The Italian war surgeon and Right Livelihood-Award winner Gino Strada has operated on over 30000 victims of war and poverty. The majority of them are civilians. "Armed violence against civilians is spreading like popcorn all over the world", he says - and urges UN officials, governments and civil societies to declare war and arms trade illegal. Sure, he knows it's a utopian dream. But why not start this discussion? To me, Gino Strada is a true agent of change. His vision and idealistic aims are rooted in the harsh realities of his experiencens as a war surgeon.
Gino Strada, you could have made a brillant and comfortable career as a cardiologist in Italy, but you decided to become war surgeon instead. Why?
The most relevant factor was pure curiosity: To see what my work would look like in countries where you have a lot of wounded and no doctors - compared to Europe where you have few civilians injured and doctors waiting for their patients in the hospitals.
Where did you go on your first mission?
To Quetta, at the border between Pakistan and Afghanistan. This was in 1989; I was working there for over a year. And there I realized the ugliness of armed conflicts: fighters we saw very rarely, 90 percent of our patients were civilians.
Women and children?
Oh yes. Children made up to 35 to 40 percent of the patients. Most of them had wounds from shrapnel, bombs and rockets. Not many were hit by bullets - patients severely injured by bullets would hardly have survived the journey to the hospital. A lot of patients though were injured by anti-personal mines. Mines that look like butterflies and function as baits for children: the mines explode if they are picked up. Today there is still an estimate of eight till ten million unexplodes landmines in Afghanistan, a country of 25 million people. So each person has got half a mine waiting somewhere.
How much can you do as a surgeon?
If you know how to do war surgery, the results are excellent. But it has been a big learning curve for all of us.
What did you have to learn?
You have to focus on what is called wound surgery, something a typical Western surgeon has harldy ever done. That means, you have to adapt to a new surgical approach. Let me give you an example: You have a tiny hole, just about three millimeters big, caused by the explosion of a landmine. For most surgeons this looks like a nursing practice, not a surgical operation. They would say: “Easy, one stich.” This is a crucial mistake. Because in doing so they don’t take into consideration that contaminated metallic fragments as well as sand, stones, grass, mud, pieces of cloth and material are sucked deeply into the wound as a landmine explosion, as far as the energy transfer is concerned, is much more destructive than a bullet. So if you have this tiny hole and make a centimeter wide incision you find a lot of things and dead tissue inside that you have to remove. If you don’t, this can lead to an infection and sepsis. Surgery of the wound is tedious and time consuming, but it’s what makes all the difference for the patients.
Let’s assume you receive thirty patients at the hospital within just a few minutes. Which patients do you operate on first?
We do a triage: We decide which patient is in need of urgent surgery and how the chances for him or her are to survive. There is no point in wasting three, four hours for an operation that is basically hopeless whereas in the meantime three or four other patients die who could have been saved. You have to make your decision for what is best for the majority of the patients. You can’t approach it individually. It’s always a difficult process and a difficult decision. Even if you have a good hospital and three surgical teams each of which can operate on one patient at the same time - if you have 30 patients, 27 have to wait.
"Sometimes we are put under big pressure by a commander coming in with a gun saying: 'You do surgery on my man first'"
How do you explain this to the families of patients who have to wait and thus are doomed to die?
This is often heartbreaking. But we can only do what we can do. Sometimes we are put under big pressure by a commander coming in with a gun saying: “You do surgery on my man first.” In these situations there are no rules or common sense. Then you just try to keep the situation as calm as you can.
How often are you confronted with family members who refuse any treatment of their child or relative?
Again and again. There are clans who refuse do donate blood for their patient, for instance. Then you have to spend endless hours to convince them that it is necessary. Sometimes you have people, who say: “I don’t want you to amputate the leg of my relative.” I answer: "Sorry, the amputation has already been done by a landmine. Now we have to try to save your relative.” Such discussions could go on for hours and which really pushes us to our limits - especially when we receive fifty patients within twenty minutes.
How do you manage fifty wounded in twenty minutes?
