Most doctors do not want to be surgeons – indeed, many view them with a slight distaste, as a necessary evil. Surgeons are attracted to surgery by blood, by the excitement of operating and by the power over patients that comes with it, as well as by the technical challenges of the handwork involved. It is a power to help and to heal, but as with so many psychological truths, it is two-sided – the power can be attractive in its own right. All surgeons have to find a balance between these competing poles of altruism and egotism.
The excitement comes from the fact that surgery is never without risk. The risk, of course, is of the patient coming to harm, and the excitement comes from the fact that you fear a bad result, not just for your patient’s sake but also for your own – for your reputation, and for the shame and guilt that most of us feel when we fail our patients. Very few surgeons, however, take this quest for excitement to the extreme of putting their own lives at risk when operating, rather than just their peace of mind.
David Nott is one such surgeon, and in his book, War Surgeon: Surgery on the Front Line, the list of countries where he has worked as a trauma surgeon is a comprehensive roster of the most deadly and dangerous places in which a doctor could have worked over the past 30 years: Bosnia, Afghanistan, the Congo, Rwanda, Iraq, Gaza and, most recently and most terribly, Syria.
Nott is clearly a man of the most remarkable courage and determination, who has taken the medical ethic of trying to help our fellow humans without regard to nationality or race or creed – or for his own safety – to an extreme. Yet, as he openly admits in this very honest book, there is an almost pathological element to this desire:
I have travelled the world in search of trouble. It is a kind of addiction… I monitor the television news avidly, keeping an eye out for developing hotspots… my heart begins to race… the desire to go is almost overwhelming.
He has come very close to being killed on several occasions. On the first such occasion, in Sarajevo, he writes that: “I felt elated, exhilarated, euphoric. I had never felt more alive; it was if I had been reborn.” And it is not just physical danger to which he exposes himself. In Chad, for instance, he tells us “my legs gave way and I slumped to the ground, holding on to the wheel of the trolley as I sobbed” when a young, pregnant rape victim dies before he can operate. On that mission he encounters other, equally terrible tragedies. When he returns to London, he is debriefed by two women from Médecin sans Frontières (MSF): “I bawled my eyes out for about four hours… [unburdening] myself of the stress, the horror
and the guilt.”
He rightly sees parallels between himself and war correspondents. He mentions My War Gone By, I Miss it So by Anthony Loyd, an author who confesses to being equally addicted to war zones. But the trauma doctor, unlike the war photographer or correspondent, tries to prevent death and relieve suffering, rather than observe and record it, and is perhaps less haunted by what he has witnessed. The current exhibition of Don McCullin’s work at Tate Britain – the way in which McCullin has been left scarred and with feelings of guilt about what he has seen and yet turned into perfect images – shows this very starkly. But Nott makes it clear that he has paid a price as well.
He has witnessed some terrible things: women, buried up to their necks, being stoned to death in Afghanistan under the Taliban, and injuries that he says are too terrible to put into words. He admits to periods of intense fear, especially on his most recent visits to Syria, when he was working in Aleppo with Isis nearby. There was a real possibility that he would have been captured and beheaded if it had not been for the protection of his Syrian colleagues. His fear, of course, makes his bravery all the greater.
The book describes the many aspects of trauma surgery – mainly from bullets, blast and shrapnel – in clear and sometimes distressing detail. In Iraq he joins the RAF as a squadron leader and finds the camaraderie of military life under fire deeply appealing, and in marked contrast to his aid-agency missions. On the latter there were often tensions among the thrill-seeking expatriate doctors, and also with local doctors who sometimes regard the aid doctors as little better than medical tourists who can always escape back to their safe and comfortable lives at home.
Nott’s determination to save lives can lead him into conflict with the aid agencies, which at times have different priorities to his. He tells two stories of how he saved children with terrible injuries that had been deemed beyond treatment, whom he brought back to England. MSF sacked him as a result of one of these episodes, but relented some years later and sent him to Nepal following the 2015 earthquake. At the end of the book Nott paraphrases the Quran: “He who saves one life, saves the world” – a saying also found, I believe, in the Talmud.
I have never worked in a war zone but I have worked extensively in impoverished countries such as Sudan and Nepal. The problems I encounter as a neurosurgeon can be very different from those a trauma surgeon sees. Sometimes I find I have to silence my heart when seeing young children with especially difficult brain tumours that cannot be treated in their own country but could be treated in the West. It is wonderful to save a life, but we live in a world of limited resources, which we must husband. It hurts.
It is clear that for many years Nott devoted himself to his work to the exclusion of everything else – other than flying. Somewhat extraordinarily, he has private and commercial pilot’s licences, as well as a licence for flying helicopters. He even worked for a while as a commercial pilot. You get the impression of somebody striving to overcome himself, utterly single-minded, with profound moral convictions and a deep need to be in control. And yet, at the same time, Nott is in the grip of forces beyond his control. For many years he lived on his own, unattached, able to abandon everything (thanks to sympathetic NHS colleagues and managers) and race off with his specially prepared suitcase of emergency medical kit to the latest conflict zone at very short notice. The crisis comes when, already in his fifties, he falls deeply in love. Torn now between his self-sacrificial, near-suicidal work, his deep reluctance not to abandon his Syrian colleagues and his love for his fiancée, he temporarily falls apart. All this he records in an honest, matter-of-fact way. But love prevails and he also becomes a father, which clearly calls for a major re-alignment of his priorities.
He goes on to make a contribution just as impressive as his operating. He throws himself into a publicity campaign to save his remaining colleagues and patients in Aleppo, as the Russians and Assad’s killers move in, even talking to a voice on the phone that he suspects is Bashar al-Assad himself. They are eventually evacuated, perhaps in large part due to his efforts.
Justly famous, he ended up next to the Queen at a dinner at Buckingham Palace. She politely asked him where he had come from and he blurted out “Aleppo”, from where he had just returned. His head instantly filled with images of dismemberment, dust and death. He was struck completely dumb. The Queen, understanding his plight, opened a silver box of dog biscuits (one assumes specially provided for such occasions) and they fed the royal dogs and discussed the care of corgis.
Not only this, he has also started a training programme for doctors from all over the world, so that his painfully acquired experience can be passed on to the next generation of trauma surgeons.
This is, at times, an overwhelming book – in places it reads like a litany of man’s cruelty to men, women and children. Nott is often drenched in blood and often terrified. It is not for the squeamish. As a surgeon myself, I can only look on what he has achieved with complete awe, overwhelmed by his heroism and compassion as much as by the world’s cruelty. It is a book that also gives us some insight into the psycho-pathology of sainthood, and yet just what the inner demons were that so drove him, he does not say. Perhaps he himself does not know. But the world is a much, much better place to have people such as David Nott in it.
Henry Marsh is a neurosurgeon and author of “Do No Harm” (Weidenfeld & Nicolson) David Nott appears at Cambridge Literary Festival on 6 April. For details visit cambridgeliteraryfestival.com
War Doctor: Surgery on the Front Line
Picador, 304pp, £18.99