Dr. Henry Marsh, 'The English Surgeon'
NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington.
More than 15 years ago, British neurosurgeon Henry Marsh went to Ukraine as a visiting lecturer and found that treatment we take for granted in the West was simply not available.
(Soundbite of documentary, "The English Surgeon")
Dr. HENRY MARSH (Neurosurgeon, Atkinson Morley's Hospital): I was seeing medical problems, the like of which have not really been seen in the West for, at that time, maybe for 50 or 60 years. It was like going back in a time machine.
And I remember talking to a Ukrainian doctor, and I said I'd like to help. He said, it's a waste of time. He said, anything you do is a drop in the ocean. The whole system will never change - basically, go away; you can't help.
CONAN: That's Dr. Marsh in an excerpt from a documentary called "The English Surgeon" that begins airing tonight on public television as part of the POV series.
He goes on to explain, in the film, that he saw so much suffering that he felt he really did want to help. By chance, the next day, he met a Ukrainian doctor who made that possible. The documentary describes their subsequent collaboration.
And Dr. Marsh joins us now from the studios of the BBC at Millbank in London.
And it's good to have you on TALK OF THE NATION today.
Dr. MARSH: Thank you very much.
CONAN: And in the film, we see a scene of you, modern day, going back to that clinic in Ukraine. And there's a corridor crowded with patients, and you wonder aloud at what kind of a dent you can make in all of the cases that you see.
Dr. MARSH: Well, the problem is that most people in Ukraine know that medical treatment in the West is better. So if you're working on a very specialized, difficult area like neurosurgery, many patients will be told they have an inoperable tumor or a very dangerous tumor. I specialize in brain tumor surgery. And, of course, they hope a great white wizard like myself in the West maybe can do things better.
And in practice - I mean, many things have changed in Ukraine since I first went there 16, 17 years ago. I suppose, of the patients I see when I go there, about 30 percent are genuinely inoperable and we could do no better in the West. And maybe another 30 percent of the ones I see, maybe - working in the clinic my colleague has set up as my help over the years - maybe we could do better than the local neurosurgeons. And another third probably didn't need surgery at all. And a very important part of my work over the years has been seeing patients with brain scans and saying, well, actually, you don't need treatment. And they've been told they do need treatment.
CONAN: Your colleague is Dr. Igor Kurilets.
Dr. MARSH: That's right. Yes.
CONAN: I hope I'm not mispronouncing that.
Dr. MARSH: No, it's Kurilets. Yes.
CONAN: And he - you don't think of brain surgery as politically dangerous, but yet he's had some troubles over the years.
Dr. MARSH: He's had enormous problems because Ukraine, as of any of the Soviet - former Soviet countries, individual initiative is not really encouraged. You can't - individualism, to be successful through your own efforts, is against the prevailing culture. You have to really be part of a group, part of one of the competing pyramids of power in the society.
And Igor stood up and criticized Ukrainian neurosurgery. He came to work with me in the West many years ago, and saw things are much better in the West than they were in Ukraine. But when he went back, he was openly critical and Ukraine is still a society where open criticism is not appreciated by those in power. And in his case, those in power really were the senior professors of neurosurgery. And they're still very much opposed to him.
CONAN: Yet his clinic that he's working in now, where this film was shot, is - as I understand it - in spaces provided by the KGB.
Dr. MARSH: Well, it was the KGB. It sounds rather strange. The KGB is now called the SBU. The head of their medical service was, in fact, a very nice man, a man I knew quite well. He's now retired. And he could see that Igor was somebody of exceptional abilities. The deal was that Igor could rent space from their hospital, where he could run what is basically a not-for-profit clinic.
It's rather ironical, strange situation, but rather typical of the rather wacky and extraordinary things you encounter when you work in a country like Ukraine.
CONAN: And another problem you encounter there is that because the cost of a brain scan is so substantial - far less than it is here, $50, $100 maybe - but nevertheless, that's a lot of money for most people there.
Dr. MARSH: Yes.
CONAN: And so they put off getting these scans.
Dr. MARSH: Yes. This is problem in all poor countries. The diagnosis tends to be delayed. So you have really - as a doctor, both for the Ukrainian doctors and for myself when I go there - you have a double whammy. The patients you see have much worse problems than we're familiar with in the West. In the case of brain tumors, the tumors are that much bigger. And secondly, you have less satisfactory equipment with which to treat them. So it makes things very difficult.
CONAN: There's a little girl, we see you looking at her brain scan and testing to see if she's blind. And she is blind and you say, no, I'm sorry. Once she's blind, there's nothing you can do.
Dr. MARSH: Yes. She had a tumor pressing on the optic nerves, but diagnosis was delayed, and she went completely blind as a result. And I've seen that quite often. That's - that was one of many similar cases I've seen.
CONAN: Totally preventable had it been…
Dr. MARSH: In - if - earlier diagnosis, yes, totally preventable.
