A muted sort of triumph

Date: 07/18/2011

I wish I could have done more

We were only two thirds through the camp and I had already seen over a hundred patients. Kartik and Gemlyn, my fellow medical officers, had seen even more and they had been keeping an eye on me the whole time. It isn’t as herculean as it sounds, really. In most cases, we just do some TLC for people with a motley collection of aches and complaints. We put them on calcium, iron, and multivitamins. Treat their heartburn with H2 blockers, deworm children, treat symptoms of cough and cold, provide antibiotics, antipyretics, and painkillers to the needy, check their hearts and lungs, counsel them on health-related matter, make referrals for ophthalmic, dermatological, and neurological conditions when we're out of our depth, etc. Some people just need to be able to chat for a few minutes with a guy armed with a stethoscope. People really just use us as a one-stop shop. I had a boy come to me with complaints of shortness of breath. Taking a history revealed that he sighed deeply from time to time and his mother freaked out about it. I probably shouldn't have burst out laughing- bad manners. Still, I don’t resent it. India has 70,000 doctors to care for her 1.2 billion citizens. With this insufficient ratio, It’s little wonder why people hoard up their problems-- big and small-- and bring them to community screenings like ours. We see a very wide range of medical problems in our camps in terms of severity.

Yesterday I saw a woman who had lost the use of her left hand after she got a serious electric shock. The hand was a claw. I suspected an issue with the ulnar and the median nerves, but couldn’t do anything. I also met a man whose body was paralysed on the right side. His steppage gait and asymmetric smile gave it away immediately, but there was nothing I could do about it. A wrinkled old lady with only one eye hobbled up to me with a cane next and complained of joint pain. I provided her calcium supplements for her bones, iron, B12, and folate tablets to correct her deficiency, and turpentine ointment for her joints, but-- basically-- I couldn’t do anything substantial for her. Kartik, Gemlyn, and I know that this is not simply not enough. Perhaps this is why we call ourselves “Quacks R Us” or “Two and half quacks”.

We can't blind ourselves to the horror of the health situation.

Soon after the lady limped away with her creaky cane and even creakier joints, a mother approached me with her son and daughter. Over the past three weeks, I’ve learned to quickly scan my patients for a few obvious pathologies. Here’s what I remember thinking in the 5-10 seconds they took to walk over:

Young woman. Looks a bit weary, though. Has the expressions of an older woman. Two children: boy and girl. Girl looks healthier than boy. Mother doesn’t have a patient form. The children do, though. The worry might be because of the health of children. The boy’s shirt is bulging just a tad. Protein Energy Malnutrition (PEM)? Make sure to check. What about the daughter? Anemia? Vitamin deficiency? General Malaise? Naah. Looks good. Let’s look at the boy. Looks a bit tenuous. How old is he? 9? 10? He’s walking a little bit awkwardly and unsurely. Is that just me? Am I scaring him?

I put on my warmest smile for the mother and the children to allay their fears. The boy was indeed tiny. I’m known to have a short torso and I still towered over him even when I was sitting down. The kid was actually 13 yeas old! Clearly, he was the victim of grave malnutrition. The mother complained that he had a weak heart. Having heard the same complaint from a couple of different mothers earlier that morning, I have to admit, I sighed silently and took off my stethoscope somewhat perfunctorily. I had to check for the kid’s PEM anyway so I unbuttoned his shirt. As expected, the PEM was there. Shobana, my translator and a dietician, began counseling the mother on the kid’s nutrition as I visually approximated the location of the the apex of his heart. I found it, placed my steth’s diaphragm on it, and closed my eyes to block out the other stimuli.

Does he look 13 to you? Note the distended belly characteristic of PEM.

Lub..swoosh...dup
Lub..swoosh...dup
Lub..swoosh...dup

My eyes opened wide with shock. It couldn’t be! I moved my steth systematically from the apex to the left of the manubrium sterni then up to the region under the clavicle and then back near the sternum at the second intercostal. To confirm the diagnosis, I checked for the sound in his left axilla. It was there. I had only heard this sound once before. I spun in my seat and decided to consult Kartik, a fount of all medical knowledge: “Kartik...pansystolic murmur...present in axilla...could be MR...please confirm.”

Kartik auscultated the boy and confirmed my suspicions in a minute: “It’s either Mitral Regurgitation (MR) or Ventricular Septum Defect. Tricky. You can feel good about it. Nice catch.” Considering, I had basically picked up rudimentary auscultation by reading in my spare time and with the help of some impromptu tutorials from my father over the phone and a Tanzanian doctor in my bungalow, I glowed with pride. Then, putting aside the glow for later enjoyment, I asked the pragmatic question: “So, what do we do?”

Kartik: What can we do?
Me: Refer to cards?
Kartik: I’m not sure if he’ll meet the requirements for free surgery.

And there we were. The familiar feeling of utter and complete helplessness darkened any remaining glow from a few minutes ago. Judging from his ripped shirt and malnourished frame, it was pretty clear that there was no way this kid’s parents could afford a valve repair or replacement. I hate not being able to do anything for the people who come and see me with hope in their eyes! For instance, I see 60 year olds with classic signs of radiculopathy and have to tell them that there’s nothing I can do for their pain. If they're 30-40, I can refer them to the orthopedics department, but 60 is considered so old that the number of DALYs saved do not justify the cost of the surgery. If these poor people persist, I have to send them off with calcium tablets. I sometimes worry that doing so might shake their faith in doctors and drive them to quacks and witch-doctors that lurk the countryside, preying on those neglected or disillusioned by India’s healthcare system.

