen of the farmer’s wife. Then back to the ship by Zodiac. As soon as all the guests were aboard and tucked into their lunch the anchor is weighed and we set off for Saunders Islands where there is a magnificent colony of King Penguins. As soon as I am back aboard it is a change into uniform and I start the evening clinic which is very similar to the morning one. The guests take no notice of clinic times or places and will stop you with a “Oh doctor” right in the middle of a Penguin colony.
I tend to eat supper early and then read and write to Vicky before going to sleep. It is not a strenuous day but you may be called at any time during the night, and it may be for a passenger who has fallen over to a crew member who has abdominal pain. As I get older, I find the struggle to wake up and start work in the middle of the night more and more difficult, so that part of being a ship’s doctor is the hardest. Luckily it is rare. Today, there was some extra excitement when one of the passengers fell off a Zodiac just as it was coming alongside the ship. Her life jacket inflated and within minutes we had her in the medical centre, warming up and unhurt. Everything happens so quickly in a case like this but now that I have a nurse working with me I can ask her to do vital signs, while I think what the hell to do next!
All the passengers are ashore. Wind and sea increasing steadily. A perfect opportunity for man overboard and that is just what happened
Ernest Shackleton’s voyage south
One of the fascinations of this voyage was to follow parts of the epic journey of Ernest Shackleton after the disastrous start of his Imperial Transantarctic Journey.
Ernest Shackleton by Anthony Smith
The weather in the polar regions varies dramatically from day to day but also from year to year. In our expedition to Iceland in 1969 we saw the sun twice in 3 months, the rest of the time it rained and snowed. Shackleton experienced far worse in 1914 in Antarctica. The whalers working out of South Georgia warned him that the season was very bad, with ice further North than ever recorded before. But the die was caste for the expedition to start and he had to proceed.
He was expecting to get stuck in the ice in the Weddell Sea and to be obliged to over winter there, but he hoped to get far South in that first summer season, then find somewhere safe for the ship to be berthed against the shore, protected from the moving pack ice over the winter. Then next spring he would be poised for a journey across Antarctica.
However, he was trapped in the ice far too soon that first summer, and then was swept around the Weddell Sea, jammed in the ice. The pack ice gyrates around this enormous bay driven by wind and ocean currents. As the ice moves, the pressure between the sheets of pack ice become so great that great walls of ice 12 feet high are forced upwards. No ship can resist this type of pressure unless protected by a safe anchorage.
The Western Weddell Sea un-frozen. Butter would not melt in its mouth!
And as the sun sits low in the sky
Very light pack ice on the Western margin of the Weddell Sea
When the Endurance was crushed, he and his crew were forced to take to their boats and drag them across the pack-ice as sledges until they reached the edge of the pack. Then they launched the boats, and set sail for Elephant Island, the only island they could reach driven by the prevailing winds. It was a terrible journey to a dismal uninhabited island with a brutal shore of ice and rock cliffs, but it was their only hope.
First sight of elephant island
And then a bit closer. There are no harbours or inlets for safe landing
As they crossed the pack ice and then the sea, Killer Whales were a constant peril, as they can detect life (seal or human) even through an ice floe and tip it over the floe to catch their prey
Killer whales working in pods of up to 30
During this epic journey the men had to eat anything that they could find, fur seals, penguins, and elephant seals.
Fur seals. Not only were they food for Shackleton. Their fur is priceless and in the next few years they were almost exterminated
Elephant seals. These handsome fellows have tons of fat which can be used as fuel to cook meals
A replica of the James Caird at Grytviken Museum. It crossed to Elephant Island and then South Georgia initiating the rescue of all those left behind on Elephant Island
A replica of the ‘Dudley Docker’ which Shackleton’s men left behind on Elephant island with most of his men. They upended it and lived under it for months until they were rescued in the nick of time by Shackleton just as their food ran out.
The beach on Elephant Island was small, and open to storms. It must have been very unpleasant living there.
The bay on which most of Shackleton’s party were stranded for months before rescue. There is now a cairn there. This is what it looks like in mid-summer in a mild year.
If they were going to be rescued, an advance party in the strongest boat had to sail on to any inhabited island, downwind. The nearest was South Georgia 600 miles away across the roughest ocean in the world. They reached South Georgia after an epic journey, but had to land on the exposed Western coast. The only part of the island which was inhabited by whaling stations was all on the East side and between the advance party and safety there was a large range of mountains and glaciers.
A shore line not dissimilar to what Shackleton’s party would have faced when they first saw South Georgia
The mountains and glaciers that Shackleton and his men had to cross to reach the whaling stations on the East side of South Georgia
Shackleton and his team climbed these mountains without climbing equipment and then glissaded down much of the other side to a whaling station where rescue was at hand. Over the next months as winter set in, Shackleton returned again and again until he could find a gap in the ice and rescue the rest of his party on Elephant island. No man was lost. The story is told in an epic book called “South’’ written by Shackleton himself.
Grytviken is now the only whaling station which remains almost intact and has become a museum for whaling and for Shackleton as well as headquarters for the local government.
The new Gritviken Government buildings behind a beached old whaler
Shackleton is buried at Grytviken after he died suddenly just as he was preparing to set out on a third expedition of exploration. If you ever have a chance to read the book, it is an epic of English Literature.
South again
In the 1950s my parents sent me away from Guernsey to a boarding school on the ‘Mainland’, as we Channel Islanders called England.
I had loved growing up on the Island. The coast and the offlying islands (Herm and Sark) completely fascinated me. At high water the sea seemed to press in on the shore. Beyond were serried ranks of waves, punctured by a few jagged rocks as far out as the horizon. As the tide fell, these rocks became turrets, then castles in the sea. Finally the sandbars appeared and now these rocks were fortresses guarding huge areas of sand. Around them were seaweed coated rocks and streams draining down to the distant sea. For a few short hours this new land provided endless scope for exploration. My happiest times were spent on my Father’s small boat exploring the channels between these half-hidden lands, or towing my model boat ( a block of wood on a string) down these unexplored rivers.
He justified my dismay at being sent away to the Mainland by saying that he wanted me to grow up to be a gentleman, competent and confident in any social situation. I now see that this was a transferance of his own concerns, a sort of Edwardian inferiority complex, but at the time it seemed incomprehendibly cruel. I think that he hoped I would go on to be something in the City and then be invited to house parties in the country at weekends. There I should be able to play a reasonble game of tennis, a decent round of golf, know when to wear ‘white tie’ and how to ‘make conversation’. Perhaps that was his dream from a traumatic time in the war and the loss of the family wealth, but it was a brutal shock to a child brought up on the next door neighbours farm in bare-feet, shorts and a heavy duty canvas smock who spent every moment in the summer exploring beaches and rocky headlands wondering what was beyond them. I never did get to those quintessentially English weekends in the Country, but some of his wishes that I should have tried everything have been refined down. My goals in life now fit a simple dictum. I want to be able to say with my last living breath “I never turned down the chance to try anything!” But that ‘anything’ is not a game of tennis, it is the chance to explore new lands. So, once again here I am off to visit another new area – the seas around Papua New Guinea. We then down Australia, New Zealand and into the Antarctic.
This time I have joined ship in Cairns Northern Australia. Flying around the world is not much fun. I now treat it as a form of suspended animation. There is not much point in worrying how long you have already been travelling and how much longer there is to go, as thirty hours passes so slowly. If I correct my watch to local time each time we land I lose all sense of how long this torture has been going on and that seems to help. This time I am lucky, because Vicky is with me for the whole trip.
Cairns is a lovely mixture of oldie world colonial and back-packers paradise but I was so jet lagged, there was little time to enjoy it. The ship Orion is absolutely beautiful and immaculately kept. It is fun meeting old friends from previous ships and new ones you have heard of but never met. However, we have sailed straight out into a tropical storm. It is not too bad but my office/cabin is on the lower deck so my porthole vanishes underwater as we roll. That just seems good fun until you step outside into the corridor to find that all the water-tight doors are closed and locked for safety!
