Knife Edge: Life as a Special Forces Surgeon (34 page)

To my astonishment, of the 190 envelopes I posted, only two agencies replied. Voluntary service was obviously harder to enter than I had anticipated. Many of the charities had standing rules that did not allow anyone to work for less than a year, or eighteen months in some cases. Perhaps it was my SAS background, I do not know. When the first offer did arrive, it came as an unexpected telephone call, during a clinic in an orthopaedic hospital in Essex. It was the Afghanistan Support Committee, looking for someone to run ambulances into Russian-occupied Afghanistan, in support of resistance operations. I was sorely tempted at first, paying several visits to a shady-looking office in London’s Shaftesbury Avenue. In the end I declined, mainly because information available about Russian troop movements was inadequate, making the venture too unsafe. By then I had also received an alternative, second offer from a Cambridge-based charity, Action Health. Perhaps I am becoming soft in my old age, I thought, but the small hospital of Padhar, in India’s
terra incognita,
was enthusiastic for my help.

Study a map of India and the village of Padhar is nowhere to be seen. Situated 220 kilometres from the city of Bhopal, it is truly in the heart of the subcontinent. The village is in the state of Madhya Pradesh, a region of 450,000 hectares, an area that sprang to fame in the mid-1980s when the leakage of methyl isocyanate gas ostensibly caused tens of thousands of casualties. Defenceless locals died and choked while they slept. Their problems continue to this day. Chronic lung conditions, due to damage from the effects of poison, are a terrible way to die. Imagine being breathless to the last, when even minor exercise such as tying a shoelace makes you pant. It is awful. I have seen patients die from it and would not wish such a fate on anyone.

From Bhopal, a tiny road passes south, winding through mile upon mile of teak jungle. This is not the jungle of the Far East or Central America. It is dry, fairly open, with frequent clearings. It is not so oppressive, nor so claustrophobic, as the humid, tropical rainforests in which I had spent much of my SAS life. There is barely any habitation. This is the home of the monkey, the panther, the elephant and every other form of jungle wildlife imaginable. It is truly an unknown land —
terra incognita
- named by the British during their Indian rule. It was not a region that early mapmakers would happily enter. If they did there was a fair chance the
dacoit
would see them as prey.

Yet one man had the foresight to go against the grain. Not only did he travel freely through the area, but also lived and worked in the villages around Padhar as a missionary. His name was Clement Moss. He began work in 1939, but after twelve years felt he could do something more for the enormous health problems of India’s rural peoples. He decided at the age of thirty-six to become a doctor, entering medical school in India’s Punjab, despite being British to the core. As a highly articulate, intelligent man, qualification did not take him long. Medical degree in hand, off to Padhar he went. At that time there was nothing in the area beyond an orphanage, a dispensary, a church and a once warlike tribespeople - the Gond. Quite illogically, or so it appeared, Clement decided to build a hospital in Padhar, the very heart of the Indian jungle. To many, placing a hospital there, for it is truly isolated, was a futile exercise. The essence of hospital construction is to place them near populated areas. What use is a hospital without any patients to treat?

Clement guessed correctly, being driven by a faith that few have the privilege to understand. With the help of local tribespeople he physically built the hospital himself. He even supervised the manufacture of the bricks. He estimated it would make no difference where a hospital was positioned. If it was good, people would travel to it. Furthermore, Padhar was a market village, on a road of sorts and so easier than most to reach. He was right - it was a well-chosen site. Now, with 200 beds to its name, Padhar is a thriving institution that sees more than 3000 patients each month. It is a true phenomenon.

Isolation unfortunately has its perils. In particular, staff become lonely and it is difficult to fill posts as a result. That was where I was needed. Having turned my back on Afghanistan, I was looking to use and develop my surgical skills somewhere that people both needed and appreciated them. Padhar seemed ideal.

A feature of primitive areas, particularly if local people are uneducated, is the variety of disease one sees. They are often different to those back home. I was fortunate that SAS service had done me proud. I was used to living in isolated surroundings, coping with contaminated water and the strange diagnoses that go hand-in-hand with the Third World. In Britain we have our share of bunions and back pain, coughs and colds, arthritis and epilepsy. In Padhar it was more common to see diseases like tuberculosis, polio, vitamin deficiency or cancer of the throat. Your medical perspective changes once you get there.

