The world’s most important doctor to millions in the war-torn villages of Sudan (#40 rebroadcast)

1. 0:00 – 5:15

   Intro

   1. PAPeter Attia0:01

      [intro music] Hey everyone. Welcome to the Drive podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com/subscribe. Welcome to a special episode of the Drive. For this week's episode, we're going to be rebroadcasting my conversation with Dr. Tom Catena, which was originally released in February of 2019. Prior to interviewing Tom, I had known about him for three years. But this interview was the first time I met Tom in person, and it's actually the first time in my life that I was ever nervous prior to meeting another human being. Now, of course, this is incredibly ironic because when you meet Tom, and this of course will come across in the episode, he is quite simply the most humble person you can imagine. But I see in Tom what I consider to be the greatest of any qualities or characteristics in a person, and it really humbled me to meet him that day and to continue to get to know him better and better over the years since that time. Since about the year 2000, Tom has been a missionary physician in Africa, initially working in Kenya, and then in about 2008, he moved to a region of South Sudan called the Nuba Hills or the Nuba Mountains, where he continues to take care of about three quarters of a million to a million people. At the time, he was the only physician in the area, and there's a single hospital there. It's hard to describe how few resources he has to run it. This is something he'll explain in the podcast. It's really nothing short of a miracle. As an update to Tom's work, after several years of relative calm, Sudan is again besieged with conflict. This time, there is fighting between factions of the government. This civil war has inflicted widespread damage across the Sudanese health system. However, even with all of this, Tom's hospital is still functioning and caring for the wounded. Not only that, but the hospital now has its own clinical training school, which has 19 physician assistant students and 30 midwife students. In 2008, when the hospital was founded, there were 15 staff members, including Tom and a few expatriate Catholic nuns, and the local Nuba were not formally trained at the time. As of today, there are 270 staff and over 50 formally trained Nuba health workers, including nurses, pharmacists, laboratory technicians, and anesthetists. And the first woman doctor from the besieged area of the Nuba Mountains is now also working with Tom. In my conversation with Tom, we talk about a lot of things. We cover some of the unimaginable suffering that he sees and how he himself copes with death and copes with being in a situation that I certainly don't think I could be in, and I suspect many of you listening would relate to that. We talk about a crisis of purpose. I think it's easy to look at what Tom does and feel sorry for him or feel sorry for the people that he serves. But I must admit, I came away from this interview actually feeling more sorry for us in a way. And Tom so eloquently, without judgment, explains some of the differences between people with all the privilege in the world, like most of us listening to this, and the people that he serves. We also talk about the sense of community that exists in Nuba. And what you start to realize is that the way we die in this country and the way that we live in this country is so different from the way that people live and die in other parts of the world. It's not surprising that people there don't die from complications of type 2 diabetes, but instead they die from infectious diseases and trauma. There's also a more subtle point here, which is that we are in many ways prisoners of our own world and our own mind and our own possessions. Tom's work is so important to me that I want to be sure anybody listening to this can get access to all the notes that we're going to put together on this topic. And as such, for this episode, the show notes will be free and available to everyone, including those who are not subscribers. Lastly, and perhaps most importantly, if anyone is curious about how to support Tom and his amazing work, we will have a link at the top of the page of the show notes where you can give directly to the work Tom does. My wife and I have been giving to Tom for about six years now, and I can say that it is unquestionably the highest ROI money that we contribute to any cause. In other words, for every dollar we give, we really have a sense of how it's being used and how it is changing lives. So without further delay, please enjoy or potentially re-enjoy my conversation with Dr. Tom Catena. [guitar music] Hey, Tom. Thank you so much

2. 5:15 – 12:30

   Background, medical training, and early days of missionary work in Africa

   1. PAPeter Attia5:15

      for making the time to come over here today.

   2. TCTom Catena5:16

      Sure, Peter. My pleasure. Glad to be here.

   3. PAPeter Attia5:17

      Yeah, there are few, yeah, there are few people that would be giving up more that they deem important work than you, so I, I know, I know your time is, is tight. How often do you come to the US?

   4. TCTom Catena5:27

      Well, this is my first time out in more than three years. So last time I was in the US was November 2015. I was here for about five days. I was in my hometown of Amsterdam, New York. And it wasn't much of a trip. I was-- You asked about malaria. I was sick as a dog with malaria. So I was, like, in bed with malaria [chuckles] the whole time. The last day I felt a bit better, just in time to go back to Africa. So it's been, it's been a long time since I've been back.

   5. PAPeter Attia5:50

      You grew up in upstate New York.

   6. TCTom Catena5:51

      Yep.

   7. PAPeter Attia5:52

      Your pedigree is like the star, right? You went to Brown, you played football, you went to Duke Medical School.

   8. TCTom Catena5:57

      Right.

   9. PAPeter Attia5:58

      At what point did you realize you wanted to do something a little different, uh, vis-à-vis working, you know, outside of the US, for example?

   10. TCTom Catena6:06

       This desire to do this kind of work really was planted in, uh, when I was in college when I was at Brown, and I always wanted to do some kind of mission work. And that term has several connotations, but I, you know, wanted to be a missionary, whatever that meant. I wasn't quite sure what it meant at the time, but I just had this idea. I wanted to work in other cultures, other society, do mission work. But I was, as you, a mechanical engineering major, and that didn't really fit with doing mission work. This was in the 1980s, and most of the jobs then were in the defense industry. They were... You know, they were good jobs, but I didn't really wanna do that kind of work. So I graduated college and kind of floating around for a while. I was offered a job by GE working with their kind of nuclear submarine program. It would've been a really good job, but I just wasn't interested in that kind of work. I remember one day, it was kind of odd, I was coming back from my great aunt's funeral. I was with my brother Felix, and an idea just kind of popped in my head. I should go into medicine 'cause I could... If I do that, then I could do mission work and, you know, I like the sciences. I could stay in the sciences, do mission work, help people, just kind of that general idea. And ended up going to medical school, and I've kind of kept that desire to do mission work, and that kind of evolved into wanting to work in Africa, work with people that don't have a lot of options for healthcare. You know, 15 years later, ended up in Sudan.

   11. PAPeter Attia7:22

       So you started out in Kenya, is that right?

   12. TCTom Catena7:24

       Right. So, you know, when I finished at medical school, then I did five years in the US Navy. I had a Navy scholarship for medical school, so I had to pay that time back. Then went, did my residency. I did family practice in Terre Haute, Indiana. Now it was time to kind of be free and do what I want. So I thought, "Well, let me just go and let me do this thing that's been kind of an itch for so many years." So I, uh, teamed up with Catholic Medical Mission Board, and I s- and they said, "Okay, we have an o- opening in Kenya at this mission hospital. Maybe go there." I said, "Okay, I'll go for one year. I'll see how it goes. If I like it, maybe I'll stay longer. Otherwise, maybe I'll just come back and start a practice." And went down to Kenya and fell in love with the place and decided to stay.

   13. PAPeter Attia8:02

       What was the first thing that you remember when you got there as far as how different this was from the way you had trained? Because you did your residence in the United States, right?

   14. TCTom Catena8:09

       Right. Did my residency in the US, and I did family practice. And the program I went to was, uh, kind of geared towards rural health. So I thought, "Okay, if I wanna do admission medicine, I better be doing more than just kind of outpatient office stuff. I need to do something with a little more, a little more meat to it." So, you know, a little bit of obstetrics. We did a bit of, uh, surgery, mostly just C-sections. So when I first got there, I think what struck me was just the volume of patients. I mean, I was a resident, and, you know, on clinic days, we'd see, like, five or six patients, you know, and get all, every little detail done on each one. And now, yeah, I'm in this rural hospital in Kenya, and, I mean, you're seeing 50, 60 patients, you know, huge numbers. The clinic, uh, the, the wards are full. You go do a ward round. I was in charge of the adult ward, and there were, you know, at the time I thought it was a huge number, like 30, 40 patients there, and I was responsible for all them. Just the sheer volume of patients you had to go through every day and the variety of diseases. So not only the tropical stuff, which I, I didn't know much about. I mean, here's malaria, TB, leishmaniasis, all this kind of stuff I had no idea about. I had to learn about when I was there. You know, learned to re- thank God some couple more senior doctors there that I could learn from. But just the volume of patients and the variety of diseases you had to face.

   15. PAPeter Attia9:24

       So what year did you get to Kenya?

   16. TCTom Catena9:26

       I arrived in Kenya, uh, January 17th, 2000.

   17. PAPeter Attia9:29

       [chuckles] That's so interesting. I, I arrived at NIH when I was in medical school on January 17th, 2000.

   18. TCTom Catena9:36

       No way.

   19. PAPeter Attia9:37

       Yeah.

   20. TCTom Catena9:37

       [laughs]

   21. PAPeter Attia9:38

       Yeah. That was, uh... Which was NIH, being at NIH while I was in medical school was one of the sort of more formative parts of my experience.

   22. TCTom Catena9:45

       Hmm.

   23. PAPeter Attia9:45

       So how long before you went to Sudan, and what led to that transition? I- I'm trying to think of my geography, right? Kenya is south of Sudan, correct? Sort of southeast of Sudan?

   24. TCTom Catena9:55

       South, right. South and a bit east, exactly.

   25. PAPeter Attia9:57

       Okay. And, and much more stable.

   26. TCTom Catena9:59

       Right.

   27. PAPeter Attia9:59

       Right? I mean, Kenya's a, a relatively safe place to be.

   28. TCTom Catena10:02

       Right.

   29. PAPeter Attia10:04

       Sudan is not.

   30. TCTom Catena10:05

       Right.
3. 12:30 – 37:00

   Tom arrives at Mother of Mercy Hospital in the Nuba Mountains of Sudan, civil war breaks out, and his staff evacuates

   1. PAPeter Attia12:30

      the listener a little bit about where Nuba is. I mean, I know it's in the southern part of Sudan.

