Perusing the book shelves in a branch of W H Smith, I picked up a couple of books more or less at random. They both looked interesting and readable, and indeed both turned out to be so. I read them quite quickly. When you read books in parallel like this, they seem to augment one another in unforeseen ways, even when you wouldn’t suppose they had anything remotely in common.
The first book was War Doctor, Surgery on the Front line, by David Nott (Picador 2019). (Let me say immediately, lest I forget, that this book should be compulsory reading for any future Prime Minister minded to enlist our armed forces in some so-called “Discretionary War”. Here is a vivid depiction of what it means to drop bombs on people.) The second book was Feel the Fear and Do it Anyway by Susan Jeffers (Century 1987, revised and updated edition Vermilion 2012). I knew that David Nott was a trauma surgeon with a vast experience of working in war zones, and as an emergency physician I was fascinated to read about his work. By contrast I had no particular interest in Susan Jeffers’ work and if I’m being honest I have heretofore entertained a scepticism towards inspirational self-help books. My preconception was that self-help was for neurotic Californians for whom having a therapist would be de rigueur. But Feel the Fear and Do it Anyway is a famous title, familiar even to me, so I thought I would give it a go.
Self-help books were tremendously in vogue in the 1930s, and James Thurber lampooned them mercilessly in Let Your mind Alone (Hamish Hamilton, 1937). He mined a rich seam of humour in contrasting the smug inner certainty of these Desiderata with the angst-ridden lives of nonplussed, middle-aged American men. I wonder what Thurber would have made of Dr Jeffers encouraging us to place inspirational “affirmations” on post-its, scattered round the house? I suspect he would have made quite a lot. I confess that Let Your Mind Alone has prejudiced me against self-help books. Did Thurber really despise them? It hardly matters, as Thurber is a persona, a character in his own bizarre and unpredictable world. It’s not that he’s in denial of the fact that he’s neurotic, merely that he can’t take seriously the off-the-peg solutions of the psychotherapists. Maybe if they went off to Aleppo and worked as an orderly in an underground hospital in what David Nott calls an “austere environment”, they would find they didn’t have time for introspection. Incidentally, David Nott runs a course called “Surgical Training for Austere Environments (STAE)”, which strikes me as quite a euphemism. It might aptly be renamed, “Surgical Training for Hell.”
So I really did think that there would be no connection between these two books, and that attending a seminar on how to make your life more fulfilling would have nothing to do with how to patch up a mangled body while somebody is about to drop a bomb on you. I mean, get real! Susan Jeffers describes the trance-like episode which turned her life around almost in terms of a miracle. Spontaneously, and without any forethought, she entered an academic institution unknown to her and told a stranger (who turned out to be the head of the department) that she was there to teach a course on Fear. The rest is history. Aye, right. I read all this with a degree of resistance. It’s all very well to say that all is for the best in the best of all possible worlds, but just look at Aleppo!
But then Dr Jeffers played the Viktor Frankl card. Frankl’s Man’s Search for Meaning (Ein Psycholog erlebt das Konzentrationslager, 1946) is a book which periodically falls out of the sky upon me. I even found a dog-eared paperback copy in a hut in the Highlands of Papua New Guinea. Viktor E. Frankl was a psychiatrist, a survivor of Auschwitz who averred that life was meaningful even in the direst of circumstances. He went on to develop a system of psychological treatment known as Logotherapy which seems to me to share a lot of ideas with Susan Jeffers. I began to read Jeffers with a new respect. I like the message that is encapsulated in the title of her book. She permits us to be fearful. Angst is part of the human condition; it is not of itself abnormal. I wonder if, amid the current epidemic of antidepressant prescribing, we have lost sight of that fact. Dr Jeffers borrows from Viktor Frankl a technique called “Paradoxical Intention” in which a patient does not try to combat, dodge, or obliterate his fear, but, paradoxically, to reproduce it. Somebody with a phobia of public-speaking, for example, might be encouraged to get up in a public place, make a speech, and deliberately fall apart. The paradox is that the subject finds himself able to make the speech, but unable to fall apart.
