Medicine and War

War and medicine have always been linked. Surgical instruments are often developed by military surgeons--Army/Navy retractors, Russian forceps, Jackson-Pratt drains, external fixators, to name just a few of the instruments developed by military surgeons. Sometimes this is obvious by the name, sometimes not. But war has helped with the development of medicine, as medicine has struggled to cope with the devastation of war. And physicians have at times been involved in development of "better ways to kill."

I have never been in a war. The closest I have come was working in inner city hospitals while drug cartels were fighting for "turf." But, I could return home to the safety of a middle class community where shootings were rare. Nevertheless, I have worked with Physicians for Social Responsibility and EMERGENCY to try to help prevent war and care for the civilian victims of war.

Tonight, as I learned more about the Malaysian Airlines jet shot down in Ukraine, I learned that there were 41 war zones around the world. Forty-one. The number surprises me and yet it does not. I know that we have always been a violent species. Perhaps, this is a typical number.

Tonight, I learned of another way war has affected medicine. One hundred AIDS researchers were killed in Malaysian Airlines jet shot down over Ukraine.(http://www.medscape.com/viewarticle/828523 and http://thinkprogress.org/health/2014/07/18/3461625/aids-experts-malaysian-plane/) Usually, medical researchers spend much of their time in academic settings, being exposed only to the violence and drug use of the inner city. Perhaps some of the researchers studied people in less developed parts of the world. Even so, they likely thought that they were heading to a convention in a peaceful part of the world, Australia. They may have even been bringing their families, evidenced by many children on the flight. They likely had taken many flights before, and so were not worried about the risks of flying.

The passengers were likely watching a movie, reviewing notes on a computer or sleeping as the plane flew at 30,000 feet. They didn't think about what they were flying over. So many war zones between the Netherlands and Malaysia. Passenger planes surely avoid the major war zones. Few of the passengers thought of the risk, until it happened. Until a passenger jet was shot from the sky.

It may have been a case of mistaken identity. Even so, the shooting down of the Malaysian Airlines jet over Ukraine may have an effect on the health of the world's citizens for years to come.

Ukraine and the Budapest Memorandum

What does violation of the Budapest Memorandum mean for the future of nuclear non proliferation and arms reduction?

As the war in Ukraine becomes more obvious to those who have not been following the situation with the downing of the Malaysian jet with the loss of 295 civilian lives, people who were uninvolved in this conflict, I feel that I need to bring up some of the other issues that I see. This is now a regional war, not even involving the territory of a whole country, but the risks extend much further.

In 1994, Ukraine, together with Russia, the United States and United Kingdom signed the Budapest Memorandum. It guaranteed the territorial integrity and political independence of Ukraine in return for signing over the nuclear weapons in its possession to Russia. Later, this was expanded to include France, China as guarantors, and Belarus and Kazakhstan along with Ukraine as nations that would give up their nuclear weapons.  Since, the launch codes for many of these warheads were kept in Moscow, the weapons in Ukraine, Kazakhstan and Belarus were really not under the control of the respective governments. In this sense, the transfer was perhaps less significant. Nevertheless, it was the first time that governments gave up nuclear weapons for the promise of peace.

More recently, with the expansion of the European Union and NATO into formerly communist countries of East Central Europe and even into the Baltic countries, which were part of the Soviet Union after World War II, Moscow has expressed concern about western interference. Similarly, it has felt pressure from the south, both in terms of Islamic influence in the republics with large Muslim populations, and with American bases being placed in some of these countries to support the wars in Afghanistan and Iraq. To counter the European Union’s trade benefits, Russia has proposed a Eurasian Union including Russia, Ukraine, Belarus and Kazakhstan as the core.

But, some former republics wanted more change. First there were the Chechen wars of 1991 to 1994 and 1999 to 2000 and the ongoing Chechen terrorist attacks and suppression in Chechnya. And more recently the Maidan movement in Ukraine. Due to both the size and historical significance of Ukraine to Russia, this was a blow to heart. Propaganda has been intense on both sides. Finally, Russia took over the Crimean peninsula and parts of eastern Ukraine are still being contested.

