Battle of the Bulge

Food portions have tripled in size since the 1950s and so have our waistlines. Worldwide, more than a billion adults are overweight - at least 300 million of them clinically obese. Could obesity surgery offer a comprehensive life-saving solution to this global epidemic?  Eimear Vize talks to pioneering bariatric surgeon T Karl Byrne.

Sporting a Harley Davison t-shirt and pale blue jeans, Professor T Karl Byrne looks no worse for wear despite snatching only a few hours sleep before our interview. One of the top bariatric surgeons in the US, he was back in Ireland for a family gathering. It was his first Irish wedding in many years, he admits over coffee in the hotel lobby, he had forgotten how much the Irish liked to party when he had made the arrangement to meet at 10 am the morning after.

Some things may not have changed in Ireland since Karl emigrated in the 80s, but he has noticed other sizeable differences in recent years.

Us. We’re bigger.

The Irish have been indulging themselves a little too much over the years and it’s beginning to take it’s toll. Alarming results of a new survey of more than 2000 Dubliners, who were taking part in a VHI pilot diabetes screening project, revealed that almost two thirds of respondents were overweight or obese, and it is not a coincidence that a similar number were also identified as being at risk of developing the Type II Diabetes.

“There is a noticeable difference in the size of people here,” Karl says with ominous gravity. “I’ve seen it on the streets and in the restaurants, I’ve seen it even at the wedding here, there are a lot of people who are really dangerously obese. I think it’s because of the affluence maybe, the culture is becoming more Americanised: poor diet, overeating, sedentary lifestyle - That’s a dangerous road to take,” he warns.

Obesity can put people at an increased risk of developing diabetes, hypertension, heart disease, osteoarthritis, stroke, gallbladder disease, sleep apnoea and respiratory problems and even some cancers. The Centers for Disease Control and Prevention recently estimated that obesity costs the US health system as much as $147 billion a year.

“In the US more than 60 per cent of the population are overweight – the estimate right now is that there are probably 15 million people who are morbidly obese, that means they have a body mass index of more than 40kg/M2, which equates to about 7 stone (100lbs) over their ideal body weight.

“It must be a by-product of my surgical speciality, but when I’m out and about and I see a young person who is morbidly obese I think to myself, that person could change their life - could save their life – with a gastric bypass or a sleeve. We spend all this money in the States dealing with the many complications of the disease of obesity without addressing the underlying cause – their obesity.”

An RCSI graduate (class of ’78), Karl developed an interest in weight loss surgery during his residency at The Medical College of Virginia (MCV), under the tutelage of Dr Harvey Sugerman, a world-renowned surgeon in this specialty. He later relocated to The Medical University of South Carolina, as a trauma and critical care surgeon, but seeing a need to provide weight loss surgery to morbidly obese patients in the area, Karl started a small program at MUSC in 1992.  He is now Medical Director of the MUSC’s Bariatric Surgery Centre where he introduced the laparoscopic approach to gastric bypass weight loss surgery procedures in 1999.

“We looked at the admissions in our hospital over the course of a year, and in 10,000 admissions, 2,500 patients were admitted for the complications of obesity, so it’s a huge problem. People are being admitted for the complications of diabetes, hypertension and degenerative arthritis and so on, but the underlying diagnosis is morbid obesity,” he says.

“In the US right now, something like 70 percent of bariatric surgery cases being done are probably gastric bypass, because it’s the most tried and tested, followed by about 25 per cent lap bands, and there’s a small number of bilio-pancreatic bypasses, duodenal switches and gastric sleeves being done, in the grand scheme of things only about 5 per cent.

“We have very clear data on the outcomes in terms of resolution of medical problems such as obesity related type 2 diabetes – an obese patient who has a gastric bypass has an 86 per cent chance of having their diabetes cured permanently. About 93 percent of patients who are hypertensive are cured of their hypertension; people who have degenerative arthritis in their weight bearing joints are often cured of that and don’t need further surgery, such as knee and hip replacements; 95 percent of people with sleep apnoea syndrome will be cured.”

He stresses: “The procedures have been tried and tested over the years, most of them are being done in certified Centres of Excellence so that now the morbidity and mortality rates are pretty damn good really.”

So, why then are the major US health insurance companies not freely encouraging their obese subscribers to seek bariatric surgery when conventional weight-loss treatment fails? Wouldn’t they rather bank those billions of dollars saved on the multiple-medications and surgical interventions needed to manage the chronic diseases associated with obesity?

“Good question,” Karl retorts. “I ask myself that one regularly. You’d think the insurance companies would embrace this as a very effective and low risk, relatively speaking, way to cure the huge medical problems caused by obesity and thereby reduce their expenditure, but they don’t.

“Coverage for procedures such as these, is dictated, to a certain extent, by a Government agency, the Centres for Medicare and Medicaid Services (CMS) and basically the other insurance companies follow along with what they recommend.

“In 2004 Medicare came out with the statement that obesity was a disease - they had never regarded it as that before - and that they would cover obesity surgery for Medicare recipients provided it was done in a Centre of Excellence, so everyone thought: this is it, the flood gates are just about to open because the other insurance companies would follow suit. But they didn’t. Nothing really happened. There was a slight upsurge in procedures for Medicare patients – the toughest patients – statistically the most non compliant and the sickest because they are older and have been on disability for years.”

It is becoming increasingly apparent that Karl, who presents as a relaxed and discerning man, laid back even, is visibly irked by the short-sightedness of the health insurance industry in his adopted country, and their overall reluctance to provide cover for some or all of the five obesity surgeries sanctioned by the American Society for Metabolic and Bariatric Surgery (ASMBS), as identified by the Surgical Research Committee. These are Gastric Bypass, Laparoscopic Adjustable Gastric Banding, Duodenal Switch, Bilio-pancriatric Diversion and Vertical Sleeve Gastrectomy.

“So if you were an insurance company who provided healthcare and you had a population of diabetics and you had a pill that you could give the diabetics that would cure 86 percent of them, wouldn’t you give them the pill?

“Now we don’t have a pill, we have a procedure. Not alone can it cure their diabetes it would also get rid of their hypertension and their sleep apnoea syndrome and a range of other problems. You would think that the insurance companies would 100 percent embrace this and pay for it willingly but they don’t,” he argues hotly.

Why not?

“I don’t know.”

“We are all lobbying for it for years now, perhaps they’re worried that it would open the flood gates but if you look at the cost analysis that shouldn’t be a major issue. The cost of a gastric bypass in the US is about $30,000 but if you have a patient who is on multiple medications for the complications of obesity, the amount of money the insurance company would pay for all those simple pills over the course of the years is way more than the upfront cost of the gastric bypass.

“After two years those lines have been shown to cross, so if you have a patient with multiple medical problems, gastric bypass becomes effective after about two years in terms of finances. When you do a gastric bypass the rapid weight loss is in the first six months, by the end of six months many of them are off all their medications, so they are immediately saving money. Within two years it would be more cost effective to have gastric bypass than to keep them on those medications.”

Karl offers another example of this frustrating misdirection of funds: “If you’re a 300 pound patient with knee problems and your orthopaedic surgeon recommends knee replacements, the insurance company has no problem paying for that. Wait a second now, why has the guy got knee problems - because he is 300 pounds, and incidentally he’s hypertensive. You’re not addressing the underlying problem. What a stupid way to spend money. It’s ridiculous!”

With obesity increasingly evident among children – 22 million children under five are overweight worldwide – this is a global crisis that will only deepen further in the coming years. Thousands of children and adolescents in the UK are using anti-obesity drugs that are only licensed for use by adults, according to a new study published in the British Journal of Clinical Pharmacology. In fact, the number of young people receiving prescriptions for these drugs has increased 15-fold since 1999. Extrapolated across the whole population, the results indicate that around 1,300 young people are now being prescribed off-licence anti-obesity drugs each year.

“They don’t work,” Karl offers flatly. “The statistics are that if you take weight loss medication constantly you can possibly lose 10 percent of your weight, so a 300 pound patient will possibly lose 30 pounds if they are taking them for six months, and there are huge side effects, but once they go off the medication they put the weight back on, so they don’t work.

“Our hospital has a huge transplant centre and I get calls from surgeons who ask if I can do a gastric bypass on a patient who is on dialysis and needs a kidney but his BMI is too high for a transplant. Here’s a patient who has had 20 years of diabetes, 20 years of hypertension and all the other co-morbidities, they are morbidly obese, and because they have had this chronic disease, now they are in kidney failure but they’re too obese to get a kidney, so I have to do a gastric bypass on them so they can get weight off so they can get a kidney transplant. We’re spending money at the wrong end of the problem. Wouldn’t it have made more sense to intervene when this patient was 20 and was morbidly obese? Why don’t we intervene when they’re in their teens?”

