It is brain surgery: Neurosurgeon Henry Marsh revisits the scene of a surgery in "The English Surgeon." (Photo courtesy SFFS)

The Doctor and the Documentarian Behind "The English Surgeon"

Jennifer Preissel May 19, 2008

When The English Surgeon had its U.S. premiere at the San Francisco International Film Festival earlier this month, director Geoffrey Smith and his subject, the inimitable London-based neurosurgeon Henry Marsh, received a standing ovation from an enthusiastic and moved audience. Recent winner of the best international feature documentary prize at the Hot Docs Canadian International Documentary Film Festival, the film tracks Marsh’s relationship with Igor Kurilets, a Ukrainian surgeon battling the bureaucracy and corruption in his country’s state medical system. This duo of dynamic doctors teams up to assist Ukrainian patients suffering from brain tumors, which in many cases have gone undiagnosed until too late. Smith’s film also focuses on the plight of Marion, a poor man from a rural village, who might be saved from a life-threatening, otherwise "inoperable" tumor by Marsh’s expert intervention. spoke with Marsh and Smith during the SFIFF, before they headed back out of town. Can you tell me how you first met Igor Kurilets?

Henry Marsh: I met Igor in a dark, gloomy and semi-derelict hospital in Kiev in 1992. It was just a year after the Soviet Union had fallen apart and the Ukrainian economy was in pieces. In the hospital where Igor worked, there was no electricity, there was no disinfectant—they were using ammonia to clean things and it smelled terrible. It was appalling. There were no patients around either—nobody was getting treatment actually. And suddenly Igor just bounced up to me, like an enthusiastic dog. I was the first Westerner he’d ever met. He’d taught himself English by listening to the BBC World Service. That’s how we met. He struck me immediately as very unlike most Ukrainian men. He’s very energetic, very dynamic, very proactive and very honest. Why do you think he’s unique like that?

Marsh: Well, I know his father and it runs in the family. They’re Western Ukrainian. Western Ukraine actually had a civil war. At the end of the Second World War, [Western Ukraine fought] against the Soviet state. There’s a tradition of independence. Igor’s very proud of being a Western Ukrainian. It’s perhaps slightly chauvinistic, but I think it’s in his blood in that sense. I think it’s very unusual because in countries like Ukraine, [after] 70 years [during which] anybody with initiative or enterprise left their country or was sent to Siberia, a vast proportion of the population died violently from the famine in the ’30s or from the Civil War or from the Second World War. He’s very unmovable and he’s remained very unmovable, which is why he’s attracted a lot of support as well as a lot of enemies. What were you doing in Ukraine?

Marsh: I’d gone out to lecture. This English businessman took me along with some other fellows to do some lectures as a sort of goodwill tour. I requested to be taken to the emergency hospital and I met [Igor] by chance—pure chance. How frequently do you visit Ukraine?

Marsh: I go, on average, twice a year. Sometimes a bit more, sometimes once a year. I used to go for longer trips but they’ve changed a bit. Now Igor sends me brain scans virtually every week as emails. If it’s a case that we could or should do together and [the patient] can wait, then I go out. It’s increasingly me not operating but supervising, sort of holding his hand and advising him. I fly out on a Thursday and come back on a Sunday. It was much more difficult 16, 17 years ago. I actually drove several times from London to Kiev, which is quite a long distance. Could you talk a bit about the state health care system in Ukraine?

Marsh: The state healthcare system is deeply impoverished. There is a statewide medical system, but the state hasn’t got very much money; it’s not very keen to invest in health care and, in practice, if people need to have a surgical procedure they have to pay illegally, under the table. Basic emergency treatment—if you’re run over, if you have acute appendicitis—you can get free of charge but that’s fairly low level. Basic medical care is very poor and poor people have no safety net. Although in theory there’s socialized health care, in practice, for the vast majority of poor people, health care doesn’t exist. And has the Orange Revolution had any effect on the health care system?

