David Nott - Conflict Zone Surgeon HARDtalk

Much more on that on the BBC website any time.

Welcome to HARDtalk. I'm Stephen Sackur.

Amid the appalling toll of civilian death in Syria,

the loss of hundreds of doctors and medical staff stands out

Many have been bombed in their clinics and hospitals.

My guest today is David Nott, a British surgeon who has spent

decades offering his services in conflict zones, including Syria.

Now he's focused on training doctors to work in conflict conditions.

But does Syria tell us medical personnel can no longer expect any

Thank you. We last spoke in the studio three years ago, 2013. You

had just come back from Syria. I ask you then, would you continue to go

and work in the midst of war, and you smiled and said, yes, of course.

You have been back once since in 2014, but not the last couple of

years. I? I did go back in 2014. I wanted to go back to Aleppo in and

the people I trained and see how they were getting on. I wanted to

help them and justly with them. It was a real joy to go back in

September 2014 and spent six weeks with them. I was absolutely

delighted to see how they had coped. From being a ragtag bag of amateurs,

really, you before that, and not knowing how to stitch public, not

knowing how to make the right diagnoses, not knowing how to

operate, they had turned themselves into a first-class group of very

good surgeons. I'm talking about surgeons that were 28, 29 and 30.

They were really very good. It was a joy to see that the training they

had had was really paying off. They enjoyed showing me how they could

operate. It was really enjoyable. That is the positive. The negative

is you were there in the midst of a spate of barrel bombs, attacks on

civilian areas and rebel held part of Aleppo. Would it be fair to say

even for a man who has risked his life in conflict zones for 20 years,

it simply now is too dangerous? I did go, and 2014 was completely

different to 2013. The barrel bombs being dropped, there were four or

five being dropped a day on the city. On civilian populations. We

dealt with really terrible injuries, probably the worst I've ever seen to

stop fragmentation wounds on families and children. It was very

difficult. There were coming in with smoke inhalation and people would

die because of risperidone failure following their operations. I think

you said at the time something like 70% of the casualties which would

and added ten -- respiratory. Yes, 70% were children under ten. That

was the most hard braking part. These barrel bombs were being

dropped on civilian houses. -- hard braking. The fathers would be out

doing something and the mothers would be looking after children, and

they were the ones coming in. It was really terrible. I was doing with

that sort of injury. In the midst of hearing oral bombs being dropped,

hearing planes going around. -- barrel. We went for a visit run the

hospital and were targeted I is Syrian jet flying around firing

rockets. It was extremely dangerous. At the time as well, we had 20 or 30

kilometres away, Islamic State and the beheadings of all of the

Westerners in Raqqa. It may be feel it to me uneasy. There was only one

road in and one road out, the Castella Road. In 2014, late

October, there were discussions about closing the road. It is nearly

two years on from when you with their in those ghastly conditions.

Do you now feel that you suffered, or maybe are still suffering, post-

ratted stress? We talked about that in 2013, and you were confident you

had steered clear of that -- post-traumatic stress. I did suffer,

no doubt about it. I often say a small amber would get into a fire

and maybe go into a rage. I did not realise at the time I was almost

having a personality change. My wife now, who was with me during this

time, really suffered, and occasionally does still suffer when

things don't go to plan and I lose the plot slightly and it comes to

listening to what is going on at the moment. I do put myself back in that

situation. I do suffer. No doubt about it. Do you see images,

particular images? Even with me now, you are talking about the barrel

bombs and the concrete dust and the children ayes ravaged bodies. Do

images come into your head? I see it now. I see it when I go to bed. I

have constant communication with my colleagues in Aleppo and they

discuss cases with me. They semi- photographs of the most awful

injuries that I look at. -- they sent me. Most of it is blunt trauma

and the occasional stabbing in this country, perhaps a bow energy

gunshot wound to the chest. But there I am seeing images which would

make the hearts of anybody basically sink. They are terrible injuries.

They are asking me what can I do with this case? What can I do?

Sometimes I am sitting there at a dinner I did need the table tapping

away saying have you done this? Have you done at? I would do this. How

much blood have you got? What is the neurology like? Is the spinal-cord

damaged? Constant images come to me all the time. There are hundreds of

thousands of civilians living in the still rebel held part of Aleppo. The

latest reports suggest there are perhaps 38 doctors of whom may be a

handful or actual surgeons. How on earth are these people being given

any meaningful healthcare at all? Given bail are still under on by

then. -- even they are. It is worse now. Since the siege of Aleppo and

since the Russians ramped up their air and bombing, they are not

coping, and they are dealing with mass casualties on a daily basis.