Karl isn’t the only one who feels strongly that, when other treatment options fail, obese children and teenagers should be offered bariatric surgery. The number of US children having obesity surgery has tripled in recent years, surging to almost 1,000 in 2007. While the procedures are still far more common in adults, they appear to be slightly less risky in teens, according to an analysis of data on 12 to 19 year olds published in the Archives of Paediatric and Adolescent Medicine in March 2007.

“Thirteen is the youngest I’ve ever done but you can go younger again and I think that’s going to be a big entity eventually, particularly if and when the lap band is sanctioned for use in patients under the age of 18.”

The Endocrine Society's 91st Annual Meeting in Washington, DC in June 2009 heard that lap band surgery significantly improved and even reversed the metabolic syndrome in a study of morbidly obese teens aged between 14 and 17.

“Trials have been done and results are good, so I think that will be something to watch because it has very low morbidity. So we may be slipping lap bands into these pre-teens who are morbidly obese, at some stage,” Karl says.

But why stop there? Why not tackle a person’s obesity before they’re born? It may sound absurd but new research just published has shown that adolescent and young children of obese mothers who underwent weight-loss surgery prior to pregnancy had a lower prevalence of obesity and significantly improved cardio-metabolic markers when compared to siblings born before the same obese mothers had weight-loss surgery. This particular research - published in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM) - focused on women who had undergone bilio-pancriatric diversion prior to becoming pregnant.

Karl predicts that the gastric sleeve is going to make a major come back as an effective and lower risk procedure in the bariatric surgery portfolio. “I think it’s going to be a real entity in a couple of years. It’s an old operation that has been re-visited and revamped and the data that we have so far has indicated that it’s as effective as gastric bypass for weight loss in the short term; we don’t really have the long-term data yet.

“It is more effective than the lap band in terms of weight loss but has less complications; there’s less morbidity compared to gastric bypass, so I think it’s going to be an entity. I have done a few but there are certain centres in the US where they are being done almost exclusively.”

Then Karl sighs deeply. “But, of course, there’s a huge insurance issue with this procedure as well.”

It appears that after relentless lobbying by the profession, the CMS finally issued surgeons with a claims payment code for the Vertical Sleeve Gastrectomy.

But they still won’t pay them for it.

“It’s frustrating as hell but we’ll get there.”

  OBESITY FACTS

1. Obese individuals spend 36 percent more on health care costs and 77 percent more on medications per year than individuals of normal weight

2. Approximately 85 percent of people with diabetes are type 2, and of these, 90 percent are obese or overweight

3. The National Taskforce on Obesity estimated direct costs of obesity in Ireland on a pro-rata population basis at 70 million. Indirect costs were estimated at 73 million

4. After obesity surgery patients can expect to lose 50 percent of their excess weight within the first one to two years, and to maintain this in the long term.

5. Research shows insurers recover their costs for bariatric surgery in two to four years depending on the type of surgery performed

6. Patients consider bariatric surgery for about three years before making their decision to have surgery, according to a 2008 ASMBS / Harris Interactive nationwide survey in the US.

7. About 220,000 people with morbid obesity in the US had bariatric surgery in 2008.

Bariatric Surgery in Ireland – overview

Bariatric surgery is a relatively new entity in Ireland with some of the first procedures being performed in 2002. However, as the level of morbidly obesity increases in this country, so too does the demand for this treatment option. In recent years, the only public Weight Management Clinic in St Columcille’s Hospital, Loughlinstown, has been struggling to cope with the growing number of seriously obese patients seeking surgery.

Waiting times are in excess of two years, and in 2005 there were almost 450 patients awaiting treatment. Since opening in 2002, at least 12 patients, ranging in age from 22 to 53, have died while on the waiting list. Emergency cases cannot be prioritised because the clinic has reached ‘saturation point’.

Bariatric surgery is also available publicly at University College Hospital Galway. Plans are in the pipeline to open a third public obesity clinic next year offering weight-loss surgeries in Cork in collaboration between Cork University Hospital and the Mercy University Hospital. A fourth public clinic will open on the western side of Dublin on the Tallaght/Connolly Hospital axis at a later date.

Currently bariatric surgery is available privately at the Galway Clinic, the Beacon Hospital in Sandyford, Dublin; Blackrock Clinic, Dublin; Bon Secour Hospital in Cork, and Obesity Solutions in the Auralia Hospital, off the Naas Road.

The three private health insurers in Ireland – VHI Healthcare, Hibernian Aviva Health, and Quinn Healthcare –provide cover for certain bariatric surgeries (procedures and amount of coverage vary between company), however benefit is subject to prior approval and the criteria are quite detailed and specific. These include cover for individual over the age of 18 only. Patients must also have been morbidly obese (BMI over 45) for at least two years.  Surgery must be carried out in pre-approved centres by an appropriately qualified surgeon, who is registered with the individual insurance company.

The supervising consultant is obliged to provide documentation to prove that the patient has received treatment management in a non-surgical obesity programme for at least six months within two years of the proposed surgery.

The Prince’s Trust

Eimear Vize tells the remarkable story of the Irish doctor whose life-long friendship with a tiger-slaying Indian Maharaja helped decorate a tiny church in rural Munster

Inside the beautiful Anglican Church of Ascension in Timoleague, in a quiet corner of West Cork, is an elaborate and unexpected treasure of Byzantine style mosaics that envelop the walls and chancel. On the south wall, among the Indian flower designs, is inlaid a tribute to a local doctor Martin Alymer Crofts, who was a life-long friend and personal physician to the ninth Maharajah of Gwalior, Madhav Rao Scindia.

In the early 1920s, Maharajah Scindia financed the completion of the Timoleague mosaics in memory of this tall and impressively moustached Cork doctor, a member of the Indian Medical Service who was the Maharaja’s tutor and companion from when he was ten.

The pages of history are strewn with accounts of colourful characters, daring deeds and the dedication to their work of many Irish doctors abroad. Medical historians agree that in the 1800s Britain would have been unable to operate its medical services in India and other colonies but for the huge role played by Irish-trained doctors.

In the Indian Medical Service, Irish recruits never fell below 10 per cent and reached a peak of 38 per cent in the 1870s. In fact, during the 1860s and 1870s, Ireland produced proportionately more doctors for the Indian Medical Service than either England or Scotland.

The reality of the time was that Ireland’s medical schools were overproducing doctors. Many elected to emigrate to England or one of the colonies, lured by the prospect of a more comfortable living. It was more attractive for many than the usual career path of an underpaid and mostly part-time post in a dispensary or workhouse in Ireland.

Feasibly, it was with this in mind that the recently graduated Dr Martin Crofts and his older brother James both signed up to the Indian Medical Service in March 1877 aged 23 and 25 respectively after obtaining medical degrees at Queen's College in Cork.

James was appointed Surgeon in the Bengal Medical Establishment, and while he entered the IMS in the same batch, on the same day, he was junior to his younger brother.

The first ten years of Martin’s career with the IMS were spent in military service, when he was for several years medical officer to the renowned 10th Bengal Lancers, ‘Hodson's Horse’ – a cavalry regiment that earned victors’ laurels in successive conflicts and upheld their distinguished reputation in the second Afghan war of 1878-80. During these years Martin served as regiment surgeon with the 10th and faced the Afghans in battles alongside his comrades in the Kandahar and Khaibar field forces.

A year after enlisting in the Indian Medical Service in 1878, the brothers Crofts found themselves among a British force of 40,000 fighting men distributed into military columns which penetrated Afghanistan at three different points – the Khyber, the Bolan and the Kurram passes – in the second Afghan war.

The priority of the British army surgeon was, of course, to treat the wounds and illness of the British and Indian serviceman, but ‘the struggle for hearts and minds’ is not just a modern phenomenon. Medical historians record that, in the aftermath of battle, medical staff would see if anything could be done for survivors of both sides, though this could be dangerous as some ghazis would feign death and shoot at their enemy, or draw a knife and swipe out in a last effort to do their duty under the jihad.

It is known that at least one of the Crofts, James, served in 1878/9 under the famed Anglo-Irish soldier Major General Sir Frederick Roberts, who was one of the most successful commanders of the Victorian era.

General Roberts was given the command of the Kurram Field Force, of which James is credited as one of the regiment surgeons, and Roberts relentlessly advanced into central Afghanistan, meeting and defeating the enemy forces head-on in each encounter, before finally taking Peiwar Kotal in December 1878. 