We are heading North up to Papua New Guinea so today is one of the few times when we will spend all day at sea. There will be lectures for the guests and a chance for me to find out where everything is. This time the hospital is also our cabin (separated by a curtain). However it is light and airy (until the porthole goes underwater) so I have no complaints.
For the next two days we were caught in the tail of a tropical storm centred in the South China sea and had to reduce speed to work our way through a 4 metre beam sea. Seasickness struck with a vengeance. Some patients very nobly just took to their cabins and suffered quietly. For others it was worse and after a few hours of retching they simply lost the will to live. It is quite disconcerting hearing them explain that they are now ready to die, but could we at least call in a helicopter to take them back to dry land. I should imagine the nearest helicopter would be many hundreds of miles away and even if they could reach the ship the patient and the crew of the helicopter would be killed trying to perform the transfer.
We finally limped into Alotau many hours late to find our berth taken by a cargo ship and no customs officials willing to come out and clear the ship where we lay at anchor. Seventy wealthy guests lined the ships rails wondering why things are not as well organised as in the developed world. Finally we got everyone ashore in light rain an hour before sunset. I had just advised some guests that they did not need to take antimalarials as mosquitos only bite at dawn and dusk, and that we always make sure that our guests are on board well before sunset. Happy days.
The passengers have been really good. Most of them have been out on the top deck buffeted by wind, soaked with spray and admiring the Frigate birds soaring overhead. But others are sea-sick, very, very seasick. There seem to be various stages of sea-sickness that are quite characteristic. The first phase is just being sick. Then if it deteriorates their mental state changes. They quite simply lose the will to live! They talk openly about being prepared to die, and in the same breath ask if a helicopter can come to rescue them. They don’t care how much this might cost. In the final ominous stage they go very quiet indeed and then I have to put up a drip. Luckily we have very few of the last sort – so far.
The crew are popping in now and then with some pretty non-specific complaints like sore throat achy chest etc. This is just testing out the new doc to see how much of a soft touch I am. I am sure that each of them then returns to the mess to report on how I can be best handled.
A total Eclipse of the Sun
The last month has been spent cruising up and along the Northern Coast of Papua New Guinea and its off lying islands. I suppose that I had expected this to be an empty part of the world, at least as far as human habitation is concerned. Not so, It is heaving with people and there are hoards of children all well fed at the moment as fibreglass boats with outboards replace dugouts and crops thrive on the fertile soil.
However mining and illegal logging is clearing great swathes of the forest and the reefs only have small fish left.
The reefs are beautiful but the large fish have gone (? replaced by Vicky!)
Like everywhere else AIDS is a problem and this sign in Pidgin says it all
A literal translation “Look out, all of you (look out him you all belong) No can copulate, stop once with one person, otherwise use a condom!
Along the way we have been feted with dances (sing-sings) and lectured on the cultures of the different groups living along this coast. Although it is all put on for our benefit, many Papua New Guineans seem passionate about maintaining the traditions of their culture and all come to watch the dances. They seem to enjoy watching us quite as much as we enjoy watching them.
A sing sing at Tami and a dragon dance on the Sepik river
Our latest group of passengers have chartered the whole ship just to watch the total eclipse of the sun. They are almost all Americans and are without doubt ‘Ecliptomaniacs”. For some of them this is their Twelfth eclipse! They travel the world every time there is another total eclipse.
Of course there were all sorts of worries whether the sky would be clear (it was), but only at the last minute!
It really was very impressive indeed, and we had a battery of experts (including an astronaut) to guide us through the 2 ¼ minutes that it lasted.
Ecliptomaniacs indulging their addiction
The highlight of travelling along the north coast of Papua New Guinea was a brilliant plan by the captain. He arranged that dinner on the special evening was to be out of doors on the quarter deck. As the main course was served, we came alongside an active volcano which was pouring lava down its side to the sea and covering us with a light coating of ash which crackled as you ate your salad. As the side of the volcano was steep, we were able to come very close indeed to the lava, an experience of a life-time.
Manam volcano erupting as we sailed past
Papua New Guinea has been described as an island of gold floating on a sea of oil, and certainly it is now wide open to exploitiation by the Chinese, the Americans, the Brits, the Australians the Japanese and a few others besides. Everyone blames everyone else, but all appear to be as bad as each other. The government has neither the skill or indeed the control to enable them to deal with such hungry multi-nationals. The result is going to be a tragedy for the people of PNG. They cannot be left in the stone age and nor do they want to be. But at the same time their wildlife and their culture is being trampled mercilessly.
We also travelled along the North coast of Papua New Guinea, anchoring at the mouth’s of rivers and travelling in to local villages where we were greeted with a lot of dancing.
One of the dancers dressed to the nines
Medically there has been very little to do on the ship. Now we head south down the great barrier reef to Tasmania and New Zealand. After that Antarctica – yes!
These beach barbecues were quite surreal; a virgin beach never visited before, a delicious barbecue and then before darkness fell, all was cleared and not a trace of our passing was visible.
The one thing that I missed was scuba diving, but even that happened quite by chance. We had diving equipment on board to inspect the bottom of the ship if there had been any damage. The captain was a keen scuba diver and the guests were due to go ashore to lounge on the sand and have a barbecue. He asked me if I could/would like to do a dive with him. I jumped at the idea but was a little more hesitant when he admitted that there were no depth gauges nor watches. So, we would simply be diving on the amount of air left in the tanks and stay above 30 feet depth by guess-work. The plan was that we would be taken 2 miles up-current from the ship then let ourselves be carried down the current towards the ship surfacing at around 40 minutes when our air ran out. The first officer was asked to launch a Zodiac at 30 minutes and start looking for us. He looked worried. He didn’t seem keen to lose his captain and legally the ship is not allowed to sail without a doctor.
The dive was fabulous. We were swept down a channel between walls of coral. There were lots of fish and turtles. We didn’t have to do anything except maintain our depth and enjoy
the view. Finally my air ran out, and we surfaced with our orange marker buoy, to find no less than four Zodiacs cruising around looking for us. The first officer was clearly leaving nothing to chance!
Later we dived on the Great Barrier Reef, where they claimed that the diving is the best in the world. Strange that, because everywhere that I have dived (Maldives, Mafia, Zanzibar, Santa Martha, The Whitsundays, Galapagos) they all claim that theirs is the best diving in the world. All I can say is that they obviously have not tried anywhere else!
Diving on the best of the great Barrier reef
Back to New Zealand
And so we have arrived back in New Zealand again having only left South Island a few months ago. But this is North Island and it is early summer.
Akaroa must be one of the most beautiful natural harbours in the world, set in a flooded crater. Very sadly for me they have just closed their hospital there, as I would have loved to do a locum there.
In the harbour there are some of the smallest and rarest dolphins in the world. They are also very inquisitive so you can swim with them (and sing to them) and they really seem to enjoy the experience, the first time any sentient organism has enjoyed my singing!
Swimming with the dolphins
It is interesting how the medical side of this job can wrong foot you at any time.
We were all swimming with the dolphins when Vicky noticed that one of the passengers was lying quite still on her back, bobbing along in her wet suit. She alerted the crew and the poor lady was dragged out of the water completely paralysed. We still have not quite worked out what happened but she had a pace-maker after a cardiac ablation and it seems possible that her circulation was unable to cope with the sudden cold shock of entering the water. As she was lying flat she remained conscious but was quite unable to even signal that she needed help. As usual I was looking the wrong way, when it happened. Still all is well that ends well.
Olde Worlde Russel in North Island — a sleepy semi-tropical township
Olde Worlde Russel in North Island — a sleepy semi-tropical township
Every time the passengers are ashore there is another safety drill. My team are all very experienced so they tell me what to do.
Launching the life boats
When we arrived in Auckland the giant America’s cup catamarans were out tuning their rigs. I was so fascinated that I nearly missed our ship sailing.
