Basket Case

Today I got holed up all day in a hotel room. I arrived in Dhaka yesterday on a business meeting representing my institution. Meeting was scheduled to start today but, apparently, the opposition party called a strike. Earlier they were planning to take us to the university, where we are meeting, in an ambulance but that plan was cancelled today. The guy told us the political situtation was too unsafe to travel.

The street looks deserted. They have told us not to go outside the hotel so whatever I have peeked out from the window at the end of the hallway (the windows of the hotel rooms are blocked, by walls, not sure if it is a protection measure) probably does not represent the whole Dhaka on the day of this strike. Just a few moments ago there were loud sounds ringing out, sounded like gun shots. Not sure if they were aimed on somebody or were just warning shots or maybe burst out tires. I dared not to check it out. 

Bangladesh was called the "basket case" of Asia, a hopeless country. But it has pulled out of that reputation lately. It has done much better than other countries in the region in terms of several social indicators. The Economist says "Bangladesh combines economic disappointment with social progress.".. "The country has achieved some of the largest reductions in early deaths of infants, children and women in childbirth ever seen anywhere."

Dhaka airport's relative magnanimity just after coming from the chaos of Kathmandu's airport had been a welcome feeling. But today's deserted Dhaka offers no such solace. On the way to the hotel from the airport, a Nepali compatriot and a colleague at a different institution told me he feels better each time he comes to Dhaka: at least we are not the only country which is in a dismal shape, there are some worse than ours. But I am afraid he might be wrong. In it's shabby exterior, this country seems to be doing the right things. That can not be said with confidence in ours. But it indeed offers a consolation that things can be done even in most dismal of states. It is a consolation we terribly need working in the current conditions of Nepal. 

Kanchii

Kanchii is making a gradual recovery. She is our dog. Every morning we take her out to take a dump. One morning, as we brought her back, a nasty black dog, which had sneaked into our compound through the open gate, lunged at her and sunk its sharp terrifying teeth. We did not realize the magnitude of the trauma until Kanchii's belly ballooned up on one side few days later. She gave up eating and camped in her box of carton where she normally sleeps. When she gave us no hope of spontaneous recovery, we called a vet. An enterprising stocky man, he came with his assistant. They grabbed Kanchii, shaved her side, made an incision in the skin which let out a gush of blood-mixed pus. She screamed through her strapped mouth all along. As I stroked her trying to comfort her, I found myself wondering if she knows we were hurting her to make her better. Does she know that? Or, maybe she is just profoundly aggrieved that their masters are inflicting pain on her. There is no way to know. But she has gotten back to wagging her tail and jumping at me as I come home now.

Why did that black dog enter our compound to bite Kanchii? Did he/she have grievances. Who knows what kind of rivalries run among these dogs? But how did she develop these grievances, if any? Kanchii lives in a closed compound. Her only exposure to the outside world is from the morning excursions where she empties her bowel and bladder. Was this black dog offended by Kanchii's morning rituals that she wanted to disembowel her? We know Kanchii as a meek animal. She functions as a door bell, barking primarily when there are people knocking at the gate. She keeps quiet as that person enters inside. How did she offend this black dog? It is hard to find answers. It just makes no sense. 

The world is witness to such black dog behavior in human society time and again. James Orbinski, a physician, who worked through Médecins Sans Frontières in Rwanda during the human carnage from Tutsi, Hutu conflict, writes in his book An Imperfect Offering: 

At one point, as I was driving through the city, a wild dog lunged at my open window. I hadn't seen it approaching as we slowed at a roundabout, and now I saw a pack of wild dogs tearing at a corpse (a dead human) in the grass by the roadside. They looked up at us as we drove by. The dogs were fat, bold and vicious. They were not moving from their mound of flesh. The dog that had lunged at our four-by-four returned to its pack, growling, baring its white teeth, and held me in its stare. 

It is a scene of evil hidden in human run amok. Orbinski who has witnessed it first hand tells us, he has seen humans even worse than the black dog. He writes in the same book: 

....She said that she had escaped being killed by the interahamwe. "My mother hid me in the latrine. I saw through the hole. I watched them hit her with machetes. The men were angry and strong. I watched my mother's arm fall into my father's blood on the floor and I cried without noise in the toilet." I listened to her and watched her lips quiver as her words came at a slow, staccato tempo. I watched her brown eyes look away as tears dropped to her cheeks and I could not stop my own. 