I'm getting picked is my phone saying, David, look at the cases we

are dealing with now. We don't have any blight, we don't have any

agreement. We are doing operations which are not the right operations

to do in these circumstances -- equipment. They are making terrible

decisions whether they can operate all leave a child, operate on

somebody else. They are not coping. That is the big problem. Do you ever

feel, and we have talked about this safety aspect, and the impossibility

of getting in in many ways, but do you ever feel one way or another, I

should be there? Yes, I do. I really feel, I said to my wife, she looks

at me and says what are you thinking about? Why are you gazing into the

abyss? I am thinking about the people and the doctors. I wanted to

be with them to help them, and the only way I can do it now is to of

advice over the phone. I know you have difficult conversations. I was

struck by one that you spoke about a little while ago. This was with a

young student doctor that you know well, and I think he sent you a

picture of a girl who had been very badly hurt in eight bomb attack, and

she had lost a child of her arm, and terrible facial damage. You

contacted him and said, that is terrible, will she survive? His

response was, unfortunately yes. To me, there is a problematic ethical

thing going on it in Aleppo right now. If doctors can save a life but

I'm not able to offer any after-care, rehabilitation, if the

damage is so severe any is so awful, is there a point where saving a

life, literally, is counter-productive? It is a very

good question. There is no right and wrong in the answer to it. A

doctor's job is to save human lives, and to alleviate human suffering.

But that alleviation of suffering may not be happening. The suffering

may be, in some awful ways, prolonged. Exactly, exactly. Without

backup support. What will you do with that patient? Where will they

go? To a bond at home? And suffer even more. A doctor's job is not to

decide on somebody... If summary is in front of you dying and you have

not got the agreement to deal with them, you have to let that patient

die -- somebody. If summary comes in with their arm blown off and they

are still alive, you cannot put them in a corner and say I will come back

in ten hours and see if you are still alive. You cannot do that. You

have to save their life. It is a very difficult decision. It

certainly is a completely different job, in a doctor in Aleppo, compared

to what you do in some of the best and most posh hospitals in London.

There is a strange disconnect in a word. But it was best encapsulated

when you were awarded an honour in the UK, and soon after it went to

see the Queen. She asked you what it was like in Aleppo. You very

honestly said, you actually could not answer. You thought your grip

trembling and felt she would break down. -- lip. I still think about

that time, really. I think I would come back ten days after being in

Aleppo, and I was severely traumatised. My really good friend I

worked with who was an anaesthetist, he was great, and the picture I got

when I walked over the border, some sent me an image of him in the

shower, he had just been killed. I arrived home and I was severely

traumatised, and then I got this in fight to go to see the Queen at

Buckingham Palace and have light without -- shroud. It was fabulous,

a wonderful thing. -- have lunch. My mind was not there. It was in Aleppo

and with all the people. It was with the people I wanted to be with. I

was in an environment whereby I could not speak. She asked me, you

know, we have you come back from? I said I have come back from Aleppo.

How was it? I could not describe what it was like. I was unable to

discredit. -- describe it. It was so bad, I just sat there and looked at

her. I remember vividly my bottom lip starting to quiver. She

obviously saw this, and then turned to the courtiers and said let's do

something else, shall we? Let's get the dogs in. So be called his

Kenyan, and we just fed the dogs for the rest of the lounge -- corgis

came in. She saved you from breaking down. She did. If she had continued

to ask me, I would have been sobbing. Let's talk about what you

are doing right now. As we have established, you were not able to go

back. But you are focusing on a particular aspect of medical

assistance, training. Training young doctors in conflict surgery, in

emergency trauma care. I know you have done it on the Turkish Syria

border. You have done it in Yemen as well. How much difference do you

think it really makes goods like yes, I think it makes a lot of

difference. What we do, I run this course with the Royal College of

surgeons, and it is a five-day course whereby surgeons from all

over the world come. And Ostia environment being a euphemism for

what some -- Ostia. You don't have an MRI, you don't have much blood,

and you have to make the right decision for your patience. Over the

extent I have had, aborted altogether. The course is based on a

lot of the cases I have dealt with and how would you manage these? --

and brought it all together. But the shorter course is called the hostile

environment surgical training course, a three-day course which I

put everything together, and then I have setup with my wife a foundation

Kolbe David Nott foundation. It basically pays for surgeons to come

from all over the world to come on the course. But the small course is

also paid for by our foundation. We took it to the Syrian border, and 30

surgeons came over the border. We taught them everything from top to

bottom, but they would need to know as a surgeon. Of course they looked

at me and said, in fact, we deal with significantly worse injuries

then you can show us. I said no we don't. Let's talk about your

injuries and the correct management. We had this dialogue during all of

the surgeons they can over. They were saying, we have had this

terrible case. How would you manage that? Then I said we would manage it

by this technique. But it was not just me, it was a group of us that

when. About four or five that go to this course.

