by Henry Marsh
This was Ukraine, in 1995. I was 2,000 miles from home, operating without any official permission – probably illegally – doing a dangerous operation on a woman’s brain never done in the country before, using second-hand equipment that I had driven out myself from London a few days earlier. My colleague was an obscure junior doctor who had been declared in an interview on the BBC World Service, by the senior professor of neurosurgery in the hospital where I was operating, to be suffering from schizophrenia. Nor was I being paid to do this – indeed, it was costing me a lot of my own money.
I muttered unhappily to myself as I tried to stop my hands shaking: ‘Why on earth am I doing this? Is it really necessary?’
I had first gone to Kiev three years earlier in the winter of 1992, almost by accident. I had been a consultant for five years by then and already had a large and busy practice. It was a few months after the collapse of the Soviet Union. An English businessman, hoping to sell medical equipment in Ukraine, rang my hospital to find out if any neurosurgeons were interested in joining him on a trip to Kiev. There was a famous neurosurgical hospital in Kiev and he wanted to take some British neurosurgeons with him to deliver lectures about modern brain surgery and the equipment needed for it. The switchboard operator was rather puzzled by the enquiry and so put the call through to Gail, my secretary, who has the well-earned reputation of being able to solve most problems. I was in my office and she put her head round the door.
‘Do you want to go to Ukraine next Thursday?’
‘Certainly not. I’m far too busy and I’ve got a clinic then.’
‘Oh go on. You’re always saying how interested you are in Russia and you’ve never been there yet.’
Gail is usually the first person to complain if I cancel an outpatient clinic as she will then have to field all the phone calls from the disappointed and sometimes angry patients and rearrange the appointments, so I had to take her advice seriously.
And so, with two colleagues, I travelled to the newly independent Ukraine. There had never really been a separate Ukrainian state before the Soviet Union fell apart, and it was not at all clear what independence would mean. What was clear was that the country was in utter chaos, with the economy close to collapse. The factories were all closed and everybody seemed to be out of work. The conditions in the hospitals I visited were out of a nightmare.
We had arrived in Kiev early in the morning on the overnight train from Moscow. The line crosses one of the long bridges over the great river Dnieper which flows through Kiev, and as we approached the steep western riverbank we could see the golden domes of the Lavra monastery above us catching the light of the rising sun – a dramatic contrast to the dark railway stations we had passed through during the night and the grim apartment blocks on the outskirts of the city. I had lain in my bunk, under a thin blanket, drifting in and out of sleep, listening to the old-fashioned, rhythmic sound of a train running over bolted rails, travelling southwards across Russia, stopping at dimly-lit stations where I could hear incomprehensible announcements echoing over the empty, snow-covered platforms.
It all felt wonderfully strange and yet also strangely familiar – I suppose from the Russian literature in which I had steeped myself in the past. We had only been in Moscow for a few hours. Long enough to stand in Red Square in the dark, in the falling snow, where despite the fall of communism, a huge red flag was still flying, a little listlessly, from the Spassky Tower of the Kremlin. Long enough to have a splendid meal in a hotel that one had to enter through three lines of armed security guards, to find long, shabby corridors with worn, thin carpets and a bewildering number of disconcertingly beautiful girls looking for business. Long enough to understand that with the collapse of the rouble the few hundred dollars we carried in our pockets made us virtual millionaires compared to the impoverished Russians we met.
Once in Kiev we were taken to the Neurosurgical Research Institute, a huge and ugly building with the endless corridors that are the curse of all large hospitals. The corridors were dark and poorly lit. On the walls one could see serious displays of the triumphs of Soviet neurosurgery, with grainy black and white photographs of heroic men in the tall white chef’s hats that Soviet surgeons used to wear, interspersed with hammers and sickles, red stars, inspirational slogans and photographs of scenes from the Great Patriotic War, as the Russians call the Second World War. But everything, from the building itself to the pictures on the walls, and the stale air which smelt of cheap tobacco and some odd, sickly-smelling disinfectant, felt tired and faded. We were ushered into the office of Academician Romadanov, an old, imposing and very eminent man and the director of the Institute. He was tall, with a large head and a mane of white hair, and he wore a high-collared white coat, buttoned round his throat. He looked, however, as tired and faded as the corridors, and was in fact to die a few months later. After the usual introductions – all conducted through an interpreter – we sat down round the long table in his office.