At that moment, I felt both despair and rage. Despair that she knew intimately our capacity for the most extreme rational cruelty; that she was alone. Animals could never do this. Animals can be brutal, but only humans can be rationally cruel. We can choose anything, we can be anything, we can get used to anything, I thought. Only humans can be evil. Only humans can make this choice. I felt my heart pounding and I wanted a gun. I wanted to kill the men who had done this to her. I wanted to pull the trigger again and again and again. My heart was racing; I was fighting my tears, gasping for air, for freshness, for something other than this. Then Eli clasped my arm with his strong hands. I felt an overpowering despair for the little girl, for myself, for all of us-- that we can be alone, trapped in our passions, in our reasons, in our minds, in our politics, that I and those men could be so angry and strong. 

Be it in an African nation, far away from where we live, it incites an indescribable torment. But we have our own share of such images and such despair. I am haunted by an image of charred body, supine in the ground with burnt arms flexed and skull bare. A result of inferno borne of rage from ethnic hatred in Tarai. This was an image I saw on TV, during the Madhesh unrest. An anguish looped incessantly in my heart, "How can a human do this to another?" Recently, I searched for that image on the Internet; maybe I could come to terms with it, seeing it again, I wanted to find a closing. But I could not find that image. Did I imagine it? Or have we forgotten? I do not know. 

But the violence we have gone through in Nepal has left its legacy. In our daily interactions, I find the remnants of that cruelty and violence it a little subtle ways: in our recklessness, greed, indifference and lies. It is disquieting.  

How do we save our honor?

Hospital that I work at runs private clinics. These are clinics where patients pay substantially larger sum of money than the general clinics to see a doctor. They are given a private room, attention from a fully qualified doctor and a personalized setup. All the revenues generated from this goes to the hospital’s charity which funds the cost for patients who cannot afford  care. I was asked to join this clinic. I will be spending 2 hours a week in these clinics. It started last week.

As I was waiting for my patient to come in, a man peeked in. He asked me if I would be able to see his neonate because the pediatrician had not arrived yet. The child was not eating well, he said. I am also a doctor, he declared. He said, he could have taken his child to the emergency room but he was worried about getting infection from that chaos. I agreed. But I told him I am an endocrinologist, I have no skills to evaluate or treat an ill child more than what he probably knows. In a typical pushy manner that I encounter in general clinics from people with some authority and recognition but perhaps also a desperate father bothered by child’s illness, he perseverated if I could still see his child. I said no.

The character in J M Coetzee’s book Diary of a Bad Year deliberates about the US administration’s involvement in torture of captured terror suspects:

Their shamelessness is quite extraordinary. Their denials are less than half-hearted. The distinction their hired lawyers draw between torture and coercion is patently insincere, pro forma. In the new dispensation we have created, they implicitly say, the old powers of shame have been abolished. Whatever abhorrence you may feel counts for nothing. You cannot touch us, we are too powerful. 

Demosthenes: Whereas the slave fears only pain, what the free man fears most is shame. If we grant the truth of what the New Yorker claims, then the issue for individual Americans becomes a moral one: how, in the face of this shame to which I am subjected, do I behave? How do I save my honour?

We doctors also work in a shame. We are scared to take our own child to where we treat other’s children. I cannot imagine of asking my parents to wait in line at our hospital to get a ticket to see a doctor at the general clinic, I would have failed as a son if that situation comes.

The question then becomes glaring to us: How, in the face of this shame to which we are subjected, do we behave? How do we save our honor? 

Rewards in Medicine

As I was going through some of my stuff the other day, I came across this medal. 

On the last clinic day of my fellowship, as I just finished seeing my last patient for the day, our clinic secretary approached me to tell that one of my patients was waiting outside to see me. I stepped outside to the lobby to meet this patient. She was a patient very well-known to me. In her hand, she had a gift bag. From that bag, she pulled out a medal. It was a marathon finisher medal. She told me, "I got this specifically for you after I finished the marathon because you made me able to do this." 

