Every year 33 million people globally are left impoverished after paying for surgery. Others die for lack of treatment. New Zealander Ian Bissett has been operating on desperately poor patients in Nepal for more than 20 years. He tells Eloise Gibson his remarkable story.
Ian Bissett is not a brain surgeon, or, at least, he never meant to be.
Given the choice of operating on someone’s brain or sending them to a neurosurgeon, he’d always prefer to send them to a specialist.
But you don’t have the normal range of choices when you’re the only surgeon serving a region of four million people.
A patient with a bad head trauma in Pokhara, Nepal, might not survive the journey to a larger city. “You couldn’t say to someone, take eight hours on a bus and go to Kathmandu for treatment,” says Bissett. “I had to drill holes with a hand drill. We did not have a CT scanner. We had X-rays, and clinical examination, and then we had to make a decision,” he says. “Does this person need a craniectomy?”.
As the lead surgeon at Western Regional Hospital, a large government hospital near the Annapurna tourist region, Bissett carried out limb surgery, abdominal surgery, burns surgery, paediatric surgery, urological surgery and virtually every other kind of operation he could manage, as well as about 30 neurosurgeries a year. He read books written by doctors in Africa on how to achieve the best outcomes using only the simplest procedures.
His first year in Pokhara was very hard. If a patient couldn’t walk, a friend or relative would have to carry them to the hospital. Sometimes the walk took several days.
Before Bissett arrived, in 1987, a population about the size of New Zealand’s had been without a general surgeon. The last one left some time before Bissett was hired at the hospital. “If someone had a severe intra-abdominal injury, then mostly they would die,” says Bissett. If they had a bad fracture, “they might get some kind of external splinting, but often it would mean that someone who could have been restored to normality would be invalided.”
That first year, the hospital had no anaesthetist. The only option was a spinal anaesthesia to numb the lower half of the body – enough to remove somebody’s appendix, but not to do any major abdominal surgery. Bissett’s first task was recruiting a British anaesthetist. That expanded the range of surgeries that they could do. Two years into Bissett’s stint, a plastic surgeon arrived and took over the burns and orthopaedics. Meanwhile Bissett helped train Nepali surgeons, who also shared the workload.
During the best times, there were three surgeons working at the hospital. That meant Bissett worked during the day and was on call every third night. He kept this up for 11 years. “Usually there wasn’t an operation in the small hours, but usually there was one in the early part of the night that you would do to get through,” he says.
He and his wife Jo had had arrived in Pokhara with two small daughters. Their third child, a son, was born in the operating theatre where Bissett did most of his surgeries. While Bissett was waiting to catch the baby, people kept trying to direct him off to do other things. “Life is different over there,” he says. “The desperation that people have is much greater. The amount you are able to do with so little is much greater.”
By 1998, he was shattered. “I was completely exhausted. There was the longstanding working too hard. And our eldest daughter was about to turn 15 and the educational opportunities were shrinking for her,” he says. “We did a lot of soul searching and decided we did not want to send our daughter back to New Zealand without us. It was time to come back.”
Bissett is calm and lanky, with sympathetic dark brown eyes. He is the kind of doctor you would probably trust to cut you open, if necessary. But surgery was not in his original plan. He started medical school thinking he’d become a GP in a nice, rural area. He was involved in Christian groups on campus, and they were interested in helping people overseas. During his final year of med school he had to do a three-month elective. He and Jo, newly married, went to Nepal and walked a day and a half with their gear to reach a remote, 20-bed hospital.
In Nepal, Bissett saw medicine he’d never seen before. “We saw tuberculosis, tetanus, all sorts of other infectious diseases.” The doctor he was helping was doing eye surgery, fixing fractures, and other very useful things. “Suddenly I saw all that could be offered by surgery into this situation where there was basically nothing.”
He returned to New Zealand with a new plan, to learn surgery. He completed his advanced training in Wellington, making sure to get some training in neurosurgery and orthopaedic surgery. He sent an aerogram to Pokhara offering his services. It took three months to get an aerogram back: Yes, come. The couple raised money from friends and their church and Bissett linked up with a Christian health aid organisation called International Nepal Fellowship. By the time they’d done all this it was 1987, and they had two young daughters.
But, despite the astonishing things he did in 11 years at Western Regional, Bissett landed back in New Zealand feeling unconfident and under-qualified. In Nepal, he’d been a senior surgeon. While he’d been helping people with an endless range of problems, his New Zealand classmates had been specialising, mastering keyhole surgery and other cutting-edge techniques. “I wasn’t up to date,” he says. “It was much harder coming back to New Zealand than going to Nepal, because suddenly I was in this place I should have been familiar with and yet it didn’t feel familiar for a long time.”