   2. TCTom Catena12:34

      Right

   3. PAPeter Attia12:34

      It's to the east of Darfur-

   4. TCTom Catena12:37

      Right

   5. PAPeter Attia12:37

      ... but it's pretty rugged country, isn't it?

   6. TCTom Catena12:40

      Right. So, uh, the Nuba Mountains is probably one of the most remote places in the world. It's a region which for many years in Sudan was kinda kept off limits. Before when Sudan was a kind of a colony, it was under the, uh, called the Anglo-Egyptian Condominium, partly kind of adminis- administered by UK and by Britain and by, uh, by Egypt. They decided to kinda keep the Nubas separate. They said, "Look, these people have a unique, uh, culture and are a unique people." They didn't really allow a lot of open tourism or, or people to go in there. It was kind of a closed area. So they really kind of have maintained this separateness and this isolation over, over centuries. It's difficult to reach. It's semi-arid. It's got, it's got this thing of rainy season, it's got a dry season, but more hills. They aren't real high mountains, but sort of, uh, you know, 3,000-foot hills, that kinda, that kinda range.

   7. PAPeter Attia13:27

      My history's not great, but I sort of remember that basically Sudan was granted sort of, uh, I forget the term, but when you're given your independence-

   8. TCTom Catena13:35

      Mm-hmm

   9. PAPeter Attia13:35

      ... for lack of a better word, that would've been in the '50s, right?

   10. TCTom Catena13:37

       Right. '56.

   11. PAPeter Attia13:38

       Okay

   12. TCTom Catena13:39

       1956, yeah.

   13. PAPeter Attia13:39

       And, and then what was the religious sort of map of Sudan, and did that figure into how it was divided? And was that partly why Nuba was ... Was it religiously diverse? Was it mostly Muslim, mostly Christian?

   14. TCTom Catena13:53

       Yeah, you know, Sudan is a v- it's a very interesting place. So you've got, it was one country up until 2011 when they divided the North and South. Now, the religious makeup is in the North, so North of Nuba Mountains, it's primarily Muslim, almost all Muslim in the North. The South is primarily Christian. Nuba is right in the middle, and interestingly enough, Nuba is a mix. It's about, let's say half Christian, half Muslim, and everybody's an animist, but half are Christian, half are Muslim. And the Nuba are unique, I think a unique tribe in the world, where you have families which are mixed. You have Nuba, uh, you have Nuba Muslims and Nuba Christians, and they, there's no conflict amongst them. For instance, my wife is, is a Nuba. Her father, both her parents when they were born, they were, just followed the traditional religions. The, the Christianity and Islam had not been introduced yet into the area. Now, as they got older, her father became Muslim, mother became Christian. They married. Her father's a polygamist, so two wives, both wives are Christian. Their oldest son is a Muslim. The rest of the children are Christian, and nobody's really bothered by this. That's in Nuba. Now the country itself, this difference between Muslim and Christian was, was really a big issue in the previous civil war. You know, we had sort of the Southern African people that were mostly Christian against the Northern Arab people that were all Muslim, uh, fighting each other, and there was very much a religious context to that previous civil war. And also in Nuba Mountains, the Nuba Mountains, the Nuba people joined the Southerners. They're all African in Nuba. They joined the Southerners fighting the Northern sort of Arab Muslim people in the North. And in the 1990s, there was a jihad against the Nuba people. So there was a real genocide in the 1990s against the Nuba.

   15. PAPeter Attia15:33

       Who, who issued this jihad?

   16. TCTom Catena15:34

       The ideologue behind this is a guy who just died last year. His name is Hassan al-Turabi. And, uh, Turabi was a member of the Muslim Brotherhood, very bright guy, went to Sorbonne in Paris and was kind of an intellectual, but really kind of a, kind of an evil genius, [chuckles] if I can use that word. He was a real ideologue in the Muslim Brotherhood, and he managed to convince some of the imams in the North to sign off a fatwa to allow jihad against the Nuba. And many imams rejected it. They said, "Well, you can't, you can't do that. It's, you know, there's nothing-"

   17. PAPeter Attia16:05

       Even though he'd be killing Muslims within Nuba.

   18. TCTom Catena16:07

       Right, exactly. His response to this was, "Okay, you can have a jihad because the Christians are, are fair game in the jihad, and then the Muslims are apostates from the religion because they associate with Christians. Some of them eat pork. Some of them drink local beer. They're not real Muslims." Like this thing with the Nuba are very much communal, and to have Muslims and Christians together at functions, it was anathema to him. The fact you could have Christians and Muslims in the same family was a huge scandal to him. He just couldn't tolerate that kind of stuff. So he said, "No, these guys are also fair game because they're not real Muslims."

   19. PAPeter Attia16:38

       So what year was that fatwa issued?

   20. TCTom Catena16:40

       That was in the, I think in the early '90s. It would've been '93, '94 somewhere there.

   21. PAPeter Attia16:45

       So a- so Bashir was already in power, right?

   22. TCTom Catena16:48

       Bashir was in power.

   23. PAPeter Attia16:48

       His coup was like late '80s, right?

   24. TCTom Catena16:50

       He took power in '89.

   25. PAPeter Attia16:51

       Okay.

   26. TCTom Catena16:52

       And this guy Turabi helped him win this coup. He was kind of the brains behind the coup. And Turabi, I mean, he was, you know, he's, he was kind of a power-hungry guy. He said, "Okay, I'll..." His fig- he figured if he helped Bashir get into power, Bashir was a military guy, and he thought, "Okay, if I help Bashir get into power, I'm much more intelligent than Bashir. I'll just kind of find a way to get rid of him, and I'll take over." And Bashir said, "Look, I'm the one in power. You're not, you're not taking over." So he kind of always kept, uh, Turabi at a distance. And there are always these, he would always, he was always throwing Turabi in prison afterwards 'cause Turabi started speaking out against him.

   27. PAPeter Attia17:21

       Hmm. [chuckles]

   28. TCTom Catena17:22

       So he would put him in a quote-unquote prison and he'd be, you know, living in some luxury apartment in Khartoum. But they kind of were at odds with each other, but Turabi was the ideologue behind a lot of this movement. He's the one that invited Osama Bin Laden to Sudan in the early '90s. So Bin Laden lived in the North.

   29. PAPeter Attia17:36

       When Bin Laden was exiled from Saudi Arabia-

   30. TCTom Catena17:38

       Exactly
4. 37:00 – 47:45

   Learning surgery on the job and earning the trust of the community

   1. TCTom Catena37:00

      practice, and when I went to Kenya- We're doing a lot of, you know, tons of tropical medicine, a lot of obstetrical care, did a lot of C-sections. But I realized a lot of the disease burden in Africa was surgically related, a lot of it. I mean, a lot of it, of course, is tropical medicine, like you, okay, do all those things. And, uh, I said, "Well," a good-- seemed like half of what we were seeing was surgically related, either just wound care, miscarriages, laparotomies, amputations, kind of the run-of-the-mill kind of surgical stuff. There's a lot of it. So I thought, "I really need to learn how to do this stuff if I'm gonna stay here long term." So luckily, where I've been, both rural Kenya and Nairobi, I met up with people that were willing to teach me things. So really it was like doing another residency. I mean, I would-- When I was in Nairobi, I had a whole day in the operating room, and we'd do tons of cases, and there was an American missionary doctor there named Mike Johnson. So Mike would just sit there and teach me stuff. You know, I would, I would do the-- Just like you did in residency. I would do the case, he would assist me, and just kind of walk me through it. There was a Kenyan surgeon there, Dr. Ruchu, who's a fantastic... He was like a magician. He was not so hands-on, but if-- He was always-- He was there in the operating room, so he would say, "Go ahead and start the case." After I got a little bit of experience, he'd say, "Start the case. If you have any problems, call me." So I'd start, open up, look around a bit, say, "Okay, I'm stuck. What do I do?" He'd come in, look around, say, "Oh, do this, do that." I'd do this and that, and things would go ahead. Before you know it, you're doing thyroids and laparotomies and resecting bowel and stitching liver and taking kidneys out and doing amputations. And I mean, you know how it is. You just kind of-- Once you learn a few, you, you have a few skills, you can add the next case, the next one, the next one. And I mean, it took-- I was there for seven and a half years in Kenya. It was like doing another residency.

   2. PAPeter Attia38:36

      I mean, at some point, though, you have to be making mistakes that are harming patients, because even in our-- And I say that not being critical, right? But just saying, like, that's the nature of medicine. I mean, I, I think of every time I hurt somebody. Even, you know, I, I remember once causing a hemopneumothorax in a patient when I put a central line in them.

   3. TCTom Catena38:53

      Sure.

   4. PAPeter Attia38:54

      It was my 500th central line.

   5. TCTom Catena38:56

      Right.

   6. PAPeter Attia38:56

      So at this point, you'd think I could do it blindfolded. And yet to cause that complication, which in my case, I'm lucky enough to have an X-ray to see that I've caused this complication, you don't even... I mean, you're missing so many of the basic tools that could act as sort of a safety net. So what was that process like?

   7. TCTom Catena39:15

      I think what I wanted to make sure of when I was in Kenya, I think those whole seven and a half years I was in Kenya, I always had either somebody assisting me in the case or somebody in the room or in the next room over. So I, I think I was pretty well covered during that time. And by the time I was finished seven and a half years, I felt pretty confident I could go out on, on my own and do, and do surgery. I think it's this concept you know better than I do, about 10,000 hours, you know?

   8. PAPeter Attia39:38

      Mm-hmm.