Russian annexation of Crimea is a clear violation of Ukraine’s territorial integrity making this a violation of the Budapest Memorandum. It is clear why Russia has not come to the aid of Ukraine. But, while both the US and UK issued statements and applied political and economic pressure, what more could they do? After all, Russia was on the other side and the possibility of war with Russia is something they want to avoid. Once again, those in former communist dominated countries feel they are again being sacrificed to political expediency.
Clearly, as Ira Helfand said in his May editorial (http://www.desmoinesregister.com/story/opinion/columnists/2014/05/04/another-view-ukraine-crisis-danger-nuclear-war/8665185/), nuclear war would be disastrous for the planet. A nuclear war between the United States and Russia, once again a possibility, is something we must avoid.But, are there other concerns in the Ukraine crisis? Does a nuclear power have the right to attack or annex a non-nuclear one simply because of the fear of nuclear war? This precedent is very disturbing. Just as when the US invaded Iraq a decade ago in search of weapons of mass destruction, while it did little about the real nuclear weapons in North Korea. Comments were made then that possession of nuclear weapons was protective. Not exactly the message we should want to send if we want nuclear disarmament. Now, again with the annexation of Crimea and further incursions into Ukraine’s territory, we again have a situation that appears to demonstrate that not having nuclear weapons, this time by giving them up, makes a country vulnerable. How can we convince these countries that the path to peace and security is through eschewing such weapons rather than by building more?

And, what is the impact of violation of the Budapest Memorandum on the behavior of smaller nuclear or near nuclear states? There was a multilateral agreement guaranteeing the territorial security and freedom from external influence protecting Ukraine. How can the larger nuclear nations be trusted when they offer security to a smaller nation again? What of other multinational agreements?

Other questions also arise? Are some people expendable? This has been a concern for half a century as the great powers have fought their wars through surrogates. Most of these people had dark skin and died so the great powers did not fight directly. Now again, the question arises in relation to those who live in proximity to Russia, and who remember, through their grandparents, the massive population destruction and relocation of the Second World War, its precursor Holodomor in the Ukraine and the aftermath of World War Two under communism. Timothy Snyder called this region “Bloodlands” since so many people died in the area of Ukraine, Poland and Belarus before and during the Second World War as Germany and the Soviets first divided then fought over this land. These memories are also causing Poland to lead pressure on the West and its guarantees to newer members of NATO and the EU. Poland remembers both the lack of help, despite treaty agreements, in 1939 from Britain and France, and the Yalta agreement which relocated it, and many of its people to the west, yet gave the Soviets control of its government. As a result, NATO is putting more troops and weaponry in Poland and the Baltic countries, and carrying out war games in the region. While this is very understandable, it further enflames the situation.

So how are those of us in the peace community to reconcile these issues? It isn’t easy. So far, the world has chosen appeasement, in essence encouraging Ukraine not to fight Russia. But is appeasement the right answer? But how can we change this path without taking to task one of the world’s largest nuclear powers? And what would that choice mean for the world? What does that choice mean for the people of Ukraine and Eastern and Central Europe?

How do we convince countries considering nuclear weapons not to develop them? So many of the messages of the past decade seem to suggest that a country is safer with nuclear weapons than without. We are sending the wrong message. I worry that more countries will embark on the course toward developing nuclear weapons, and this will also increase the risk of nuclear war in the future.

I find that reviewing this situation has left me with far more questions than answers. And more concern for the future of the world.

Monte Cassino

Today is the 70th anniversary of the Battle of Monte Cassino. The Polish Forces under General Władysław  Anders finally succeeded in taking the mountain topped by a monastery. One thousand fifty two Polish soldiers died in the battle.

 

My mother's step brother fought in that battle. He was not yet 16. He had been taken from his home together with his family in 1940 by the Soviets. His grandparents were simply killed. They were dropped off in a frozen forest. They asked, "Where do we live?" only to be told, "There are trees, you can build houses." They had brought no tools to cut down the trees.