It occurred to me that “Feel the fear and do it anyway” – recurrently – is what David Nott has done. Sarajevo, Kabul, Freetown, Monrovia, Darfur, Rwanda, Yemen, Libya, Haiti, the Central African Republic, Gaza, and of course, Aleppo. It clearly is a very special person who volunteers repeatedly to subject himself to this level of risk, and to operate in an environment of utter degradation, for no material reward. What drives him? David Nott tries to address this question in his book. From a professional point of view, he clearly relishes the challenge of practising in the austere environment, where you have little if any recourse to laboratory and radiological back-up, and you are forced to rely diagnostically solely on your own clinical acumen. To make the right decision, and to achieve the right outcome, is very gratifying. This is closely aligned with the humanitarian aspect of the work he does. You sense his sense of pride in saving the life of a terribly traumatised child. With respect to personal risk, he admits to being something of an adrenaline junkie. He describes watching the news in London, hearing about the destruction being wrought in the world’s latest war-zone, and having an irresistible desire to go there.
I was very interested to read about David Nott’s other professional life. He is a pilot, both fixed wing and rotary, and he has practised that art at a high level. I wouldn’t claim for a moment to have advanced half so far as Mr Nott in either aviation or medicine, but as an emergency physician and a private pilot I do claim a special interest here. You might imagine going fishing (a fishing rod was his chosen luxury on Desert island Discs) would be a more therapeutic off-duty pursuit for a stressed surgeon, than flying a Lear Jet from Luton to Heathrow in the world’s busiest airspace. But it was during the 1990s in Auckland that I began to appreciate that aviation was therapy for the emergency physician. I would leave the madhouse of Middlemore Emergency Department in South Auckland and drive south out of Auckland through Alfriston to Ardmore Aerodrome. I would take Whisky Alpha Echo, a Slingsby Firefly, aloft and do loops and barrel rolls and stall turns and spins. The act of putting yourself into a situation of extreme personal vulnerability, in which you are totally reliant on your own skill to retrieve the situation, somehow invests you with the power to help somebody else in extremis. After the sortie I’d have a pint in the club bar and then drive home to Bucklands Beach (legal there and then – couldn’t do it now). I’d always have to stop, at the same lay-by in Alfriston, and get out and look at the view, overcome by a very strange mix of serenity and euphoria.
I would hazard a guess that something like that feeling is what drives David Nott.
But it comes at a price. Things can go wrong. David Nott is candid – remarkably candid for a doctor I’d say – about cock-ups, in both medicine and aviation. That trip by Lear Jet from Luton to Heathrow did not go well. Aviators will recognise the symptoms: if you’re not flying all the time, you lose currency. There’s a hierarchy of multi-tasks a pilot must carry out, and if he can’t do some of them unconsciously, he gets overloaded; pilots call this being “maxed out”. Then there was that close shave in the helicopter.
He doesn’t gloss over the medical mishaps either. The burr hole on the wrong side of the skull, the massive transfusion reaction from incompatible blood – it’s all there. There are many extraordinary and highly dramatic scenes depicted in War Doctor – the many passionate and acrimonious disputes between colleagues in the operating theatre; the occasion of being abandoned in the pitch dark in theatre during a bombing raid; the decision to continue operating under threat of immediate obliteration; but the episode which stood out for me occurred in Aleppo when Daesh broke into the operating theatre. David Nott’s assistant whispered to him, “Don’t say a word.” David Nott prayed to God that his hands would stop shaking. They did. He was able to complete the operation.
I have the sense of a man who has taken his craft to the absolute limits and who finds himself in a zone in which he no longer has any reason to put up any sort of front. You can sense it, if you track down his appearance on Desert Island Discs on the BBC Sounds App, and listen. I liked his musical choices. His soundscape had serenity. And when he recounted his experiences, he relived them. You are never more in touch with humanity than when on the verge of tears. I recognise this zone myself, again, from clinical practice. It’s a kind of catharsis. Catharsis, the purgation of pity and terror, was for Aristotle the defining characteristic of tragedy. I never really had an inkling of what this might mean until I saw Roman Polanski’s film of Macbeth. The terrible world Shakespeare conjured – and Polanski recreated – might not be unlike the world to which David Nott is recurrently compelled to return. It is a frightful place, but towards the end of the Polanski film there is an inexplicable lightening of the atmosphere which is truly cathartic. I remember I used to experience something similar at the end of a particularly hellish and protracted shift in the emergency department. I felt I could do anything. I was as light as air. Yes I will stitch up that gash on the beautiful face of the daughter of the Professor of Plastic Surgery. No problem. Next morning, I’d be back to my old neurotic self, braced for another day. Feel the fear and do it anyway.