Episode 2: Jullien Gaer

“Access to healthcare is what matters, not how your system functions.”

Jullien Gaer and colleagues in Afghanistan

In the second episode of ‘More than a Hospital’, find out how consultant cardiac surgeon Jullien Gaer became involved with developing the cardiac surgical unit at a hospital based in Kabul, during the height of the Afghanistan war.

Working with the French humanitarian association, La Chaîne de l’Espoir (The Chain of Hope), Jullien continues to this day to help train cardiologists in Afghanistan to support the needs of cardiac patients in the country as well as building crucial educational links between the hospital and Royal Brompton and Harefield hospitals. 

Jullien, who has worked across several different healthcare systems around the world, also recounts the moment when he invited a collection of artists - including Grayson Perry - to watch him perform open-heart surgery, to help raise vital funds for the hospitals. 

 

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Our new podcast, More than a Hospital, delves into the untold and inspiring stories of the people at the heart of our hospitals. In each episode, host Oli Lewington interviews a guest with a particular connection to Royal Brompton and Harefield, as they share the story that forged it. 

You can find each episode here, or listen to them on AcastSpotify or Apple.

Oli Lewington

Welcome back to More Than a Hospital. It's not uncommon for hospitals to have links with similar institutions in other countries. But when I heard that the Royal Brompton and Harefield hospitals had an informal link with the French Medical Institute for Mothers and Children in Afghanistan, I wondered why a couple of hospitals in Greater London, would have a relationship with somewhere more than 4000 miles away, in a war torn and dangerous country.

To find out more, I spoke to the man who instigated the programme and who clocks up more miles to Kabul than anyone else.

STING

Oli Lewington

Like all of the surgeons at Royal Brompton and Harefield hospitals, Jullien Gaer performs lifesaving and life changing work, every single day. Unlike a lot of surgeons, he also dedicates months of his year to supporting cardiac surgery in Afghanistan. As a country, it's still on the government's red list as an ‘unstable’ and ‘politically charged’ state that has been back under Taliban control since 2021.

Despite the risks, Jullien still travels there at least twice a year, with the support of other Brompton and Harefield colleagues. 

Jullien trained at some of the leading cardiac surgery centres in the world, including the Broussais Hospital in Paris and the Austin Hospital in Melbourne. In this podcast, we talked about his work in the UK and Afghanistan, his charity work, and the power of the community feeling at the Brompton and Harefield hospitals.

But first of all, I asked him why he'd extended an open invitation to watch surgery to a collection of artists, including Grayson Perry. 

Jullien Gaer, thank you so much for joining us.

Jullien Gaer

I'm very glad to be here. Thank you for inviting me.

Oli Lewington

So, while I was doing the research for this podcast, one of the things I came across is that a while back you invited a load of artists, or you gave artists an opportunity to come into theatre and watch you doing cardiac surgery. What was the idea behind that?

Jullien Gaer

Oh, hard cash, pure and simple. It actually wasn't even my idea. So, the background is the following... My wife is an art dealer and a contemporary art dealer. And Bob Bell, who was chief executive until relatively recently, as you probably know, dragooned me one day and asked if we could use the connections that we have in the contemporary art world to do some fundraising for the hospital.

You have to understand that artists get asked for this sort of stuff all the time. People sort of don't realise that it's their work. And if you say, would you like to donate a piece of art for some charitable purpose, you're asking them to undertake a significant piece of work for nothing. So, they have to kind of believe in it. That's the first thing, and they have to want to do it. They are saturated with requests for it because everybody thinks that churning out a piece of art is just something you do. You just press another button and another bit comes out. And so, we asked a number of artists that we know to engage in that and said that rather than simply, as it were, pressing the button and donating something, why not come and spend some time in the hospital. This was at Harefield. See how it works. See what makes Harefield tick and then create a piece of work based on that. So, there were a number of artists, many of them very well known, Grayson Perry, among them, Tracey Emin, who came to the hospital and spent some time there.

Grayson was particularly good at it and actually came back on more than one occasion, became a sort of ambassador for the hospital. And the artwork that was donated by these artists, some of whom didn't visit the hospital, but donated works of art nonetheless, was sold at an auction at Sotheby's, in 2010, or something like that. It was a while ago and that's what happened. So that’s what you will have read will have been some of the coverage that was in the press at around that time. Charitable auction for medical endeavours are kind of a bit stale now. And I think if you went round and asked a bunch of contemporary artists now, you would get a smack in the chops. But ten years ago, it was relatively novel. And many of the artists we know well enough to call in a favour.