CONAN: The other thing you talk about is the equipment, and we see you schlepping a large box of used equipment from London to Kiev, including something that looks like a drill bit that you say is used once?
Dr. MARSH: Yes, that's right. And the waste in England is 100 time - I'm a professor of neurosurgery in Seattle so I'm familiar, to some extent, with the American health-care system. And believe you me, the American health-care system is even more wasteful than the health-care system in England.
CONAN: Well, I don't doubt it for a second. But this is…
Dr. MARSH: It's appalling what gets thrown away.
CONAN: Is this a throwaway thing? It's used once and thrown away.
Dr. MARSH: Yeah, that's right. And it's made of metal.
Dr. MARSH: And they're just put together with a plastic clip, so you can't sterilize it, so it will melt if you autoclave it.
CONAN: And - but Dr. Kurilets tells you he's had one of these - he's used it for 10 years.
Dr. MARSH: Yes, that's right. Yeah.
(Soundbite of laughter)
CONAN: Oh, that's ridiculous.
Dr. MARSH: It is ridiculous. It's a bit of a reminder to us in the West how wasteful we are, and that we are dooming the planet with our wastefulness.
CONAN: And at the same time, you are an accomplished neurosurgeon - we see in the course of this film, for those of us who are unfamiliar with this, a rather disturbing brain operation as you scrape away a man's tumor - but it's also that you have to be, not just a skilled surgeon. You have to be a plumber and a mechanic.
Dr. MARSH: Well, that's Igor's side of it, working in Ukraine. He's a bit of a one-man hospital, yes. I mean, he's had to develop and look after all his equipment. And one of the first problems with surgical equipment is not just getting it, it's in maintaining it and making sure it doesn't get broken and it runs effectively. In the West, we have large numbers of hospital staff to do that and technicians. Igor - as of other doctors in Ukraine - you have to do the work yourself.
CONAN: There is also the sense - and getting back to that crowded corridor, and there's a case that does haunt you after all of these years and we see you examining yourself about it. I think the dark night of the soul is not too strong a term, and that's the case of a girl named Tanya.
Dr. MARSH: The - I think goal of neurosurgery - sounds a rather throwaway line - neurosurgery, technically, is not as difficult as people commonly suppose. But what characterizes brain surgery is it's very dangerous, very minor problems with catastrophic consequences. So all neurosurgeons are haunted - or they should be haunted, if they're decent human beings - by cases they've dealt with over years.
Well, the problem with Tanya is a slightly strange one, to the extent that part of me feels, in retrospect, I shouldn't have tried to treat her in the first place. I should have - when I saw her, she had one of the largest brain tumors I'd ever seen, which had been diagnosed earlier but deemed untreatable, both in Moscow and in Kiev.
And I was overambitious, in retrospect, thinking I could remove it. On the other hand, you know, I tried. And I suppose one says that there's a certain nobility to trying and failing. And I still find myself very uncertain as to whether I was right to try what perhaps was impossible without knowing for certain, or whether I was wrong and I should have walked to the other side of the street and said, no, I can't help. I should take on some simpler cases. It's very difficult.
If you go out to poorer countries - and I work a bit in Sudan now as well as in Ukraine - you will often see cases like this, and you have to make slightly ruthless decisions sometimes. And if one's sentimental, perhaps one doesn't achieve; one does more harm than good. I don't know. It's not clear. Tanya's mother, who you see at the end of the film…
Dr. MARSH: …was very happy I tried and more than grateful. But I don't know the answer. It's very difficult.
CONAN: You also talk about the character of a neurosurgeon and, I guess, the American term we would use might be cowboy.
Dr. MARSH: Well, neurosurgery is any one branch of medicine, but it's a rather extreme one because it's so dangerous. All medicine, to a greater or lesser extent, all doctors are torn between two opposing needs. One is the need for compassion and kindness and obviously, we should all treat patients as we wish to be treated ourselves. But at the other extreme, you have to be detached. It's terribly difficult to treat people who - whom you're close to.
I once operated on a very close friend of mine with a malignant brain tumor. She was my daughter's godmother. I wasn't very keen to operate because I knew it was going to be emotionally difficult. But the family were very anxious that I should do it, and it was technically an easy operation. And even that, I found almost impossible because I was so anxious and so nervous, and all my - the barriers of professional detachments had been demolished.
So in a sense, one's constantly struggling to find a balance between these two opposite extremes. One of sort of brutalization and callous detachment, and the other of compassionate involvement. And it depends on your personality as to whether you - how you find that balance. Some people fail; power corrupts. Many surgeons become arrogant and detached and a lesser people as a result.
CONAN: There is a scene where you say that, while you explain the risks to all of your patients - and in the operation we see, the risk could be paralysis of one side of the man's body, you can lose your memory and some operations, you can lose your personality. Even though you explain those risks, they say - you say - they all look at you and say, well, that won't be me.
