Geneva, Saturday 25 April 2020

It was 1989. I stumbled out of the small plane. “Welcome to South East” said Pauline, an OT nurse I knew from a previous mission. Big smile. Big hug. I was very happy to see a familiar face. I had already been travelling for four days. “It’s a two day drive to the hospital.” she said “We’ll be leaving tomorrow morning.”

This was my fourth trip as surgeon with the International Committee of the Red Cross. The out-going briefing in ICRC’s HQ in Geneva hid nothing. “South East” was the name given to a very discrete and politically sensitive surgical action in a corner of the poorest of African countries riven by a brutal cold-war era civil conflict. South East was a vast former national park occupied by rebels and their situation was desperate. Furthermore, no patients would ever get to us from the front within two weeks of being wounded. The whole set-up was so discrete that we would never know precisely where the hospital was. My other job, I was told, was to hook up by radio with the ICRC office in the neighbouring country and receive the weekly plan for our relief flights out from the capital on the government side of our conflict. (Direct communication with the ICRC team on the other side was not permitted.) I would give the flight plan to “the responsible person.” The idea being that if the rebels knew the where and when of our flights, they wouldn’t shoot them down. The system worked. It was also explained that my route in to South East was on a supply flight from another country and it would be circuitous to say the least. And so I left Geneva on a nice clean and comfortable Swiss Air flight for my first taste of Africa.

The flight in on the supply plane was five hours. I was the only passenger and was squeezed into a gap between boxes of hospital supplies. Under a huge African sky, the pilot flew just above the tree tops to avoid our being picked up by the government’s Soviet-made radar. The plane had no GPS. The co-pilot had a map on his knees. The intrepid pair assured me that they would find the airstrip but they might have to fly around the area a bit. Eventually they spotted it… and spotted a problem. A herd of elephants! The pilot buzzed them and they all charged off into the forest allowing us to land. We taxied to the end of the strip and out from under the trees trundled a lorry with a gang of young men in fatigues. And Pauline. While the plane was being unloaded, I was interrogated about my political sympathies and had my passport checked and stamped.

Early the following morning, we met the team that were coming up to the hospital with us. Our guard comprised five young men in khaki uniforms and red berets with AK47s over their shoulders. Chiko was in charge. They were all very happy. I was soon to learn why. We all clambered up onto the back of the lorry and set off; the boxes of supplies were to be our seats for the long journey.

There was no road. We were travelling through light forest and around wide swamplands. It was unspeakably beautiful. The ground was the softest of sand; progress was slow. Occasionally the lorry would lurch to a halt; usually because the driver had spotted some elephants. They would look at us for a while before lumbering away. When we came across some gazelles, Chiko gave an order and one of the guys took off through the bush and bagged one (using ten rounds on automatic!) This meant meat for supper… and explained why being detailed to look after us was such a great job. It was the only time they were allowed to hunt for meat. That night we feasted on the most delicious venison with fries and tomato ketchup.

The following day we were moving reasonably fast on some firmer sand. The lorry stopped. To a man, our guards were rigid; whites of eyes showing. “What’s the problem?” I asked. “Cobra!” one replied, pointing. There, about twenty metres right in front of us was a huge black snake coiled with head raised looking straight at us. We waited. I still couldn’t see what the problem was; we were in this massive lorry. When I asked why we didn’t just drive right by, I was told that a cobra’s spit could pass through the windscreen and the steel sides of the lorry. We would surely die. The only option, apparently and according to Chiko, was to kill the snake.

Very reluctantly, one of the young soldiers climbed down, knelt, took aim and emptied a whole magazine at the snake. When the dust settled, there it was; unharmed, coiled and still giving us the eye. “Give him some more ammo!” ordered Chiko. Embarrassed looks all round. Ah…. No more ammo! The decision was made, we had to run the snake over. The lorry reversed up. Moving forward with engine revved to the max – we must have been in third gear – we ran right over the snake. I looked over the edge of the lorry and saw that he had slithered out between the wheels and into a stand of small trees. The lorry stopped. Everyone was very tense. They were looking to see if they had squashed the snake. “Oh, don’t worry!” I said, “I saw it go into those trees over there.” So, inexplicably, they turned the lorry around and chased Hissing Sid through the forest snapping saplings off at the roots as we went. Eventually the snake got the better of us and Chiko decided that we should continue on to the hospital.

An hour later, we ground to a halt again. The driver pointed among some trees.

Advice: If you are ever in a country plagued by landmines, do not get out of your vehicle to grub about amongst a whole lot of elephant bones. Yes, that’s me holding the beast’s femur! I was young and foolish then. 

The extraordinary journey up to the hospital was simply a prelude to an extraordinary three months. I had been twice to the Afghan border of Pakistan and once to the Thai-Cambodian border. I thought that, by then, I had seen it all; then came South East. There was nothing glamorous. The wounded, those poor guys, arrived 40 or 50 at a time on the back of a lorry every few days. No first aid. Covered in dust. Heavy wound infection. The surgery was largely hopeless despite the best efforts of a great team. 