Oli Lewington

And how common is it to have visitors in a surgical theatre? Was it strange for you to have people like Grayson Perry hanging around?

Jullien Gaer

Well, yeah. I mean, interesting enough, I got into trouble for it because many of my colleagues didn't realise that the chief executive had asked me to do it. And so, the usual jealousies and rivalries that pervade in any organisation, found their way to the fore and some took exception to it. I think the way I rationalise it, and this is how I've rationalised it subsequently, is that if anyone donates a significant sum of money to the hospital, they kind of have a right to see what they're getting for their money.

And whilst we try and restrict visitors to the operating room for purely professional purposes, this would be fundraising for the organisation. What I would consider to be a professional purpose. So it was, in my view and indeed that of the then chief executive, completely justifiable.

Oli Lewington

So, talking about access to to surgery and seeing what's happening is one thing. But you've spent a lot of time over the last decade or so looking at access in a much different way when it comes to the work that you've done over in Afghanistan, helping people there who might not have been able to access top level cardiac care. How did that come about?

Jullien Gaer

I did quite a lot of my postgraduate training in France, and as with anything in medicine, and this is absolutely no exception, perhaps it's even more the case. Everything we do is standing on the shoulders of giants, and very little that we do is entirely original. And necessarily so. I did quite a lot of my postgraduate training in France.

My then chief was a man called Alan Carpentier, who's now sadly very old and quite frail, but his one of the giants of our specialty. And there were in the department a number of other individuals. Alan Carpentier was very good at surrounding himself with people of considerable talent, one of whom was a man called Alan De Losh, who was, among other things, the founder of Médecins Sans Frontières, which is perhaps one of the largest medical aid charities in the world.

Now, I don't know what the league table is, but everyone will have heard of MSF. And De Losh is an extraordinary character. And he then set up, among other things, Médecins du Monde and a charity called Chaine de l'Espoir, The Chain of Hope. And the Chain of Hope was slightly different in as much  they don't send people into war zones.

It's not about conflict medicine. It's about building medical infrastructure. And it comprised three components. One was bringing children predominantly to Europe for surgery, not available to them in their own countries. The development of medical infrastructure in countries that don't have it, and the training of doctors in countries that don't have access to. And that came about because this was all in the mid-nineties where there was a coincidence of things that happened.

 The first was the disintegration of the Soviet Union. The second was Alan De Losh finding himself traveling in Vietnam, a country which at that time, because of the disintegration of the Soviet Union, was having to open its doors to the West or to the wider world in order to try and develop its infrastructure. And to remember, France was the ancient colonial power. So, it was quite a sensitive and difficult relationship initially. But the then dean of Saigon Medical School, or Ho Chi Minh City Medical School was a cardiologist, and there was no cardiac surgery in Vietnam at all at that time. And he wanted to set up a heart hospital. And Carpentier was asked if he would do it and acting through De Losh his deputy, the centre was set up and it worked like a charm.

Within three years it was functioning. There was a local team who were initially operating and working under some sort of supervision from France, but very soon were completely autonomous. It was absolutely the perfect storm of sort of medical infrastructure development and emerging markets. You do something, it works. And very soon, the guys who are locally training, no longer need you.

And we thought and I was part of that at the time and this is, you know, when I was still a senior trainee and we thought, we need to do this. This is easy and without taking account of the fact that and there are unique things in Vietnam that made that a success, we tried to repeat it, for example, in Cambodia, and it wasn't such a success.

 It still limps on, but it was not the shining success that the Vietnamese endeavour was. And it's been repeated in a variety of other places. And one day I was working in Cambodia, and De Losh arrived in town, just flew in. We didn't know. And it was so typical of him. And so, we were having dinner together that night. This must have been in 2005 or thereabouts, and he said, oh, you know what, I can really see you in Kabul. And I thought he was insane. Actually, I knew he was insane, but I thought this was just another manifestation of his insanity. And I didn't really think any more about it. And then, of course, but, you know, these guys are a brilliant and they're also transactional.

And we were operating in the francophone world substantially. And I happened to be also Anglophone. And De Losh knew that Afghanistan was always going to be essentially Anglophone. So, they needed somebody who was Anglophone. And so that's how it became my particular. But there are other projects – Senegal, Ivory Coast, Mali, Mozambique. You name it, there's a bunch of them.

So, in that respect, this hospital was just one of a number of projects undertaken by Chaine de l'Espoir. Each of them has its own unique components. The initiative for the for the Afghan project came from a very well-known French journalist called Marianne Giacomo, who was covering the war in Afghanistan for a long time. And it was initially conceived as a maternity unit, which is why it's called the French Mother and Children Hospital.