With British forces occupying much of the country, a deal was struck in May 1879 that relinquished control of Afghan foreign affairs to the British. But that autumn, General Roberts and the Kurram Field Force were summoned into Kabul to suppress an uprising that had been triggered by the slaughter of a British resident and his staff in September that year. The ensuing battle added another victory to Roberts’ extraordinary reputation.

But it was the formation of a force of 10,000 men in Kabul in August 1880, which had to journey hundreds of miles to relieve British troops besieged in the city of Kandahar that brought Dr Martin Crofts under the command of General Roberts. 

Scant documentation makes it unclear if Martin had actually served under Roberts prior to this. Indeed, it is also uncertain if brother James accompanied the relief column on that gruelling 319-mile march from Kabul to Kandahar as his service record makes no reference to him being present for action at Kandahar, the last battle of the second Afghan war.

Martin was certainly one of at least 30 surgeons who made this epic march, and there were many other Irish doctors among the medical compliment. Most notable was General Roberts’ Principal Medical Officer, Irish-born James Hanbury, who was educated in Trinity College Dublin and served with the British Army in China, India and America.

Afghanistan was, then as now, an inhospitable place for visiting armies. Roberts’ troops struggled daily on the march through thick clouds of dust, under a blistering sun and over a hard-baked road from camp to camp. The column would march in the early morning to avoid the full heat of the sun, halting a few minutes every hour. In this way, they managed to cover up to 20 miles a day.

Although the march was unhindered by the Afghans – news of Roberts’ approach had preceded him – it was an historic and remarkable feat of human endurance and organisation.  Finally, on the morning of the 31 August 1880, the relief force reached Kandahar. The inevitable battle was long and bloody but, on 1 September, a decisive victory was claimed for the British.

Martin saw brutal action once again two years later in the Egyptian war of 1882, when he was present in the Battles of Tel-el-Kebir and Kassassin, receiving the campaign medal with a clasp, and the Khedive's bronze star.

In 1886, the princely state of Gwalior was grieving the death of its Maharajah Jayajirao Sindhia, whose sole efforts over the previous three decades had made Gwalior the most advanced city of India. His son and heir, Maharaja Madhav Rao Scindia, was a boy in his tenth year.

As Gwalior held a strategic position between north and south India, the British considered it one of its most important strongholds in the country. It was no small honour then when the young prince was entrusted to 32-year-old Dr Martin Crofts, who was appointed residency surgeon of Gwalior and tutor to the new Maharaja Madhav Rao Scindia.

From a young age, and under the Cork man’s guidance, Madhav Rao threw himself with the utmost keenness into a broad education and the supervision of every detail of State management.

However, during these years, Dr Crofts was still a soldier and military surgeon and as such subject to the call to battle. Promoted to the rank of Surgeon Major in 1889, he served in the Zhob Valley expedition in the same year, on the North-West frontier of India, a long and hotly contested region where many British officers honed their soldiering.

Perhaps it was the Surgeon Major’s war stories from the battlefield that charged the young Prince’s active interest in warfare. Or perhaps it was the emergence of a sovereign spirit in one born to lead that gave the 14-year-old the idea of launching his very own military expedition in 1900. The destination was China where the Boxer movement, a brutal anti-European/Christian organisation, had rebelled with the aim of forcing out colonists.

It seems plausible that the teenage prince’s personal physician and friend of four years may have influenced how such a dangerous journey was undertaken. The mode of transport chosen was a hospital ship and Surgeon Major Crofts accompanied Madhav to China. Once docked, the Maharajah presented the vessel Gwalior to the authorities, at his own expense, for the accommodation of those wounded in the Boxer Uprising. Crofts himself was the senior medical officer of the Gwalior while the now fifteen-year-old Madhav served as orderly officer to General Gaselee in 1901. Both friends were decorated with the Third China War Medal for their efforts.

In 1894 the Maharaja came of legal age and obtained power. He was proudly Western in outlook, a marvellous host and staunchly pro-British. Eager for Western-style progress, he made Gwalior one of the most advanced states in India. He balanced the budget, encouraged local industries, built schools and hospitals and provided honest judges who sent their prisoners to model jails.

At leisure, he enjoyed driving steam engines, crying out to his admiring people “No danger – Sindhia drives.” He also had a passion for tiger shooting, even writing a book about it titled A Guide to Tiger Shooting, which became prescribed reading for the British dignitaries at his hunting parties. Martin Crofts would often accompany the Maharaja on these hunting trips, which were acclaimed for their entertainment value by distinguished foreign guests.

The Irish doctor’s military career was one on the ascension: he was elevated to the rank of surgeon lieutenant colonel in 1897; promoted to colonel in 1908, and to surgeon general three years later.  He was appointed Honorary Surgeon to the King on March 2nd, 1913.

During this time, Martin Crofts became residency surgeon of Kotali and Gialawar in June 1905 and months later, administrative medical officer of the newly created North-West Frontier province.  As surgeon-general he was principal medical officer of the Rawal Pindi division.

Martin maintained contact with his one-time ward and was honoured when Madho and the Indian princes, who presented the hospital ship Loyalty to the Indian Government for service in First World War, expressed a desire that Surgeon General Crofts should be appointed to the medical charge. But Martin’s health would not allow him to accept the post.

Less than a year after he retired, Surgeon General Martin Alymer Crofts died “suddenly of heart disease” in London on 12 March 1915. There was no record that he had ever married or had children.

Days later a brief notice appeared in the Cork Constitution regarding his funeral at Timoleague. It added, simply: “A man who knew how to do a day’s work and who did it”.

The Immortal Mind

Debate and controversy surrounds the occurrence of Near Death Experiences. Do they offer glimpses of human consciousness as a separate entity or are they merely hallucinations induced by physiological changes during the dying process?  Eimear Vize talks to Dr Sam Parnia, who is heading up the world’s first and largest scientific study of the brain and human consciousness during clinical death.

What happens when we die?

It’s the biggest mystery of them all, the million dollar question.

Critical care specialist Dr Sam Parnia believes that as many as 10 to 20 percent of us will experience a sublime and lucid consciousness after our bodies die and our brains stop working.

Although his theory tosses all of science’s accepted wisdom out the proverbial window, Dr Parnia says that recent medical studies in cardiac arrest patients have shed light on the controversial phenomenon known as Near Death Experiences (NDEs), providing the first indication that our minds and thoughts may in fact be what remains of us after death.

He has personally documented hundreds of cases of NDEs, as recounted by patients of all ages and from every walk of life, and has also interviewed the attending doctors and nurses. He has written a book about it - What Happens When We Die (Hay House, 2008) - but more importantly, he is now leading the world’s first and largest-ever study on the relationship between mind and brain during clinical death at major medical centres across the United States, Europe and Australia.

His thought provoking hypothesis is that human consciousness may work independently of the brain, perhaps using the grey matter as a mechanism to manifest the thoughts, just as a television set translates waves in the air into picture and sound. Switch off our brain and our mind continues regardless.

A Fellow in Pulmonary and Critical Care Medicine, Dr Parnia is acknowledged as one of the world’s experts on the scientific study of death, having researched the state of the human mind-brain and NDEs for more than a decade. He currently divides his time between hospitals in the UK and Weill Cornell Medical Center in New York, from where he spoke to Scope about his deep professional and personal interest in finding out what happens to us when we die.

And he is not alone in this pursuit: an international consortium of scientists and physicians have come together to set up the Human Consciousness Project, based at the University of Southampton, to research the nature of consciousness and its relationship with the brain, as well as the neuronal processes that mediate and correspond to different facets of consciousness.

In September last year the Human Consciousness Project – of which Parnia is Founder and Director - launched the innovative AWARE (AWAreness during Resuscitation) study, which recently completed the first of its three years’ examination of the relationship between mind and brain during clinical death. 

“I don’t like the term Near Death Experience, I prefer Actual Death Experience,” Dr Parnia clarifies from the outset. “Because in our research we are trying to understand from a scientific perspective what happens to the mind and consciousness in people who have gone through a cardiac arrest and basically died. They are clinically dead when they have these experiences.

“Contrary to popular perception, death is not a specific moment. It is a process that begins when the heart stops beating, the lungs stop working, and the brain ceases functioning. During a cardiac arrest, all three criteria of death are present. We’re looking at the stage before the brain has become irreversibly damaged.

“In a cardiac arrest, there is a period of time, ranging from a few seconds to an hour or longer, in which emergency medical efforts may succeed in restarting the heart and returning blood to the brain cells while they are still viable, basically reversing the dying process.

“What people experience during this period of cardiac arrest provides a unique window of understanding into what we are all likely to experience during the dying process,” he says, his curiosity and enthusiasm palpable.