   9. TCTom Catena39:39

      And I think in residency, you have to do, like, 1,000 cases. I suppose, like, 1,000 cases at least. Like, that's, like, a minimum of cases.

   10. PAPeter Attia39:43

       Yeah, maybe 1,200 or something.

   11. TCTom Catena39:45

       Yeah.

   12. PAPeter Attia39:45

       Yeah.

   13. TCTom Catena39:45

       So I did... You know, by the time I finished my time in Kenya, I'd done-

   14. PAPeter Attia39:48

       But, but for you, it's harder because you're doing a breadth of cases that-

   15. TCTom Catena39:51

       Right

   16. PAPeter Attia39:52

       ... like, e-even if you took something as broad as general surgery, I mean, you're still doing basically orthopedic surgery as well.

   17. TCTom Catena39:59

       Right, orthopedics.

   18. PAPeter Attia39:59

       And, and obstetrics.

   19. TCTom Catena40:01

       Right. Tons of obstetrics.

   20. PAPeter Attia40:02

       And yes.

   21. TCTom Catena40:02

       A lot of urology. There's a mix, and I think maybe the trade-off is the surgery in Africa is much broader but less depth. Like, we don't have any laparoscopic stuff. Of course, we don't have any of the, these da Vinci-

   22. PAPeter Attia40:14

       Yeah. [laughs]

   23. TCTom Catena40:15

       ... things and all that, and all this high-tech stuff. You trade off kind of depth of, of surgery for breadth. I felt after doing around 2,000 C-sections and over 1,000 other major cases, I felt, "Okay, I think I can do whatever we're doing in Nairobi, I can do that, I think, safely in Sudan." I mean, obviously, you know, we have complications and other problems, and there are a lot of limitations in terms of going into the case. So you tend to do more laparotomies because you, you don't have a diagnosis.

   24. PAPeter Attia40:43

       You don't have a CT scanner.

   25. TCTom Catena40:44

       Right, no CT scanner. You don't know exactly what's going on. To get a tissue diagnosis might take you six months. So you say, "Go, hey, let's do a laparotomy and see what that thing is." That's, that's your CT scan in the end. But that's about the best you can do. So I think what I always-- what I try to do when I approach a case is, you know, the primum nil nocere, first do no harm. So if you think you'll make the patient worse by doing this, like, "Okay, I'm not an expert at doing this case," um, and sometimes I say, "I'm not gonna do it." You know, I won't, I won't do an op if I think I really cannot improve this patient's health. I think, "Okay, uh, this is too much of a risk." Sometimes I say, "Look, I just-- I'm not really comfortable doing this." But usually I'll feel, I'll say, "Okay, I think it's better if we try to do this operation. I think we can-- the patient can improve, and, uh, we'll go ahead." And it works, uh, I mean, it normally works out pretty well.

   26. PAPeter Attia41:30

       I was talking with my wife and my daughter a couple days ago and-- about how we were gonna be speaking today, and they had so many questions. You know, we all watched The Heart of Nuba together, and, um, one of the questions my wife had was, how do you deal with exactly that type of situation you described, which is what we would consider, quote-unquote, "end of life" here in the United States, or palliative care? What do you do in a situation where somebody comes in and your judgment says this person is not an operative candidate?

   27. TCTom Catena41:55

       Mm-hmm.

   28. PAPeter Attia41:56

       But also by not operating, they need to be palliated. I mean, they're not going to... They're not-- It's not like, you know, they're gonna walk home. How do you deal with that? And, and more importantly, I guess, than medically how you deal with that, it's emotionally and how is that communicated to the community, because you're still a foreigner, right?

   29. TCTom Catena42:13

       Right. Right, I'm still a foreigner and, and will always be one. So I would say when we first started 10 years ago, people did not trust us, and it was incredibly nerve-wracking, something we just got here. People d- kind of have this-- 'cause they've been-- these people have been traumatized and oppressed for so many years. They're not gonna trust some foreigner showing up saying he's there to help them. So you gotta prove yourself. So I'm thinking, "Well, you know, I'm doing these operations. What if we have bad outcomes? You know, what happens?" So it was really nerve-wracking for all of us. And, you know, thank God things went pretty well, and we went ahead. So the issue with palliative care, you know, we try to just talk to the family, talk to the patient, say, "Look, we think we can't do much, uh, for you, and that's why if you go home, we'll take care of the pain or the things we can do." One good thing there is the people, their expectations are extremely-- are low. And I'm not saying that in a negative way, I'm saying it in a positive way. They don't expect-- they don't really expect miracles. They wanna be treated as a human. They want that human touch. They want us-- they wanna talk to us and they talk to you and say, "Okay, what, what can we do?" If you tell them, "Look, I, we, we can't do much," they're not, they're not saying, they're not like demand-- they're not very demanding saying, "No, you gotta get-- send me to Nairobi for a second opinion." They're very accepting. I think that's just 'cause their lives are, are, are very hard. They're not used to good outcomes. So I think first off, they're, they're very accepting 'cause when you tell them, "Look, I think there's not much more we can do," we often will talk to the relatives. Uh, culturally, uh, usually the relatives will say, "Well, just," you know, uh, they don't, they don't like telling the patient, which is very different from here in the US. So we just talk with the relatives, and they're usually very accepting. They say, "Okay, we," you know, "we see you've done what you can. We'll t- we'll take him home and make him comfortable there." They have some of their local traditional things they might try with the person at home, but they're usually very accepting of negative outcomes or bad news. When you're kind of at the edge of survival all the time, when you get this kind of bad news, it's not so shocking to you. [chuckles] It's like, well, you know, that's what happens. People die, you know, and people have bad outcomes. Bad things happen to you. So it's not so unusual for them. You know, in the US, we're kind of anesthetized that everything has to be perfect and we're not supposed to die. We're supposed to, you know, have this kind of outlook on life. It's, it's a very different way of doing things, so it-- they're fairly easy in that respect. They understand this stuff. You know, most people have some level of faith, whether Christian or Muslim, they can accept this stuff in a, in a, in a theological sense also. It's not so difficult.

   30. PAPeter Attia44:36

       When you showed up, how primitive was the extent to which people were receiving... I don't know what-- how to describe the type of care, but there must have been local traditions and shaman and stuff like that, right?
5. 47:45 – 59:45

   The amazing people of Nuba, and why Nuba feels like home to Tom

   1. TCTom Catena47:45

      when they go to the kujur.

   2. PAPeter Attia47:46

      So how many people does your hospital serve?

   3. TCTom Catena47:51

      Catchment area is roughly a million. Anywhere from 750,000 to a million people is in our catchment area, and the physical region is around the size of Austria, somewhere in that, in that, uh, range.

   4. PAPeter Attia48:02

      The people there I-- for example, how many of the people that you serve would understand what you meant if you were going to New York?

   5. TCTom Catena48:10

      [laughs]

   6. PAPeter Attia48:12

      Like, how big is their world?

   7. TCTom Catena48:15

      Well, it's, it's interesting you ask that. I mean, even the ones that have finished secondary school wouldn't have an idea. Like, if they ended up here or-- I mean, it'd be-- it would blow their mind. Maybe I'll give you an example. My mother-in-law is probably in her 70s, so we went to talk to-- My wife was talking about writing a book. Actually, she started writing her book. And we went to my mother-in-law, and we said, "Let's go and interview your mother as part of your book. You know, you can write down about her life." And my w- my wife didn't actually know a lot of facts about her mother 'cause they don't have that, you know... Mothers and daughters there are not like buddy-buddy. You know, the girls are, you know, o- once they, once they get weaned from the breast, they start working, carrying water and firewood and everything else, and cooking for the family. So we went to talk to her mom, and my wife asked her mother, uh, her mother only speaks the tribal language. She doesn't speak Arabic or English or anything else, so we talk, she, she's talking only tribal language, saying, "Do you know where Tom is from?" And she said she thought for a minute. She says, "He's from Kenya." [chuckles] And she said that-

   8. PAPeter Attia49:11

      That's the furthest place she can imagine?

   9. TCTom Catena49:13

      Right, because she's heard of Kenya, so in her mind, anybody who's not from Nuba Mountains must be from Kenya.

   10. PAPeter Attia49:18

       Mm.

   11. TCTom Catena49:19

       Doesn't matter who you are. You know? So that's the outside world. And we say, "Well, no, he's from America. You ever heard of America?" No. She'd never heard of it, had no concept of America. "Have you ever... You know what an ocean is?" No concept of an ocean, no concept of a lake, no concept of Africa. She didn't know she was in Africa. So what she knew was her local area, it's just a few of the villages there. She'd been to Khartoum once. She's-- My wife's mother has leprosy. We've treated her for leprosy, and they've amputated, I think, all of her fingers at one point or other. She's really, uh, quite disabled. She'd gone to Khartoum some years previously to get treatment there and ended up not getting treated. But besides that brief trip to Khartoum, she'd never been out of that local area. A lot of my wife's siblings have never been out of this 15-square-mile radius. You can't imagine the worldview.

   12. PAPeter Attia50:06

       Presumably your wife also hadn't experienced things outside of that until she met you, and what was the first time she left or traveled with you or-

   13. TCTom Catena50:15

       The first time we-

   14. PAPeter Attia50:15

       Given especially that you don't travel much.

   15. TCTom Catena50:17

       Right. So the first time we traveled was after we married. It was just this past June. We went to Armenia. So that was really her first time out of rural Africa. She'd been-- She went to nursing school, but that was in South Sudan, in Wau, which is... I mean, for, for South Sudanese, they call it a city, but it's, it's a village, you know? It's a big village. So imagine we went from, we went from, uh, Ituri refugee camp down to Juba, which is the capital. I mean, Juba's more or less a city, but it's really not very nice. Then we fly from Juba to Dubai, and we were in the Dubai Airport. [chuckles] And I mean-

   16. PAPeter Attia50:49

       Which, which I was just there a month ago. Even for someone who's from the United States, the Dubai Airport is an overwhelming-

   17. TCTom Catena50:56

       Yeah. It's, I mean, it's, it's terrifyingly huge. It's a city.