And then it expanded and it became a tertiary care hospital. And I think it's fair to say that the cardiac surgical component of it was the flagship of this big hospital, which is the sort of reference centre in Kabul. And up to the point just before the pandemic, there was an Afghan head of department, Najibullah Baena, who is a good buddy of mine, who was an iconic figure in Afghanistan. And he was running the department. He was trained in France as a cardiac surgeon, and they were doing a lot of surgery, 600 cases a year with outcomes that would be far from embarrassing anywhere in the world. And when you bear in mind the difficulties of the extreme poverty and co-morbidity, as we call it, the patients coming for surgery in Afghanistan have that was pretty impressive.

Oli Lewington

And just so that people understand this properly, what do you mean by co-morbidities?

Jullien Gaer

So, you know, patients who come to surgery in Afghanistan are frequently malnourished, frequently coming present presenting at a stage in their illness where it is so far advanced that the risks of surgery are very considerable and so on and so on. And so, they're the things that increase the hazard of surgery. But it was going pretty well and we had trainees coming through.

The hospital is right next door to the Kabul University, which still trains high calibre medical graduates. But there's been a brain drain in Afghanistan since forever. And it's got immeasurably worse as the war became more and more, obviously futile, and particularly when the Taliban returned to power in 2021, as they did.

Oli Lewington

And I mean, Afghanistan is, as a place, it's not a place that that it wouldn't be your top holiday destination. Let's put it that way. What is it that keeps you going back to the country and that kind of gets you over those reservations?

Jullien Gaer

Don't know. Oh, I think well, the personal safety issue is one that you just sort of make peace with when your own experience of something tells you that perhaps what one reads in the newspapers, hears in the press, is not entirely representative of the whole thing. There have been times when I've been to Afghanistan and felt not unsafe, but certainly been aware of the tension in the city, whereas now you see a city that is, you know, bustling and peaceful and it feels quite sort of relaxed now.

So, I think in that respect, I've sort of, you know, those are the things that contribute towards making peace. But also, you know, I committed myself to this project and it's kind of a in sickness and in health commitment and so I didn't want to you know, I felt, you know, I know these guys. I know all of the team there and I'd given a commitment to it and felt I should honour that, if at all possible. Now, there were times when it was impossible through the pandemic, for example, you couldn't travel.

 And then in the immediate aftermath of Taliban returning, we didn't quite know what was going to happen. And every time I go there, I expect to see, you know, familiar faces missing because people have, you know, because it's one thing to go and visit for ten days or so. But if, for example, you were a female doctor working in Afghanistan and somebody offers you the opportunity to go work somewhere else, you have to have a pretty compelling reason to stay behind.

 I mean, the remarkable thing is that people are staying behind and still you know, they're still there and they're still committed to.

Oli Lewington

And what do you do? What is a sort of classic trip out there look like?

Jullien Gaer

So, I usually travel with an anaesthetist and an intensive care nurse and the team that travels with us depends, you know, where you're going and what you need to do when you get there. Time the project. I'm involved in, elsewhere in the world where we take a whole team of anaesthetists, perfusionists, nurses, etc., etc. but there's a lot of staff there already and they're good, you know, they're good people.

So, I travel with an anaesthetist and an intensive care nurse. I usually go out a day or two ahead of them and see patients in clinic and sort of try and get things moving. And then when they arrive, we go to work and we go to work on the stuff that the team locally wants us to help them with.

 So that is cases of a particular complexity or so on. And because while we're not they're operating away doing plenty of work, but things that they particularly want our help with, we sort of store them up for the week or so that will be there. So, if I travel out on a Wednesday, typically the other guys will fly out a day or two later and we operate every day for the following three the following week and then come back the following weekend.

Oli Lewington

That's a busy schedule, though, isn't it?

Jullien Gaer

Oh, we get a lot of work done. We get a lot of work done. Far more work you can get done in the same facilities and time frame in the National Health Service, I can assure you. Because we're not encumbered by some of the bureaucracy that plagues us here.

Oli Lewington

And you were talking about the pandemic and obviously that kind of change of control in Afghanistan. How did the pandemic affect the work over in Afghanistan? Because obviously it affected every health service.

Jullien Gaer

It almost completely came to a stop, as it did, frankly, here. But we maintained an emergency service. They were unable to do it in Afghanistan. Of course, you know, there's no such thing as lockdown and furlough. You know, you eat tonight what you earned earlier in the same day. So, there was no question that people would be able to stop work, stay home or any of these things.