New Zealand’s contender being manoeuvred back into dock
Moored next door to us was the biggest cruise liner I have ever seen, quarantined because she had norovirus on aboard.
When South Island came into sight, it was snow capped mountains over a choppy sea scattered with shearwaters, petrels and albatrosses, a far cry from Papua New Guinea and tbe Great Barrier Reef.
The weather deteriorated rapidly and in the face of 70 knot winds we sneaked back down a fjord to Picton Harbour.
We then moved on to White Island, another active volcano. Here we were issued with breathing sets, and were able to wander over the steaming fumaroles.
It was one of the first days in the past three months when the guides said it had been clear of mist, so we were very lucky. Very lucky indeed: a group of guests from a cruise ship landed on the island in 2019 and were overwhelmed by the gases released from an eruption. Twelve died and some of the bodies have never been recovered.
White Island. An active volcano.
Helmets on and gasmasks at the ready as soon as we landed on White Island
The landscape was coated in sulphur and wreathed in steam
The beaches in New Zealand were lovely and mainly litter free, and of course absolutely deserted apart from a few local fishermen.
Having worked our way down the great Barrier reef we headed to Norfolk Island which was a bit like Surrey suburbia in the middle of nowhere, lovely English houses surrounded by paddocks with horses. All very strange.
Japan, The Kurils and Aleutians
The Silver Explorer
Having sworn that my days as a ship’s doctor were over, here I am again on a small expedition ship in Japan heading up to Kamchatcka, then the Aleutians, then Alaska.
It is really no different from Humanitarian work: an emergency phone call from Florida. Can you jump on a plane to Japan now. A doctor had fallen ill and the ship could not sail without a doctor (by law). Actually the first flight to Hiroshima was eight hours later so I had time to finish the teaching course I was doing while Vicky packed my bags. Then there was 15 minutes to change and head for Heathrow. These days I have checklists for equipment, uniforms etc. for any job anywhere in the world, so it is really is a streamlined process.
Up until now I have been working mainly on Saga ships. They have 4-600 passengers average age 84, then a similar number of crew 50 years younger, and two nurses to help out. That number to look after is tiny compared with the big cruise ships which can have well over 5000 passengers, several doctors and an ITU. But this ship I am on now really is tiny, only 125 passengers and the same number of crew. The problem for me is that you are on your own – no nurse, just you. That means you have to be your own receptionist, nurse, clerk, orderer of stores, and tester of water supplies. If there is a cardiac arrest you can run the results but you will be running it by yourself.
On top of that the amount of paperwork is awesome. It is private medicine, so bills have to be made up, notes written and filed, referral letters to doctors ashore prepared and then all the inspections of water supplies carried out and logged. Finally, all the equipment has to be tested and the results logged. Each day there are no less than ten forms that need updating and signing off.
I suspect that many of you can set-up a nebulizer, or perform an ECG, but can you take an X-Ray, run blood analysers, and carry out Legionella and E.coli testing.. If you can’t – well the instruction manuals are there for the reading, racks of them. There are also over 1200 different compounds in the Pharmacy and that stock needs checking and re-ordering 3 months in advance. I suppose it is rather like an old-fashioned single-handed GP surgery. There is just tons more paperwork to do.
The ship is 6 star. The sommelier wears a tail coat and white gloves and there are six guides (each in a different specialty) to lead the guests on the shore excursions in Zodiac dinghies. When they serve you tea it is in a proper teapot with an hourglass beside it to show you how long you need to leave it to brew. The sand in the hourglass is made of blue crystals which are lighter than water so they rise up into the top part rather than sinking to the bottom. So it is an intriguing upside-down hour glass.
Japan is of course quite fascinating, very tidy with very polite people who are very proud of their history, or at least most of it! And I have seen none of it. The first three days has been spent scrabbling to understand how the medical clinic works on this ship and fighting with jet lag. The guests come back from shore saying that the gardens are quite lovely. I am very jealous. They are mainly Australian and US so their expectations of medicine are quite different from mine.
With luck, we will rub along together.
Hiroshima
One of the buildings immediately beneath the blast left as a memorial to it
The last month has been spent cruising up and along the Northern Coast of Papua New Guinea and its off lying islands. I suppose that I had expected this to be an empty part of the world, at least as far as human habitation is concerned. Not so, It is heaving with people and there are hoards of children all well fed at the moment as fibreglass boats with outboards replace dugouts and crops thrive on the fertile soil.
However mining and illegal logging is clearing great swathes of the forest and the reefs only have small fish left.
The news each night is so full of human tragedy that it is easy to become immunized to it. Within hours of natural disasters, reporters and cameramen are in there taking close-ups of human misery. One of their first comments is often “Where is the medical rescue team?’ Well, firstly we have to be recruited (we are only volunteers) and secondly the media has already chartered all the transport (helicopters, jeeps and boats) so we have to wait for the media frenzy to die down a little before we can even get transport in. The film and commentary that they prepare for our evening news is harrowing. Indeed, sometimes I don’t know how the reporters and camera crews can continue their work when there is so much pain and suffering around them. If they put their equipment down for a minute and lent a hand, for heaven’s sake! That was certainly the situation after the earthquake in Haiti.
But Hiroshima was different. First, it wasn’t a natural disaster and second, all communications were destroyed so it was some days before anyone outside the region had any idea what had happened. The few pictures of the aftermath are stills and in black & white and can give no feeling of the agony of the situation as it had unfolded. But there is another record, so powerful, that after a while I could not stay to look. Children who had survived the initial blast and the burns were now dying over days weeks, months and years of radiation sickness. Teachers in their schools encouraged them to draw with crayons what they saw, and then to write short pieces (almost Twitters) of what had stuck in their memories. I don’t know whether it was supposed to be some kind of therapy but the results of their work are hanging in a museum in Peace Park close to the center of the damage caused by the explosion. Every politician and military leader in a country with nuclear capability should spend some time there. Perhaps it would give them an inkling of the horrors that they are able to unleash with this horrible weapon.
In many ways the crayon drawings and the short, written descriptions are more powerful than any news footage I have ever seen, perhaps because it is a distillate of the utter horror of what happened.
I didn’t realize that there weren’t many men left in Hiroshima. They were on military service. The city was mainly women and children. The bomb was deliberately exploded at 9000 feet to maximise the area of damage and was centered (I cannot believe this was deliberate) over a hospital. This was not a military target. Those thousands who died instantly were lucky. Those who survived found their skin falling off, flayed by the heat of the blast. Then their intestines disintegrated from radiation leaving them so thirsty that they threw themselves into the river to get at water and then they drowned there, leaving the river piled with bodies. Many were trapped alive under rubble but there was no rescue, nor pain relief for their burns.
They say it was necessary to shorten the war, that the invasion of Japan would have cost millions of lives, but whose lives, Japanese women and children or American soldiers? Japan had run out of fuel. A siege would not have lasted long and surely would not have caused such carnage. I keep on thinking that Hiroshima and indeed Auschwitz could never happen again. How naïve is that, particularly now and what we are seeing in the Middle East?
Paper Work
There has not been much medicine to do on the ship so far, apart from the plumber who came to see me this morning with a numb weak leg. His Bp is 200/130. He is on anti-hypertensives but when I asked him to bring them up from his cabin it was clear that his 6 month supply was completely intact!
The real work on this ship is paperwork. There are a whole team of staff ashore whose sole job is to design more forms for me to fill in and then pester me for them to be completed. They all require tons of the same information like dates of birth of patients etc. but each time I have to look up every single data bit to put in each box. Apparently, when we arrive in Russia they are going to empty the controlled drugs cupboard and check every pill and ampoule against our inventory. We have over 500 pills and ampules so this is going to be a little time-consuming. But as the staff captain put it – they need work to justify their job.
I wouldn’t mind all the forms so much if I didn’t have to fill them in on the computer, print them, sign them, scan them, file a copy, and then send them off electronically to HQ where I don’t think anyone reads them.