   18. PAPeter Attia50:59

       Yeah.

   19. TCTom Catena50:59

       I mean, it's a, it's a major city. So we get there, and her eyes are, you know, the size of saucers.

   20. PAPeter Attia51:05

       Has she seen that much electricity in one place?

   21. TCTom Catena51:07

       No. I mean, not even close. Not even close. I mean-

   22. PAPeter Attia51:10

       Has she seen fresh water to that extent? I mean-

   23. TCTom Catena51:13

       No. I mean, I'm trying to think if she'd ever seen a, a tap. No, we had taps in the hospital. We have a pump that pumps water up, and we have some s- some, uh, taps in the hospital. But, you know, flush toilets were... She'd never seen before, but all this stuff. So get-

   24. PAPeter Attia51:26

       Elevators.

   25. TCTom Catena51:27

       Elevators. So that was one of the things. We get in there. We're at the airport. We get in this, you know, push a button, this door opens. We get in this thing and pressing the button, then the thing goes up, and we get off. She's like, "What was that?" [chuckles] So no concept of an elevator. We get on the escalator, and she's, like, falling over the place. We go to get off the escalator. She's like, "What i- how is, how is this thing moving?" I think when she was in nursing school in Wau, I think they had one set of stairs. There might've been a second floor. But just the concept of walking up stairs is something strange, let alone a moving staircase. So all these things were very new to her. Now we get to Armenia, and, I mean, just being in a city. I mean, Yerevan is the capital of Armenia. Not like New York, but very different experience for her. Now, she came to the US for the first time just this past October, and, I mean, she was in Times Square. [chuckles] I mean, saw the ocean for the first time. She went to my brother who lives in, uh, near Boston, on the North Shore of Boston. So that was the first place she went. So first place she went to, went to Boston, and our hospital was getting an award by a group called Medicines for Humanity, which supports us, and they were giving us an award for the work that our out- outreach team is doing. So nobody could make it. You know, I couldn't go. My, you know, other staff couldn't go. So my wife went, uh, to accept the award on behalf of the staff. So she lands in Boston, and the first thing she does is goes to the Harvard Club to get this award. [chuckles] It's a very opulent place.

   26. PAPeter Attia52:45

       Right.

   27. TCTom Catena52:45

       Goes to my brother's place. He's up in Rockport, Massachusetts. She sees the ocean for the first time. Sees a train for the first time. Goes to malls, to Walmart, you know. She loved the dollar store. And, you know, my family just went, went crazy with her. They had so much fun being with her, you know, seeing all these things for the first time through her eyes. And, uh, I mean, she's very, has a very kind of infectious joy to her, and they really kinda tapped into that, and, uh, it was really eye-opening for her.

   28. PAPeter Attia53:12

       And the flip side of that is we can sit here and have this discussion, and of course, most of us would be thinking how amazing at all the things that they don't have. But I'll, I'll share with you a, a, a story that I suspect will resonate, and you will understand it. This past Christmas, my daughter's school, each grade picks something they're going to do.

   29. TCTom Catena53:32

       Mm-hmm.

   30. PAPeter Attia53:33

       And that grade decided that they were going to buy Christmas presents for all of the kids at the Sudanese Community Center in San Diego.
6. 59:45 – 1:12:00

   NY Times article about Tom’s work, and Tom’s new venture on the board of the Aurora Prize Foundation, raising awareness and funds for other missionaries

   1. PAPeter Attia59:45

      Rick Gerson, his brother Mark Gerson, and ultimately met John and, and, and I think they learned about you through a piece that, uh, Nick Kristof wrote in The New York Times in 2015.

   2. TCTom Catena59:54

      Mm-hmm.

   3. PAPeter Attia59:55

      How did Nick come to find you? Because that story, we're gonna link to that story. The story is amazing, right? It leads off with about a 10-minute video-

   4. TCTom Catena1:00:03

      Right

   5. PAPeter Attia1:00:03

      ... that I watched over and over and over again.

   6. TCTom Catena1:00:08

      Hmm.

   7. PAPeter Attia1:00:08

      And I came home, and I made my family watch it, and I sent it to my family back home. And there's a part in it that just says everything about it. I mean, first of all, I think Kristof did an amazing job framing the story, and he was there, which is in and of itself, I wanna actually understand how someone actually gets there [chuckles] 'cause that's, that's, that strikes me as quite a challenge logistically. But he, he ends the article with a story of a Muslim man who proclaims that you are Jesus Christ.

   8. TCTom Catena1:00:38

      [laughs]

   9. PAPeter Attia1:00:39

      And I always... It's the title of the article, if I'm not mistaken.

   10. TCTom Catena1:00:42

       Yeah, yeah. [laughs]

   11. PAPeter Attia1:00:42

       He's Jesus Christ, which coming from a Muslim man also speaks to the religious harmony that you've described.

   12. TCTom Catena1:00:48

       Right.

   13. PAPeter Attia1:00:48

       And for people like me who aren't especially religious, it makes you think, well, I guess that's what religion should be about, right? It shouldn't be about most of what we think of religion as. Religion has, has its taboos here, but I think the point Kristof makes, and makes it beautifully, is if you wanna be critical of all of the religious hypocrisy, by all means do so.

   14. TCTom Catena1:01:10

       Hmm.

   15. PAPeter Attia1:01:10

       But you can't then fail to acknowledge the times when, in the name of religion, people are doing these incredible things. In the name of all religions, by the way. It's not just your religion. I mean, as you know, it's, it's people of, of all faiths that are doing these things. But in many ways, I think that story brought amazing attention to your work that It breaks my heart to think, are there other Toms out there whose stories are not being told? So how did Christof find you or how did you guys find each other?

   16. TCTom Catena1:01:35

       He has an interest in Sudan. I think he's had it for a number of years, and I, I think for him, he saw this, uh, what Bashir was doing as such an egregious affront to humanity that he felt obligated to go and see firsthand what was happening. So he made a couple trips into the Nuba Mountains. You can fly into Juba, then you got to flight up to the refugee camp in Yida, and then manage to come into the Nuba Mountains. You know, you don't come in with official permission of the Sudan government.

   17. PAPeter Attia1:01:59

       So you're sneaking into the country.

   18. TCTom Catena1:02:00

       Right. Basically sneaking in. You get a permit from the, uh, rebel government, and they allow you to come in, and I think he just has an interest in that, in that part of the world and, and really wanted to do something that shed light on the situation there against Bashir. And he'd been into Nuba I think one previous time and heard about the hospital, wanted to come and see us there and, and see what kind of work we were doing, to see for himself, and was there for, for a few days. He's, he's a real, I mean, he's a really intrepid traveler and incredible journalist. I mean, he's unbelievable, and what I respect about him the most is he can disagree with you, like, you know, whether whatever, religiously, politically, not agree with your beliefs, but he can realize what you're doing has benefit, and he can look at it objectively and say, "Okay, you know, I don't believe in this religion, but I, I see what these guys are doing," and highlight that. You know, not many people are willing to do that.

   19. PAPeter Attia1:02:48

       I thought it was very elegant how he framed that in, in that piece in The New York Times. And that video, though it's only about 10 minutes, that was really my first introduction to you, uh, God, about three and a half years ago now.

   20. TCTom Catena1:02:59

       Right.

   21. PAPeter Attia1:03:00

       So the world's a better place. Certainly, the Nuba Mountains are a better place because of Nicholas's work.

   22. TCTom Catena1:03:05

       Right. And he, he tends to highlight people that are kind of not, not well known, and there are others that are out there, and it's actually part of what we're trying to now with Aurora. Aurora's focus is on, is on highlighting what they say is unsung heroes, but people that are kind of operating in the weeds that nobody knows about. So shine a bit of spotlight on them, not so much for publicity, but to help them both in their, in their work and to raise, uh, by raising their profile, you raise the issues that they're involved with.

   23. PAPeter Attia1:03:31

       So tell people a little bit about what the Aurora Prize is and what it means for you to now be... You're the 2018 recipient, is that right?

   24. TCTom Catena1:03:39

       2017.

   25. PAPeter Attia1:03:40

       2017 recipient. So what is the Aurora Prize? I know it's based on... I know a few things about it, so I'll fill in the little bits that I know. It's a prize that has a finite life, correct?

   26. TCTom Catena1:03:49

       Right.

   27. PAPeter Attia1:03:49

       It was began in 2015 or '16, and it will run till about 2022, '23. And that duration, if I recall, is meant to commemorate the length of the Armenian Genocide in 1911-ish, 1915?

   28. TCTom Catena1:04:00

       Well, it's 100 years onward. The genocide went on for about eight years-

   29. PAPeter Attia1:04:04

       Okay

   30. TCTom Catena1:04:04

       ... from 1915 to 1923. So this is hund- hundred years henceforth those eight years. That's the, those eight years the Aurora Prize will be given out.
7. 1:12:00 – 1:19:45

   Tom’s mind-blowing ability to deal with chaos while seeing hundreds of patients per day

   1. PAPeter Attia1:12:00

      does the pattern of mortality look like in Nuba? My guess is infant mortality must still be quite high.

   2. TCTom Catena1:12:07

      Right.

   3. PAPeter Attia1:12:08

      How much of that is due to challenges with prenatal care-

   4. TCTom Catena1:12:11

      Mm-hmm

   5. PAPeter Attia1:12:11

      ... versus the actual deliveries and, and postnatal care?