And, of course, the hospital services are substantially overwhelmed at the best of times. And so, I don't suppose anyone really has any idea what the impact of COVID would have been on the population. It's probably impossible to work out, but suffice to say it was probably not good.

Oli Lewington

And how much work has it taken to get the service back up to where it was when you left it? How much have you had to put in to reestablishing what you've been doing?

Jullien Gaer

Me personally? Not a great deal, honestly, because the people there and extremely committed to it and as soon as they were able to do it, they went back to work. There's a shortage of trainees, some of whom have fled the country. There's the usual financial constraints but they're very committed.

So I think, honestly, our presence is is most I mean, yes, it's to do with providing direction and help with work that they want us to help them with, but it's as much as anything to make them feel that they're not working in isolation. And actually, the trust has been incredibly supportive of that.

The team in Kabul can dial into our MDT meetings, our multi-disciplinary meetings and they can access the educational material online that they would otherwise have to pay for they can access it for free. Don't forget, I learn a lot from going to Afghanistan. It's not it's not entirely one way traffic.

Oli Lewington

And it's not it's not just Afghanistan for you either. You've experienced the health care systems and all sorts of other things in other countries around the world. What are the biggest things that you take away from seeing how healthcare runs or how your particular field is kind of carried out, I suppose in other countries.

Jullien Gaer

I think we grow up, particularly in the English speaking first world economies, the global north, we grow up with a notion of exceptionalism, of which is, at best, slightly irritating and worse, frankly ignorant. So, you know, when I went to work in France as a trainee, somebody at Harefield Hospital looked up to me and said, oh, really? Cardiac surgery in France. Wow. I didn't know they sort of did it there. 

We have a notion in this country, in the United Kingdom, that, you know, healthcare free at the point of delivery publicly funded is a uniquely British invention, as though the rest of Europe, Australasia parts of Asia, even parts of South America aren't doing the same thing.

So, I think the important thing is there are lots of ways to skin the cat and many of the preconceived notions that we have about our own and other health systems need to be carefully scrutinised and verified, you know, trust but verify, as Ronald Reagan said, because the reality is that what we do is of such fundamental importance, in some ways, that it's too hard to value it.

And I think that's important. So, access to health care is what matters, not how your system functions or how it's structured. It doesn't matter which model of health care you use, as long as you ensure access.

Oli Lewington

What other things should we aspire to learn from other countries, health care systems?

Jullien Gaer

This isn’t one question within an otherwise 30-40 minute podcast. That's a Ph.D. thesis. And you know, the notion that we don't or, you know, it would be a lot easier to make a list of the things that we don't need to learn because there’s manifestly so much. But I think there are good things. If we're thinking specifically about the health service in this country, the United Kingdom, you know, unless you've been living on another planet, you will be aware is under a certain amount of strain in the moment.

If we think back to the pandemic, I think that the way in which health care is centralised had an impressive advantage during the pandemic because the output in terms of high quality, multi centre research, rapidly organised that delivered results with answers that were affordable and effective was truly impressive. And I think that's a benefit of our centralised health system.

The list of disadvantages to our massively centralised health system is a Ph.D. thesis in its own right.

Oli Lewington

So, one of the things that you've done over here is you’ve founded a charity called the Aortic Center Trust. What was the reason behind that? Why was it an important thing for you to build?

Jullien Gaer

Well, first of all, I was, again, you know, acknowledging the standing on the shoulders of giants. I'm one of the founders of this organisation. And the simple truth is that my colleague, Nick Cheshire, who is not as a colleague, a friend and an extremely distinguished colleague, received a donation from a patient and it was not an insubstantial sum of money. And we looked into what we would do with that money and whether we, as it were, blow it on the project, you know, doubtless worthy and help a significant contribution or whether we use it to seed something a little bit bigger. And we decided to do the latter, which is why we set up this foundation. And we were both active working in aortic surgery.

Aortic surgery, we think is a somewhat neglected, somewhat neglected area. Everyone you know, knows where their prostate is, or we know when their breast cancer screening is due. But, you know, most people would say errrr, when you talk to them about their aorta and aortic diseases are challenging to treat and often are undetected. So, we thought there was a gap there.

And so we set up this foundation. And we used the money from this donor, which was a significant sum of money. We did the rounds of artists again and raised some money from an auction. And we have, you know, a fund now with which we are doing a number of things, one of which is to embark, we're about to embark on a campaign to increase awareness of aortic screening services, specifically targeting postcodes, areas of the country, where the uptake of this free service is notably poor.