“There are multiple cases out there of people who have experienced conscious thought while clinically dead; physicians have resuscitated patients who have come back and told them about their experience. That’s exactly what got me interested in this area of research in the first place, I had a number of patients who I took care of who basically had these experiences and I became more fascinated by it.

“Since then, I’ve spent much of my time trying to understand what happens when we die. I think that everything, including the question of what happens to us at the end of life, can be studied through the objectivity of science. And in the last few years, mainstream science has shown an interest in investigating these very issues. This is a very new area of science and may at first appear somewhat unconventional, yet I genuinely think that there’s no other area of research as potentially rewarding for all of humankind.”

A number of recent scientific studies carried out by independent researchers have demonstrated that 10-20 per cent of people who go through cardiac arrest and clinical death report lucid, well structured thought processes, reasoning, memories, and sometimes detailed recall of events during their encounter with death. 

“The remarkable point about these experiences,” according to Dr Parnia, “is that while studies of the brain during cardiac arrest have consistently shown that there is no measurable brain activity, these subjects have reported detailed perceptions that indicate the contrary—namely, a high level of consciousness in the absence of detectable brain activity. If we can objectively verify these claims, the results would bear profound implications not only for the scientific community, but for the way in which we understand and relate to life and death as a society.” he remarks in a quiet and plainspoken manner that belies the magnitude of his words.

Under Parnia’s direction, the AWARE team aim to recruit 1,500 cardiac arrest survivors. So far, about 20 medical centres in the UK, the US and Australia have signed up. And Dr Parnia tells Scope that he would welcome hearing from other hospitals willing to participate in the trial, including interested centres in Ireland. “We haven’t approach Irish doctors yet, it’s something we should have done but we haven’t had time to do it yet. Perhaps if you write your article you could mention that we would be very interested to hear from doctors or hospitals in Ireland?” he suggests.

During the study, researchers will give patients’ specific auditory stimuli and their ability to recall this information will be tested after recovery. In addition, in order to test the claims of visual consciousness (out of body experiences), hidden images will be strategically placed in the resuscitation areas so that they are only visible from the ceiling above and not from the ground below. These simple methods will thereby independently test claims of conscious awareness and out of body experiences.

The patients recall of the images and auditory stimuli will be related to cerebral function as measured using portable EEG, as the key to solving this mystery lies in the accurate timing of the experiences.

“If it can be proven that this period of consciousness had indeed taken place during the cardiac arrest, rather than a period before or after, this will have huge implications for the scientific discovery of consciousness and will support the concept that human consciousness is a separate, yet undiscovered scientific entity as proposed by some researchers,” Dr Parnia proposed in a paper published in Medical Hypothesis (2007), in which he outlined his theory and study design.

Now 12 months into their 36-month project, has he or his team members recorded any interesting phenomenon? “You have to be patient with us,” Parnia insists. “We don’t have any results to reveal right now. It’s important for us to collect all the data first before we start making any sort of announcement.”

However, Parnia and his colleague Dr Peter Fenwick at the medical and coronary care units of Southampton General Hospital made some surprising discoveries in their 18-month pilot study – the precursor to the AWARE research – that was conducted at several hospitals in the UK and involved 63 cardiac arrest survivors. Their findings, published in the journal 'Resuscitation' in 2002, demonstrated that approximately 6-10 per cent of people with cardiac arrest have NDEs and out of body experiences. They also revealed no evidence to support the role of drugs, oxygen or carbon dioxide (as measured from the blood) in causing the experiences.

The patients said they remembered feelings of peace, joy and harmony. For some, time sped up, senses heightened and they lost awareness of their bodies. They also reported seeing a bright light, entering another realm and communicating with dead relatives. One, who called himself a lapsed Catholic and Pagan, reported a close encounter with a mystical being.

Similar reports were documented in another important study by Dutch cardiologist Dr Pim van Lommel (Lancet, 2001), in which 344 cardiac arrest survivors from 10 hospitals were interviewed over a two-year period – 18 per cent experienced "classic" NDE's, which included out-of-body experiences. Patients with NDEs were then followed up for a further eight years following the event and reported less fear of death and a more spiritual outlook on life.

Dr Parnia maintains that there is no known common thread that links those patients who experience NDEs; they are old and young; religious and atheist; men and women. What is startlingly similar, however, is the experience itself. Just about every description of an NDE is beautiful. People feel connected, calm and care free. They experience unconditional love. They report seeing a bright light, frequently accompanied by the awareness of a presence in that light. Some report experiencing an instantaneous, panoramic review of their lives.

“Everyone has these experiences. Children younger than three have had these experiences and what’s incredible is that they are too young to have a concept of death or the afterlife,” Dr Parnia points out.

He recalls one very young patient who was two and a half years old when he had a seizure and his heart stopped. His parents contacted Parnia after they noticed their son was repeatedly drawing a picture of himself as if out of his body looking down at himself. It was drawn as if there was a balloon stuck to him. When they asked what the balloon was he said, 'When you die you see a bright light and you are connected to a cord.' “He wasn't even three when had the experience,'' Dr Parnia stresses. “But six months after the incident he was still drawing the same picture.”

He adds: “We don’t know how long this consciousness after clinical death continues, but we hope we may find out by the end of this study. It appears that, at least for the time within which we can resuscitate, which is up to about an hour or so, that it’s going on.”

Dr Parnia pauses for a moment, considering his next remark, then says: “The key thing here is, are these experiences real, or is it some sort of illusion? If no one sees the pictures, it shows these experiences are illusions or false memories. But if we get a series of 200 or 300 people who all were clinically dead, and yet they're able to come back and tell us what we were doing and were able see those pictures, that confirms consciousness really was continuing even though the brain wasn't functioning. It allows for the possibility that consciousness is a separate entity.

“There have only been theories out there so far, no one has tested them on a large scale like this. AWARE is the first comprehensive study systematically examining the mind, brain, and consciousness during cardiac arrest. Is our consciousness produced from electrical activity of the brain or not? Our study should answer this one way or another, but it’s a very important undertaking because we are all conscious, thinking beings and yet we have no idea how our thoughts come or how they relate to the brain. Our research will potentially provide a huge step forward. It may open up a whole new field of science.”

The emergence of a new science of consciousness?

Naturally, there is some resistance from mainstream science to studies like Parnia’s because they are pushing through the boundaries of science, working against assumptions and perceptions that have been fixed. Conventional neurobiological theories propose that the subjective sense of consciousness and the human mind are products of the brain, even though it is accepted that no one yet knows ‘how’ cerebral activity may give rise to consciousness and the mind.

The assumption that the mind and brain is the same thing holds true in 99 percent of circumstances, we can't separate the mind and brain; they work at exactly the same time, explains Dr Sam Parnia, but then there are certain extreme examples, like when the brain shuts down, that this assumption is brought into question.

“Today, the problems facing researchers into understanding the nature of consciousness are similar to the problems faced by physicists at the turn of the 20th century where it was discovered that classical physics cannot account for the observations made at the subatomic level,” he remarks. This then led to the eventual discovery of quantum physics.

“In a similar way, current conventional neuro-scientific models involving neuronal processing and plasticity cannot account for the observations being made as regards human consciousness.”

Consequently, he says that “a new science might be needed to account for the nature of consciousness” and large-scale studies of human consciousness during cardiac arrest, such as the AWARE trial, may in fact provide “the first key discovery” as regards the nature of human consciousness and its relation with the brain. 

What Science Says:

Four published prospective studies of cardiac arrest survivors have demonstrated that paradoxically human mind and consciousness may continue to function during cardiac arrest. This is despite the well demonstrated finding that cerebral functioning as measured by electrical activity of the brain ceases during cardiac arrest.

The first clinical study of NDE's in this patient group was published in 2001 by cardiologist Dr Pim van Lommel and his team from the Netherlands. Of 344 patients who were successfully resuscitated after suffering cardiac arrest, approximately 18 percent experienced "classic" NDE's, which included out-of-body experiences. (Lancet 2001;358:2039-2045)

In the same year, Dr Sam Parnia published his initial analysis of NDEs in cardiac arrest survivors. He reported that 11.1 percent of 63 survivors reported memories, the majority with features of NDEs. Parnia penned another review of this phenomenon for the same journal in 2007 (Resuscitation 2007;74(2):215-21).