Marsh: Not really. The Ukrainian economy has been growing. The situation there is very different than when I first went in 1992. And that’s one of the exciting things about working in a country like this, you see so many changes so quickly, some good, some bad. But it’s all quite blurry to me. Igor, with my help, in effect discovered 30 years of neurological progress in the West in just 10 years. It’s clear that his practice is successful but what he offers is a private service. You’re able to offer your services for free, but he’s got to charge his patients.

Marsh: Yes. But in fact it’s cheaper—it’s legal and cheaper than for people going through the state system. They’ll pay more for the same operation. It’s again more complicated in the Ukraine—the bribes you have to fulfill, the extralegal charges, are actually more than what Igor charges legally.

Geoffrey Smith: In the film, [Igor] has a little interchange with his secretary, where he says, ‘These people are very poor.’ And she says, ‘Well, we have to pay our staff.’ There are those costs versus the costs that the hospital charges—the bed. But, in many ways, he operates with an approach of making money from spinal operations, then helping people like [surgery recipient] Marion, who just aren’t going to be able to afford it. I wanted to ask you a question about that surgery. How long was it?

Marsh: It was only three or four hours, short for a neurosurgical operation.

And how many cameras did you have set up for that scene?

Geoffrey Smith: We had one, which I was operating because I wanted to be close to Marion. I had become quite good friends with him. He knew me, obviously, because he’d had some contact with me before. It was good to just help him, strap him in, calm him down. I was standing above him, tucked right up against the wall. We had two other handheld cameras. A lot of people coming and going. Igor has four or five people who are all very interested in watching. So it’s a typically crowded room—and it’s smaller than rooms in most Western hospitals.

Marsh: Many times smaller. There is no storage facility so it’s quite cramped in this one room. How common is that type of surgery?

Marsh: Not really [common]. That particular operation, the tumor, which Igor and I removed, is fairly rare.

Smith: Hadn’t ever been done before.

Marsh: Hadn’t ever been done before in the Ukraine. They were judged inoperable in the West until 20 or 30 years ago. In the modern era, with the MRI scanning, most could be operated on. But Marion had been told that his tumor was inoperable. That will come; more will be operated on. What goes on elsewhere in the Ukraine, I don’t always know. There is a big neurosurgical hospital in Kiev. Igor tells me, and I believe him on the whole, ‘What we’re doing is better than what they’re doing.’ I know we have some better equipment. Because I don’t speak Russian or Ukrainian, I tend to rely on what Igor tells me so I’m well aware that I might see things through his eyes. There are several instances in the film where you are speaking with a patient and you’re telling the patient that their tumor is inoperable. Obviously, that’s something you have to do almost on a daily basis.

Marsh: When I go there, yes. In the Ukraine—which has a population of 50 million—tumors of course are very rare, but these people have been told they have an inoperable tumor. They know that Igor has this visiting surgeon who comes from the magical West and they hope I’ll be able to help. Also, I don’t charge. So you get this great big queue of people. In these few days I will see more difficult, more inoperable brain tumors than I will see in six months in London. My hospital is one of the biggest in London—we cover a population of three-and-a-half million. It’s professionally very interesting for me—I see all sorts of extraordinary problems and there are no minor problems at all. But at the same time, a lot of them are inoperable or very tragic. In the scene with the 23-year-old girl, you and Igor are discussing how difficult it is to diagnose someone, especially someone so young, and basically tell that person he or she is going to die. Igor does not even tell her how ill she is.

Marsh: No, he does not want to get too involved with it. The problem was, she walked into the room and neither of us knew her. She looked fine. The story I got through translation didn’t quite add up. I held up her brain scan and it was a death sentence. What do you say? When I see similar cases in England, which is not very often, there are other members of the family present, the patient has been told they have got a brain tumor. In that case, I’m not sure if she had been told. She had been told in Moscow that it was encephalitis. In Western Ukraine, there is still a tradition, which maybe some of the patients want: they’re not always told the truth. How do you decide, on the spot, what to say? Igor’s in a difficult position. It was all left rather unclear at that stage.