When I started teaching the undergrads in Oxford I used to prepare long reports on each student at the end of each course. No response, So I started sending them in Greek. For 2 years the med school didn’t notice until I pointed out what I had done. Well, this ship is an order of magnitude worse.
We could start with some simple rules.
- What does this form do that no other form is doing already?
- Is that important?
- Is there any overlap with other forms – if so – correct it
- Who needs to read these forms and what do they do once they have read them? If it is just reassurance that all is going according to plan then why not get rid of the form – no news is good news.
- Most of the forms are justified “in case there is legal action’ – as if you can drown a lawyer in paperwork. You can’t! They live and breathe paperwork – the more you give them the merrier they are.
Then there are the drugs and medical equipment none of which, of course, I have been taught to use. There is a new X-Ray machine. I think I need a license to use a machine that emits radiation. Then we have a ventilator, I don’t know how to use a ventilator and certainly could not manage one as a single doctor without even a nurse. So what with the files of copies of reports, equipment that it is not appropriate to use and drugs I have never even heard of, I really could lighten this end of the ship.
It is the rainy season in Japan so it is bucketing with rain, and the guests are coming back from huge long coach journeys to see yet another temple, looking a bit jaded. I feel sure that Russia will be worse because it will be cold too.
The passengers are a perfectly pleasant lot. Frankly, I don’t think they are getting any feel of Japan compared with the walk along the old Nakasendo Highway with Vicky, Jill and Richard, where we walked from east to west Japan through forest and farm land from one old tea house to the next, a few of years ago.
Japan & Korea
The Japanese we have met on this trip are making a huge effort to make tourists welcome. There are flags to welcome us, dancing school-children, drums, and lots of bowing. Some people say that the Japanese are very arrogant, racist and xenophobic, but if they are, they are making a brilliant job of hiding it. Clearly it is a country going through a massive transition. The fields are cultivated only by very elderly people. The few young people that there are in Japan (and they have a demographic crisis) have all headed for the cities. I had not realized that Tokyo is the biggest city in the world at nearly 14 million people, and of the total population of Japan 127 million, less than 10% of the population live in the countryside and 98.5% are ethnic Japanese. So, as soon as you get out of the cities the place seems to be empty, populated only by a few old people digging away at rice paddies and beautiful vegetable gardens. But beside this there are huge new factories going up. I have no idea what they make as everything is written in Japanese.
Contrast of the new and the old
At least some of the work in the paddy field is mechanized. Even so, a lot has to be done by hand
This is what passed for a cruise terminal at Pohang, Korea
Entering a Korean Harbour alongside a bit of their Navy.
The Japanese do love their uniforms and standing to attention guarding things. If you look carefully you can see no less than 4 guards evenly spaced guarding Silver Explorer (what from I am not sure).
They also love flags (as you can see), batons for controlling traffic that flash like light sabers, and absolute orgies of drumming.
My view of Japan has been limited for much of the time to the view from the Med Centre porthole (it only has one and there is none in my cabin).
Their history is castles, castles, castles, shrines, temples and castles (perhaps that is what the UK looks like to a visitor too)
In a few days, we move on to Russia (if my visa arrives), then the Aleutians (on my bucket list because of that extraordinary book “Where the Sea Breaks Its Back”, and Rudyard Kipling’s Kotik, the White Seal), then Alaska and home.
We crew don’t see the passengers as there isn’t enough room for us in the dining room. So, it is a solitary existence, being the ship’s doctor unless Vicky is with me. Plenty of time to read Tilman’s books on sailing in Mischief down in Patagonia. His descriptions are a bit of a contrast to Silver Explorer.
The Sea of Okhotsk
Rather few photographs I’m afraid. You can’t get pictures of heavy seas, they just don’t come out right, and we have had plenty heavy seas.
We changed our passengers in Northern Japan. Out went the Japanese garden coach tour parties: in came hardened passengers expecting to go out on Zodiac inflatables to see wild-life in really remote places. Some of them I know from previous trips to Antarctica. All have been to Spitsbergen and talk in a blase way about encounters with Polar Bears. I don’t tell them that Vicky and I ‘sailed’ up there in a yacht in 2001.
Our first stop is Korsakov in Russia, where we have to pass immigration. It takes one whole day. They wanted to count every single one of my controlled drugs then put a seal on the Drug safe. They do not smile. They glower. Is that how they are always if they are sober, or have they got a thing about us, our wealth, our politics? I considered asking them, then decide – better not. They all have naval caps except that they are green and the peak at the front is very, very tall. I also consider telling them how silly these look and decide against that comment too.
Then to sea. First to Turgiyev Island which we reach in a full gale. It is tiny with a cluster of derelict huts on it. On either side there are great reefs going out for a mile covered in breaking surf.
Turgiyev Island
Even where we have anchored in the lee of the island and its reefs, it is pretty rough and very, very windy. The captain launches one zodiac helmed by the expedition leader. After only a couple of minutes, he is winched back up. Not safe. Too big a sea, and a howling wind. It is not actually only wind. It is driving fog, full of rain. It is the same picture you get from a plane window as you come into land when there is a low cloud and you are passing through it before landing.
Through the binoculars, before they mist up, you can see hundreds of bobbing heads, fur seals, and walruses. Over their heads, thousands of birds are wheeling. The noise over there must be wonderful. It takes an age to leave as we have to weigh anchor. It is now a full gale and the ship is surging from side to side in the wind.
The weather is deteriorating and we have a very confused sea with at least three sets of rollers running in different directions. The result is sudden peaks 8 metres high which break harmlessly over the bow. But there are also big anti-waves, holes in the sea where just for a moment the valley between each set of rollers coincides. We drop into these like a brick and the whole ship shudders. The captain finally decided to change our destination and head for the end of the Kuril Islands where there is at least shelter from the waves, if not from the wind. The doors out onto the top deck can’t stay completely sealed against the wind, and wail like Banshees. The only other place I have heard that sound is in Scott’s Hut in the Ross Sea, where I had to do a day of guard duty while the guests were allowed in for a few minutes in small groups. There is something chilling ‘literally’ about the sound.
At dawn the sea looked as ugly as it could; the tops of each wave being whipped off by the wind. But literally inches above each crest were hundreds of dark phase Fulmars, the Black albatrosses of the North pacific, swirling and sweeping along the tops of and in between the waves. What elegant flyers they are, quicker and more urgent than albatrosses. Flying top cover above them are Black-backed Gulls. If they see a fulmar catch anything they are onto it like a rash, trying to steal it off them before they can swallow it.
This island was a Gulag, a prison for women. Their job was to gather seal pelts and prepare them.
The Aleutians
Well. We are a bit stuck now. We are sitting in the lee of an uninhabited Aleutian island veering and heeling to a wind that is gusting to 125kph. The ship is on two anchors but still, she doesn’t feel very secure. The gusts are actually ripping the surface off the sea in walls of white spray. We are supposed to be landing by Zodiac to go bird watching but for the moment that is not possible.
But that is not all our woes. Apparently, as we were sailing in Petropavlovsk we picked up a fishing net that wrapped itself around a prop. Divers have cleared it but clearly, damage has been done so we are limping along on one engine, and the cruise is to be cut short.
As soon as we reach Alaska in 5 days the passengers will be whisked away in a chartered jet, their pockets bulging with a full refund. We will then limp emptied of passengers all the way down to Vancouver where there is a dry dock. For me, what was supposed to be a quick fill-in of one week to cover a sick doctor has turned into more than a month and I don’t think that we are finished yet.
Despite that, we have had some great moments. One was an extraordinary Zodiac trip deep into a large kelp bed which contained no fewer than 20 sea otters almost all of whom had cubs lying on their chests.
Our guide had only ever seen one sea otter before so she was as blown-away as we were.
I suspect the kelp protects them from killer whales, as well as calming the waves so the bed makes a perfect nursery. They were unphased by us in our Zodiacs, but I don’t have a telephoto and the lack of light would have prevented it from being used, so I don’t have any good pictures. As time went on, the fog got thicker and by the time we were on our way back to the ship visibility was down to less than 200 yards, and as the ship was over a mile away, we were navigating back using a handheld GPS, a slightly worrying situation, because if it had failed we would have had problems.