Professor of Psychiatry, Bruce Greyson, of the University of Virginia Health System in Charlottesville, led a 30-month survey to identify NDEs in a tertiary care centre cardiac inpatient service. Just over 110 of the 1595 admissions were in cardiac arrest, and of these patients 10 percent later reported NDEs. (Gen Hosp Psychiat 2003;25:269–76)

A prospective evaluation of all patients who suffered a cardiac arrest at Barnes-Jewish Hospital from April 1991 through February 1994 revealed that 23 percent had a NDE. “The results suggest that NDEs are fairly common in cardiac arrest survivors,” the authors suggested. (J Near Death Experiences 2002;20(4))

Other Doctors encounters with NDEs:

At the age of twenty, American psychiatrist Dr George Ritchie died of pneumonia in an army hospital in 1943. Nine minutes later, miraculously and unaccountably, he returned to life to tell of his amazing near-death experience in the afterlife - one of the most profound near-death experiences ever documented. His book “Return from Tomorrow” tells of his out-of-the-body experiences, encounter with other non-physical beings, his travel through different dimensions of time and space, and ultimately, his transforming meeting with Jesus. How this encounter influenced his life is detailed in his follow-up book “Order to Return: My Life After Dying”.

In 1975, Dr Raymond Moody's best-selling book entitled “Life After Life” focused public attention on the near-death experience like never before. In fact, the US Psychiatrist provided some of the first descriptions of NDEs, recounting cases of people who had come close to death for various reasons. He has since published several books on the subject. In 1998, Moody was appointed chair in "consciousness studies" at the University of Nevada, Las Vegas.

Dr Michael Sabom is an American cardiologist whose latest book, "Light and Death", includes a detailed medical and scientific analysis of an amazing near-death experience of a woman who underwent surgery for an aneurysm. The woman reported an out-of-body experience that she claimed continued through a brief period of the absence of any EEG activity.

Human Cruelty

When I was a child I deliberately poured salt on a slug because someone told me it would ‘melt’. I had to know if that was true. And I stood there, horrified, as the unfortunate slug shrivelled up in a hiss of desiccating fluids. On the spectrum of humanity's inhumanity, plotting this harmless garden occupant’s foul end may not register, but I was nevertheless appalled that I had followed through on a nasty impulse. From cruelty's minor variants, such as bullying and domestic abuse, to the extreme, twisted malice that begot the Holocaust and the massacres in Turkey, Cambodia, Tibet, Bosnia, and Rwanda - why does cruelty exist? Do impulses towards sadistic brutality lurk in the depths of every human psyche? Could I be, am I, also cruel? Alas, the answer, according to Oxford Neuroscientist Dr Kathleen Taylor's latest book, is yes.

While writing “Cruelty: Human Evil and the Human Brain”, her research led her to the sad conclusion that the possibility of cruelty, including extreme cruelty, is a part of human nature.

And it seems our cruelty and violence can be rampantly baroque. Humans are staggeringly creative when it comes to hurting and killing other humans. You don’t need to read the Marquis de Sade to know this; you only need to listen to the news, read fiction, watch a film or TV, or learn a little history.

Kathleen’s first chapter opens with a harrowing example of this cruelty: a German army photographer sent to the Lithuanian city of Kovno in 1941 witnessed a young man beat to death about 50 people with an iron crowbar; dragging them one at a time from the condemned group and killing them all within 45 minutes. Onlookers, women and children included, clapped. When he finished, they sang along as he stood on the mountain of corpses playing the Lithuanian national anthem on an accordion.

“Neuroscience has taught me that both cruel behaviour and the motivation to be cruel may be inescapable, in that they arise as a result of how human beings have evolved. To this extent they are 'natural' aspects of what we are,” Kathleen says in a candid interview with Scope.

She flags a simple truth that society at large seems to be unwilling to accept but one that almost all researchers into the subject acknowledge: “Cruelty is not, by and large, the domain of madmen or natural born-evil doers. Rather, much cruel behaviour is rational, that is, it is done for reasons, which seem good to the perpetrators at the time, and done by people like you and me. Even in the most extreme cases perpetrators generally know exactly what they are doing. Some, long after the have had the chance to rethink their views, hold fast to the reasons which motivated them to act.”
Irrational violent harm doing does occur, for instance in homicides committed by psychotic individuals, but we are reluctant to describe such killers as 'cruel' precisely because their reason is so disordered. Kathleen stresses that cruelty implies “deliberation, free choice and moral responsibility”.

The second fundamental tenet in her book is that the difference between someone hurling verbal abuse at an immigrant or someone beating an immigrant to death is a difference of degree, and not a difference in-kind.

Of course, this is not to say that the two are the same, but she proposes that they are features on a continuum of cruelty from the mildest thoughts and behaviour to the most extreme. At one end lies the initial separation of ‘Them’  (The Other, the inferior out-group) from ‘Us’ (the superior in-group).

Its minor implications include stereotypes, prejudices, off-colour jokes and mild verbal abuse directed at out-group members. Moving along the continuum there are more vigorous verbal abuse, hostile and aggressive stereotyping, and then increasing physical violence. “Eventually we reach the spectacular rarities which involve destroying people identified as Them,” Kathleen explains.

She uses the term “Otherisation” to express the sense of creating an increasingly impassable gulf between Us and Them, and enables "us" to treat "them " as Untermenschen.

A research scientist and science writer affiliated with Oxford's Department of Physiology, Anatomy and Genetics, Kathleen seeks to describe and define cruelty in this, her second book. She strives to distinguish between callous brutality and sadism, and ground them in the workings of the human brain and evolutionary theory.

“I wrote my book Cruelty: Human Evil and the Human Brain not to lay down the authoritative summary of how things are, but to stimulate research and discussion. I'm a student, with plenty more to learn, who seeks to bring together the fruits of work in psychology, sociology, and my own field of neuroscience to shed light on the nature of cruelty and what makes human beings cruel.

“I understand the possibility of cruelty, including extreme cruelty, to be a part of human nature. There are many risk factors, which make it more likely that someone will be violently cruel, not least among them being young and male. However, most people, in certain circumstances, would probably find themselves behaving cruelly, no matter how well-intentioned they were beforehand,” she maintains.

While researching the book, she identified several conditions that appear to facilitate the emergence of cruel behaviour or convert average citizens into torturers.

“War or war-like situations is the obvious example. In general, two conditions are necessary: the cruel behaviour must be rewarded - for example by financial gain or the approval of friends or bosses - and there must be a significant difference in power to enable the cruelty to occur without much likelihood of prevention or reprisal. That power difference needn't necessarily be a matter of physical force; it can relate to how many allies the perpetrator and victim can draw upon, for instance.”

As cruelty is, basically, about action, to understand what makes people cruel Kathleen also explored the source of cruelty, and every other human behaviour: our own nervous systems. What is the sensorimotor alchemy that can turn a vicious idea into a vicious action?

In one of the most technically difficult chapters in her book, Kathleen suggests that the metaphor of brains as computational storage devices, soggy PCs, is misleading. Instead of mental ‘hardcopy’, what we have is a causal connection that results, on the whole, in similar neural patterns when we perceive similar events. These neural patters in turn tend to generate similar behavioural responses.

Contrary to popular myth, everything that makes us human is not necessarily done by the prefrontal cortex, and that includes making choices. Unlike a leisured person motivated to explore alternatives, the pressured individual will make more use of the strongest networks available, paying less attention to weaker, conflicting ones. He or she will be less likely to override initial impulses, more likely to disregard information about consequences or moral prohibitions, and more likely to show stereotyped behaviour and react aggressively.

In addition, she argues that activating part of a neural pattern increases the likelihood of activating all of it. “Even mild Otherisation primes people for aggression….To think about doing something cruel is to take a step along the Otherising path which leads to cruel behaviour. Whether the next step is taken depends on how the person reacts to the thought of being cruel,” she writes.

Essentially, she says that if these cruel thoughts are unchallenged, if there is “little interneural discussion”, the thought’s underlying neural pattern will tend to strengthen, and when next activated the person will be that little bit more likely to cross the threshold into verbal expression etc. If, on the other hand, the thoughts trigger unpleasant feelings the resultant neural conflict will prompt inhibitory signals from other brain regions to block the flow until the conflict is resolved.

“Like bad habits, viciousness is most easily halted early on,” she surmises. “Because related actions are represented by overlapping patterns in the brain, repeated activation of even mild Otherisation makes even more extreme behaviour easier to trigger.”

This, she adds, would explain why people used to violent cultures, like gang members or the Khmer Rouge cadres, kill for, in our view, tiny and trivial reasons. Otherisation and social acceptance of violence have lowered the threshold required to trigger murderous aggression.

A key argument of her book is that, in understanding cruelty, morality matters. The moral codes, which reward and punish us, lay down the neural patters that serve to inhibit our cruelty and boost our kindness – sometimes.

She tells Scope that, in general, science approaches this issue of cruelty, when it does so at all, analytically, trying to break down cruel behaviour and its causes into distinct components. Religion tends to focus on the moral aspects of cruelty rather than on understanding its mechanisms.