They asked, "What do we eat?" The answer was similar, "There are rabbits." Yet somehow a few survived. His brother, who was 3 when he was taken, was "too young to live." His father also died before making it to freedom.

Yet my uncle and his mother, who married my widowed grandfather, did. And my uncle then joined the General Anders army, even though he was under aged. He stayed in the British army after the war and was in one of the last units to leave Palestine before it became Israel. He later was sent to Korea. Meanwhile his mother came to the US via Mexico.  He then left the British army to join the American army, spending additional time in Korea, and then going on to teach at the Monterey language school.

Still a young man, he used his GI bill benefits to complete his education and became an electrical engineer.

He and my mother were close until her untimely death. She always loved poppies. We had hundreds in our yard.

Slavery today, here in the US

As a physician, I can't even count all the times that I saw an injured worker who came in with two or more employer representatives. Most of the time, I am sure this is simply out of concern, but sometimes it may not be innocuous. Sometimes that injured worker is held as a slave and the others with him are there to make sure he doesn't tell anyone of the conditions he works under. This is a new realization for me.

Not long ago, I read the book, "The Slave Next Door," by Kevin Bales and Ron Soodalter, and began to realize that sometimes things aren't so innocuous, even here in the US. I had heard about the sex trafficking of minors, garment sweatshops in LA and tomato growers in Florida, but never thought that a slave might be sitting in front of me. I now have gained awareness of this situation, but still don't know how to approach such a patient. 

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Clearly, one can't ask in front of the employers. One must make up a pretext for privacy and have a hospital employed interpreter if necessary. The employer supplied interpreter may be yet another guard. The reason for privacy could be the need to do a pelvic (for appropriate specialties) or rectal examination.  Then, I have sometimes asked, as I do when I suspect a battered wife, "Are you safe? Are you OK? Anything you want to tell me? Anything else you want me to help you with?" but have not yet gotten a response of someone asking for help in such a situation. (I have had battered women and teens tell me they need help.)

Yet, I know that one must be aware of a pathology before one can identify it, whether it is a disease of the body or of the culture. I can see my awareness growing, in that I now suspect it, even when simply reading the medical records where it is stated that "two employers and the employer's interpreter" came with the patient. It also gives me the greatest reason to need a hospital or clinic employed interpreter, or phone service.

It is necessary for physicians to become aware of the problem so that there is a chance of recognizing and addressing it.

Mother's Day

My mother was a very generous woman. I remember that she was always helping others. When I was small, she was very involved in resettlement of Displaced Persons. Today, I wrote up a memory. I don't remember the name of the other woman, nor all the details, so just made her a composite of several that I remember.

 

 

 

The Changing Room

 

It was a cold, dreary day when we picked up Mrs. Nowak. She was dressed in the only dress I had seen her wearing, a threadbare, pale green and tan plaid shirtwaist dress with long sleeves which hung loosely on her frame. I hadn’t seen her in any other dress since she arrived in Colorado during the summer. My mother greeted her in Polish. She greeted me in broken English. She wanted up to make us breakfast, but my mother insisted we should get going since we had a drive ahead of us. “We’ll eat when we get there.”

She relented and took out her coat. It, too, was threadbare, once red, now faded unevenly, with a black collar. It, like her dress, was probably worn when she got it second hand.

Her daughter was off at school and her husband at work or maybe sleeping since he worked two jobs. She usually worked nearly every day as well. But today was her day off. My mother wanted to take Mrs. Nowak to buy her some clothes, she knew Mrs. Nowak was proud and wouldn’t easily accept charity.

As we drove, my mother and Mrs. Nowak chatted. I wished I could understand, but could only catch a word here and there since I hardly knew any Polish. I mostly just watched the snow. Sometimes a big, fluffy flake would stick to the window in a way that I could see its’ structure, before merging with the others. I loved the trip to the big department stores in Denver. They had so much more than the stores in Boulder, which was still a small town then. Fancy clothes and toys, and this time of year, fantastical Christmas displays, often with moving parts, not just mannequins dressed in the clothes of the season. I was hoping for a new party dress in velvet, maybe dark blue this year. Even then I loved dark colors and jewel tones.