The ship, an otter and the kelp beds before the fog closed in
And after – navigating home on a hand held GPS following another Zodiac.
The sea here is teeming with birds, fulmars, kittiwakes, guillemots, shearwaters, and puffins, but there is no way to photograph them in this fog.
If you think you have seen litter on the sea-shore you ain’t seen nothing compared with Russia
Abandoned fishing gear! The probable cause of our woes
An abandoned engine craving to be rebuilt.
We have had one beautiful day anchored in a fjord with the last remnants of snow on the sides. They were short of one zodiac driver so I was dragooned into service, not that I put up much of a fight. We saw brown bears and Steller’s Sea Eagle, hundreds of black guillemots, and the inevitable rusty hulks of abandoned ships which are everywhere.
Brown bear watching
There are abandoned ships everywhere. This one is actually inhabited by two men with their dogs. I think the dogs are needed to keep the bears away, but I have no idea what the men are doing living there.
Lenin in Petropavlovsk
Petropavlovsk is right on the tip of the flaccid willy which is the Kamchatka peninsula. It is slightly larger than the whole British Isles but has a population of only 300,000, of whom over half live in Petropavlovsk. The town is surrounded by active volcanoes (in fact the whole peninsula spits and fumes. It is so far from anywhere else that there is no road out of the peninsula. You can only get to Petropavlovsk by sea or by air. It is a curious mix of tumbling down state buildings and brand-new skyscrapers, exemplifying the collapse of communism and the rise of capitalism. I hope it makes them happy.
Collapsing buildings but note the posh gin palace in the background
Church old and new
A new bank building in downtown Petropavlovsk
Today the foul weather eased slightly after midday so we went ashore in the zodiacs. Attu island is utterly dismal in pouring rain but it was such a joy to be able to get some fresh air. Wikipedia says there are only 8 – 10 clear days a year, and it rains 5 or 6 days every week. This island was the scene of fierce fighting between the Japanese and USA in the 2nd World War. What a dismal bog they fought over. Eventually the Japanese were cornered by superior force and performed a Banzai charge knowing that they would die. There were only 23 survivors and over 2000 killed. What a waste.
Limping Home
We left the Aleutians under a cloud, literally and metaphorically. The weather was vile (it always is) with driving rain, and mist. The landscape was bleak beyond anything I have ever seen before, except perhaps in Iceland. But the cream on this cake of desolation is the rubbish. There are crashed planes and machine gun emplacements from the 2nd world war,
Crashed Liberator lost in low cloud
Japanese gun emplacement
Then there are the abandoned remains of fish and whale processing plants and rusting ships jammed against the shore-line.
Remains of a shore-based fishing factory
Japanese warship
Remains of a Japanese 2-man mini-submarine 10 feet above the current sea-shore probably a result of land uplift during an earthquake since 1945
Each day we landed in another empty bay, ferrying the passengers ashore in Zodiacs to walk half a mile up and down the beach and then re-embark. I felt sorry for them spending so much money muffled in their red arctic anoraks wandering along. wondering what this was all about.
Unfortunately we had no botanists or geologists as guides, and these specialities were what we needed most. Evidence of every kind of volcanic activity was all around us, but the active volcanoes producing it were unfortunately all hidden in the clouds.
Recent landslides from earthquakes
One of the active volcanoes. The interesting bits remained hidden in the clouds
Landing our intrepid explorers
Wandering an empty beach
What I hadn’t realized until I found a book called ‘Rats’ was what an extraordinary job the Wildlife service have done in these islands. This wilderness was originally trashed when Steller brought back the first sea otter pelts. They are the best there is and the otters were very tame, so they were slaughtered close to extinction. At the same time the hunters cleared out the seals and the whales for oil. They then started Arctic Fox farms. The foxes escaped and preyed on the ground nesting sea birds on many islands which had previously been fox-free. The Kurils and Aleutians cause sea-current upwellings so are rich in plankton and fish. The islands are perfect nest sites for Auklets (tiny puffins) , Murres (Guillemots) and Cormorants. Indeed Shilka point may have held the largest number of any one species in the world (over 300 million Least Auklets). Even now, when we sailed past it, the sea was covered in them.
Least auklets off Shilka point
But worse even than the damage done by the whalers, and the sealers was the destruction of nesting birds by the rats, mice, rabbits, pigs and goats that the hunters brought with them. Rats were a special problem as they hoard food and could survive the harsh winters by stockpiling eggs, chicks and even adult birds when there was a super-abundance in the breeding season. They succeeded in decimating colonies of millions of sea-birds. Just as in New Zealand and South Georgia, the American wildlife service laid rat poison by hand and by helicopter and now over 400 islands all over the world have been cleared of predators and sea bird numbers are recovering.
Lupins are everywhere
The Chocolate lily (Fritillaria kamchatkaensis). A real rarity which is two a penny here.
The vegetation on the shore was also being destroyed, first by grazing but secondarily because the plants were getting no more nutrients once the rats had destroyed the bird breeding colonies, which were providing, quite literally, a steady stream of Guano.
We have limped all the way to Vancouver (5 days sailing) where we have gone into the dry dock to have the it repaired.
In dry dock
Grinding away at the propeller
Before we went into dry dock the whole crew had to attend a one hour presentation on safety. The words ‘paper-work’ and ‘accidents’ must have come up one hundred times. Methinks the talk was about avoiding litigation much more than the welfare of the staff, but then maybe I am getting cynical.
In just under a week the dock floods, the ship floats off and heads away up towards Alaska and through the North East Passage. I should love to see the mouth of the Ob, the Lena and the Yenesi and set foot on Nova Zemlya where red-fronted geese breed, but I am not wanted and I think my ship’s doctoring days are now over. It is time to play Pooh sticks with the grandchildren and make grand voyages in my dreams.
Red Sea
Things in the cruise business were changing. Saga had decided that their doctors were to do the same contracts as their other officers 6 months on 3 months off. Up until then we doctors had really organised our own rotas choosing cruises that we and our wives wanted to do then returning to normal life. This was tremendous fun as we had our wives with us on cruises that interested us. We were also effectively treated as guests and reasonably well looked after. The team of four were effectively retired GPS but we had two extra doctors, one from Croatia and one from Colombia who were happy to fill any gaps. They would go anywhere for any length of time. They were quite competent, although the passengers preferred to see a British doctor. The Colombian lady doctor was a little prone to panic and achieved a record of 5 helicopter medical evacuations in 7 days. I think that in 6 cruises of 2-4 weeks each I had two helicopter patient evacuations. They are incredibly expensive, but Saga didn’t seem to be concerned. Anyhow they decided on the new rotas and all the British doctors said we would resign rather than do these new rotas. Saga accepted our resignations with alacrity, and that was the end of a wonderful time.
The allocation of doctors to most of the expedition ships were handled by an ambitious company called Vikand in Florida. They still needed doctors to fill gaps and I was offered a highly secretive one week contract on a ship in the Red Sea which was to act as a hotel for the staff that Prince Saud of Saudia Arabia was holding to celebrate a new super luxury resort that he was building at the top of the Red Sea not far from Sharm El Sheikh. Every super-luxury yacht in the world was invited, while the owners came in by helicopter. Over 70 of them came, and the Sultan brought in over 1000 extra people to staff the island with security, chefs, waiters, entertainers etc. We were the team who were to look after the team who were looking after the guests.
Arrival in Saudia is always a tense affair. Pakistanis or Indians do all the immigration work while in the background Saudis in gleaming white Thobes and Keffiyahs stand around ostensibly supervising the work being done, but actually just collecting a salary for doing nothing. There is an overwhelming sense of contempt for the rest of us.