You need an infrastructure that is able to respond to mass casualties. That means you need to have a sufficient number of operating theaters, intensive beds as well as ward beds. And trained staff. Surgeons, anaesthesiologists, nurses. An experienced nurse does the triage. She says: “These three patients first, then the next three.” We carry on for 24 hours, then we have operated almost all patients. The problem becomes a big one, however, when you start having fifty wounded per day. Then you have to start reviewing your admission criteria. There have been occasions when a patient with an exposed fracture was refused, because we knew that it would have been impossible to deal with him. We just stabilized the fracture, gave him antibiotics and told him: “Ok, come back in two days.” We have to limit ourselves to the most urgent lifesaving procedures.
How do you stay awake at the operation table?
I drink coffee from early morning till late in the evening and then go to sleep. But I like it. I love surgery. I am a surgical animal.
I had the honour to interview Gino Strada for the Swiss magazine
annabelle in Zürich just days after he received the Right Livelihood Award.
His core message: To declare war illegal.
Hospitals in conflict zones have been severtely targeted what makes it even more difficult for medical personnel to do their work. How do you deal with that?
I just try to go on. But yes, Yes, work has become more difficult. The so called rules of the Geneva Convention are very good in times of peace, in war they mean nothing. I have never seen a hospital respected - particularly in the last 10 to 15 years. Moreover, in Afghanistan we have been under threat because we have been accused of treating Talibans. Whenever that happened I said: “Yes? So what? This is a hospital” When you receive a patient in Zürich or in London, do you ask: “Who are you? How do you vote? Are you right or left wing?” Or do you take care of the patient?
How frustrating are such incidents?
Very, very frustrating. The fact that soldiers have enemies doesn’t mean that we have enemies. We just have patients. I don’t care about the political field or the opinion of a patient. I don’t care if the patient is a soldier fighting for democracy or a terrorist fighting for the wrong ideas. In Libya we sometimes had patients who might have been associated with ISIS. But this is not our problem. A doctor is a doctor, not a judge. This, however, is difficult to understand for those who are involved in military activities.
What makes you stick to the job as a war surgeon?
The fact that’s a necessary job socially and interesting from a surgical point of view.
Your organisation Emergency doesn’t only provide medical care to victims of war but also to people who live in poverty and can’t afford medical treatment. You provide free medical care from Afghanistan to Sudan – which made experts of international development and cooperation raise their eyebrows in disbelieve.
So what? Every single person on this planet has the right to get access to excellent medical care that is free of charge. There can’t be any differences in quality. It’s scandalous that there is no specialized hospital for cancer patients in Africa, for example. Either the right to treatment applies to everybody or we start defining basic health care as a privilege for the rich and wealthy.
"The so called rules of the Geneva Convention are very good in times of peace, in war they mean nothing"
The centre for cardiology in the Sudanese capital Khartoum, that you opened up in 2007, has less incidents of infections than a comparable clinic in Europe. How do you do that?
It’s all about hygiene. It’s the single most important factor. This is something that has been neglected by a lot of hospitals in Europe. Doctors and nurses don’t wash their hands, don’t wear masks. Cleaning is delegated to some private companies. And why should they care? We are maniacs about hygiene. If somebody fails twice in following our rules, he or she is dismissed.
You plan to establish eleven more clinics in Africa. The costs will sum up to 250 million Euro. Isn’t that amount out of reach for an NGO like Emergency that is mainly financed by donations?
Why? 250 million Euro – these are the costs for a single day of war in Afghanistan. The money is there. It’s just the question: What do you want to spend it for?
Having worked in all those conflict zones, you would be perfectly fit for a political career. Are you playing with this idea?
Not at all. Of course, politics affect our work. But too often have I seen that members of war faring parties fighting each other basically say the same. This was particularly true in Iraq: I had a very good relation with leaders of both sides, I even had a kind of friendship with them. And I asked them: “Guys, why are you shooting each other? You have the same goals!” I never got a convincing answer. Thus I try to stay out of politics.