Finally we got to the department store parking lot and picked a spot as close as possible due to the weather. I wanted to go in the front door to see the displays, rather than the side door by the parking. The women relented. The display seemed so magical, with giant nutcracker’s opening and closing their mouths, and mannequins of children sitting under a giant Christmas tree opening packages, some as big as the children.

But we had not come to see the displays today. Instead we headed inside to the restaurant. Mrs. Nowak ate slowly, taking time with each bite. “I can’t eat fast anymore. I have trouble swallowing, still. It’s from the lye.”

“Take your time.” My mother slowed down her eating and looked at me, expecting me to do the same. “We came for the day.”

After we ate, my mother paid for the food and then we headed for the women’s department. Mrs. Nowak looked admiringly at the dresses, fingering them and walking past. My mother noticed a few that she looked at the longest and picked them out. Mrs. Nowak turned to her and said that she couldn’t afford any of them, but my mother persisted, “What harm can it be to try them on?”

“I guess it couldn’t do any harm.” Mrs. Nowak finally agreed. We went to the changing room, choosing the largest since there were three of us. There, Mrs. Nowak took off her coat, hanging it carefully on a hook. She then took off her dress carefully, leaving only her slip. Then I noticed it. She tried to hide it from me, but could not. There was a number tattooed on her left arm.

 

The sharp end of the knife

As a surgeon, it is a difficult position to be a patient. Perhaps this is why there are so many comments about doctors and nurses being 'bad' patients. We know too much.  Enough to be scared. We know about risks.  After all, we talk about them everytime we consent a patient for surgery. We review complications and deaths with our colleagues in the attempt to improve care for future patients. And perhaps some of us went into medicine in the hopes of cheating death. But, everyone of us is human and subject to illness and death just like every other living being on the planet.

Years ago, I had my first surgery and recently a second, though I am soon to have another more major surgery than either of the previous two. Each time, I have known that there was really no other reasonable choice. The day before my first surgery, I was talking to two colleagues. I commented that, up to that point, I had maintained a 'double standard' about surgery. One of my colleagues, looked stunned. He was Black and thought I was referring to race. I explained that it had nothing to do with race. I tried to treat all patients the best I could, but rather it had to do with the fact that I had done surgery on thousands of patients but no one had ever done surgery on me. I felt scared. I really didn't like the thought of being on "the sharp end of the knife." Or at least, I didn't feel comfortable as a patient, I didn't know how to feel, while I had become quite used to being a surgeon. His expression changed and he said that he certainly could understand that. That surgery went very well. I was home the same day and back to exercising within the week.

My second surgery didn't go as smoothly as anticipated. Hospital stay and pain were both far more than I had anticipated. But it was still necessary and has helped to heal me.

Since my recent hospitalizations, I have seen several of the people who took care of me. All have commented that I seem to be doing well. Again, during the hospitalizations, I had some times that I was scared. While in the emergency room, I was placed in a private room. I'm sure it was done to give me some privacy since I was a staff member. But it was scary for me to be alone. I was in pain and my blood pressure was quite low. I had yet to have any significant treatment. I thought they would just leave me there alone as things got worse. I thought that I might die. I worried about my children, still far too young to be on their own. I called for help, more than I truly needed it, but I didn't want to be alone. I was happy when friends and colleagues came by to visit.

Being a patient, or the family member of a patient, is certainly important for medical professionals. It can teach us a huge amount about how the patient feels and how the family feels. It can teach us how to be more compassionate as caregivers. It can help make our care better for future patients. But, the process is far from enjoyable.

AANS Neurosurgeon – Interview with Dr. Sarah Woodrow

Here is a recent interview I did with Dr. Sarah Woodrow who worked in Ethiopia, helping to train neurosurgeons there.

AANS Neurosurgeon – Interview with Dr. Sarah Woodrow