We were taken by bus to a small harbour and then out to a large (2000 passenger) cruise ship which did not look in very good condition. I made my way to my cabin to find that it was tiny, with sloping walls, as it was right in the bow. This was not a doctor’s cabin: this was a crew cabin, and I was not some green-horn who knew no better. I complained at once. After a lot of grumbling by the manager, a crew member (a friend of the manager), who had taken the doctor’s cabin in his absence was moved, and I had an adequate but by no means luxurious cabin. Once that was sorted, I made my way to the medical centre. This is always difficult when you are new on a ship because you have no idea where you are and everything looks the same in the crew quarters which are always in the depths of the ship.
Something was very wrong in the medical centre. Apparently the ship had two doctors, one Turkish for the crew (who spoke no English) and me to cover the guests, who spoke no Turkish. Waiting at the door was a very tall thin South African nurse in her fifties who was not looking pleased. Skulking in the background was the Turkish doctor who was also looking very unhappy. The nurse asked for a word with me right away. She had already been on board for three days, and had found that the medical centre was filthy. Also, some of the drugs were out of date, and the drug cupboards were a mess. She had photographed this before spending three hard days sorting things out. But it was the final pictures which held me riveted. They were pictures of the Turkish doctor lying naked on the examination couch having a massage from one of the staff from the beauty centre.
I sat down and composed an email to my employers in Florida explaining the situation and asking for advice. On an impulse, I attached the photos which the nurse had taken. What I did not know was that the CEO of the company I was working for was a personal friend of the owner of the ship, so he forwarded my email and photos straight on to him. The first the captain and the hotel manager knew about things was an email from the owner. They were livid. For a start the ship was a mess, and secondly I had bypassed the line of command so they had no chance to cover things up. We were summoned to a meeting in the captain’s cabin where all the ship’s senior officers were present. The captain proceeded to deliver a rambling monologue for just over an hour which ranged over subjects like loyalty and teamwork. Neither the nurse nor I were asked to speak, nor were any plans made to change things. We were just simply sent to Coventry by all the officers including the Turkish doctor who was giving vitamin injections for non-specific maladies, and who refused to help with carrying out a drug inventory.
Meanwhile, on shore, a party was going on, with Madonna as the guest artist. We were not allowed ashore but went anyway. The sand on the beach was a coarse sharp grit interspersed with rocks, but presumably, the sheikh would bring in the ‘right’ sand in due course. I decided that I did not wish to continue the contract anymore. The nurse was being abused verbally and the ship was not acceptable. I phoned Florida to explain what I was going to do and why, expecting full support for actions. Instead, I was immediately offered the ludicrous sum of £8000 if I was prepared to stay on. The amount of money told me two things. First, my employer was well aware of what he was letting me into, and second whatever he was offering me to finish the contract was nothing compared with what he was receiving for providing the contract. This was sad because until then I had thought of them as good people. Now little things came to the fore that I had passed over at the time which all pointed to my employer running a company that was lackadaisical and greedy. The nice thing was that I did not have to work for them. I came home immediately.
Christina O
Well, this has to be one of the strangest ship that I have been on, The Christina O. was once one of the largest private yachts when she was converted from being a naval frigate in 1954. At 99 metres she is only a little shorter than the Royal Yacht Britannia. But these days she does not even come into the top 30 of largest private yachts. She has just had a major refit at a cost of £50 million and is impeccable.
The Christina O with one of her beautiful wooden ‘Hacker’ tenders
She is a floating mausoleum to Jackie Kennedy (Onassis). Every wall has a portrait, an Andy Warhol print, or black and white photo of her with Onassis or of Winston Churchill (not quite sure why he is here!).
Jackie Onassis by Warhol and Winston Churchill at his most pugnacious
One of the living rooms
and another
Dining room
Then there are the toys on board. Two beautiful Hacker launches are set on davits to take the guests ashore. Then for the children, there are two water-ski boats, three (very quiet) jet skis, water slides, and this extraordinary water jet thing that allows you to fly high in the air (photo below)
Water slide
One of the toys — a sort of water jet rocket flyer
Some of the toys on the foredeck
Feast your eyes on these views as they are the only ones you are likely to see. Security is tight and if you want to charter this ship, then you will apparently need $45,000 per day.
Most ordinary cruise ships work on a ratio of one crew member to every four or five passengers. I am used to working on luxury ships where the ratio of crew to passengers is one to one. On this ship there are only 22 passengers but there are 43 crew, including two masseuse, two security staff and one crew member solely in charge of setting up and operating the ‘toys’.
Each night we move to a new port. Then we dock for a few hours if the harbor is big enough for those who want to go shopping. Then the ship moves out and anchors a mile off shore. It then launches all its toys in complete privacy. It creates a private beach in the middle of the ocean for the youngsters to play.
So, what is my job? Well I have been hugely busy. Yesterday I had my first two cases to treat. One stewardess had a rash on her arms, and then, yes you have guessed it, one of the guests broke a finger nail, and I was summoned to ‘save’ her. Actually, so far, there is lots to do: the inventory needs checking, and I have to work out how I would handle a major emergency, and make sure that I know where everything is.
The charter group this week is an extended family. The pater familias books the ship for a week every year, as he values his privacy. He is from a wealthy oil family in the Southern United States. It is clear that their pleasure (his and wife) is to be surrounded by their children, and grand-children. It is a delight to see. This evening we are in the shadow on. Mt.Etna which is smoking away as usual. I would not like to live under this mountain. The extra staff on top of the $750K dollars for the week’s charter are two armed security guards and me the doctor. Like so many ambassadors he and his wife were charming. Being US Ambassadors they are not trained in the diplomatic service but instead are appointed because they are friends of the President.
His passion is horse racing, so when he was appointed Ambassador to London he brought with him a string of race horses which he put into training at Newmarket. But not satisfied with that he also had horses back in the States. So, every week there was a big race in the USA he and his wife fly Concorde to New York on Friday evening then back again Sunday morning ready for work.
Each time the children wanted to swim or play with the toys the ship went out to sea and the bodyguards went onto a state of high alert. Apparently, the worry was kidnap, so there was no question of the children being allowed near to the beach. I wonder how much fun it is to be really rich.
Thoughts on Health Care Reform
One of my colleagues calls me a ‘Butterfly’ because I never seem to settle anywhere. I think it was said a little wistfully but I am not sure. Certainly, if you spend your life in one circumscribed area (as he has), then you will certainly get a ‘fine reputation’. The sense of fulfillment in being recognised as ‘a’ or even ‘the’ expert in a field must be deeply fulfilling. On the other hand, anyone choosing this path must miss that surge of excitement that I certainly feel when embarking on a new career challenge. Working in an Emergency Medicine department in New Zealand has been a double challenge both because it has been a huge jump in the kind of medicine that I have performed to date, but also because culturally the country, and indeed the hospital, is so different from anything that I have been used to that I am routinely left bemused. The fun of making such a jump is that it turns on its head the accepted wisdom of how things work and why. I had always thought that a large hospital fully staffed with all specialties would obviously provide better care than a small rural hospital. Well, of course, it depends how you define and measure ‘better care’, but the self-evident nature of many such ‘truisms’ are now no long so obvious to me.
Being a locum Medical Officer makes you a pretty small fry in the Department. This means that you can observe without being required to do anything about the way that the system runs. I suppose the contrast between being a Professor at Oxford and a Medical Officer in Invercargill is about as great as you can get, but it is much easier to analyse and understand when you are not expected to act, and can observe a simpler, smaller system in action.
And that has meant that I have done a lot of thinking about what a health care service would look like in a developed world if we had a clean sheet to redesign it from scratch, rather than for ever trying to patch up a juggernaut created three generations ago for a completely different society.
I cannot be the only doctor who feels that the sooner that we as a society front up to the question of what kind of health care we want, the better. Surely, first of all we need, an open and fair system for determining what we spend that money on. It should not be biased by the petty ambitions of individual doctors for their arcane specialty, nor the pork-barreling of politicians who fight to ‘save’ the hospital in their constituency which passed its sell-by date a hundred years ago, nor the pharmaceutical companies tending to the profits of their share-holders. Our current system does not incorporate any fair or logical system for providing appropriate health care nor for society to decide how much it actually wants to spend on providing it.