   6. TCTom Catena1:12:16

      I think a lot of the neonatal deaths are just from difficult deliveries. You know, the, their baby gets asphyxiated. The baby's born and dies. Uh, they're, is a stillborn or, or dies soon after birth. And there are very few deliveries done. I mean, 99% of women there still deliver at home. To deliver in a clinic with maybe a traditional birth attendant is rare, let alone in a hospital. So I think a lot of it is just due to, you know, most of those people probably would end up in a C, with a C-section if they were at a hospital in the US or even in Kenya. If they had access to care, they would end up with a C-section. We are s- you know, we have one place doing C-sections, or actually two now that do C-sections.

   7. PAPeter Attia1:12:52

      How many, how many babies do you deliver in a typical year?

   8. TCTom Catena1:12:56

      I think there are maybe 300 or 400 in our hospital, somewhere around there. I can't remember the exact number. So it's, it's, you know, it's really, it's not... It's a very small number compared to the number of deliveries. So mo- the vast majority of women still deliver at home. And-

   9. PAPeter Attia1:13:12

      But you're doing th- presumably more of the high-risk ones. I mean, if, if a, if a child is breached, is there Can you deliver a breech baby at home? That's-

   10. TCTom Catena1:13:21

       So-

   11. PAPeter Attia1:13:21

       I mean, the risk would be enormous, right?

   12. TCTom Catena1:13:23

       Right. Some make it out, but a lot of those babies are gonna die-

   13. PAPeter Attia1:13:25

       Yeah

   14. TCTom Catena1:13:25

       ... because they just get, they get stuck, they get asphyxiated, and the baby dies. So I mean, when we do our antenatal clinic, you know, these women will come, and they, the midwife there fills the card out for them, says, "Okay, they've had 10 deliveries and four living children. You know, this one died at birth, this one died at birth, this one died from diarrhea, this one died from fever," you know, this kind of thing. So there's a lot of-

   15. PAPeter Attia1:13:44

       And what about the mothers? What, what, what is the maternal mortality like?

   16. TCTom Catena1:13:48

       I don't know. That's something I really wish I could have a, a grip on. 'Cause you hear occasionally, you know, we don't... It's not, it's not that often we hear about it, but once in a while you hear, "Oh yeah, this woman died from, she bled to death, you know, after giving birth to the baby at some remote village." There's not really r- It's so remote, and people are so spread out, there's not really a system to collect that kind of information. So I don't really know. It's got to be... It's got to happen, 'cause, you know, we have a lot of women that we end up doing C-sections on that would have died without that.

   17. PAPeter Attia1:14:15

       Yeah.

   18. TCTom Catena1:14:15

       You know, they've... You know how many times the baby is stuck, the mother's already septic, and, you know, we have to do a C-section or something to get the baby out.

   19. PAPeter Attia1:14:21

       And this says nothing of preeclampsia and all of the other things that would just show up even under the most normal, you know, circumstance.

   20. TCTom Catena1:14:28

       Right, and getting a woman with eclampsia is not uncommon. So if you get eclampsia at home, especially young, you know, most of them are, are primips that are very young, they're not gonna survive when they start convulsing, and to get to us is a chore. I mean, it's really hard to reach us.

   21. PAPeter Attia1:14:42

       What are the patterns of diseases like there? I mean, when w- when we're watching... And again, I, I keep mentioning this because it's just such an important film, "The Heart of Nuba." You see these things that you're doing, Tom, that just, I mean, they blow my mind, and maybe because I know enough about medicine that I can watch what you're doing and appreciate, you know, the partial nephrectomies you're doing on kids with, you know, tumors in their kidneys. And, like, how did you even learn to do that operation? Even within the realm of surgery, that's not a trivial operation to do on a child that size.

   22. TCTom Catena1:15:15

       Yeah. I'd done some nephrectomies before, total nephrectomies on, for tumors or for trauma, for whatever.

   23. PAPeter Attia1:15:20

       So meaning remove the whole kidney.

   24. TCTom Catena1:15:22

       Remove the whole kidney.

   25. PAPeter Attia1:15:23

       Yeah.

   26. TCTom Catena1:15:23

       So I wasn't so worried about that, but I was worried about was the other k- the other kidney-

   27. PAPeter Attia1:15:26

       It's, it's harder to take part of the kidney out 'cause you have to be able to preserve the blood flow to the part that remains.

   28. TCTom Catena1:15:30

       Right, and you, you know, they could complete it. So if it, if it was just, say a tumor was partially involved in the kidney, and say you're doing the operation, and you can't stop the bleeding, your backup is just to take the whole thing out. But you couldn't do that in this case.

   29. PAPeter Attia1:15:41

       'Cause this child had one kidney that had to fully come out, and then there was a partial ne... So you basically, this kid would die if you couldn't save half of the remaining kidney.

   30. TCTom Catena1:15:50

       Right. Exactly. So it was lower, the tumor was in the lower pole of the kidney, so we had to take out half the, half the kidney. So there was a visiting, actually a visiting... It was a friend of mine was, who was visiting. He's a family practice doctor. Corey Chapman was there, and we were talking about this case and going back and forth, and he said, "Let's look on YouTube if there's something." 'Cause I, I read, read- been reading about it, and everything I was reading was talking about all these fancy things. You know, there was some kind of a slush, like an ice slush that you have to bathe the kidney in to get the, the metal- metabolism way down so you can do the operation. Just different things we didn't have. So we looked on YouTube, and I'm just... When I think about it now, I wonder how we did it because normally we can't watch YouTube there because we have internet, we have a satellite dish internet, but the speed is very, very slow. So normally we can't watch any videos 'cause it's just too, it's just too slow. But for some reason, we were able to see this video, and it was this group of Polish surgeons that were doing the partial nephrectomy and with a fairly low-tech approach. So we watched that and said, "Okay, I think, I think I can do it following what these guys are, are advising." We kind of followed their system, managed to put these, um, sort of buttresses, like, on the, on the lower pole of the kidney to kind of staunch the bleeding, and it, and it worked. And the, the ki- the child did very well. That was helped by YouTube. [laughs] I mean, I think they really helped us out in that case. [laughs]
8. 1:19:45 – 1:30:00

   The most afraid Tom has ever been, and how he copes with the emotional trauma of his daily experiences

   1. TCTom Catena1:19:45

      it was rough.

   2. PAPeter Attia1:19:46

      One of the other questions my daughter wanted me to ask you is, what's the most afraid you've ever been there? You know, she was sort of taken aback, and we told her before the movie. I, I said, "Look, Olivia, this is, uh, this isn't a Disney movie." [chuckles]

   3. TCTom Catena1:20:00

      Right. [laughs]

   4. PAPeter Attia1:20:00

      You're gonna see people getting killed. You're gonna see bombs dropping on innocent people.

   5. TCTom Catena1:20:04

      Mm-hmm.

   6. PAPeter Attia1:20:05

      And it's not a movie. It's real.

   7. TCTom Catena1:20:06

      Right.

   8. PAPeter Attia1:20:07

      So are there times when you are just afraid for your own safety?

   9. TCTom Catena1:20:11

      Yeah. I, you know, I think every time they bombed the hospital twice, and they bombed our, our local region kind of within a half kilometer several times. So the first time the area was bombed, our... We were at church, and the church was just outdoors. It's not really a church. It's kind of an outdoors thing. And we were finishing up, and the, the catechist was up there talking to people, and we heard the airplane overhead. We, we were used to it, 'cause every day the airplane came overhead, but we'd never been, or immediate vicinity had never been, had never been bombed. So we just go, "Oh, the airplane's overhead. It's gonna bomb somewhere."

   10. PAPeter Attia1:20:38

       And, and is that because you had this belief that said even these people, as wicked as they are, wouldn't actually bomb a hospital?

   11. TCTom Catena1:20:47

       Right.

   12. PAPeter Attia1:20:47

       Was there some sort of view of we'll respect at least one-

   13. TCTom Catena1:20:50

       Right

   14. PAPeter Attia1:20:50

       ... sanctity of life?

   15. TCTom Catena1:20:51

       Yeah. So that was, that was the bit in the back of our minds, and we hadn't been bombed yet. This was, this was a couple years into it. Our... We hadn't been bombed directly. There weren't commercial flights, so anytime you heard an airplane, it was going to bomb somewhere. And then we hear the, we hear the airplane. Then invariably, a few hours later, wounded would show up. They bomb somewhere, and people are wounded, and the, the wounded show up. This day was a bit different. We hear the airplane overhead, and the, the mass was over, and we're kind of... We're standing there. All, all of a sudden, somebody says, "Everybody get down." So we, we just dive on the ground. Everyone's lying flat, and I heard the airplane droning overhead, you know, this Antonov sound. Then I heard the, the pitch change. It, so it was high-pitched, like a whirring sound, almost like a jet engine noise, and then boom, this incredibly loud explosion. It felt like it was two feet away. I mean, it was, like, half a kilometer away. It wasn't right... But it was so loud, and it circled again. Then, then I realized that what that whirring sound was was the sound of the bomb falling through the air. So then I... Now, so now I know what that sounds like. [chuckles] Then this happened six... It bombed six times. You kept hearing this thing. Comes around again, bombs. And you're lying there terrified, thinking... You just, you feel like you want to burrow yourself into the ground and disappear, you know, just lying flat, exposed, thinking, what, you know, what happens? And the thinking is not even so much being killed, but what if, what if my, you know, what if my leg is blown off or my arm gets blown off? You have no control over this. You're totally at the, at the mercy of these people, and you feel like you're, you feel like you're just an, like a hunted animal. That's the, that's what I felt like. I felt like I'm, I'm a hunted animal. And at that time, since we hadn't been bombed, we didn't have the, the foxholes dug around. So immediately after that, we went, and we dug foxholes all over the hospital grounds.