‘Why have you come here?’ he asked angrily. ‘As tourists? To amuse yourselves by seeing all our problems? This is a very difficult time for us.’
We tried to answer diplomatically and talked of friendship and professional collaboration and international cooperation. He looked unconvinced and he was, of course, entirely right.
We were then shown round the famous institute by one of his assistants.
‘This is the largest neurosurgical hospital in the world,’ we were told.
‘There are eight departments and five floors and four hundred beds.’
I was amazed – my own hospital, one of the largest neurosurgical units in Britain, had only fifty beds. We traipsed up and down the stairs and along corridors and visited each identical department in turn.
We started on the ground floor.
‘This is the Department of Posterior Fossa Tumours,’ we were told.
As we came through the doors the staff came out to meet us, to shake hands and to be photographed with us. I was told all about the wide range of operations that went on in the department, although any detailed questions on my part were usually met with rather vague answers. We went through exactly the same ritual in the seven other departments. When I asked if we could see the operating theatres I was told that they were being redecorated and were closed. We saw scarcely a single patient.
We delivered our lectures. The few questions afterwards showed a complete and utter lack of understanding of what we had been trying to explain. We returned to our hotel. As with the hotel in Moscow, there were beautiful young women to be seen everywhere. I was told that they were not professional prostitutes but respectable women desperately trying to make some money. One session with a western businessman was, at that time, worth more than a whole month’s income. Embarrassed and fascinated, we made our way shyly past them and retreated to one of our rooms to drink duty-free whisky, confused and shocked by the surreal discrepancy between what we had seen and what we had been told as we toured the hospital.
The next day I was taken to the Emergency Hospital on the eastern side of the city. I had asked to see how trauma was managed and my guides – a little reluctantly – had agreed to take me. We arrived in the late afternoon. The light was starting to fade. The hospital was ten storeys high, apparently with eight hundred beds. It was only ten years old but already looked derelict. We approached it through a wasteland of broken buildings and those gigantic, incomprehensible pipes that always seem to surround Soviet buildings, on which pure white snow was starting to fall from a leaden sky. At one side there was a large and ramshackle open-air market, with battered zinc-covered huts displaying rather sad little collections of cheap cosmetics and vodka. Decrepit Lada and Moskvitch and Volga cars were parked in utter disorder. Everything was grey, colourless and drab in the way that only Soviet cities could be. Collecting the illegal rent paid by the market traders was, I subsequently heard, an important part of the hospital director’s job and a u
seful source of income for the officials of the city’s health administration.
The electricity supply had failed and much of the hospital was in pitch darkness. The whole place stank of ammonia – the hospital had run out of disinfectants and only ammonia was available for cleaning. The building seemed almost uninhabited. I was taken to one of the dark operating theatres – a huge cavernous place with a large window looking out onto what appeared to be a bombsite. Flurries of snow could be seen there, caught in the dim light from the window of the theatre. An operation was going on. A surgeon was ‘operating’ on a paralysed man, paralysed from the neck down in an accident some years previously, I was told. There was a small tray of battered instruments beside him that looked as though they came from a scrapyard. The patient was lying on his side and was partially covered with old curtains with a faded floral pattern. The surgeon had inserted several large needles into his spine and was injecting cold saline through them into the spinal canal. This was, apparently, supposed to stimulate the spinal cord to recover. The reflex movements in the paralysed man’s legs that the injections produced were greeted with cries of excitement and seen as evidence that the treatment was working.