“Forensic psychiatry shows the clash between two world views clearly. On the one hand, we have the moral view, which emphasises the responsibility, motivation and free will of perpetrators as 'persons', wishing to punish violent perpetrators more as their actions are judged more cruel.

“On the other hand, the scientific view tends to focus not on questions of motivation but on the causes and mechanisms underlying the behaviour, to the extent that sometimes the person underneath almost seems to vanish.

“Although I am not a forensic psychiatrist, I would venture to say that the scientific understanding of such behaviour is not yet so advanced that psychiatrists can treat it effectively. More is known about how such extreme cruelty can arise. In other words, prevention may be more feasible than treatment.”

Kathleen confides that she was drawn to the topic of cruelty for two reasons. Firstly, when writing her previous book, Brainwashing, the question of motivation kept arising: why would people want to inflict this kind of psychological torture on others? Secondly, she wanted to understand what makes people cruel “because I couldn't help hoping that this would help, in some small way, to reduce the amount of cruelty in the world”.

Having immersed her self in this difficult subject for her research, she admits that it left her with an uneasy view of humanity and “our tendency to barbarism”, but she adds that any unpleasantness encountered as a result of writing the book was as nothing compared with what the victims she was writing about endured before they died.

“Cruelty was very difficult indeed to write, and I feel it has left me more fearful and pessimistic. My agent says it has made me ill; however, speaking as a scientist I don't have enough data to comment on that!” she laughs uneasily.

Having emerged on the other side of this journey into cruelty, Kathleen believes that that humankind would be better advised to try and manage cruelty than to try and eliminate it.

“Neuroscience has also taught me that understanding how brains work, while it may help us eventually to 'treat' cruelty more directly, is not a necessary prerequisite for reducing cruelty. We don't have to wait; there is much that can be done now. Human brains are immensely changeable, and much more influenced by their situations than we often realise, so changing the situations can change the brain and make behaviour more, or less, likely to occur.”

But will we do it?

Kathleen’s own opinion is that any changes we manage to make will be minor, slow, and grossly inadequate to the task at hand. If intelligence and knowledge were all that were required we could begin ensuring less cruelty tomorrow, but we also need the wisdom, courage and the will to change. Until then, Kathleen says we remain at risk: of suffering cruelty and of being cruel.

Brainwashing: the science of thought control

Ever since the Korean War, when it was first coined, the idea of brainwashing has fascinated, baffled, frightened, and appalled us. Around the world people are being pressured, deceived, or persuaded into adopting beliefs which are extremely and obviously harmful to them and to others. How does this thought control happen, and how can we resist it?

Dr Kathleen Taylor’s Brainwashing (Oxford University Press, 2004) is the first book to apply modern neuroscience to the topic of thought control. It combines psychology, history and cultural studies with cutting-edge brain research and case studies ranging from modern-day cults to sixteenth-century England. 

The Man Who Makes Faces

It started out as a career crafting disguises for undercover spies in the CIA. Now Robert Barron uses his incredible talent to build artificial features that give disfigured patients back their faces - and their identities. Eimear Vize spoke to the master of disguises about his remarkable work.

“It’s not Mission Impossible; it’s mission possible,” says Robert ‘Bob’ Barron, capturing in that succinct remark the essence of his work for the past four decades, as a former CIA Master of Disguise creating new faces for undercover spies, and now bringing the disfigured out of hiding with his hyper realistic silicone prosthetics. 

These life-like creations abound in his sophisticated laboratory in Ashburn, Virginia, not far from CIA headquarters where he once worked in secret. Since he retired in 1993, Bob’s second career is creating custom-made prosthetic devices for patients with conditions resulting from trauma, disease, and congenital defects.

The detail of his natural looking prosthetics – whether a finger or hand, an ear, nose, orbit with ocular, full or partial face - is a marriage of artistry and science fused by his natural talents and more than twenty years as the Central Intelligence Agency’s top Advanced Disguise Specialist.

Yes, as it happens, the CIA really does have agents traversing the globe undetected behind other people’s faces á la Mission Impossible. In a clandestine world where lives depend on meticulous detail and realism, Bob’s lifelike facial prosthetics are indistinguishable from real human features.

Circumstances may have changed but this self-professed “little old country boy” is still saving lives. He knows that some of his severely disfigured patients have contemplated and even come close to committing suicide, until Bob’s state-of-the-art prosthesis made them whole again and gave them a new lease on life.

“There came a point in my career with the CIA when I thought to myself, Bob, if you can put someone in hiding, you can bring someone out of hiding. If you can change someone’s identity then you can give some person their identity back – It’s not Mission Impossible; it’s mission possible.”

However, it is impossible not to be drawn into the fascinating world of this candid and empathic man. He recounts for Scope tantilising snippets from his former covert existence in the "wilderness of mirrors" of international espionage, along with disturbing accounts of the tragedies and pain visited on some of his patients: thankfully, with happy endings.

Realism, he says, is the common thread that connects these two remarkable careers. “Agents depend on the realism of that disguise to keep them alive, and their lives would definitely be in jeopardy if that disguise attracted attention; you want them to distract attention. I have to say that I never lost an agent. There was a lot riding on my shoulders to keep that agent alive, especially when they were going into an area where they knew that they wouldn’t come back if they were caught. I must have made a pretty big name for myself when I was in the CIA because all the agents wanted me to work on them,” he laughs softly. “Sometimes I had to go to where they were to fit their disguise, and it was dangerous. It was challenging and dangerous and it was fun. I would definitely do it all over again. If it hadn’t been for the Agency I wouldn’t be doing what I’m doing now.

“I put all my effort and my ability and my creativity, everything into my prosthetic devices just as if I am saving a life. And I have saved lives in this arena as well because there have been patients that have contemplated suicide. Every prosthetic device is unique and it takes it’s own amount of time and it demands the inspiration and the creativity, so that’s what I build into my prosthetic devices through decades of research and development. If this job were easy everybody would be one.”

Born in Du Quoin, Illinois, a small coal-mining town near St Louis, Barron’s gift for creating photo-realistic art surfaced at an early age. In high school he worked five months on a painting of the Grand Canyon he planned to enter in the annual state fair's art contest. When he went to see it on display, his heart sank when he couldn't find it among the other paintings. Contest organisers, it turned out, had put it in the photography section - where it had won a blue ribbon.

After completing a degree for commercial art at Southern Illinois University in Carbondale, Barron spent four years in the Marine Corps. He left as a sergeant in 1967 and was offered a job at the Pentagon in the office of the Chief of Naval Operations, where he became art director of Direction, the Navy's public-affairs quarterly.

Working in the Pentagon was exciting for a while, but Bob soon realised that his workday was shaped by the tyranny of the commute, made all the more intolerable by the daily hunt for a spot in the crowded Pentagon parking lots. So, putting his talents to work, Barron forged a perfect General rank auto pass and parked near the building.

The permit was perfect, but one of his co-workers spotted the young man parking in rows reserved for the Pentagon's top brass and squealed. He was fined and fired. But his masterpiece forgery, it appears, found its way into CIA Headquarters and impressed the right people, who couldn’t let this canny talent go to waste. Days later, young Robert was called to an interview and recruited to the Agency.

He spent years training how to completely alter a person’s appearance by crafting imitation ears, noses, eyebrows, moustaches and complete masks. Barron learned how to interchange the colors of skin on black, white and Oriental spies. He learned how to make silicone look exactly like living skin.

After a long, distinguished career, the details of which are still classified, Bob was awarded "The Career Intelligence Medal”. On his retirement, former CIA Director, James Woolsey, described him as “an extraordinary artist and master of the highly specialised craft of personal disguise…the ideal by which all other disguise officers were judged in the area of advanced disguise fabrication. His creativity and initiative were extremely instrumental in the research and development of what the silicone mask is today”.

Still young, Bob knew how he was going to spend his retirement, and it certainly wasn’t by abandoning his hard-earned craft.

“In 1983 I was still with the CIA as their senior disguise specialist and we were starting to look around for more sophisticated disguises. The agents would rely on the disguises to keep them alive, and the realism is what they were looking for. You have to pass the closest of scrutiny, about six to 12 inches. We had to see if we could better our product so that the agents’ lives were not jeopardised.

“I was undercover at the time and they sent me to a Biomedical Sculptors Association’s seminar in New York to see if the commercial field had a product that we could use to better our product. As it turns out the CIA was about five years ahead of the world. But when I saw all the disfigurements of people who had no nose because it was eaten up by cancer or their eye – orbital with ocular – was gone because a tumour had formed behind the eye and had to be removed. And burn survivors without a nose and without ears. And I thought, my goodness Bob look at this, if you can put someone in hiding, you can bring someone out of hiding. If you can change someone’s identity then you can give that person his or her identity back. That was nine years before I retired, and I already knew what I was going to do for my second career,” he tells Scope.