And of course, that has a lot to do with economics. We have sponsored a scholarship with the national body that oversees cardiac surgery and training in this country to enable people to go. You know, young, either people at the end of their training or newly appointed consultants to go and visit centres of excellence elsewhere in Europe or indeed in North America or wherever, frankly.

And that could be one individual going for, say, a year to another centre or, you know, a team travelling to go for a matter of a few weeks to observe, you know, a particular procedure or particular technique. So, that's what that is about. It's extraordinary in a way, to have been a part of that in a sense it never crossed my mind.

What were the mechanics of setting up websites and so on and so on. And the way that people publicise such causes now, and the money trickles in and we're doing our best to make good use of it.

Oli Lewington

Having been in a position where I founded a charity myself years and years ago, it's not an easy thing to do, but there is something immensely satisfying about that feeling of kind of kicking off something new and making a difference with it.

Jullien Gaer

Yeah. And just the surprising element of it all. One day, I took a phone call from a solicitor in Bristol ringing on the behalf of the widow of a man whom I never heard of, wanting to know if we would be willing, prepared, to accept a donation which was a five-figure sum of money. I said, what you think? You really don't need to ask! And that kind of blows you away. A guy you've never heard of, for reasons that are entirely personal to him, leaves a sum of money to you based on you'll never know necessarily.

Oli Lewington

But I think it's an important recognition of the work that you do that someone would be prepared to do that because it means they know who you are, and they know that that you can use the money to good effect.

Jullien Gaer

Well, we do our best, we do our best. It's actually surprisingly difficult to give away money. Interestingly, it's not it's not always easy.

Oli Lewington

Yeah, you're right. It's a deceptively difficult thing to do in a kind of robust manner. 

Just finally, a big part of what we're trying to do with this podcast, is to explore the community of the Brompton and Hatfield hospitals and the way that there's something about it that feels unique to me. And I was I was particularly struck again, going back to the research that we were doing for this chat, there was a story that you related in an article, I think it was in The Guardian a good, good number of years ago.

But you were talking about one particular patient who was a 40-year-old mother of two who had emergency surgery, unexpected, based on the condition she was in when she was admitted. And it lasted from midday on a Monday to 5 a.m. the following morning. So that's, what, 17 hours in total. And you mentioned that there were five consultants involved all together, some of whom weren't even on duty at the time.

And I'm guessing there were a lot more members of the wider surgical team. What is it that forges the kind of spirit, that togetherness, that makes people willing to work through the night and willing to work when actually it's not their shift or they're not on duty. What is it about your teams that make that sort of thing happen?

Jullien Gaer

Well, it doesn't always happen, that’s the first thing, but there is a level of commitment, engagement and community, which I think is impressive in both Harefield and the Brompton. They’re small hospitals, so there's a sort of relatively homogenous, cohesive community. We don't have access to emergency departments. We are actually technically the sort of rather outmoded thing, which is a single specialty hospital, which is, you know, supposedly not what health care is about nowadays.

You know, I can identify nurses, for example, in both the Brompton and Harefield who've been there since I came here as a senior house officer in 1984. And I've been and gone in those times and worked elsewhere. But there are people there who have worked in this same organisation now for almost as long as I've been a doctor. And that is unusual, I think. That is unusual. And Harefield has its own... Harefield and the Brompton are very different they have their own strengths and weaknesses, but one thing they have is a sense of their place in the community that they serve and a sense of community within the organisation.

Oli Lewington 

Thank you so much for taking the time to join us today. It's been fascinating talking to you and hearing about the work that you do. I've no how you fit all of it in, but it's been great to talk to you.

Jullien Gaer

It was very nice to speak to you Oli. I know that your attachment to this organisation has a long history and I'm glad to see you in good health.

Oli Lewington

I really enjoyed that conversation with Jullien. I think what struck me was his humility in not necessarily recognising the significance of the work that he does in Afghanistan. It's still a country that the UK government doesn't recommend to travel to and so I think the fact that he's willing to go there and his colleagues are willing to go there, I think it shows a real passion for their work and for wanting to help make a difference to people's lives.

And it doesn't matter where they're practicing their craft and where they're taking their expertise, their passion is in helping people. And I think that's a big part of this sense, of this unique sense of community, within the hospitals. And it was really lovely to hear that he recognises that as well, that it's not just that sense that I get and that you might get from the outside, that it's recognised within the hospitals as well.

I really hope you enjoyed listening to this episode. There are plenty more coming down the line, so make sure that you’re subscribed wherever get your podcast. And if you can write and leave a review that makes a massive difference for us in terms of helping people discover the podcast and hear the stories that we're trying to share.

Thank you so much for listening, and I'll talk to you next time.