   16. PAPeter Attia1:22:36

       And that's what you see in the film.

   17. TCTom Catena1:22:38

       Right.

   18. PAPeter Attia1:22:38

       There's actually one point when you're being interviewed, and y- the bombs start coming, and you guys have to jump into these foxholes.

   19. TCTom Catena1:22:43

       Right. Right. And then another time we were bombed, I was in the hospital and just down on the, on the floor of the hospital, you know, and you're thinking, "Well..." You know, you're just, you're just thinking, "This, this might be it." [laughs] This thing might... 'Cause you can't tell where it's gonna fall. You hear that whirring sound, and when you hear that whirring sound, you don't know if that's gonna fall on top of you, if it's gonna fall right next to you and, and, and just then shatter your body. You have no idea. So it's really, it's, it's really terrifying. I mean, there's no other way to describe it. And I mean, you know, when you see this stuff that's happened in Syria, people living in these cities, I mean, you c- you can imagine what that is like. And the kids that were in that situation, that's something they'll never, they'll never outgrow that fear and that feeling of, of being bombed. You really, you feel like you're a hunted animal, I think is the closest thing I can... Not that I've ever been [chuckles] hunted or I'm an animal. But you just feel like... A- I remember thinking to myself, we were down... This is after, uh, this is a few bombings later. We're down in the foxhole, and there was a, a Sukhoi 24 jet going overhead. A Sukhoi 24 is a supersonic jet bomber, you know, bombing villages, you know, huts, and thinking, "What are these people doing?" And we were thinking to these guys, I say, "How can they bomb us? Don't they know there are people down here?" That's what I felt, you know, like it was some exercise where they made a mistake. And of course, they knew exactly there are people down there. [chuckles] That's why they're bombing, you know? But I, I really hope someday I will meet these pilots, not that I... I don't even feel any animosity towards them. The feeling is never... It's strange. You don't feel anger. You don't feel animosity towards these people, just kind of wonderment, like, "What are they doing?" Like, "Why are they doing this?" So I would love to meet these guys someday and say, "What, what were you thinking?" You know? "What, what'd they tell you before you did your mission?" You know, I was a flight surgeon in the, in the Navy, so I know you have a briefing before the pilots fly out. They discuss the mission. "Today we're gonna f- fly here. We're gonna bomb this target. This is our objective." What were you told in the briefing room? Did they say, "Okay, today you guys are going to bomb a hospital. There are a bunch of civilians there." [laughs] You know?

   20. PAPeter Attia1:24:45

       I mean, presumably, if you're, if you're trying to put your psychology hat on, you have to believe that they are being told that the people that they are bombing are somehow a threat to them or their sovereignty-

   21. TCTom Catena1:24:59

       Right

   22. PAPeter Attia1:24:59

       ... or supporting rebel... I mean, you, you'd have to concoct a story that's so orthogonal to the truth.

   23. TCTom Catena1:25:05

       Right. Maybe that might be it, because, I mean, after one of the times the hospital was bombed, one of our staff heard a, a radio broadcast from Al-Bab, which is a city in the north, and, um, the way they portrayed it on this radio was they admitted they bombed a hospital. They said, "We bombed an American church hospital In Kawta, which is the kind of capital of the rebel-held territory, hospital taking care of the rebel soldiers. That's how it's portrayed. So you're an American hospital, and America, of course, is a great enemy, is a Christian hospital, therefore they're no good, and it's-

   24. PAPeter Attia1:25:39

       And they're taking care of rebels

   25. TCTom Catena1:25:40

       ... taking care of rebels. So you're, you're justified in this, in this act. And my guess would be that's what these guys were fed. Who knows if the pilots were true believers? You know, I know, worked with a lot of pilots in the US military, and they would, they would not go along with the mission if they said, "You're going to bomb a hospital with civilians." They wouldn't do it. They would say, "Look, man, we're not doing this." I know these guys. They were not, uh... These guys, they, they loved to fly and they loved the country, but they were not interested in killing civilians. And, uh, I still hope someday I can meet these guys and just have a talk with them and, uh, just to know what they were thinking and what, what, what went on in their brains. Like, whether they know this, how'd they feel about it. I'm just interested what they would, what they would say.

   26. PAPeter Attia1:26:22

       How do you cope with what I could only imagine is... Stress and anxiety aren't the right words, but just sort of the gravity of it. Like, you know, when you describe a day in your life, you know, getting up at 5:30 in the morning, making rounds at 7:00, operating. If you said, "Peter, you gotta go do this for a month," I mean, first of all, I could provide no assistance to you. That's the unfortunate [laughs] reality of it, right? Despite my medical training, all I would... I mean, I could, you know, put IVs in patients, and that's about... I mean, I, I don't think I could provide any benefit. But let- let's assume I could even magically provide benefit. I can't imagine how physically, but more so emotionally exhausted I would be-

   27. TCTom Catena1:27:04

       Mm-hmm

   28. PAPeter Attia1:27:05

       ... at the end of 30 days.

   29. TCTom Catena1:27:06

       Right.

   30. PAPeter Attia1:27:07

       Even thinking back to my training where, you know, you'd have every other night call, but on one of the nights in between, you didn't get to go home, and so you've been in the hospital for three and a half days, and it's been one trauma after another. Like, even that feeling is just as physically tired as you are. There's something different going on, which is just an emotional depletion.
9. 1:30:00 – 1:35:15

   The basic tools, technologies, and medicines that Tom is lacking that could save many lives

   1. PAPeter Attia1:30:00

      CBCs or UAs even? I mean, what, what's the extent to your diagnostic toolkit? So until recently, you had nothing. I mean, now you have an ultrasound.

   2. TCTom Catena1:30:09

      Right. We've had the ultrasound from the, from the beginning.

   3. PAPeter Attia1:30:11

      Okay.

   4. TCTom Catena1:30:12

      So we've had that the whole time. That's been hugely helpful.

   5. PAPeter Attia1:30:14

      You don't have an X-ray machine.

   6. TCTom Catena1:30:15

      Uh, X-ray we do now.

   7. PAPeter Attia1:30:16

      Okay.

   8. TCTom Catena1:30:16

      So we just got that about a year ago.

   9. PAPeter Attia1:30:18

      So you can do a chest X-ray at least if you want some assistance with does this person have pneumonia or a pneumothorax or something like that?

   10. TCTom Catena1:30:24

       Right. So prior to a year ago, we didn't have the X-ray. Now we do. It's, it's been a help. Lab has been difficult. We can do a urine. We can check a stool. We can do a hemoglobin. Sometimes we can do a CBC, but the, the machine always seems to be broken. You know, we'll get in the machine, work it for a while, then it just stops working. Can't do a CBC. Chemistry tests, we can sometimes do a creatinine, but then that machine breaks, and, you know, we can't do a creatinine. Sometimes you can do ALT, AST. Machine breaks, can't do anything.

   11. PAPeter Attia1:30:53

       But would those things matter? In other words, if, if, if, if someone's listening to this and says, "Well, gosh, if it's $50,000 to buy a new lab, piece of laboratory equipment, can we have one of those, you know, brought in with next year's supplies?" Would that cha- would that make life easier for the care you guys provide?

   12. TCTom Catena1:31:12

       It would help. And, you know, like there's a... Just saw this chemistry analyzer. It's called a Piccolo, which is supposed to be kind of built for these remote locations. It's pretty doctor-proof. I mean, you kind of have this thing that's pretty hardy. You slip in a disc You put a drop of blood on it, and it gives you results. So our guys in the lab could do that. Not-- Our labs-- Our guys in the lab can do the other tests, but the machines are just very so-

   13. PAPeter Attia1:31:31

       Yeah. It, it, it's less about the human, it's more about the m- you need a robust machine.

   14. TCTom Catena1:31:34

       You need a very robust machine. So this is kind of a, a thing, and that's about 14 grand. If we had one of those and some of the, the discs which have the reagents-

   15. PAPeter Attia1:31:43

       Yeah

   16. TCTom Catena1:31:43

       ... kind of embedded in them. Um-

   17. PAPeter Attia1:31:45

       So if you had a year's supply of, of test strips or reagent discs-

   18. TCTom Catena1:31:49

       Right

   19. PAPeter Attia1:31:49

       ... and then the machine-

   20. TCTom Catena1:31:50

       Right

   21. PAPeter Attia1:31:50

       ... you could do a CBC and a CHEM-7 or a metabolic panel of some sort?

   22. TCTom Catena1:31:55

       Right. That would, yeah, that would definitely help. We're pretty limited. We can do a peripheral blood film, so taking blood, you know, guys can do the film, we can look at that.

   23. PAPeter Attia1:32:02

       So you're a pathologist now too.

   24. TCTom Catena1:32:04

       Yeah, in a very bad way.

   25. PAPeter Attia1:32:04

       You're a hematologist.

   26. TCTom Catena1:32:05

       Yeah. I'm terrible at it, but I, I can pick up, like, a chronic leukemia, chronic myelogenous, chronic lymphocytic, or an acute leukemia. Those are... If, if it's pretty obvious, we can pick those up. But a lot of blood films I'm baffled by.

   27. PAPeter Attia1:32:15

       And when you have a child that has leukemia, I assume you send them to Kenya?

   28. TCTom Catena1:32:19

       It's impossible.

   29. PAPeter Attia1:32:21

       Why?

   30. TCTom Catena1:32:21

       It's too far, it's too expensive, it's too difficult, like just the administrative stuff to get them there. And the chance in Kenya of them being... I mean, maybe at a higher-end hospital they could get decent care, but there's just, we just can't do it.
10. 1:35:15 – 1:38:30

    The logistical challenge of helping Tom’s hospital, and what Tom really needs

    1. TCTom Catena1:35:15

       to at least get her through a year. There are few people that have CML. It's a few. It's not a huge number.