Smith: It is even law, Igor told me, to protect someone from harming themselves, that you cannot inform them of such a diagnosis without a family member present. Because you can imagine someone leaving a hospital after being told that and walking in front of a bus. In the meantime, Igor asks the patient to come back with her mother. It does seem like the people you diagnose who are accompanied by family members, while not necessarily accepting, do not express the anger or frustration you might expect.

Marsh: It’s a different culture. I’ve never, in all the years I’ve gone there, seen people react the way they do in films under these circumstances. Also, it is a country that has seen so much suffering in the last 100 years—they’re not inured to it, but they are more accepting that life is terrible. At least 25 percent of the population of the Ukraine died violently in the last century, from the civil wars and the famines in the ’30s and during the Second World War. These families are not unfamiliar with tragedy and they have to get on with things, so they’re not going to throw up their arms. Igor had suffered some professional setbacks because of the Ukrainian bureaucracy. He was unemployed for two years at one point. How dangerous would it be for Igor if something were to go wrong during a surgery?

Marsh: Quite dangerous. It’s still dangerous. Just last week, he did an operation on a baby, which I wasn’t very keen for him to do. He was doing an operation nobody else wanted to do. He doesn’t normally operate on the babies. The official neurosurgical establishment, when they heard he was thinking about doing this, Igor said, were very angry and they called in to sponsor it. But the baby’s parents found that Igor’s treatment was superior to what was on offer from the official neurosurgical hospital and they trusted him to do it. It’s a dangerous act, a big gamble. But he is willing to take risks—they’re all calculated risks, but over the years I’ve worked with him, he’s usually got things right. As you see in the film, his practice is legal—he has a private clinic, and he has protection to a certain extent because he’s operating in the SPU, the Secret Police Hospital, from which he rents space. The senior doctor there is very supportive of him and recognizes his individualism. But it could get very dangerous for him if he has a bad result because then the government will publicize it and say, ‘This guy’s not a proper neurosurgeon and shouldn’t be doing this.’

Smith: In fact, before we made the film, this journalist from the TV station dug up a patient from 15 years ago, when Igor was following the textbook, which was wrong—

Marsh: This was before he met me.

Smith: And now, they present the woman as if it’s just happened. They go interview her and they show this program eight times. Can you imagine? Eight times. And he’s really paranoid so he closes down, not in the sense of operating, but he will not take any patients that could be a risk.

Marsh: And he tells patients, ‘I can’t take the political risk.’

Smith: For six months he flies under the radar. The patients suffer.

Marsh: He had a few patients who died, who probably would have survived if he had operated.

Smith: So that’s typical of this highly jealous society.

Marsh: Some people say jealousy is the national characteristic of the Ukraine; or, if a Ukrainian peasant’s neighbor’s cow is better than his, he will kill his neighbor’s cow…. It’s really like that. He has to struggle all the time. When he was less protected, he was a victim of death threats and department shutdowns. Could you tell me a little bit more about your patient Tania? Did she go to London to receive treatment?

Marsh: I brought her to London, yes. I paid for that myself, in fact—not for the hospital treatment—I was able to, and my National Health Service hospital kindly agreed to let me do it. It wouldn’t happen now. They’d be much more cost-conscious, saying they would not want to treat patients free of charge. But it was a kinder world 10, 12 years ago. It was obviously a good humanitarian thing to do. She had a benign tumor; it was one of the largest tumors we’d ever seen. You can see in the video, she was slowly dying—so she was going to die anyway. In that sense, there wasn’t that much to be lost. One of the problems in neurosurgery is when operations go wrong; it’s not necessarily that people die but they are terribly disabled. Her personality was pretty amazing, fully intact, but she had a completely paralyzed face and terrible coordination [in] her arms and legs and she couldn’t breath, like Christopher Reeve. She was stuck on a ventilator for several months in my hospital. She didn’t speak a bit of English, and her mother didn’t speak a word of English. Although we had a translator, it was psychologically a very difficult time for both of them. And the nurses as well. They were sort of conciliatory but it was a very stressful time. The what?