Getting answers to these questions means requiring everyone in society to consider some pretty awkward issues relating to the quality of our life and even more importantly the time and form of our death.
The other big question must be around the ‘The Freedom of the Individual’. Should people be free to take drugs, drink, or indeed eat themselves into an expensive and early grave, or should we just accept that we are in the middle of a global epidemic of obesity which suits the manufacturers of Insulin just fine, but which is destroying the self-esteem and health of more and more people young and old?
In the Emergency Department we hardly see anyone who is not supremely obese (I prefer ‘supreme’ to morbid). In fact almost the only other attendees are those poor malnourished folk in the terminal clutches of alcohol and/or drugs, and sportsmen (another form of addiction with self-inflicted injuries).
I realise that it is not politically correct to even pose this question, but how is that there seems to be a direct correlation between how poor someone is and how fat they are. Where do they find the money to feed these enormous frames? And how come they have so many children. Conception must be something like scenes from David Attenborough’s Frozen Planet! Best not think about it.
A nice example of a New Zealand trendy T-shirt
I have just finished a long series of duties doing evening and nights, the time when the invertebrates on the coral reef of society come out of their burrows and visit the Emergency Department seeking some sort of help, so excuse me if my views are a little jaundiced. It really does seem that we are seen by the public as an out-of-hours convenience store, a sort of Tesco’s of General Practice – open 24/7 for that bit of spur-of –the-moment buying(check-up) that is now the hallmark of our modern society. But in the ED, we only have a skeleton staff at night and are really only open to cover major problems, so being used as a convenience store is quite frustrating for us and the patients. Maybe it is we who should change our perception not the patients who choose to wander in when it suits them.
So looked at from the patients side, what are their expectations?
Well, they certainly want dentistry – now. We don’t provide that.
They also want lots and lots of tests and imaging which either confirm to them that they haven’t got cancer (after the TV programme they saw the other evening), or for us to give a proper name to their general malaise with life so that they can feel good about it. Unfortunately our lab and imaging services are closed out of hours, so once again we don’t help much there.
Of course what they want, doesn’t bear much relation to what they need, but is it our job to try to ration what we see as their unreasonable demands, and incur the wrath of the patient? Be in no doubt, if you refuse to perform a test often enough because “it is not necessary”, you will eventually get a patient who has that rare brain tumour. Then, watch to see how much support you get from the service whose costs you were trying to hold down.
They also want an opinion that they can trust, and that usually means a fully trained doctor. But we staff our ED depts with the most junior doctors (especially at night) who, despite their best efforts cannot convey the gravitas and conviction that comes with age.
The patients also, of course, want a good listening to. But we havent got time for that. The four hour rule and the relentless pursuit of efficiency means that listening is something which we really cannot afford.
Finally, and perhaps most tragically, they are sent to us by the nursing homes, when they are dying. If you want to die quietly and with dignity, I cannot think of a worse place to be sent than an ED department which knows nothing about your final wishes and which is geared up for one thing and one thing alone – preventing people from dying, however hard they try.
So, here we are duplicating a GP service without any communication between the two of us. Now that is what I call a wasteful and inappropriate way of organising things.
A service that cannot and will not provide what its ‘clients’ want, is doomed to have a pretty rough ride in this consumer-orientated society. Staff morale cannot help but suffer. The New Zealanders are much more accepting of a service that doesn’t work for them than we are in the UK, but even so, it is so frustrating when I feel sure that we could do better.
Retired diagnosis of heaven knows what
Some people are not supposed to retire. They live for their work and without it they are husks. In a way I envy them. Life must be so simple until you retire. I lived to work but got bored very easily so needed a new challenge. I was caught out by illness. An old colleague whom I had not seen for 10 years came to dinner. When they got home they rang Vicky and asked her how long I had suffered from Parkinsons. I didn’t take this very seriously. I had a tremor in one finger, that was all. I was leaving shortly afterwards for Antarctica and was not missing this voyage for anything especially as we were covering much of Shackleton’s rescue journey to Elephant Island and South Georgia.
While I was down there, I developed a bilateral foot drop and had to be helped off a hill where there was a stiff walk. I read up the condition decided that I did have Parkinson’s and started myself on a course of DOPA.
When we got back to the UK. I got myself referred to a neurologist, but not the one recommended by everyone. She was booked up, so I was referred to another one. My main symptom was now the most horrible night terrors where night after night I was dying or being murdered. I suspect that some of my colleagues would have called it poetic justice.
I wrote out a history sheet (two sides of A4) of what I had developed over the past few years covering everything neurological I could find in the text books. I went along with Vicky and neither of us took to the consultant, nor he to us. When he started, in a rather bored tone of voice, by asking the standard history question, I’m afraid I was a little dismissive and suggested that he read what I had written, as it was all there and a bit pointless duplicating the exercise. He did not like to be told his job, especially when he could not find anything missing. When it came to examination, he pulled and pushed me around but was unable to elicit any the physical signs he clearly wanted to be present to confirm his diagnosis. So determined was he that he became quite violent, and my thoughts were “if you do that again, I will thump you”. We used to do a lot of training of doctors in behaviour, in fact I think we ran 2 day courses for over 20,000 doctors all over the world. But a couple of things became clear. One was that beyond a certain age (around 40) they became fixed in their ways and were untrainable. The other was that most reverted to their old ways. He belonged to this category and for the first time I was confronted by the helplessness of the patient when trust is lost.
Reluctantly he agreed to get a Dopa scan of the base of my brain, the test needed to exclude one of the Parkinson like illnesses. . When I saw him next, he grudgingly admitted that the scan was clearly positive. After that I saw a brilliant physiotherapist who clearly recognised the condition and knew exactly what advice and assistance Vicky and I needed.
So now it is progressive deterioration. I have to admit that I spend most of my time in denial until I find I simply can’t get out of a chair. Intellectually I feel fine except that Vicky is now consistently faster at the daily Sudoku than I am. Depression looms like a low cloud over me. While I have a project I can hold it at bay but if I am not wanted or needed for anything then down comes the cloud. Poor Vicky is continuously thinking up jobs, trips and entertainment to keep me happily occupied.
I have come to love Vicky’s garden more and more. I can’t kneel now, or bend over, so weeding is done by lying on my side like a Roman emperor gorging on grapes. We have turned into galanthophiles (snowdrop lovers), and I have developed a fascination with the innumerable markings which identify them. I read more and more, and I am battling to finish this book.
The following paragraph is written a year later. My short-term memory is now very unreliable. I have floppy feet which try to trip me up. I have brutal back-ache, and I can’t turn over in bed. I seem to have psychological detrussor spasm, so I must get myself ready to pee very very quickly, or I wet myself. My bladder capacity seems normal (400 -500ml) but the detrusor spasm comes any time after 150ml, so I may need to pee more than ten times a day and three to four times a night. I can’t touch-type anymore, so I dictate to Vicky who then hands it over for me to read. . I can’t eat without dribbling and dropping food, and I now use a wheelchair to get around. It is the most cruel illness, particularly for someone who needs to be active and whose constant need in life is to ‘do’.
Some days I convince myself that there is not much wrong. On other days I am almost immobile. Am I suicidal? Yes – the question arises daily and I have all the means ready. Vicky is the only thing that stops me, as she makes me feel valued. Amazingly after almost 25 years she still loves me very much, and I love her to eternity. I was so lucky that she came into my life, and I am forever grateful. It is also a joy to see Harry succeeding (nay – thriving) in the most difficult career there is. What tenacity, intelligence and patience. Jenny is the same. From an absolute pit of depression she has risen to dizzying intellectual heights. JJ has his demons to fight (and I appear to be included amongst them). It makes me sad because I did exactly the same and it was only on my father’s death that I realised that he was a kind and loving person. I am not a kind and loving person, but nor am I a demon. I am just someone drawn through an unusual life-path, who unwittingly must have glanced off the hedges of other people’s personas, sometimes bringing humour and help and to others distress and humiliation. I just hope that the positive outweighs the negative.