    2. PAPeter Attia1:35:19

       If someone's listening to this and they say, "I'm gonna tell you a story in a moment called the starfish story, but I wanna save one starfish." That's, that's... I'll tell you the story. Logistically, would it even be possible for someone to provide one year's worth of Gleevec to a patient in your hospital? Is that something that they could do through the American, uh, the African mission? How would someone even logistically go about providing specific or project-based funding to your mission?

    3. TCTom Catena1:35:43

       Mm-hmm. If they could get the drug, say they had a-access to the physical drug here in the US, maybe if they sent it to, say, Catholic Medical Mission Board, which is my sponsoring lay sending agency, and they also help us a lot with logistics and with the, the overall-

    4. PAPeter Attia1:35:58

       Mm

    5. TCTom Catena1:35:58

       ... managing the hospital. They might be able to find a way to get it down to us, at least get it to Juba, and then we could figure out a way to get it up to us if they could get the physical drug. There was a program when I was in Armenia the time before last. We met some guys, and there's a, there's supposedly some Gleevec program that you can register. Like, the patient can register, and they can get drugs at either low cost or no cost. So we went through all this thing, contacted the person. She said, "Okay, all you have to do is take, have, fill out these forms, have the patient go to Khartoum to get the drugs." That's absolutely impossible. We can't get to Khartoum. That's on the other side of the enemy lines. And, uh, you just can't reach there. So it's-

    6. PAPeter Attia1:36:33

       Which gets back to your point of providing the money is half the battle.

    7. TCTom Catena1:36:38

       Right.

    8. PAPeter Attia1:36:38

       But the logistics of actually getting it in there. And I mean, just spitballing, you can't have these things air-dropped or airlifted in because the enemy fighters will obliterate anything that's trying to... It's not like you can fly the Cessna in there to-

    9. TCTom Catena1:36:51

       No

    10. PAPeter Attia1:36:51

        ... get this stuff in there.

    11. TCTom Catena1:36:52

        There's been no non-bombing aircraft in our airspace for, it's been since November 2011, so.

    12. PAPeter Attia1:36:58

        So even foundations like the Gates Foundations, which do a ton of great stuff in Africa, I mean, Sudan's basically off limits.

    13. TCTom Catena1:37:04

        You know, say they were able to provide money for a bunch of Gleevec. One of the problems, and one of the problems I've, I've decided to go with Aurora, is a lot of these funds are, are kind of unassailable. If you're like I'm an individual or even a small organization that's trying to apply to one of these big organizations, to just get through that application process to get funds and then to account for it and do monitoring, evaluation, and follow-up It's a very daunting task. You need, you need people who are trained in this area of writing proposals and monitoring evaluation, all this sort of stuff, to really follow through with all this. It's very difficult to access some of these big funds and big organizations. You know, a lot of these bigger groups are set up to do that kind of work, and their administrative size has grown exponentially because in order to get these, this funding, you need a big administrative staff to apply for the funds and follow-up and accountability and accounting and all that kind of stuff.

    14. PAPeter Attia1:38:00

        Right. And you, uh, I mean, you've got tons of extra time, I'm sure, to do that, right? [laughs]

    15. TCTom Catena1:38:04

        I just can't. I just can't do it. I just can't do it unless it can be made fairly simple. Worst one's okay. If I got the drug, I'll send it to Catholic Medical Mission Board, and then Catholic Medical Mission Board will send it down, and we get the drug, you know, at least as far as Juba, then we can try to figure out a way to get it up. But it's just... It's really there's a problem with access and just getting through the administrative things you have to do to, to get some of this stuff. There's, um... So there, there, there are several

11. 1:38:30 – 1:55:45

    Diseases in the adult population

    1. TCTom Catena1:38:31

       kind of different levels of, of difficulty.

    2. PAPeter Attia1:38:33

       So going back to the sort of state of diseases you see, if a person makes it out of their sort of their, their young life, right? If a person sort of your age or my age-

    3. TCTom Catena1:38:43

       Mm-hmm

    4. PAPeter Attia1:38:43

       ... what are they gonna die from?

    5. TCTom Catena1:38:46

       Middle-aged people, we have a lot of cirrhosis, liver cancers, and that's-- There's a huge-

    6. PAPeter Attia1:38:52

       Is it hepatitis based?

    7. TCTom Catena1:38:53

       Hepatitis B.

    8. PAPeter Attia1:38:53

       Yeah.

    9. TCTom Catena1:38:53

       Yeah, huge. Like we do-- We screen all of our pregnant women for hep B.

    10. PAPeter Attia1:38:57

        Do you guys have a hep B vaccination program?

    11. TCTom Catena1:38:59

        We do. We do. Um, the reason we started screening the, the pregnant women is just to get an idea about the basic rate, and it's about close to 20%. Hepatitis B positive, just in the general population. These are people who are not sick. They're pregnant with children. So what we're doing is we encourage the mother when the baby's born, we give the baby hepatitis B vaccine immediately after birth, and we hope with that, that will stop, prevent this baby from getting hepatitis B as they get older and prevent all the complications from that. We haven't really scaled up to the point where we have so many hep B positive people.

    12. PAPeter Attia1:39:31

        And can you only vaccinate the women who are coming in for deliveries, or are you able to get the vaccine into the community for the women who are still delivering at home?

    13. TCTom Catena1:39:40

        No. We haven't, we haven't reached that point yet.

    14. PAPeter Attia1:39:43

        So you're only scratching the surface-

    15. TCTom Catena1:39:44

        Right

    16. PAPeter Attia1:39:44

        ... then because the majority of these births are outside of your hospital.

    17. TCTom Catena1:39:47

        Right. Exactly. I mean, eventually, we'd like to have kind of midwives at these places and have the testing capability to test all these people for hepatitis B. Or if people delivered in these clinics, we say, "Look, we can't do the testing, but we'll just give the vaccine. We'll assume the kid has hepatitis B. You get the vaccine." 'Cause they have to get hep B anyway as part of the pentavalent series. So after that first shot, we continue with pentavalent, which is DPT, diphtheria, pertussis, tetanus, hepatitis B, and, um, Haemophilus influenzae b.

    18. PAPeter Attia1:40:13

        I, I've heard that kids actually can get diphtheria in, in Africa.

    19. TCTom Catena1:40:17

        Yeah.

    20. PAPeter Attia1:40:17

        Has there been a case of diphtheria in the United States since the '40s?

    21. TCTom Catena1:40:21

        No, I think that, I think the disease is-

    22. PAPeter Attia1:40:22

        I don't even know what diphtheria is.

    23. TCTom Catena1:40:24

        Yeah.

    24. PAPeter Attia1:40:24

        I mean, like, I mean, it sounds stupid to say that, but I remember learning about it in medical school, and I know we all get the vaccine for it. What, what is the disease?

    25. TCTom Catena1:40:30

        Yeah.

    26. PAPeter Attia1:40:30

        What is it? How does it manifest?

    27. TCTom Catena1:40:32

        We've only had, from what I remember, one case, and I think she had diphtheria. It was, it was in an adult. But it's, uh, Corynebacterium diphtheriae, and it's a bacterial infection. It affects the throat, and they get like a-- It looks almost like a, a thick scab that forms in the throat. They kinda die from airway problems. You know, this thing is thick, and they can't really swallow. They can't really breathe well, and they can die from airway problems. It's, it's a horrible, really a terrible disease.

    28. PAPeter Attia1:40:58

        And you mentioned your mother-in-law has leprosy.

    29. TCTom Catena1:41:00

        Right.

    30. PAPeter Attia1:41:00

        Again, I've never seen that in my life. It's a bacteria as well? It's a-- Is it in the tuberculosis family or something like that?
12. 1:55:45 – 2:07:15

    Living without possessions, finding meaning, and being a missionary

    1. TCTom Catena1:55:45

       So it's pretty, uh, it's, it's pretty easy [laughs] to be married to a Nuba lady. It's... You know, she doesn't... The expectations are very low.

    2. PAPeter Attia1:55:52

       How has your life changed since you've been married? I mean, do you have a greater sense of obligation to not die, to put it bluntly?

    3. TCTom Catena1:56:00

       Yeah. Yeah, I would say, yeah, definitely. So I'm like, you know, you can't be so cavalier with things because now I've got a wife, and I wanna kinda look after her and make sure she's okay. There's been a little bit of a change in perspective with that, and I think if and when we get children, I think that'll change another degree up, for sure.

    4. PAPeter Attia1:56:17

       Do you think you could do what you do if you had children?

    5. TCTom Catena1:56:20

       I think we could stay there, and if things got really hairy, we'd have to see how to proceed.

    6. PAPeter Attia1:56:25

       But just in terms of... I mean, your wife is a nurse-

    7. TCTom Catena1:56:28

       Yes

    8. PAPeter Attia1:56:29

       ... so you have the luxury of working together. So as focused as you are on your work, she is there with you.

    9. TCTom Catena1:56:35

       Right.

    10. PAPeter Attia1:56:36

        When you have children, they will not work with you [laughs] for, for quite some time. I just wonder, would it be challenging to sort of now be torn between two obligations that for many years will not overlap at all?

    11. TCTom Catena1:56:49

        It'll be difficult. You know, I think one thing, and one thing I, I, I remind my wife of, is that, you know, I, I finish work late, and I'm always, you know, often preoccupied with things and things with the hospital and all that sort of stuff, but at least I'm there every evening. The weekends, we have a little bit of time on a Sunday to be together, and even though the work is, is, is very much all-encompassing, there's no commute, and there are no distractions. You know? We don't have... There's no TV. There's no radio. We don't have other things that kind of occupy our minds, so when we, when we're together at home, we really can be present to each other. And I would hope that if we have children, I'll be able to use that to really spend time with the kids and not be always in work, you know. If life continues like that in Nuba, there's not any travel involved. I'm, I'm just there. You know, I'm a stone's throw away.