That seems a continuation of your dedicated work, trying to improve

the healthcare environment. I see the continuation with your actual

bodily presence on the ground. But you seem to have gone in a new

direction over the last few years. You have become phenomenally

outspoken. And not just outspoken on specific detailed healthcare issues

by political issues as well. In particular, what it seems you feel

to be the flagrant violation of the Geneva Conventions, and in the case

of Syria, you appear to be pointing the finger of blame at Assad's

forces and the Russians as well. Very much so. I have become far more

political because there needs to be a voice. The people they need a

voice. The only ones who can talk are those who have in there. It is

difficult to wave a flag and say this is what we should do unless you

have been there. It is those people who should voice and say how

terrible it is. I completely understand the point that people

say, well, yes no, David, you are not a politician, you are a dog to.

That is true. You are a man who has four years offered humanitarian care

to all who present themselves. From the Red Cross, to MSF, to any other

medical organisation, there is a principle of nonpartisanship,

independence, for the Red Cross in particular, neutrality. You have

walked a long way from that. I have. I am happy to say I am glad I have

done it. Someone needs to speak out. We can't just sit there and be

basically, umm, walked over by what is going on. I am upfront about what

is happening in Syria at the moment. Should they do that? This doctor

has. I am taking sides against people who are killing and maiming.

Against people who have no idea what is going on in the war. And things

like that which happened before my eyes. I can't bear to witness it any

more. It is such an important principle. The Theory of Everything

if you were able to go back, the Russians in particular, having seen

you in using the word, et al ET, of what they are doing, they might take

the decision that they are going to target you. -- brutality. That

wouldn't be a problem just for you but for all your colleagues. I

wonder whether, and I don't mean this to be rude, but whether ego and

sort of personal profile... The best way to do your work, is it the best

way to do your work? No, I don't think that is correct. I am not

egotistical. I am not wanting to push myself forward. I am just

basically standing up for people that have been severely almost

destroyed. And that is what I am standing up for. Not for anything

else. Not for myself. I want to do it and say there has been a complete

ignoring of humanitarian law. Hospitals have been bombed. The

Geneva Conventions are there for a reason. They are not there to just

the walked over and laughed at. That is what is happening now. President

Putin, President Assad, they are laughing at the West. No one is

standing up and doing anything. Let's push the politics further.

Because of your position, you have actually said that you believe the

Western powers, and you are speaking mostly about Britain, should have

intervened militarily, 2013 you say, much earlier. But you say that in

your view, Western military boots on the ground were and are required to

offer salvation to Syrian people. And again this point, is it right

for a doctor to be calling for a new and expanded military intervention

when war is always cost lives? I called for humanitarian corridors in

2013. I called for united humanitarian corridors. You asked me

who was going to police that and I said ousts on the ground. It had to

be United Nations boots on the ground, not Britain or the US. What

I am saying from 2013, when Obama said we had crossed a red line by

dropping chemical were 10 cents to 1500 people, that, you know, that

there was a time where the West should have shown leadership and

sincerity to the Syrian people. We have talked about the situation in

Aleppo. What do you think should be done today? I don't think boots on

the ground are the right thing to do today. I think that of course be an

Nusra Front, who have changed their name to Al Sham, they have decided

not to go with Al Qaeda, and they have a huge amount of people on the

ground now. What should happen is that the Western governments,

talking about Europe, all the Western governments, they should

come together and say, look, we cannot have three... Sorry, 300,000

people in Aleppo being killed and under siege. What should happen is I

think that the Western governments should first of all put massive

pressure on President Putin to say you cannot just use a power and kill

as many people as you want to kill. -- air power. What you are doing is

a war crime and you will be held responsible and taken to The Hague

in due course by the international community. So will President Assad.

You will both be taken to The Hague. So, smile now, you won't be smiling

later. It is international pressure that needs to be put on the Russian

regime. We should also be talking to the Al Sham, the new groups of

fighters now in Aleppo, we should be talking to these people. That is

what I think we should do. That is your political, sort of, diagnosis.

But is now back to doctoring for the very end. You said all those years

ago, you know what, I have made a conscious decision not to have a

family, a wife, children, because I could not do what I want to do if I

was in that situation. Now you have been blessed by not just a wife but

a one-year-old daughter. Does that mean your days of this hour Rover?

Probably. -- are over. I have a great responsibility to my wife and

daughter. I feel that I can voice for the people that have been

severely injured and wounded around the world. I can go and train

doctors that can give to the best of their abilities the help to people

wherever they are. When I was in the Yemen, it is a smaller warzone, not

a big one, and I can still go to these places where the security is

not too bad. But places like Aleppo now, I don't think I could go to

them. I can relate to this as a former war reporter. We have talked

about the adrenaline and bars. It is not just a truism. -- buzz. There is

something powerful about risking it all. You don't have that any more? I

do. I do. I just suppress it. I have to suppress it. Because if I don't I

would the letting my family down. David, we have to end it there. But

thank you very much for coming on HARDtalk. Thank you. It is a real

pleasure to have you back in the studio. Thank you.

If we take a quick look at the chart for the start of Wednesday you get