Initially, she came to us, referred by her primary care doctor, for overactive thyroid gland. A woman in her 40s, she was tense and irritable. I vividly recall her sighing constantly while I was trying to get a detailed information about her problem, as if she was bothered by my questions. I gathered she was an avid runner, physically very active. With the overactive thyroid, she was not feeling herself. She was very vague about what exactly was happening. As I was prodding her to get text book descriptions of symptoms associated with overactive thyroid, she was half-heartedly throwing out statements. I went through her laboratory investigations. It was a classical overactive thyroid disease called Graves' disease. I drew a picture of pituitary and thyroid in a piece of paper and started explaining her what was happening to her, a routine for me for this kind of disease. After that I told her that we had three options to treat: medications, radioactive iodine treatment and surgery. We discussed about each of them. She was interested to know what will make her feel better the soonest. I told her medications would be able to do that. But they would not cure the disease. We have to constantly monitor labs and adjust medication dose because the disease activity fluctuates. So it might be a reasonable option to treat the symptoms immediately but generally we do a definitive treatment: most commonly, destroy the gland with radioactive iodine or rarely, remove the thyroid gland surgically and replace thyroid hormone which is a much steadier treatment modality. She was desperate to get symptoms controlled, she opted to go for the medication.

She was one of my needy patients. After each test result, we would have a lengthy conversation on what it meant and what she should do. She was feeling much better with the medication but was worried about the return of the symptoms in the future. At a point, she started questioning if she should actually have radioactive iodine treatment. 

In radioactive iodine treatment, radioactive isotope of iodine is given to the patient. Since the thyroid gland preferentially and avidly takes iodine, it gets concentrated primarily in thyroid. It emits radiation there which destroys the thyroid gland. It is extremely safe. Resulting thyroid hormone deficiency is easy to replace; once the proper dose is determined there is not much fluctuation and does not require frequent monitoring. 

Her main concern was how long it would take for the radioactive iodine to completely destroy the thyroid gland. Because until it is completely destroyed, there may be fluctuation of hormone levels and she was scared about having the previous symptoms. She asked me, how long will it take before hormone levels stabilize? Will it affect her ability to do physical activities? Being active was very important to her. She was planning a marathon. Will she be able to do it? I explained to her the response is very variable and generally takes months. It's hard to predict. We discussed it at length. By this time, we had established a good rapport and trust. Stepping the boundary of objective discussion, almost patronizingly, I told her, it will be OK, because there are many patients who have this without much problem. She agreed to have radioactive iodine treatment, she had a very good response, and she reached steady thyroid hormone dose smoothly. She was able to complete her much planned marathon.

For an endocrinologist, it was a routine disease. It was a routine treatment. It was a routine interaction. 

But here she was in the lobby of my clinic with a gift bag, marathon finisher medal and a gift card. She must have asked my clinic staff when my last clinic day was. She wanted to make it special. I was much overwhelmed. I thanked her and gave her a hug. Later I emailed her: 

Dear _(first name),

I was profoundly moved by your visit and thoughtful gift today. Of all the gifts and awards I have received in my professional life, this is the one I am going to cherish the most. I hope I can live up to the standards you have attributed me and be of service to the ones with illnesses and ailments.

Thank you,

My first name.

It was a strong lesson for me, how a routine mundane illness can be a gargantuan issue in the patient's life. These days, it distresses me when my colleagues speak of interesting case. I tend to think there is nothing interesting about these illnesses. They are irksome at the least and sinister at worst. I have yet to find a patient who is tickled by an interesting illness. 

Furthermore, this humbles me to realize the special platform the creed of doctoring offers. Each patient who comes to us with suffering offers us an opportunity to help her. A reward of incomparable substance. We are offered an opportunity to reap rewards with each patient. It just seems so cruel to brush off any of these patients, ignore and neglect any of these patients. 

Imploring Amnesia

Everyday, we are served a sight of our statesmen exiting important places: President House, party offices, Mr. Sushil Koirala's house. These are men, with protuberant bellies mostly. From the push and pull of reporters, we are demanded to infer that these men are important people. What they say matter.

But we find ourselves lost to their magniloquence most of the times. Rather, I find myself appreciating, many a times, their sleek attire, lustrous cars of diverse makes and models; on the eminence granted by security personnel clad in neat dark suits running alongside the moving vehicle. How do these people finance such oppulence? In these dusty roads, filth, how do they keep themselves so neat? We wonder. Indeed, our proletarians have come a long way. In their splendor we seek our dreams. Forget about what they have to say!