Dr. MARSH: Exactly. And I mean, I often - because I'm - dare I say, as a very senior and relatively eminent surgeon in this country, if I explain a particularly dangerous and difficult operation to a patient, and the patients are saying, Mr. Marsh, I have 100 percent confidence in you. And indeed, they have 100 percent confidence in me, but they, you know, since being fallible human beings, as we all are, because they have 100 percent confidence in me, they therefore think the operation is going to be 100 percent safe, even though I've just said it's not, you know, and there are significant risks.
And all surgery is a question of balancing the risk of the operation against the risk of not operating. And sometimes, the balance is totally obvious, that surgery is safer than no surgery.
But as you move up the professional ladder, you take on more and more equivocal cases, where the balance of risk is less certain. And then it's very difficult. And I suspect in as patients, we tend to be influenced by, you know, whether the patient - whether the surgeon has a nice smile, or whether he's plausible, things like that.
(Soundbite of laughter)
Dr. MARSH: Because what does it mean to say there is a 1 percent or 5 percent risk of your being left blind or paralyzed; or is it 10 percent or 11 percent? It's a very - the more you think about it, the harder it is. You really rely on the surgeon to advise you. However much one wants to think one makes an independent decision, in practice, we're going to be influenced by lots of emotional, social cues rather than raw statistics.
CONAN: Neurosurgeon Dr. Henry Marsh is featured in the film "The English Surgeon" by filmmaker Geoffrey Smith. It premieres tonight on many PBS stations as part of the POV series.
You're listening to TALK OF THE NATION from NPR News.
And we have this e-mail from Paula in Cleveland Heights: The documentary was shown at the Cleveland International Film Festival within the last year or two. I was moved by Dr. Marsh's efforts and very struck by the limitations and resources he confronted. What has happened to his Ukrainian colleague's practice since the documentary was made?
Dr. MARSH: The - the answer to that is Igor is still busy. The economic recession has hit Ukraine very hard. Because he runs a - it's a commercial clinic, although it's not for profit, so it's actually - is pretty cheap. And state health care, in theory, is free in Ukraine but in practice, it isn't. Everybody has to pay under the table - is the phrase. You have to pay - well you can't call it a bribe, but you…
Dr. MARSH: …you have to pay some extra tax to the doctors. So his workload has diminished a bit because people have less money. But more problematic, because being that a criminal investigation has been started against him - or was started; it has now been temporarily rescinded over an operation he - well, one of his juniors did under his supervision 17 years ago. I mean, it's completely ludicrous and absurd but is all part of this continuous and grinding campaign against him by his professional rivals.
In countries like Ukraine, the idea of civilized competition is an unfamiliar one. If somebody is more successful than you in the West, on the whole, you would expect that either people give up or they try to out-compete their rival. But in countries like Ukraine, the immediate reaction is to try to destroy your rival. And that's still deeply ingrained in the culture of the country. So, a very successful individualist, like Igor Kurilets, has enormous problems as a result.
CONAN: I just have time for one last question. I guess it's a personal one. I had somehow always imagined that once you opened up the skull and looked in, it would be pretty easy to tell the difference between regular brain matter and a tumor. I suppose I thought it was green or yellow or something.
Dr. MARSH: No. It depends on the tumor. But the particular sort of tumor you see in the film, and the particular sort of tumor I specialize in operating in Britain, the tumor looks like the brain. It doesn't quite feel like the brain when you're working on it with your neurosurgical sucker but visually, it's more or less the same. And this is why they're so difficult, because the more you remove, the more the risk is you'll stray into the brain and cause damage.
And that is why with operations of this sort, increasingly - and in Britain, for what it's worth, I pioneered technique - you operate with the patient awake under local anesthetic, so you can see if you're starting to produce any significant brain damage as you operate.
CONAN: And you say something fascinating as you're doing that. You're looking at it and saying, it's impossible to believe, really, but that is thought.
Dr. MARSH: Yes.
CONAN: That is consciousness I'm looking at.
Dr. MARSH: It is extraordinary. And I still, in fact, the more I think about it as I get older, the more extraordinary and incomprehensible I find it, that thought - that mind is a physical entity. It's a hugely revolutionary idea which none of us have really quite come to terms with, I think, yet.
CONAN: And it makes the person whose operating on that substance - it must give you pause.
Dr. MARSH: Well, it does and it doesn't. I mean, it's a job. I've done thousands of operations. It's extraordinary what one can get used to. So, one has to struggle to continue to remember the reality of it. And all neurosurgeons should be in awe of the brain and really, in awe of their patients.
CONAN: Dr. Marsh, thank you very much for your time today.
Dr. MARSH: It's been a pleasure. Thank you.
CONAN: Dr. Henry Marsh is a senior consultant neurosurgeon in London. His story is told in the POV documentary, "The English Surgeon." It premieres tonight on many PBS stations.
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