A Siberian post mortem

“Do you work in Humanitarian Aid?” the man asked.
I’d just finished my weekly swim and was waiting for my hair to dry. After all, when it’s minus 29ºCentigrade, you don’t go outside with a wet head, even if you have got a cosy Russian fur hat.
Yes,” I answered.

He was staring at me. “Do you work with tuberculosis?” he asked.
“Yes,” I sighed. People often came up to me in the street here in Tomsk, asking whether what I’d said on the local TV was true.
But I wasn’t expecting his next question: “Do you want to go to a post mortem?”

Now I laughed. “It’s got to be yes to that too,” I said. “And you win the prize for the best chat-up line I’ve ever heard!”
He stepped back. “So you’ll come?”
I smiled. “When and where?” 

Three days later, he picked me up in his Jeep. “I’m Mikhail Alexandrovich,” he said. “Misha to you. I’m a pathologist. Have you ever been to a post mortem before? I hope you’re not squeamish?” He started driving me through the back streets.
It was January 1995 and Russia was falling apart. The food shortages meant you grabbed anything edible you saw for sale. The hyper-inflation was so out of control that, although bread was still baked in tins engraved with the Soviet price of 4 kopecks, a loaf in this brave new world now cost thousands of rubles. It wasn’t uncommon to see old women crying when they couldn’t afford even half a loaf. You bought anything you could even imagine you might want, before it got too expensive. Since that might be only a few minutes later.

I had it easy. I was paid in dollars.
Life was much more difficult for the Russian TB doctors.
Most of them hadn’t been paid anything at all for months. Many had pogrebs, cellar-stores of pickles and preserves and vegetables gathered in the brief summer. Even so, I never worked out quite how they survived. Or why they kept on turning up to work. 

The prison TB service was a branch of the military. So when the local regiment were shipped out to what was later going to be called the First Chechen War, many of my favourite prison doctors had been sent along. Only a few returned and they, well they were never quite the same again. 

Misha turned onto the bridge over the River Tom. “This’ll be new for you,” he said.
I wasn’t so sure of that. We seemed to be driving towards one of the places which relied on the humanitarian aid medication I was in charge of: the big adult TB hospital. The Russian TB system was based on inpatient care and the largest TB hospital in Tomsk had over 800 beds. Length of stay there was measured more often in months than in days.
Misha drew up by a low building. He jumped down to greet two doctors sitting outside, wearing bulky winter coats under their medical white uniforms. Plus their fur hats of course. 

“Caroline!” one of the ladies gasped. “What are you doing here?”
Olga Sergeyevna and I got on well. I knew what a good doctor she was. But for some reason she wasn’t at all happy to see me now. 

“Ah!” Misha said. “You already know each other.” He bowed his head, and turned on his heel. “Stay here. I won’t be long.”

An uncomfortable silence followed.
“Misha invited me,” I said, brightly. “Why are you sitting outside? Let’s go in.”
Olga’s companion, Zhenya, was scornful as well as gloomy. “It’s even colder inside,” she told me grimly.

It took a while and several false starts before I worked out what the problem was. Post mortems in Russia are apparently more adversarial than educational. A doctor who makes a single wrong diagnosis, or starts the wrong treatment plan even once, can get in real trouble.

“Isn’t it the same in London?” Olga asked, wide eyed.
“Not exactly”, I said. “We try to recognise that bad systems cause more problems than bad individuals.”
They both looked puzzled and I started to worry they might think we didn’t care about our patients.
“Of course”, I said hastily, “if someone kept making mistakes, or made a really basic error, they’d have to explain themselves.”  

Misha had returned by now.
“We pathologists always get the last word!” he said. “It’s the same everywhere.”
He smiled broadly, then unrolled a soft leather sack to reveal his collection of knives.
Now he set about sharpening the largest of these: knife onto knife. It was very noisy and very impressive. The longest of the blades was longer than my arm. It had been ground away by Misha’s sharpening and looked dangerously thin. 

We all went into the morgue and Misha positioned me opposite him.
“What am I standing on?” I asked. “These parcels are … crunchy.”
“Sorry,” Misha said. “The police bring us all of them.” 