While I was walking along one particularly dark and dismal corridor, a young man came hurrying up to me like an enthusiastic spaniel. It was the surgeon I had seen ‘operating’ on the paralysed man.
‘This is neurosurgical department,’ he announced in broken English. ‘There are three departments of emergency neurosurgery. I am Igor Kurilets, director of spinal emergency department.’ I expected the long and tedious description to continue. I was quickly becoming familiar with the litany of departments and beds and achievements with which one was greeted when one visited a Ukrainian hospital and expected to be reassured that Ukrainian emergency spinal neurosurgery was the equal of the world, if not better.
‘Everything terrible here!’ he said.
I liked Igor immediately. Apart from Academician Romadanov, he was the only doctor I met on my first visit who seemed able to admit openly that the medical situation in Ukraine – at least in neurosurgery – was dire. The Soviet Union had excelled at producing guns and rockets but failed miserably at producing decent health care. Although there were impressive-sounding research institutes and thousands of professors, the reality was of poorly trained doctors and poorly equipped hospitals that were often little better than what one might find in the Third World. The Soviet Union, it used to be said, ‘is Upper Volta with rockets’ – Upper Volta, as it was then called, being the poorest country in Africa. Most of the doctors I met, driven by a mixture of shame, patriotism, envy and embarrassment, felt compelled to deny this, and did not welcome people like Igor who dared to point out the emperor’s lack of clothes. Soviet culture had never encouraged criticism and had gone to great lengths to isolate its citizens from the rest of the world. Despite the fall of the Soviet Union, newly independent Ukraine still had the same leaders as in the past, but the country and its people were suddenly exposed to the outside world and the huge gulf that had developed between western and Eastern European medicine.
Before I left Kiev after this first visit I attended a meeting at the Ministry of Health. An expressionless, florid-faced bureaucrat, the umpteenth secretary of some umpteenth department of this or that, walked round the long table handing out his business card, where his umpteen titles were all duly listed. The more important bureaucrats, I had noticed, would have so many titles and appointments that more than one card was needed to list them all. This man was only a one-card bureaucrat so clearly not too important.
I soon lost interest in what was being said. Besides, it all had to be slowly translated, which made it doubly tedious. The room, panelled in cheap plywood like most Soviet government offices, had tall windows that looked out onto an attractive park. Snow was starting to fall again. A police van was disgorging heavily armed riot police in grey uniforms with German shepherd dogs. Both dogs and men seemed to be jumping out of the back of the vehicle with great enthusiasm. We had seen a demonstration by the Ukrainian Nationalist Party going on outside the nearby Parliament building on our way to the Health Ministry so perhaps the policemen and their dogs were looking forward to a good fight. The English businessman who had brought me to Ukraine was sitting next to me and leant over to whisper that the riot police were the pimps for the girls we had seen in the hotel.
There was an inconsequential and meaningless conversation about furthering international medical cooperation. At the end I commented that I would be happy to arrange for a Ukrainian neurosurgeon to come to London to work with me but added that it could only be one man, Dr Kurilets, the director of the obscure and unimportant spinal trauma department in the Emergency Hospital. This was a post he had been given, he later told me, as a form of demotion, Soviet medicine having little interest in the lame or paralysed. I knew well enough that it was highly unlikely that Igor, low down the ladder as he was, would be allowed out of the country but it seemed worth a try and I was damned if I was going to invite one of the elderly, dissembling professors. The bureaucrat looked nonplussed and I returned to London via Moscow that afternoon.
A year later, I had almost forgotten the high hopes which I had had when leaving Kiev, when, quite unexpectedly, a Christmas card from Igor arrived, enclosing a letter from Academician Romadanov asking me to bring Igor to London and show him modern neurosurgery.