    12. PAPeter Attia1:57:35

        You know, it's funny. When you say it that way, it's actually... You may actually spend more time with your kids than many of us do-

    13. TCTom Catena1:57:42

        Right

    14. PAPeter Attia1:57:42

        ... here because of our distractions and our travel and our this and our that.

    15. TCTom Catena1:57:47

        Yeah. Life here is, is much more hectic. I mean, it's, it seems almost ironic to say that.

    16. PAPeter Attia1:57:52

        You feel out of place here even though you grew up here? I mean, when you walk down Park Avenue or Madison Avenue, are you sort of like, "What in the hell is this place?"

    17. TCTom Catena1:58:01

        [laughs] Yeah, I do. I do feel a bit out of place. In a sense, I do enjoy it. Like I, I've never... Even when I was... I grew up in Upstate New York. I never spent time in New York City, so this is really kind of... It's, it's exciting. I like it, but I don't think I could, I could stay long term. I mean, a lot of people, I'm sure, say that about New York, but I do feel much more at home in the Nuba Mountains where it's, it's very quiet and kind of sedate, and your time is your own when you're off.

    18. PAPeter Attia1:58:24

        What possessions do you value? I mean, I, I, I know you have some textbooks and things, but, I mean, your home is very modest, obviously.

    19. TCTom Catena1:58:33

        Right.

    20. PAPeter Attia1:58:33

        By the standards of someone living in the United States, it would not really... You wouldn't even really call it a home in the same way.

    21. TCTom Catena1:58:39

        Right.

    22. PAPeter Attia1:58:39

        But you don't give the impression that you're wanting.

    23. TCTom Catena1:58:43

        No, I really don't. I'm, uh... I think that has been my character since I was a kid. I'm, I'm, I'm very much... I think I'm very much a minimalist since I was born. All these clothes you see me wearing, the, from the, the... Well, the socks, the trousers, th- both these shirts I bought when I came out of Nuba last month. So I have scrubs. I had scrubs. I had one pair of trousers. I had a suit, a few T-shirts, and that was it, and they're like, "Hey, look, you gotta go and meet people. You can't be wearing [laughs] your scrubs around." So I had to buy all this crap when I came out. It was painful for me to buy clothes. Like I don't, I just don't like it. When I go back, I said, "Look, when I go back to the mountains, all this, these winter coats and this stuff, I'm not taking this stuff back with me. I'll keep it in Armenia. Let p- someone there use it. I don't, I don't want it." My suit, I do have one suit that I wore to the ceremony in Armenia, the Aurora Prize ceremony, but I bought that suit in 1985, so I haven't [laughs] hadn't bought one since then.

    24. PAPeter Attia1:59:37

        Probably when you were interviewing for medical school or something.

    25. TCTom Catena1:59:39

        Well, I was interviewing for jobs, like for engineering jobs, and that's the reason I bought it. So it was the one I... The same one I used for interviewing for, for medical school, and then, uh, I've used it when I come out for this Aurora Prize ceremony. I'll, I'll take it out and wear [laughs] that suit with a blue shirt and a tie. But I bought that crap in 1985.

    26. PAPeter Attia1:59:55

        And I know that you... It's absolutely against your nature to sort of be critical of anyone, but do you spend any time thinking about the way the world works here and how most of us are somewhat attached to our possessions?

    27. TCTom Catena2:00:11

        Yeah.

    28. PAPeter Attia2:00:12

        And the more possessions we have, the more complicated our lives get. I mean, you certainly hear people talk about minimalism. Few people can apply it to the extent that you can, of course, but, I mean, what have you learned about this, and how, how could you speak to somebody like me who, you know, loves his possessions as much as the next person and can't imagine giving up these comforts? I mean, help me understand, 'cause you don't look like you're miserable. [laughs]

    29. TCTom Catena2:00:40

        No. [laughs]

    30. PAPeter Attia2:00:42

        And you look even happier in these videos in Nuba. I'm sure that this is about the hardest thing you've had to do all year-
13. 2:07:15 – 2:15:15

    Happiness, sense of purpose, and suicide: contrasting the US with Nuba

    1. PAPeter Attia2:07:15

       Are there any cases of suicide in Nuba?

    2. TCTom Catena2:07:17

       We had one guy who's the husband of one of our staff, and, uh, yeah, he sh- he shot himself, and that really shocked everybody. He, he seemed to have some kind of psychiatric problem. He was kind of acting a bit strange a few days. They didn't tell us, but he, he'd been in one of the, in one of the refugee camps, was acting a bit odd there. Came back to Nuba and was acting a bit odd at home, and then the night he was acting a bit odd, he went and he shot himself. That's the only case I know of. It's, it's extremely rare. Extremely rare.

    3. PAPeter Attia2:07:46

       I mean, to me, there are so many amazing contrasts between Nuba and America

    4. TCTom Catena2:07:54

       Mm-hmm

    5. PAPeter Attia2:07:54

       Right? I mean, they're so obvious they're not worth stating. It's these subtle ones that to me-

    6. TCTom Catena2:07:58

       Right

    7. PAPeter Attia2:07:58

       ... are interesting, right? There must be a different sense of fulfillment, contentment, happiness, sense of purpose there versus here. I mean, as you know, I'm sure you're not paying close attention to statistics in the United States, but suicide is among the top 10 causes of death in every... I may be incorrect on this, but I'm, I'm not far off, in every age demographic except for 0 to 10. So once you get above, you know, 10 to 20, 20 to 30, suicide is always in the top 10 as a cause of a disease, and that doesn't include... That's what we call fast suicide-

    8. TCTom Catena2:08:31

       Right

    9. PAPeter Attia2:08:31

       ... when you kill yourself immediately with a clear-

    10. TCTom Catena2:08:33

        Right

    11. PAPeter Attia2:08:33

        But then you have all the slow suicide, so the alcohol-related-

    12. TCTom Catena2:08:36

        Right

    13. PAPeter Attia2:08:36

        ... you know, ba- basically-

    14. TCTom Catena2:08:37

        Sure

    15. PAPeter Attia2:08:37

        ... people that kill themselves with alcohol and drugs.

    16. TCTom Catena2:08:39

        Drug overdoses.

    17. PAPeter Attia2:08:40

        Yeah.

    18. TCTom Catena2:08:40

        Right.

    19. PAPeter Attia2:08:41

        So when you include all of those, I've heard analyses that would suggest that self-harm would be sort of top five causes of death across the board. What does that say to you, given that you're, you live in a world that has 1/1000 of the privilege, and for all intents and purposes, like, shouldn't everybody be killing themselves in Nuba-

    20. TCTom Catena2:09:03

        [laughs]

    21. PAPeter Attia2:09:03

        ... so to avoid being, uh, you know, ripped apart by shrapnel?

    22. TCTom Catena2:09:06

        Yeah. It's very interesting, and, you know, my, the initial thought that comes to me is the people are... When you're really gripped in this struggle to survive, so your, your life is based on, you know, every day is you're, you're just trying to survive. When you have that sort of primal instinct of survival, you don't... Your mind doesn't drift off to other things. You don't think about, so much about your life is hard, your life is this, your life is miserable. So I think you become less inward-looking. Suicide is, is so inward-looking, so focused on your own misery that you can't come out of it. I mean, it's such a miserable thing. I mean, it breaks my heart when I hear about these things. It really does, because I think, man, to get to that point when you just, life is so miserable for you and you are so miserable you kill yourself, it for me is heartbreaking.

    23. PAPeter Attia2:09:55

        Does that break your heart more than the tragedy that you see every day? I mean, not, not to compare miseries, but, like, what you see breaks my heart. Maybe I'm numb. I mean, and it's not to say that I'm not heartbroken by anybody who hurts themself, but what you see is so staggering. Do you see this as an even greater source of tragedy?

    24. TCTom Catena2:10:15

        For me, I would, I would equate that with-

    25. PAPeter Attia2:10:17

        The five-year-old girl who's got the shrapnel ripping her arm off.

    26. TCTom Catena2:10:20

        Yeah. I would. I, I r- I would see, I would feel the same sense of, of pain and heartbreak with that. Suicide has a similar effect where, you know, if a child dies from this kind of thing, the effect you have on the whole family is devastating, the grief. Suicide, the grief you leave behind, I think that's really tough and that really, really breaks my heart, not only for the person who was so miserable that they decided to take their own life, but for the people behind.

    27. PAPeter Attia2:10:44

        The ripple effect.

    28. TCTom Catena2:10:45

        Oh, gosh. And that's terrible. Man, I would just never wish that on anybody.

    29. PAPeter Attia2:10:50

        And yet it's almost impossible in the United States to not have your life touched by suicide. I think it would be very rare that someone listening to this in America wouldn't know somebody first or secondhand who hasn't taken their life either clearly and deliberately or sort of slowly and maybe less deliberately.

    30. TCTom Catena2:11:08

        Yeah. Yeah, I think it's wrapped up in that struggle for survival. There is a will, you know, a natural will to survive, and when you're in this kind of daily grip, even when there's, when there's not fighting, just to survive there, the amount of work it takes to get up in the morning to, you know, make food, to cultivate crops, to keep the animals out of your garden, I mean, it's, it's a, it's a tremendous struggle.
14. 2:15:15 – 2:18:30

    Other than donations, is there a way people can help Tom and other similar causes?

    1. PAPeter Attia2:15:15

       I don't think it's just giving. I think there's more to it, right?

Episode duration: 2:39:46