 It's not like I think we do more bad than good. We've been able to help an enormous number of patients and catch some tricky diagnoses early. For instance, I caught a breast lump and a nasal cancer in two women yesterday and urged them to get them checked out before they grew any more. I suppose my frustration is just that I am not convinced that the work I am doing in my current capacity is bringing us very close to the utopic future people in global health envision and long for.

They're waiting to get the healthcare they deserve. We can't fool them. We can't cheat them. Not anymore.

Ultimately, we directed the child’s mother to the paediatrics department at CMC where we figured at least his PEM would be treated. We think there may be a chance that his heart problem will be attended to given his young age and CMC’s charitable mission. Thank god, for Christian charity! However, I have never ever been good with uncertainty and the very real possibility that that poor child will be left untreated for petty financial reasons bothers me and makes me smile wryly when anyone tells me I’m doing good work in India. I love diagnosing patients. I love being right. But what’s the point of it if treatment and resolution don't follow?

Amputations and Asymmetry

Date: 06/29/2011

I noticed the streams of sweat run down his bare neck and chest as I was squashed between my brother and sister-in-law in the back of a small air-conditioned Hyundai. It was an oddly humid night in New Delhi and he was only wearing a loin cloth. He was younger than me and, for a second, I found myself envying his toned chest and abdominal muscles. But my envy was short-lived because I suddenly realized the most striking thing about this handsome lad: he was missing his left arm and leg.

Asymmetry is one of the first things we’re taught to note as medical students. Perhaps that’s why I was captivated by him when I saw him hobble up to the car next to mine at a red light. I anticipated that he’d come to us next and started scrambling for my wallet and couldn’t find any reasonable change-- the smallest denomination I had was a 500 rupee note (~30 USD PPP). I frantically urged my mother, brother, and father to give him something smaller, but the light turned green and we had to drive off just as he got to our car. His eyes met mine for an instant. I wanted to tell him to wait. I wanted to tell the traffic light to wait. I wanted to tell my father, who was driving, to wait. My voice failed me in my desperation, the car moved on and he was gone. I slumped back in my seat and felt ill.

I’ve seen beggars all my life. I’ve seen mothers with desperate looks in their eyes and emaciated babies cradled in their arms braving the heat and the horrific fumes of vehicles at red lights. I’ve had mud-smeared children, with bellies distended because of protein-energy malnutrition, approach me with their pleas for alms. I’ve been threatened with curses and promised divine blessings by beggars of several different faiths. I’ve seen hundreds of mangled bodies-- amputated limbs, distorted trunks, legs bowed by vitamin and mineral deficiencies, blind eyes, and undernourished bodies that just barely look human, clinging to a wisp of life with progressive tremulousness. Why then did I feel ill? I should have been inured to these sights by now. Was it guilt due to my relative prosperity? Was it my long sojourn in the west? Was it the incongruity of the coexistence of his muscular physique and his chopped-off limbs?

I don’t know.

As I slumped silently in the back of the car, my stomach churning at the lachrymosity of the situation, my thoughts drifted from the asymmetry in the lad’s amputated body to the asymmetry in the landscape of Indian society. New Delhi is filled with posh malls, BMWs, palatial bungalows, luxurious hotels, and world class hospitals. It’s also home to emaciated children, amputated beggars, and poverty that is capable of exhausting the world’s supply of tears. I understand how it is easier to ignore the agony of people who live away from you and whose suffering doesn’t immediately affect you. However, I cannot fathom how the lawmakers of India, who inhabit Delhi, reconcile themselves to the simultaneous existence of BMWs and beggars in the city and the dichotomy of malls and mutilations. I beseech them to do something.

This slum, under a bridge in New Delhi, is only a few kilometres of the government of India (pictured below). Note the infant in its mother's arms.

When I got home, I looked at the Rs. 500 note in my wallet. I hadn’t been able to give it to the anonymous amputee. Any middle class person would have justified my inability: “It’s too much”. In a practical sense, they’re right. You’d have to be very very rich to be able to give Rs. 500 to every beggar you meet in India. However, I feel Rs. 500 is simply not enough! Even Rs. 5000 is decidedly not a long term solution that’ll free them of the poverty trap. Instead of only giving money once in a while to a beggar whose sorrow moves us, it is important for us to agitate, to educate, to advocate, to vote, and to ultimately bring about significant changes.

Perhaps giving alms to beggars is something we do mostly to salve our consciences, to atone for the asymmetry.


P.S: In the upper-middle class Indian society I inhabit, encounters with amputated beggars are usually followed by discussions of horrific gangs that abduct and amputate children to force them into mendicancy. This practice was also depicted in Slumdog Millionaire, where a homeless child who was a decent singer was taught a religious song, blinded in his sleep, and forced into beggary. These discussions frequently (not always) conclude that we should not give money to the mutilated mendicants on the streets. The logic: by not giving alms we express a refusal to be emotionally manipulated that will make this heinous practice unprofitable and force the gangs to find other wicked ways of making money. I follow the logic, but-- at the end of the day-- it doesn’t help me ignore the individual pain of crippled beggars. What if he isn’t the pawn of a diabolical gang? What if he really has been disabled by some tragic accident and can’t find work? And even if he is the victim of a gang that is using him to tug at my heart strings, can’t I at least spare him a beating from his boss today by making sure he doesn’t go back empty handed?