Marsh: Then she got off the ventilator and I had them in my home and took them around London in my car. I felt very personally involved with both Tania and Katy even though they didn’t speak English and I didn’t speak Ukrainian. It was odd to be so close to someone without actually having a shared language. Eventually she got back to the Ukraine and was stuck for a year in Kiev because she was too old to get to her own home, which was 300 miles away. Then she did get home and was slowly improving. She could not only stand but almost walk. Two years after, she died—probably because I had to put some tubing in her brain to correct an obstruction, and I’m pretty sure the shunt [effectively prevented her from life-saving treatment]. In effect, I sent her back to the Ukraine with a bit of a high-tech medical implant, which was inappropriate or couldn’t be fixed in rural Ukraine. It wasn’t as if it was a mistake in the sense of doing the wrong operation or making a technical mistake. The mistake was a much more morally complex mistake. It was taking on a problem I couldn’t help with really, in a sense making things worse. But, in [another] sense, nothing ventured, nothing gained. In fact, throughout the film, I still don’t have the answer, although practically I wouldn’t be in a position where I could offer that kind of free medical treatment to somebody from overseas. Again, that’s not the way things work. And also, having one case like that, which must have cost a half million dollars in theory to the hospital, I couldn’t reproduce it. But it’s a problem. How so?

Marsh: There’s a Jewish saying, ‘He who saves a life, saves the world.’ Such as when Madonna goes to Africa and adopts a baby. Given the [financial] resources, if we’re going to try to help people and save lives, maybe being sentimental and trying to save one child is actually not a good investment. The resources are limited. You have to consider, What are you trying to achieve? Of course an awful lot of Western aid is trying to massage our own egos, our own guilt about the fact that we’re so wealthy and comfy and most of the world isn’t. So we save the lives of a few children and send teddy bears to Romanian orphans, which makes us feel better, but actually doesn’t make much difference. Coming from a wealthy affluent country and going to work in a poor country, these gestures really don’t mean anything. First off, the effort has to be really sustained. Whereas just flying in, a hit-and-run consultancy—things could be done better. It has to be sustained. And of course then to do this sort of work in a sustained way it has to be on a private basis. You won’t do this through an NGO. It’s really on the basis of a professional friendship. To me, ultimately, that’s what the film is about. I go there because Igor and I have become close friends. I’m not going there now for the greater good of humanity. Igor and I like working together and solving problems. It’s creative work. How did you two [Henry Marsh and Geoffrey Smith] meet each other? I know you made another film together.

Smith: We met each other because I was asked by the BBC to make one of a series of films about surgeons. I was the last [filmmaker asked to participate]. And I said to the boss, ‘I’m the last one, but who is the most interesting surgeon you have met from a humanitarian point of view?’ And he said, ‘Oh, Henry Marsh, in south London.’ So I sat down with Henry and we clicked immediately and soon discovered this mutual love/hate relationship with the Ukraine—very few people have ever been there, have the history that both of us had. I’d always wanted to make a film there. That was the beginning of it. That first film [Your Life in Their Hands (2004)] was very successful, won a big award, six million people watched it on the BBC. It put Henry on the map. It opened up the idea of doing a doc [about his work in Ukraine]. When you were shooting the doctor-patient sessions, I presume you were asking permission in advance?

Smith: We had a Ukrainian crew in the corridor [where patients waited]. They were talking to everybody because those people were obviously there for many hours.

Marsh: They come from all over the Ukraine. They can’t afford to stay in a hotel. Although it’s against the rules of the hospital, Igor lets them sleep in the corridor.