Gino Strada (2nd from left): ""I am a surgical animal". Photo Credit: GiBi Peluffo
However, you have become a peace activist. You said once, humanity has never before been as endangered as it is today. Isn’t that too bleak a vision?
No, the risk for humanity is becoming higher and higher. In my opinion, war and terrorism are exactly the same thing: There is no difference between the killings of civilians by the occupation of Afghanistan or the killing of civilians by suicide bombers. We see that every day. Those forms of violence are popping up like popcorn all over the world - particularly because weapons of mass destruction are available to so many people – not only to official armies.
You fear a nuclear attack?
Of course. Today even a nuclear test or an accident could produce innumerable victims. Take Italy which is around the corner of Switzerland. It has at least 70 warheads, each one of them at least 20 times more powerful than the bombs in Hiroshima. These warheads are not even stored in places that are protected. Moreover, I would be surprised if the guys from ISIS weren’t busy trying to get a hold of nuclear weapons. So - the overall risk is increasing.
You make passionate pleas for the abolition of war. Isn’t that naïve?
Why? We have to start thinking of a possible world without war, terrorism and violence. A world where human beings eventually learn to solve their controversies without using violence anymore. The first step would be to start thinking – which hasn’t been done so far. Why, for example, hasn’t this issue of the abolishment of war been put on the agenda of the general assembly of the UN? Not even once? And this despite the current situation and the risks that have been increasing since World War Two? When I was in Geneva lately to speak at the UN I said: “Take the preamble of the UN charter. The UN were established to save succeeding generations from the scourge of war. Now, there have been 170 conflicts since then and you have never even discussed the issue? Come on, guys, this is incredible!”
What did UN Secretary General Ban Ki-Moon comment on that?
“I couldn’t agree more”. That’s a beginning, at least. We need to start to imagine a possible strategy: If war is declared illegal, this could probably constitute a base for discussion and push further steps in direction of disarmament. Will say: This could increase the pressure on governments to disarm rather than to re-arm. As long as there is hardly any pressure and as long as there is no strictly led discussion concerning these issues, there won't be a change. No one will ever say: “Ah well: We reject weapons. We will not produce weapons any longer.” Because most people will argue: “Why should I stop producing weapons? The others do it anyway!”
What does prevent people from thinking?
Lack of information. Those who are in power are very well informed, but they have the their own interests. The abolishment of war, like the abolishment of slavery, will never come by an initiative from governments. It only comes when citizens start to exert pressure on governments.
You ask civil societies to start pressuring governments?
Absolutely. But to be able to do this we need education, knowledge, information, the media raising those issues. I would never vote for any government that doesn’t put disarmament and the abolishment of war on its agenda. It’s an intellectual, philosophical and moral issue. It’s a matter of understanding that if we continue like this there will be no bright future for the planet. We don’t have much time left anymore. It’s three minutes before midnight.
2015 Gino Strada received the Right Livelihood Award for his work and activism.
Photo credit: Pascal Mora
Gino Strada (67) studied medicine and trauma surgery at the University of Milan and worked as a heart-lung transplant surgeon in the United States at the Universities of Stanford and Pittsburgh as well as in hospitals in the UK and South Africa. From 1989 to 1994 he served as a war surgeon with the International Committee for the Red Cross (ICRC) in eight countries including Afghanistan, Pakistan, Bosnia-Herzegovina and Somalia. In 1994, he and his wife Teresa founded the NGO Emergency with the aim of providing high quality, free-of-charge medical and surgical assistance to the victims of war, landmines and poverty. By 2015, Emergency has provided medical and surgical assistance to over 6 million people and has worked in 15 countries, building hospitals, surgical centres, rehabilitation centres, paediatric clinics, first aid posts, health care and maternity centres as well as a Centre for Cardiac Surgery. Areas of intervention and admission criteria are defined by Emergeny in agreement with communities and local authorities, on the basis of recognised needs and in the absence of similar interventions. Emergency sees healthcare as a basic and inalienable human right.
For his work and activism Gino Strada received the Right Livelihood Award in December 2015.
The above interview with Gino Strada was published in German in the Swiss magazine annabelle.