On coming out, I wept and wept. Maybe fatigue. Maybe malaria (that we all suffered.) Weeks later, working back in the UK’s National Health Service, I realised the cause of my overwhelming sadness. This was just one war on a whole continent; all over Africa many thousands of wounded people, soldiers and civilians alike, had no chance of ever receiving adequate surgical care. I had seen what that looked like. Organisations like ICRC and MSF, if they could get access, barely made a dent in the needs. Those prosecuting the war – right up to Washington and Moscow – didn’t give a damn. 

It’s some years since I was in the field. I’m pretty sure that, out there “in the developing world,” not a lot has changed. I sincerely hope someone will prove me wrong.

Geneva, Friday 24 April 2020

A culinary advance! Donald the sourdough starter enjoyed his third day of half-discard. We spotted an overripe banana in the fruit bowl. It was just crying out to be mashed in with the sourdough discard and My O My!…. Golly Gee!…. Call the police!!

Fry it up. Turn it out onto a plate; add a little lemon juice and some strawberry jam. Prepare for transport to heaven! Just incredible what we’ve learn’t during the lockdown.

To more serious matters. We only had one lecture at medical school on legal medicine. One phrase has always stayed in my mind…. “Never, ever, give casual medical advice.” What the wise teacher was telling us was that whatever the context of a consultation it is, in legal terms, a consultation nevertheless and therefore carries ethical implications and legal responsibilities. In other words, don’t give medical advice to a friend over the dinner table because, if this advice proves to be wrong, you could be deemed professionally negligent. We were given some knee-tremblingly awful examples of just how badly things can go wrong.

I wonder…. If a President of a country – surrounded by medical advisers – gives a whole nation unsolicited medical advice on TV about treatment of a certain condition and that advice is both wrong and dangerous, what responsibility does he have for any deaths that might arise from people following his advice? It would be strange if DT had absolutely no responsibility for the death of an American who slugs a few pints of bleach as a sure cure for COVID-19. As far as I can see, in relation to treatment for COVID-19, most of the world’s leaders leave their health professionals to dispense advice to the public; and most such advice out there on the net pertains to what not to take. 

Casual medical advice is at once worrisome and fascinating. Here’s a conversation I have had many times to avoid the casual consultation. “Robin, can I ask you a medical question… ” I take a breath in and wonder whether to admit that I have forgotten most of the medicine I ever learnt. “Before you ask, you should know that I only ever give one piece of medical advice: that is, to go and see a doctor!” A moment of head scratching on the part of my non-patient. “OK, but my problem is (….description of problem.)” I give the standard reply: “Well, if you’re worried, you really should go and see your doctor.” The response is usually “Oh, do you think so? Thank you so much, Robin.” It seems that people are quite happy when a clueless doctor tells them they should see their doctor!

“Is there a doctor on the flight?” Aargh! The rule is to establish whether the person really wants to see a doctor or really needs first aid. Like that, you are either a doctor going through with a consultation (remember to keep notes) or you are a member of the general public helping with first aid. The call for a doctor is often made by the cabin crew and not the person concerned; this is an exercise of passing on responsibility. Credentials are never checked. I know of one doctor who, realising that his services were requested by the pilot and not the passenger, put in an invoice to the airline for his professional services.

So here’s one that I put to you, the reader. Some years ago, I gave unsolicited medical advice. I was in the changing room of a squash club. I had just showered and another man, unknown to me, walked past me – also having just showered – with a towel wrapped around his waist. I noticed on the small of his back a large black irregular mole that I thought could well have been a malignant melanoma. As it was on his back, it was quite possible he didn’t know it was there. Dilemma! Did I have an obligation to give my opinion or should I say nothing as he had not consulted me? By the time we were both dressed, I had made a decision. The exchange went something like this: “Excuse me, Sir! We don’t know each other. I’m a doctor. I couldn’t help noticing that you have a mole on your back and I think you should see your doctor about it.” The man locked eyes with me. “Well, thanks for ruining my evening!” he said and walked out. Did I do the right thing?

The putting: My wife had a particularly stressful day at work. I won by quite some margin. That’s me up, 18-9.  

Here’s today’s painting. (If you can’t paint trees, don’t paint trees!)

Geneva, Thursday 23 April 2020

The clapping for carers here in Geneva each evening at 21:00 is getting shorter and less energetic. I have the impression that people feel the end is in sight. We may even get on a Swiss golf course on 1st May.

European governments, taking hope from China and South Korea, are beginning to lift some of the imposed lockdown measures. At the same time, there are strong messages from the German government, the UK government and the WHO that the story is far from over and that some measures will need to be maintained until the end of this year. Some experts are predicting that the required public health / economic balancing might entail a series of stop-start measures. Whatever, focus will be on protecting those most vulnerable and emerging mortality statistics would indicate that care homes constitute the bull’s eye of COVID-19.  

Boris, my wife’s sourdough starter delivered the goods today. Delicious golden crust. Very professional. Donald waits in the wings, though; quietly fermenting and fomenting.

Thinking that golf may not be too far away, here’s a little painting I did a few years back. It’s called “iDrive.”

Thinking of our cancelled hiking fishing holiday in NZ, I bought a small light-weight spade for camping; it’s called an “iPood”!!