Smith: They were being spoken to by the second crew of Ukrainians. When it came time to [enter] the room, they knew exactly what to expect. Igor did tell them that we were part of his team. People enjoyed talking about their stories. There’s no history of exploitative or obtrusive television in that country, so if someone is interested, they will talk to you about their experience. That’s what I like about the Ukraine. The people have a great capacity to tell stories and to engage you directly. You [Geoffrey Smith] have made a couple of films about Haiti. In one of them you tried to track down a man who shot you?

Smith: It was a long time ago. I had some friends who were making a film there. I went there to live for six months. I turned up and was working with them. It was voting day and things were going well, but then, as we were going downtown, a group of people were coming down the side of the street with guns. The two guys I was with knew immediately what that meant—they radioed the radio station to tell people to stay inside, which turned out to be a very wise decision. Those people had been sent down with no other mission than to kill people, anyone, to spread terror. They had gone into a polling station and they had massacred 23 people; they would have killed more if there were more in there. My guys were filming the aftermath of that. But 20 minutes later, two of the [armed men] came back because they were aware that we were journalists. The guy in front of me put his hands up—he was shot and he later died. I’d gone behind a wall. I felt this red-hot light through my shoulder. Eventually, I got to hospital and was told, ‘You can’t stay. You shouldn’t stay.’ Within a week or so, I was back in the U.K., much against my best wishes. Going from this country, which copes with [dire circumstances all the time], I went to a place where I had all this time to think about having no job and it was the wintertime. It was the wrong thing. I didn’t get over the situation. I just said to myself, ‘I have to go back and exorcise this.’ In the end, I met with a guy who was a voodoo priest. He had this very wise way of talking me through what was happening. We met in the countryside. It actually made me feel better. It [Searching for a Killer (1987)] was a very haunting, cathartic film. It showed me that you could use a camera to get better. You could work things out with a camera. In a way, it’s become quite important to me to focus on people who go do things that are quite difficult. To go back to an earlier remark, you said that you both have a love/hate relationship with Ukraine. From where comes this love/hate?

Smith: I caught the Trans-Siberian train back in the mid- ’80s. On the train, you meet lots of people and several of them were from Kiev. We kept in touch, and when the Wall came down, I went there. I did really fall in love with the place. It was very dire back in the mid ’90s. But since [then], the possibility for change—it’s intoxicating. That’s what I like about it. I just felt strongly connected to the people and, in a way, [was] trying to help them. Henry has a very tangible way to help them. I don’t quite have that. It’s one of those places I come back to—something about the landscape. It took about 70 years of not being able to talk, but these people have such stories, some of which are so traumatic, dramatic. They’re willing to engage in a very dark, black humor which I like. And I just find it visually quite interesting.

Marsh: It’s not really love/hate—it’s almost love/frustration, isn’t it really? Though you can meet some very unpleasant people.

Smith: There’s this corrupt businessman who got a bribed court order to say the road around Igor’s new hospital is his. So he’s going to charge Igor to have access to his road. But that’s up against great things like Marion coming to Igor’s practice so he can get treatment. How likely do you think it is that Igor will be able to build his own hospital?

Marsh: I think it’s quite likely. It won’t be for two or three years and it rather depends on the political situation. It continues to lurch back and forth from authoritarian, corrupt Russian tendencies. It’s very unclear whether the country will end up more like Europe or not. Are you [Geoffrey Smith] working on a new project?

Smith: Not quite, although I have a couple of things brewing. This film has dominated my life. It took a year to make it. When did you shoot?

Smith: February-March 2007. We had the world premiere at the London Film Festival in October. In essence, I am a one-man distribution company. So you’re still looking for distribution?

Smith: We’ve got a TV deal for next year on PBS. But in the meantime, we’re trying to get it into cinemas. People generally like it and they’re very moved.