He established Custom Prosthetic Designs Inc (www.prosthesis.com), specialising in prosthetic replacement of facial and digital anatomy. Made of silicone and painstakingly hand painted, Barron’s removable prosthetic ears, noses, fingers and faces are nothing short of transformational. Subtle changes in skin tone, texture, and even tiny, hair-thin veins are carefully recreated.

As his business as a certified clinical anaplastologist started to take off, he teamed up with two highly respected specialists – Dr Craig Dufresne, a renowned Plastic Surgeon, and Dr Michael Singer, a top Prosthodontist – and began working on state-of-the-art technology in which titanium screws are surgically embedded in the patient's bone structure at the site of the defect. A retaining substructure is attached directly to the implants. Bob then designs, sculpts and tints the prosthesis, which may be clipped to the implant or fastened with small magnets. With such osseointegrated implants, a patient can wear the prosthesis for hours, even swimming, without worrying about adhesive loosening.

After more than 15 years in this business, Bob has acquired some very strong opinions about certain practices in plastic surgery, and tends to express his views rather passionately. “The corrective surgery that fails all the time is ear reconstructive surgery. I think it should be abolished, I think it is a medical abuse and I think it is criminal,” he chides.

Many of Barron’s patients, especially younger children, have undergone extensive reconstructive surgery to correct their ear deformity, whether due to trauma, disease or a birth defect such as Microtia, Artesia, Goldenhar Syndrome, and Treacher Collins Syndrome. Some have gone through so much surgery with such disappointing results that they have lost their faith in medicine.

“There is no surgeon on this good green earth who can reconstruct an ear. I’m sure they are good at other things but they should stop this. Kids suffer more, psychologically, with botched ear reconstructive surgery than Microtia. I feel that the doctors who perform this surgery, their passion is in their wallet,” he rebukes.

As Bob’s caseload increased, so to did his reputation. He was featured in dozens of respected publications, on major TV shows including Oprah, Montel, and 60 Minutes, and in documentaries for the Discovery Channel and National Geographic. And he is repeatedly approached with million-dollar job offers from major Hollywood movie moguls, including John Chambers, a pioneer in special effects makeup.

“I wouldn’t fit into the plastic world in Hollywood at all, that’s why I stayed away from it. Sure, I don’t make a fortune off of someone’s misfortune but I get a great high in changing that person’s life and making that person whole again. There is no better feeling. I mean, who are we if we’re not helping someone? What’s the purpose in life if we’re not helping someone; that’s the way I look at it. I feel that the good Lord gave me a talent and now he’s looking down on me and saying, okay Bob, I’m going through you to help others, and I believe that 100 per cent.”

One of Bob’s early accomplishments was a complete face for Jim Alexander of Detroit who was trapped in a car fire that burned away his entire face. Jim survived dozens of operations and painful skin grafts, was blind from his injuries and lived as a hidden recluse, not wanting to hear children scream at his sight.

“I made a full mask for him so he could interact in public without having the embarrassing stares and the unwanted attention going to his differences. That was a very, very complicated thing to do but it increased his quality of life dramatically,” Bob recalls.

After numerous operations Jim’s sight was restored. He remained Bob’s happiest achievement until, one evening, five years later, Jim Alexander fell asleep smoking in bed and burned to death.

The former Agent has made ears and noses for Pentagon men and women burned in the September 11th terrorist attack in 2001. And he also offered his services free for survivors of the two World Trade Centers who lost ears, faces and hands.

Among his most striking case to date was a horrifically mutilated woman from Pakistan. Zahida Parveen, a beautiful 24-year-old woman was three months pregnant when she was attacked and tortured by her husband, a barber, in a fit of unfounded jealousy. He gagged and bound her and hung her upside down from the ceiling. He brutally beat her with a wooden axe handle before trading his axe for his barber’s straight razor. Then he cut off most of her ears, sliced off her nose and finally gouged out her eyes with a metal rod.

He left her for dead; another of the many hundreds of mostly unpunished yearly honor killings in Pakistan. Though she survived with devastating injuries, Zahida was most upset by her little children screaming every time they saw her destroyed face.

In 2001, Dr Nasim Ashraf, a kidney specialist and Pakistani expatriate living in the US, arranged for Zahida to have her face reconstructed. She was flown to Washington where she met Robert Barron and Drs Dufresne and Singer.

They worked on her for six hours. They fabricated the eyes and the skeletal foundation of the nose for Zahida, and Barron replaced her nose and ears. She returned to Pakistan, blind, but content, with her children wanting to hug her again.

And Bob tells Scope that he is facing another massive challenge in the coming weeks when he begins the complicated process of crafting a new face for a cancer survivor, who lost most of his features through radical surgery to save his life.

“We are working on someone right now, as we speak, we’ve been working on this patient for three years, and we are reconstructing his face. He is a cancer patient, half of his face was lost, his nose, cheeks, eyes, and some of his mouth: literally the centre of his face.

“Craig and Michael have been constructing the ‘scaffolding’, so to speak, that will support his new face. Now it’s just about my turn. Next week I will take an impression of the face, and then I have to sculpt the new face - I use clay, initially, I don’t use wax because after your finished it looks like a woodcarving. I’ll turn that sculpture into silicone and tint the prosthesis to the surrounding tissue. I have to say I mastered the technique of making silicone look like skin, and that was in the Agency, it was research and development, this just didn’t happen overnight,” he stresses.

This painstaking transformation will be documented step-by-step by High Definition Net – the world’s only all high definition national television network.

Bob is unfazed by the habitual glare of the media spotlight on his work. “I’m just a little old country boy. I’m from Du Coin, Illinois, a town of 6000 people. I don’t let this publicity get to me, I’m still who I use to be a long time ago and I don’t let all this go to my head.

“The purpose of my second career is to give someone back the quality of life they had before their differences. My priority is always the patient’s expectations, to really fulfill their needs. The patient’s main objective is to return to society no longer embarrassed by the stares and unwanted attention produced by their differences. There really, really is no better feeling than when you can do something like that for someone.”

Many are cold but few are frozen

Surgeon Rear Admiral Frank Golden OBE is a world authority on survival at sea and is credited with unravelling many of the mysteries surrounding immersion hypothermia. He talked to Eimear Vize about his acclaimed research and life in the Royal Navy

A born raconteur, Corkman Frank Golden vividly evokes one particular night spent at sea in near gale conditions. The waves were climbing to 13 feet and the sea’s incessant battering had caused the floor of his life raft to peel away, leaving him clinging to the inner-side of the raft tube, awaiting rescue. The story is even more remarkable when you realise that the Irish doctor didn’t have to be there. In fact, he volunteered for the entire experience.

Golden spent much of his career as a medical officer in the Royal Navy (RN) involved in cold-water survival research. He believed that the best and most accurate way to test the safety and endurance of a new life raft being proposed for Her Majesty’s sailing fleet was to spend a week inside, adrift on the open sea.

“Simulated conditions may be reproduced in a specialised laboratory ashore but all the variables likely to be encountered in a real life survival situation can only be satisfactorily replicated at sea. We were testing some new life rafts being introduced to the Royal Navy ships to determine the most appropriate type, in particular the thermal habitability qualities.

“In World War II, over two thirds of all Royal Navy fatalities escaped their sinking ships only to die subsequently in the survival phase from hypothermia. In wartime, modern search and rescue facilities may not be readably available so survivors may have to spend a considerable time afloat before rescue,” he explains.

The University College Cork graduate notes, with annoyance, that the thermal protection built into most modern life rafts is deficient for longer-term survival. However, these still meet existing, lax international standards.

Now retired, Frank recalls the life raft trials as hard, challenging but extremely satisfying. And, like many an old salt, he has a story to hand about a particularly hairy moment: “One night, in a Sea State Seven, the floor began to peel off the raft and we were quickly up to our armpits hanging on to the inner side of the raft tube while waiting to be rescued.”

Such assiduous methods were well rewarded, however. These real-life trials resulted in the thermal protective properties of the rafts being significantly modified and upgraded before they being fitted to the Royal Navy’s ships.

Indeed, Frank’s efforts over the decades has translated into a myriad of life-saving benefits for those who make their living or take their pleasure from the open sea. The high-ranking Naval Officer has come up with practical solutions to many of the critical factors leading to immersion-related deaths. His efforts have also significantly enhanced operational protocols for international air-sea rescues.