Neglect is a problem. Patients travel for miles to visit Padhar and appear with conditions that have been present for ages. It would not be strange to see someone with a broken leg, for the first time, four weeks after the accident that caused it, or an infection that had been discharging pus for a year. Because diseases are so advanced, treatments that are effective at home do not necessarily work in the Indian jungle. Take a child’s dislocated hip. In the UK I would hope to solve the problem easily with mild, albeit prolonged, treatment. The same condition in Padhar, because it will have been present for longer before detection, would require lengthy, high-risk surgery without guarantee of success.

It was into such an environment I was thrust one sunny Monday morning in September. Struggling from a Land Rover that collected me from Bhopal airport, I extended my hand to greet the hospital’s superintendent, Vincent Solomon. I was feeling awful. Already, a brief stop in Delhi had managed to poison me when I had foolishly downed an ill-cooked hamburger. Vincent, an experienced orthopaedic surgeon, smiled broadly, as if he had known me for years. ‘Dr Richard? Welcome,’ he said. ‘This is Padhar Hospital.’ Though I had never met him before, Vincent’s reputation went before him. He had trained worldwide, not just in India and, though an orthopaedic surgeon, was just as skilled at a variety of other operations - Caesarean sections, womb removals, opening skulls for bleeding, even repairing a birth-deformed heart. He was also brilliant at badminton. This level of surgical talent is only rarely seen in the more developed countries as specialization has intervened. In Padhar there was no choice. If the job was not done there, the chances were the patient would die. You could not be surgically choosy.

I was given little time to think or prepare. As Vincent walked with me the short distance to the hospital buildings, he described the situation in a precise, efficient tone. ‘Once we heard you were coming, Dr Richard, we advertised in the newspapers and on radio and television. You can do that here. We have had an enormous response. More letters than you can imagine. We have filtered out the serious ones… Watch out!’ He grabbed my shoulder tightly, pulling me back from the edge of the dirt road. A massive, overladen truck whisked by, horn blaring, exhaust fumes pouring into the atmosphere. Even in
terra incognita
I could see pollution was a problem. I watched the tail end of the vehicle disappear into the jungle, scattering chickens, cows, children and dogs before it. The driver had no intention of stopping, whatever stood in his way.

Crossing the road to the main hospital gates, I could see everywhere the thriving community that had developed around the complex: dozens of roadside stalls offering food, refreshments, odds and ends, even a haircut. Some poor fellow was being assaulted by the barber as I stared. A fine head was being reduced to a pale shiny pate before me. The barber saw my gaze, shouting incomprehensibly to me as he brandished his comb and scissors. Vincent shouted something equally impossible back. I saw the barber recoil in horror at his words. ‘He says you are next, Dr Richard,’ explained Vincent, obviously enjoying the occasion. ‘I told him he can cut
your
hair after you have done
his
operation. I think he will keep quiet for a while now.’

Approaching the main hospital buildings I could hear the low murmur of many voices, though there were few people to see. Vincent guided me up a small wheelchair ramp, following signs indicating ‘OPD’ - the Outpatient Department. Despite my distinctly unstable stomach, already sounding orchestral, I was looking forward to this. Cambridge had been turning me soft, so the challenge of a rugged Third World clinic was something I relished.

It was as we rounded the final corner I almost changed my mind. The low murmur had now become an unbearable din, hitting us hard the moment we entered the patient waiting area. The place was jammed with people, an immense mass of them. There must have been at least 300. A clinic in the UK would be regarded as big if it saw more than thirty. Men, women, children, crutches, wheelchairs, even a few patients crawling. It seemed as if all humanity had descended on Padhar that day. Vincent’s advertising would have done credit to a major conglomerate, so excellent was the response.

It was impossible for me to deal with every case, particularly working through an interpreter. Hindi and Gondi are the local languages. My abilities in either tongue are appalling. An interpreter may seem a good idea but frequently loses those little nuances of expression that are so important to a doctor. Patients often tell you they are well when, in fact, they are as sick as a dog. Particularly so when they have some ghastly sexual problem. To make the best of a clinic, you have to speak the local language, preferably like a native. Clement Moss could speak six of the things with an accent that was indistinguishable from the original. I can barely speak my own.

Women struggle to be heard in Padhar, despite the heroic efforts of Vincent’s wife, Meenakshi, to raise their profile in Indian society. That first clinic showed me how far they have to go. A large, overfed woman perched herself precariously on the patient’s chair to one side of my desk.