What had begun on my part as casual tourism became more serious when Igor started to encounter opposition from the Ukrainian medical establishment. After three months working with me in London he had returned to find that his patron Academician Romadanov had died. Rather than find a new source of patronage and support (an essential requirement in Ukrainian society and known as ‘a roof over your head’) Igor proceeded to declare in public that Ukrainian neurosurgery was primitive and backward and that a revolution was required. Matters were not helped by the fact that a somewhat Byzantine struggle for succession to Academician Romadanov’s post was going on. The position came with important perks such as a large apartment and a chauffeur-driven car. Igor’s own boss had been hoping to get the job and his chances were not helped by Igor’s insubordination.
The next few years were very difficult indeed for Igor as he struggled to reorganize and modernize his department along western lines. There was a long series of official denunciations, investigations and threatening phone calls. For a time he slept in a different room each night. How he coped with all this I cannot even begin to imagine.
I realized that my rather naive wish to help him had caused as many problems as it had solved and yet I could not very well abandon Igor. So each time that his ‘detractors’, as he put it, tried to ‘bump’ him – to close his department or sack his staff – I would do what I could to help, although admittedly this was usually from a long, safe distance. And when I did go out to Kiev I knew that I could always escape back home again, however unpleasant some of my encounters with senior bureaucrats might be. With Igor’s help I wrote articles in Ukrainian newspapers and staged press conferences. I drove second-hand medical equipment out to Kiev and brought his own junior doctors over to London to work with me. I carried out brain operations that had not previously been performed in Ukraine. In retrospect, given the poor operating conditions and the implacable hostility of the medical establishment, what I did in those years seems to me now to have been verging on lunacy. It certainly required a self-confidence and independence that I was subsequently to lose.
Despite the inauspicious start and my ignominious panic the operation on the woman with trigeminal neuralgia was a great success and she appeared on the national TV news next day to say that she was pain-free for the first time in many years. I flew back to Poland to collect my car, which I had left with a friend. I had driven the microscope which I had used for the operation to his home in western Poland and Igor had then come from Ukraine in an old van to collect me and the equipment.
On our way to the airport we made a detour to the Bessarabian Market in central Kiev. The Bessarabian Market is Kiev’s equivalent of Les Halles or Covent Garden – a large circular nineteenth-century building with a ribbed cast-iron glass roof. Below is a market, with fierce but friendly women in brightly coloured headscarves, standing behind pyramids of beautifully displayed fruit and vegetables and pickles. There is a flower section – the Ukrainians give flowers to each other on any social occasion – and a meat section, with whole hog’s heads and mounds of fresh meat, and the rear-quarters of pigs, hanging up from hooks like pairs of trousers. There is a directness and rawness, a rough beauty to the place that is typical of Ukraine but which is starting to disappear now that supermarkets have arrived. Igor was later to tell me that the Bessarabian Market was only still functioning because it had become something of a tourist attraction. He suddenly became quite excited and pointed to one of the fish stalls.
‘Very rare!’ he said, pointing at three long smoked eels in a glass cabinet. He bought one of them and gave it to me as a present. It smelt rather awful.
‘Very unusual!’ he said proudly. ‘They are in Red Book!’
‘What’s the Red Book?’ I asked.
‘Book of animals soon dead. None left. You are lucky to have one,’ he said happily.
‘But Igor, this could be the last Ukrainian eel!’ I said, looking at the long and once-beautiful creature, who had been swimming, glittering, in some remote Ukrainian river and was now smoked and dead and wrapped in a grubby Giorgio Armani plastic bag. I took it from Igor and dutifully packed it in my suitcase.
On my return to London a few days later I threw the smoked eel into my back garden, since I could not face eating it and I thought an itinerant fox, who I often see walking quietly past early in the morning, might like it. The eel had disappeared the next day but I was rather saddened to find it later a few yards away under a bush – it had been rejected even by the fox. So I dug a hole and buried it, the last Ukrainian eel, in an overgrown flowerbed at the end of the garden.