Bissett started studying for an MD with Graham Hill, a professor of surgery at Auckland University medical school. In 2002, Bissett took over Hill’s job, and continued rising up the med school ranks. He established himself as a colorectal specialist.
But Nepal wasn’t finished with him, or maybe he wasn’t finished with Nepal.
Starting in 2004, he returned every year for a decade to run surgical camps with International Nepal Fellowship. He and a team of medics would be invited to visit a remote district, where the hospital did not have a surgeon, but needed one.
In the space of just over a week, he and the team could see and assess up to 1500 people. Some patients would need medication. Others would need an ultrasound to see if they required surgery. Others had already had an ultrasound elsewhere and been diagnosed as needing surgery, but had no money to pay for it.
Even at government-run Nepalese hospitals, only about 10 percent of the beds are free, says Bissett. “You will pay an admission fee, you will pay for your bed, you will buy every bit of medication that you get – your intravenous fluid, your catheter, the stitches that we use in theatre,” he says. “So, for some of them, by the time they’d had their ultrasound scan and one or two other things done, their money was gone. It is a global problem, this problem of the expense of surgery.”
The Lancet Commission on Global Surgery supports this. It found that over half the global population cannot get the surgery they need should they, for example, haemorrhage after childbirth, suffer a burn, or develop cancer. The commission estimated 33 million people a year suffer what the report calls “catastrophic expenditure” on surgery. According to the commission’s report: “One quarter of all people who have a surgical procedure will face financial catastrophe, as a result of seeking care.”
“The decision-making is hard for families,” says Bissett. “Do they get treatment or do they not?”.
At the camps, surgery was given free. They would advertise on the radio, and people would just turn up. “It was basically a M.A.S.H. camp,” says Bissett. “You couldn’t ever catch up, because we would only go for two or three weeks.”
After the 2015 camp, things changed. Following an influx of aid organisations after the 2015 Nepal earthquakes, the Nepalese government changed the visa rules for foreign medics. It became time-consuming to get the work visas needed to gain temporary medical registration. Applicants had to be present for the lengthy process, which ruled out many volunteers who also had full-time medical jobs. Twice, Bissett organised camps but had to cancel when he realised they wouldn’t get visas.
He still goes back to Nepal most years to teach, and see his former colleagues, several of whom have become close friends as well as stellar surgeons. One is head of surgery at Western Regional Hospital – more or less Bissett’s old job, only the hospital is more advanced now. Another former trainee is a professor at a medical school. The groups always gets together for a big dinner.
There is another friend that Bissett always tries to see. In the late 80s, he treated a 29-year old mother with a debilitating infection that had left her digestive system in tatters. Bissett operated, but her wounds leaked digestive fluid into her bloodstream. He treated the woman for three months, but she died, because he couldn’t get enough nutrition to absorb into her ravaged system. Since the woman’s husband was away working in India, her 12-year-old son washed his mother and brought her food to hospital each day. The son is now a 40-year-old accountant with two children of his own. Back in New Zealand, Bissett has been developing a medical device that could help people like the man’s mother. He came up with the idea after talking to his New Zealand colleagues about ways to help his Nepalese patients. The device reduces the time it takes until patients can use their guts again following bowel surgery from five months to two weeks, allowing them to get stronger, quicker by absorbing food. It has already been trialled at Auckland City Hospital. Now a start-up company – just renamed the Insides Company – is working to commercialise it.
Bissett hopes the product will save lives in Nepal, as well as helping New Zealanders recover faster from bowel surgery. But although the man who lost his mum is always keen to see Bissett, he finds it hard to talk about his mother’s illness. Bissett doesn’t blame him. He sits quiet for a moment after telling their story. “It would be interesting to talk to him about it. It must have been hard for him.”
Unless the visa status changes, creating a product may be Bissett’s best shot at saving more lives in Nepali hospitals. It is possible he has already performed his last Nepali operation.
In Auckland, he publishes research on topics such as how to help people with bowel cancer. He is senior at the medical school and serves as a surgical consultant at the hospital. He chairs the New Zealand National Bowel Cancer Working Group. For a time, he was president of the Australia and New Zealand Colorectal Surgical Society, and for years he was the academic head of surgery at Auckland University.
None of it is brain surgery, mind you. And that’s probably an enormous relief to Bissett, who started out wanting to be a rural GP and only switched to doing operations out of sympathy for people.
“There was a big need,” he says.