Thoughts of a retired doctor
When I retired I made a bucket list of things that I wanted to do. Most of it was places I wanted to visit. I didn’t do private practice so did not have a pot of gold to spend. My motives for not doing private work were, I am sure, not so altruistic as I would like to think. I just don’t like being ‘owned’ by patients. I would also rather make decisions on surgery based on the ‘needs’ of the patient not their ‘wants’. This new scandal about retropexy with nylon tapes seems to fit into that category. So, the only way to travel was to use my medicine and work as a ship, base, or repatriation doctor doing the work for free, in return for visiting the most wonderful places on my list.
This decision was finalized by a locum job in the Emergency Department. I arrived to do a locum shift at the Horton Hospital the other morning. There are supposed to be four doctors on duty, but they had not been able to find any others, so I was on my own. A little bit of me felt proud that they trusted me to carry this load, but another side of me coldly warned me that this was dangerous and if anything went amiss, the coroner would take a very dim view of what I thought I was doing trying to work single-handed. All Emergency departments are under terrific pressure now but making yourself a martyr is not the answer. Almost immediately three blue light ambulances arrived. Luckily, when I called the medical registrar he appreciated my position and came straight down to help. But the damage was done. I couldn’t go on like this.
A&E shouldn’t really even be called the ‘Emergency Department’. It should be called the department for PNEWS (Patients No-one Else Wants). If the police can’t cope with a mentally disturbed patient they bring them to ED. If a GP can’t get an urgent outpatient appointment they send them to ED. If a school has a child with a scratch on their knee, and are worried about litigious parents, they send them to ED. If a family can’t cope with an elderly relative, they bring them to ED. The list is endless.
It is a cruel specialty for the doctors too as you get older. Day and night, weekends and Bank holidays it never stops. You come on-shift and there are fifteen patients waiting to be seen. You get your head down and start trying to clear the back log, chivvied by managers worrying about the four hour wait times. Nine hours later, (there was no time for a meal break) you slip out of your scrubs, and there are now twenty waiting to be seen. You had been running to stand still, but actually you were slipping backwards. So, there is none of the satisfaction of finally sitting back having seen the last patient in a clinic, just a sense that if you dropped dead tomorrow no-one would even notice. That is not quite true. There would be a flurry of emails from medical staffing trying to find a locum to stand-in for your shifts. No wonder juniors do their 6 months and then shake the dust from their feet heading for specialties where there is no night or weekend work, and they can see their families.
But there is a real pleasure in the job too. The variety of patients is a cornucopia of training material for medical students and junior doctors. You can lead them through this fascinating world building their confidence and competence, and patching up their fragile egos after another ‘gumming’ from a specialty registrar trying to block a referral. At the end of each shift I write a thank you note (copy to consultant) to any specialty registrars who have been constructive and helpful when taking a referral. I don’t have to write many letters, certainly fewer than the letters of complaint I would like to write to all those who don’t answer their bleeps and, when they finally, do are rude and unhelpful. One staff grade, who received one of my ‘thank you’ letters said it was the first and only nice letter she had received in fifteen years working in our august teaching hospital.
But something has to give. Attendances are up again. We have a public now well attuned to the Amazon culture. They want 24/7 service, and they don’t want to be kept waiting. I don’t blame them. I wouldn’t want to wait a fortnight for a GP appointment and then another week for my blood results, but it doesn’t half put a load on the system. They certainly don’t want to be told that their attendance on a Sunday evening for a trivial and chronic problem was not appropriate. When I started in the NHS we were encouraged to see ourselves as guardians of an extraordinary social experiment – free health care. We did not hesitate to ‘educate’ patients in the importance of not abusing this great service. Now, no more, the customer is always right. Viva Amazon, and indeed those doctors who get a buzz out of making martyrs of themselves!
Then there is the antediluvian way in which we still process Emergency patients. Para-medics now do superb ‘clerkings’ as they bring the patients in by ambulance, but as soon as the patient arrives, the process is repeated by a triage nurse who again does a great job. Then it is the turn of the casualty officer to perform another clerking and then present the case to their senior who may choose to clerk the patient again. Now it is time to call the specialist team who send their most junior doctor to repeat the process, and present to their registrar. Finally, the case is presented to the consultant on duty for that specialty. The patient has been poly-clerked half to death, darkness has fallen, and if it might have been safe to send the patient home earlier, it certainly isn’t now.
All this has been done without sight or access to the GP notes which may be a gold-mine of information on the patient’s illness and attitude to it. All the information we gather is entered on the hospital computer. Our system requires more than 50 separate clicks on tiny boxes on many screens just to progress through the system. That does not include any notes written. So the C/P ratio, (the time spent working the computer compared to interacting with the patient) is well below 30%. The health service doesn’t need more money it needs to streamline its working practices. It cannot be appropriate to have each patient clerked 5 or 6 times before a decision is made on admission, nor a computer system which wastes 15 minutes of doctor’s time on each patient however trivial the complaint. Providing life-long job satisfaction in a career of night and weekend shifts will be the most difficult problem of all. But if we don’t do something radical soon, I fear that ED may collapse and bring the whole NHS system down with it. I can imagine a history lesson in a school in one hundred years time. Children will be taught that in 1948 a small island off the west of Europe created a staggering advance in civilization, which was the talk of the rest of the world. It was free health care and universally available. My fear is that the next sentence will be that it collapsed in the year 201….
Ship’s doctor
Working as a ship’s doctor is a great way to travel the world as the cruise ships go, by definition, to interesting places. The large ships (over 4000 passengers) are I suspect a bit ghastly, and I believe that Iona the new P&O ship takes 5,600 passenger and the MSC ships even mores. Certainly from afar they look like a floating block of council flats built in the brutalist style. The smaller cruise (expedition) ships go to more exotic places and are also much more friendly. Even so there may be several hundred passengers living in luxury and the same number of crew sharing tiny cabins with no windows in the bowels of the ship, so you usually have at least one thousand souls to look after. Even so there should be very little for the doctor to do, if the crew are fit and the passengers are screened to dissuade those who are ill to delay their cruise.
On a cruise ship like Saga Pearl or Saga Sapphire (now replaced by Spirit of Adventure and Spirit of Discovery) the passengers have an average age of over 80 and the crew are on board for a 9 month contract so they suffer plenty of stress related illness. The time when trouble really starts is if there is an outbreak of norovirus or we have to sail through a storm, when there will be night calls for sea-sickness and for falls. As the ship’s doctor you come to dread the Code Alpha alarm which alerts the medical team to a serious problem on board.
The most impressive part of working on a ship is their pre-occupation with safety. Every single week, week in week out, we have a full fire practice with hoses run out, breathing apparatus on and casualties evacuated back to the hospital. What is a complicated set of actions involving dozens of people becomes second nature within a few months. I would be much happier if we did the same in NHS hospitals.
However my times on board the various trips, particularly with Vicky acting as hostess and guide, have been some of the happiest times for us. We have formed friendships for life and travelled the world together. Admittedly she declined any more trips to the Southern Ocean after the 40ft waves threatened to sink the ship, but we have gone from Antarctica to the Arctic, Australasia to South Africa to South America and Japan.
Sadly my condition has now progressed to the stage when I am unable to look after myself, and therefore I rely on help to travel. In 2023 we managed two holidays to Spain, during which British Airways showed they really could “take good care of you”, the pilots taking a sledgehammer to the battery in my wheelchair which stubbornly refused to come out and had to be carried on board.
Postscript
Very sadly Chris died in December 2023 as a result of the still yet unnamed neurological illness which so cruelly afflicted him. His was a life well lived.
“Success is not how high you have climbed, but how you make a positive difference to the world.”
― Roy T. Bennett, The Light in the Heart