‘Namaste -
hello,’ I said, hands clasped firmly together in prayer like fashion as welcome. With this one word I had already exhausted my knowledge of the local tongue. The woman did not move. She simply looked at me - a vacant, expressionless stare, half smiling. Perhaps I had tried the wrong greeting, I thought. Never mind, there was a job to do.

‘What is your problem?’ I asked, now in English. I had given up with the interpreter as I had caught him asking a patient the World Cup football score instead of taking details of a painful hip. ‘Is it your knee?’ I added. There was a fair chance this would be so.

Vincent had known of my interest in the joint and had advertised widely.

‘Oh yes, doctor. It is her knee,’ came the reply. Only it had not come from the patient but from some distance away. I glanced around me. The consulting room was bursting with people, more than fifty in its tiny area, hundreds more milling outside. Orderly queues did not exist and appointment times were a forlorn hope. The rules were simple - every patient tried to be first. A clinic auxiliary would attempt valiantly to keep order, but was frequently flattened in the rush. Through all of this he would maintain a calm, controlled exterior, plying me with soft drinks and tea whenever I looked overcome. He was a lifesaver that man. Once a patient had made it into the consulting room, his next task was to find his way to the chair beside my desk. That might mean elbowing dozens of other unfortunates to one side. Crutches were ideal. When in trouble they could be used as spears. Plaster casts also made vicious clubs for fighting your way to the front.

So it was that day as I searched through the morass of bodies, trying to identify the voice. From somewhere in the middle of the crowd I could see a small, dark head bob up and down - jumping up on its toes, trying desperately to be seen. I could tell it was a man, not a big man, but unquestionably he was trying to attract my attention. ‘Her knee, doctor. Her knee. Pain,’ he shouted, his arm waving frantically above the heads of his fellow patients. Then, slowly, at times forcefully, I saw him push his way through the bodies to reach the side of my desk. He collected dozens of irritated glances as he moved. ‘My wife,’ he added as he breathlessly gained his destination, pointing to the large, silent, motionless creature in the chair. ‘My lady wife.’ I learned then that most consultations with women took place through their husbands. No matter that you might seek information on menstrual cycles, piles or vaginal discharge, the husband answered all.

Women also appeared to have a raw deal in marriage. I confess to a small degree of male chauvinism. However, rural Madhya Pradesh tested even my tolerance to the full. During my first weeks in Padhar, I noticed several women were admitted as emergencies with burns. Sirpandi Bai was one of them. She had awful injuries. As I walked into her small room, away from the main hospital ward, I could smell the rotting flesh. Sirpandi was a beautiful woman, what little of her I was allowed to see. Young, no more than twenty years old, with a delicate appearance. Her normally smooth face was now lined with distress and racked with pain. Her top half, above the belly button, was fine. Below that level was a mangled, infected mess. It took all my self-control not to vomit as I pulled back the single sheet to examine her. Apart from a small area at the top of her right leg, the skin was missing from the rest of her. Bright red flesh shone like a huge, bloody beacon. Small patches of black, dead tissue hung off her in thin strands, as green pus began to seep from several areas. The bed was stained with body fluids. Not urine, but serum secreted by the exposed flesh. The sight was horrific. Full thickness, infected burns affecting more than 50 per cent of her body. Sirpandi Bai would die for sure. Worse, she had no family or friends to sit with her. She was suffering her fate alone.

Sirpandi’s crime had been to marry without a dowry following her. It had been promised, but had never appeared. Arranged marriages still exist in Indian society and are largely very successful, but a dowry is usually agreed beforehand. There is unquestionably a business element to many Indian partnerships. Within months of the dowry failing to materialize, Sirpandi had sustained her terrible accident. Some would say it was bad luck, something that Nature had decreed, but Sirpandi was not the only one. During my time in Padhar I saw this fate befall more than six young women. Rumour had it new wives would be disposed of by fire if the dowry did not follow over the marital threshold. Rumour is not always accurate, but six cases says more than bad luck. Often at dead of night, the unsuspecting victim would be thrown on to an open fire, or her flimsy dwelling set alight. Petrol could not be used as this, of course, would be obvious murder. Rotting to death is not a pleasant way to go. Sirpandi died two days later. Overwhelming infection of the raw flesh, combined with kidney failure, were more than her young frame could take. Fifty per cent is a large skin area to destroy. Even professional burns units in the West would have had their work cut out to save her. This was
dahej hatya,
bride burning or dowry death, in action.