When I still didn’t understand, he spelled it out: “They assume anyone found in the street is one of ours. Dead from TB.”

The ‘parcels’ I was standing on were frozen bodies.

He grinned. “They always take ages to defrost. You won’t have done any harm”, he reassured me. The hospital doctors had already told me that many of their patients were vagrants who ran away whenever the temperature went above minus 21ºC.“They go because we won’t let them smoke or drink,” the doctors had explained. “When they’re out, they sleep in the drains. When it gets too cold, they can’t survive outside.”

Misha’s assistant cleared me some space. 
Then Misha breathed in, focusing on his knives and the body in front of him.
Before, I’ve always seen chests opened with power tools. But Misha used his knife to slice through the sternum as smoothly and quickly as if he were cutting through butter. 

I couldn’t take my eyes off him. It’s hard physical work getting deep inside a human body, especially if your only tool is a sharp knife — but Misha was almost sensual in his gentle handling of this lady and her insides. She had been an inpatient in the TB hospital, and you could easily see the classic tuberculous ‘caseation’: multiple cavities, full of a cheesy goo.

Then we got to the abdomen. Even through all that cold, there was a faint whiff of putrefaction. “It’s pus”, he said and I nodded as he started slowly, systematically working through the guts from top to bottom.
“Look at this,” he purred. “Look. At. This!”
“What is it?” Now he was interrogating me.
“Appendix?” I hazarded a guess.
“Yes!” he exclaimed. He frowned at the other doctors. “An avoidable death. Who’s the doctor?”

Olga started burbling: “She’s been complaining of stomach pain, and head pain, and leg pain, and everything pain for months now. There wasn’t anything out of the ordinary.” 

“Except,” Misha interrupted, “she didn’t ordinarily die. Did she!” 

All this lady’s insides were lying outside her, on the table. I was shocked when Misha now dumped them back in the wrong way round — lungs in her abdomen, guts in her chest. He sewed most of the torso back together, and told his assistant to finish off.
Then he grabbed my arm. “Now you’ll see what happens next.” 

He drove us all up to the main hospital building and strode through the wards, until he found the doctor in charge for the day, Natalia Ivanovna. She was having tea with Ivan Nikolayevich, that day’s lead surgeon. 

All hell now broke loose.
Misha started explaining about the “terrible mistake” he’d found.
Olga Sergevevna told everyone in earshot how difficult this patient had aways been.
Natalia Ivanovna wanted to know how on earth I’d got involved in all this.
Ivan Nikolayevich obviously didn’t like Misha and especially didn’t like being interrupted by him.
I joined in too, trying to explain the system failure concept. 

Eventually Natalia Ivanovna took control. “Mikhail Alexandrovich,” she said loudly, “we’ll discuss this privately.”
She grabbed Olga, waved me away, and firmly shut the office door.  

My Russian was good enough to argue and tell jokes — all you can ask for from a language. My hearing, though, wasn’t — still isn’t — good enough to hear what is being said behind a closed door.
And really this was none of my business.
I might have had humanitarian aid in my job title.
I might know how the rest of the world treats TB.
I might even have been the person with access to the funding and medication the Russians desperately needed.
But this was their health service. 

As I stood alone in the corridor, I remembered I was only here to lead a large-scale academic project. To support and nurture, not supplant or take over.

Afterwards, despite what I had been told about the trouble doctors could get into after post mortems, I think nothing very bad happened to Olga. She and Natalia Ivanovna and Ivan Nikolayevich carefully, but very definitely, avoided ever talking to me about what had happened. Misha disappeared and I never saw him again.

And I learnt that external consultants, however ‘humanitarian’ they might be, are not all-knowing or all-powerful.
And certainly have no right to think they always know all the answers.

IMAGE: Nurse giving meds to a prisoner behind bars in the Tomsk TB prison. The prisoner’s open mouth is so the nurse can check the meds were swallowed. Image: Nachtwey. https://prisonphotography.org/tag/tuberculosis/

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