Author: David Nott
This book is a thrilling and nerve-wracking account of the author’s perspective of humanitarian work – ‘helping those who can’t help themselves and taking a risk to do it’. The author was driven to assist the down-trodden in some of the most ferocious war zones around the world, from Sudan to Syria, and he narrates the challenges of ‘working in an austere environment’, and of performing life-saving surgery under ‘intense and almost overwhelming‘ circumstances. The book however also conveys the rewarding aspects of the work, from the altruistic satisfaction of ‘making a difference‘, to the gratifying thrill of ‘living my own life closer to the edge‘ in ‘situations most people can’t begin to imagine‘. The book is the embodiment of the courage required to face the hazards of conflict zones – both inside and outside the operating theatre, and the ingenuity needed to overcome the restricted resources that bedevil such work. Besides portraying the practical dimensions of war medicine, the author also explores the conflicting emotions that come along with it, from helpless despair of witnessing inhumane acts, to anger at ‘how people could do this to one another’. Beyond it’s core lessons on humanitarian medicine, the narrative is also a masterclass on imparting skills and attitudes, and on the appreciation of the scale of global health (pages 112, 1-5, 8, 26 and 70-77).
The largely autobiographical nature of the book provides a wealth of insights into the author’s world view and motivations – the factors that led him to study medicine and specialise in surgery, and to later embark on the perilous path of war medicine. Being raised by strong-willed parents, an orthopaedic surgeon and a nurse, perhaps explained the source of the determination and drive that enabled his medical and humanitarian work. Whilst he attributed his yearning to go to ‘far away lands‘ to the transfixing stories of adventure his father told him, he traced his empathy to the simplicity of his early years growing up in Wales surrounded by love. He however pointed out that it was watching the film, The Killing Fields, that ignited the spark of humanitarian work in him – a passion that ‘burned strong‘ and evokes ‘a powerful physiological reaction when confronted with scenes of humanitarian disasters’. His surgical training also conferred on him the ‘enormously empowering‘ qualities of acting decisively and justifying his judgment – the type of critical skills humanitarian work in high risk areas required (pages 27-41 and 47-53).
The horrific nature of the war injuries that confronted the author everywhere he worked formed a very important, even if distressing, theme of the book. The book described many appalling combat injuries resulting from gunshots and high-explosive fragmenting devices such as mortars, bombs, and shells – weapons which cause ‘terrible damage to soft human bodies’ and result in ‘missing body parts. One of the most gruesome of such injuries the author encountered, what he characterised as ‘beyond words‘, was a child whose ‘half of her head and brain were missing’, and ‘some of what was missing was now splattered across her brother’s face’. Other similarly ghastly examples were of the family of eight who were all wiped out but for the father whose explosive device had fallen out of his pocket and detonated; the old woman who had lost three limbs, ‘all blown off by shrapnel‘; and the youth who exsanguinated after his inferior vena cava was punctured by fragment. Other war emergencies the author explored were exposure, catastrophic bleeding, and ‘the trauma triad of death’ – hypothermia, coagulopathy, and acidosis (pages 13-14, 57, 288, 59-64, 21-23 and 90).
A compelling feature of the book is the diversity of war zones the author worked in, each of them representing a unique form of savage brutality. For example, he conveyed the sense of the callousness and senselessness of the combat that characterised the war in Sierra Leone where the rebels exercised power ‘without control or the fear of retribution’, and carried out ‘mass amputations as a terror tactic’. It was also where ‘gangs armed with machetes paraded around the streets hacking off the hands of government supporters’, and it was where the author ‘spent several weeks simply refashioning amputations of the upper limbs of children as young as three, as well as elderly men and women’. Similarly, the author’s depiction of the war in Chad conveyed the effect of the limited resources of war zones, such as when the author was unable to save a thirteen year old pregnant girl who died before he could operate on her. In other places, his experience was marked by the new skills he acquired; such was the case in the Democratic Republic of Congo where he performed a forequarter amputation surgery for the first time on a boy with gas gangrene; filled with trepidation and self-doubt, he nevertheless successfully removed the boys upper limb and shoulder with the remote guidance of a colleague. The author also achieved several humanitarian objectives outside the conflict zones, such as by developing a training programme for doctors practicing in war zones which was modelled on a teaching course he pioneered in Libya (pages 98-104, 119-123 and 168).
As momentous as the author’s work was in every war zone, it was his work in Syria which took a special place in his heart; this was because of the intensity and duration of the conflict, and because of the difference he made in terms of skills transfer and global advocacy. His first worked in Aleppo, a city where 95% of the physicians had left, and a place where government snipers ‘shoot civilians from their own side in cold blood simply to stop them getting food’. Aleppo was also where he witnessed ‘probably the most upsetting and shocking act of violence‘ – the deliberate targeted killing of a full term baby in its mother’s womb by a sniper. It was this incident that prompted the author to embark on media and political advocacy on behalf of the people of Syria whom he had come to feel ‘a strong affinity‘ for. It was also in Syria that he developed very strong personal and professional affiliations with the local healthcare workers who he portrayed as ‘perhaps the most remarkable group of individuals I had ever met’. Syria also afforded him the opportunities to perform and teach truly complex surgical operations such as the Whipple’s procedure for pancreatic injuries (pages 219, 233-243 and 319-346).
As expected, the emotional impact of the author’s experiences featured prominently throughout the book. In demonstrating how humanitarian work places a heavy burden on the mental health of volunteers, the author said ‘in a very high-stress environment some people do crack with the pressure‘ and become either ‘a lot quieter‘ or ‘more vocal‘. He illustrated this with such examples as the psychiatrist who appeared ‘drawn, haggard, devoid of humour, exhausted by stress’ after months of working in a war front. The author himself was not spared the psychological repercussions of his experiences, and he described how he became ‘a person marked by war‘, his idealism ‘challenged‘ by the intense pressure and the preventable deaths he saw. He also admitted that he become miserable and cynical when ‘about 80 per cent of those who came in after a barrel-bomb attack died’. Perhaps the height of his emotional crisis was when death became ‘all too routine’, and he became ‘too numb to grieve‘, adding that ‘the mission had taken me apart‘ and ‘I was no longer sure who I was’. It was following this that he became depressed with a post-mission stress that manifested with outbursts and ‘increasingly irrational‘ behaviour from which he ‘slipped into a trough of psychosis and paranoia‘, only managing to recover with therapy and the support of his wife (pages 19-20, 56, 65, 292, 301-310).
This narrative work is replete with stories which are both gripping and bleak, and this reflects the double-edge sword that is humanitarian medicine. With graphic representations of the conflict zones and their victims, the book successfully paints an unalloyed picture of the brutality of war, and the humanity that attempts to mitigate its impact. The author captures the sense of adventure that comes with saving desperate lives in horrendous environments, but it also portrays the mentally destructive potential of the work. The last chapter was probably overdrawn and largely repetitive, but the diversity of locations, and the surfeit of examples, provide a comprehensive account of war medicine and compensate for this minor downside.
The book is a revealing insight into how humanitarian work and political activism complement conventional medical practice. The author shows the global perspective of medical practice, and the difference that doctors can make in less fortunate parts of the world. Whilst the author’s experiences reflect the extreme end of the spectrum of humanitarian medicine, they nevertheless symbolise the opportunities doctors have to extend their experience beyond narrowly defined job descriptions. The book is an insightful portrayal of the breadth of medical practice, and I recommend it to all doctors.
Publisher, Place, Year: Picador, London, 2019
Number of chapters: 13
Number of pages: 359
Star rating: 5