Dr Golden has received worldwide acclaim for his research and numerous awards, including an OBE for his work on sea survival; a Gilbert Blane Medal from the Royal College of Surgeons for his research in post-immersion death; and a Stewart Memorial Prize from the Royal Aeronautical Society for his work on the rescue of immersion victims.

Indeed, the name of Surgeon Rear Admiral Frank Golden is internationally synonymous with research into cold-water survival. He has quiet literally written the book on it with Survival at Sea being published in 2002, some nine years after he retired from his RN post.

Prior to hanging up his hat in 1993, the Munsterman spent 30 years in the Royal Navy, directing its survival medical research department whilst also acting as consultant advisor in applied physiology. He also advised government departments and interested bodies – including the UN International Maritime Organisation (IMO) – on matters pertaining to survival at sea.

He quips that it was his bank manager who acted as an inadvertent recruitment officer for the Royal Navy when the recently qualified medic was still struggling as a GP trainee.

“I was being paid a pittance and my bank manager said he’d like a chat with me, during which he pointed out that on looking at my monthly pay cheque and my essential outgoings, it was quite clear that I would be 80 before I could change the figures to black,” Frank laughs.

“He suggested – ever so politely – that I should go away and get a decent job! I decided then to do a short service job in the Navy to help reduce my overdraft.”

It seemed a sensible career choice by any standards until Frank readily confesses that he was petrified of the sea – a phobia that had been with him since childhood.

Born and raised in Cork city, like many children he enjoyed trips to the seaside and spent many happy family holidays fishing in Ballycotton. But the pernicious potential of the sea was brought home to him repeatedly as he weathered the trauma of the summer drownings of a number of friends and acquaintances.

“I was a very poor swimmer myself in my youth. I was tall and thin with negative buoyancy – I swam like a stone and thus became very phobic about water. I think that was what stimulated a latent interest in the nature and causes in immersion- related drowning deaths,” he muses.

Frank, who graduated from UCC in 1960 and travelled to the UK thereafter, recalls his life was ‘suddenly transformed’ when he donned the uniform of a Royal Navy Officer in 1963.

“It took me sometime to get over the transition from pauperism to the status of being a Naval Officer with an obvious solution to my monetary problems. The work was exciting and very stimulating. In addition to being paid a very good salary, over an 18 month period I cruised the world visiting locations that included the Mediterranean, Middle East, the Asian subcontinent, Africa, the Southern Atlantic (Tristan da Cunha, and South Georgia), Antarctica, and the east coast of South America.”

A subsequent posting to the Navy Air Station in Culdrose, Cornwall, offered a sample of air-sea rescue work. The young Irishman was soon hooked.

One of the major rescues he participated in involved the stricken oil super tanker, The Torrey Canyon, which went aground on the rocks between Lands end and the Scilly Isles on 18th March 1967.

“I was flown out to The Torrey Canyon to provide immediate medical care to members of the salvage team who were injured following an explosion on board. The leader of the salvage team unfortunately died from extensive internal injuries before I could get him ashore. The remaining members of the salvage team all survived,” Frank recalls.

“It was that helicopter work which reawakened my interest in immersion deaths. It quickly became apparent that all the immersion/drowning casualties did not exactly conform to the information in the medical textbooks. A subsequent posting to the RN Air Medical School, which had a refrigerated pool, presented me with a opportunity to further my enquiries.”

Through personal experimental investigation Frank learned a great deal about ‘hypothermia’. Although the problem of hypothermia in sea survivors was well recognised by the end of World War II, there were still a great number of associated unanswered questions. These included the most basic one: Why did people die after just a few minutes of cold-water immersion?

“The popular belief was it was due to hypothermia but I knew from my experiments that even in ice-cold water, body temperature took some time to start dropping following immersion,” says Frank.

And the medical officer was troubled by many other questions. “Following cold water immersion, what was causing the muscular incapacitation, even in people who could swim, which prevented them swimming even five to ten meters to a safe refuge?

“Why did competent swimmers die after 20 or 30 minutes of swimming? Why did people who were wearing approved lifejackets drown?

“Why did about 20 per cent of those rescued alive – especially by helicopter – die during or shortly after rescue?” 

These puzzling phenomena were what drove Frank’s search for an understanding that he knew could be used to save countless lives at sea. In 1979 he undertook a PhD at the University of Leeds focusing on the physiological changes in immersion hypothermia with special reference to factors that could be responsible for death in the early re-warming phase. 

He explains that it was only after years of detailed studies at the Air Medical School and in open water situations that he was able to provide the heretofore-elusive answers (see panel right).

Another area of Dr Golden’s research involved studying the problems associated with escape from submerged vehicles, particularly helicopters. A key collaborator in this work was Frank’s PhD student at the time, Mick Tipton, now Professor of Human and Applied Science, University of Portsmouth.

Their pivotal research led to the development of an underwater escape device that provides the individual involved with sufficient air to facilitate escape, and it is now used extensively in the offshore oil industry.

Frank is rightly proud of his work. He has not just identified critical factors leading to immersion-related deaths, but used this new understanding to deliver practical solutions. One of many involves devising a simple method of lifting a victim in a horizontal attitude. Frank’s technique is now used worldwide by many helicopter sea rescues.

The information derived from the Irish pioneer’s many tests and experiments has also played a significant role in the design of much of the modern maritime lifesaving equipment, and he is frequently consulted by a variety of national and international organisations on matters related to survival at sea.

“My respect for the sea has increased enormously. I despair of many users who don’t follow the advice that is readily available, or who fail to learn the lessons from all those situations where lives have been repeatedly lost by inaction, carelessness, and the ‘it’ll never happen to me’ attitude. I could go on and on.

“The first and most important thing is to understand and respect the environment, and never think ‘it’ll never happen to me’. Identify potential disaster scenarios and rehearse the most immediate and essential actions required to prevent them worsening,” he advises.

Of course, the nature of some of Frank’s experimental work has precluded him for taking his own advice at times. A case in point was outlined at the outset of our interview when he recalled clinging helplessly to a disintegrating life raft with the sea surging around. But Frank is not one to go overboard without purpose. Asked if any of his perilous encounters were truly touch and go, he replies sagely: “Not really, although I’ve had several exciting ones.”

Essentials of Sea Survival

In 2002 Frank Golden co-authored the authoritative international handbook on survival at sea with his friend Prof Michael Tipton of the Department of Human and Applied Science at the University of Portsmouth.

Each year, 140,000 water-related deaths occur worldwide and Essentials of Sea Survival is a compelling, informative, and comprehensive guide that can help avoid disaster, even in worst-case scenarios.

Drawing on historical anecdotes as well as published scientific research, it examines the nature of the many threats confronting the survivor at sea and outlines, in lay terms, the methods that can be used to prevent or minimise the dangers.

Essentials of Sea Survival is a fascinating blend of historical anecdote, scientific fact, and practical application, including step-by-step explanations of how to safely abandon ship, board a life craft, dispense water and rations, divide duties, conserve energy and strength, and proceed with a successful rescue.

Scientists and academic readers are likely to find the technical research of interest, whilst the real-life scenarios will be striking for recreational water sport participants.

The sea survival mysteries unravelled by an Irish doctor

Surgeon Rear Admiral Frank Golden’s research has offered vital explanations for many of the mysteries that surrounded sea survival and hypothermia.

He discovered that difficulties experienced on initial cold-water immersion are associated with cardiac and respiratory reflexes resulting in tachycardia, intense peripheral vasoconstriction, hypertension and arrhythmias. These responses may result in an incapacitating cardiovascular accident or cardiac arrest in susceptible individuals.

“The respiratory response included an immediate, uncontrollable, substantial inspiratory gasp response, followed by hyperventilation during which breath-holding is impossible, frequently resulting in aspiration and drowning, especially in turbulent water,” the sea survival expert adds.

Frank also discovered that the swim failure, which often saw strong swimmers fail to make it five or ten metres to safety, is due to peripheral neuromuscular cooling before deep body temperature fell substantially (>2°C).

He established that longer term sea survival problems were associated with general hypothermia, leading to an inability to perform basic lifesaving actions, such as paddling to keep ones back to the oncoming waves, or providing additional support to keep one’s airway clear of the water in lifejackets. The lifejackets on many who lost their lives were “poorly fitted and without a crotch strap”.

Frank also realised that the puzzling collapse of many seas survivors on rescue was not – as Nazi experimenters in Dachau believed – due to the continued fall of deep body temperature, but was in fact related to the sudden removal of the hydrostatic support provided by the water pressure around the immersed body.

“In the absence of effective cardiovascular pressor receptors, due to cooling, the blood pressure collapses and cardiac arrest may ensue,” he adds.