However, not all is lost to our ears. Some of the recent events are incapable of being buried in  the platitude of our political oratory.

1. A Nepali colonel Kumar Lama was detained in UK. He is charged with intentionally "inflicting severe pain or suffering" as a public official, says BBC. Our government has objected to the detention.

2. A Nepali journalist Dekendra Raj Thapa was killed in 2004 by Maoists. Thanks to persistence of the journalists in seeking justice, recently the perpetrators of the crime have been arrested by the police. They have apparently confessed to burying Mr. Thapa alive. Our Prime Minister has tried to stop the trial. He argues, if this process goes forward it will derail the peace process. We should forget what happened in the war. 

What are we to make of all of these? 

We are told, it is wrong to seek justice when someone has been tortured and buried alive. We are told, we should get our colonel back who has been arrested for war crimes. This is what it has come to: these are the moral battles of our government, of our politicians. 

We had seen it coming all along. They told us, it's okay to kill for a larger purpose. We were told it was necessary to let barbaric men pin a man to a tree and torture him till his soul scrammed out of the battered body, in order to achieve justice and prosperity for all the downtrodden. Bombing a bus and burning 39 people alive, to kill 3 army personnel, was deemed a possible error in war. When our teenage girls and women were raped and killed by our tax-paid army, we were told that happens in war and that our army was fighting to protect us. 

In more than a decade of blood-bath, we were visited by the darkest of the evils. Our children's innocence had been violated by the daily display of heinous atrocities in our news media. Numbed by the horror, we were speechless, motionless. 

Now we are told, we need to forget that time. All those were done for a purpose. We have agreed to move forward. In strong rhetorical terms we are told, our only way is way forward. 

But we ask, where are we on that purpose? What was that purpose anyways?

Mr. Prime Minister and Mr/Mrs/Ms Politicians, we might have been speechless but our memory teems with every detail of the horror that happened in that time. We beg you not to try to trample our basic intelligence and human character. The fact is clear: now that your phantasmagorical philosophies are going down the drain, you have to face the deeds of your past. You have served us void where you had told us gold would be delivered. Now that we are empty handed, we ask you why you made us witnesses to the darkness inside you?

Some of us, unfortunately, are not blessed with amnesia to the horror of violence as you seem to be endowed with. Whatever the pragmatic way out of this mess might be, we have learned a solid truth about loud voices that say violence is a justified force. Even now we hear some of you saying you are ready to take up arms once again: please know, we have been disillusioned.   

Interrupt after 17 seconds

Few weeks ago I got a distinct privilege of sitting at a viva station in the exam for first year medical students at our medical school. These are brand new students. Fresh out of 10+2, they have started their arduous journey to become doctors. Enthusiasm is palpable. Their trepidation is apparent: it must have been just few weeks or months that they have been introduced to esoteric terminologies and concepts of medicine. Furthermore, our school places a big emphasis on social responsibility and critical thinking. They must be torn out of their minds in this bewildering world where concepts are being played around them, teasing them, taunting them and daring them. 

I had two questions to ask : one was about communication with patients and another about a concept in patient care. One answer by three of the twenty six students that I talked to intrigued me. They said, "You should interrupt patients after 17 seconds if they keep talking." It did not make a sense to me. But three students are saying the same thing. It has been a while since I last saw one of these History and Physical Examination cook books. Have they come up with new stuff? 

So I decided to pull one out of library shelf and take a look. What they meant was, on an average, physicians interrupt patients after so many seconds. Poor students, who probably have slept only a few hours trying to cover all the bases for next day's exam, got it upside down!

These students are just starting, the mistake is almost cute. But you hope they don't have to go through this confusion in some of the basic stuff of being a doctor. 

These are the kind of things they should be learning by seeing it done. There is no good substitute than the example of deed. Let's talk an example: 

Being a diligent student at the medical school, text book concepts about good patient care was not totally unknown to me. Concepts of empathy, respect did make a sense. But my real education on those issues was seeing the doctors do it. On my first day of residency rotation, a senior neurologist helped an elderly patient take off her socks to do ankle and plantar reflexes. After being done, he put back the socks, helped her with the shoes and walker before she could sit down to talk about her problems. I was taken aback. Does a senior doctor do such things:Take out a person's socks and put them back as if he is a helper in an elderly home? But as the residency days passed, it became obvious that it was a basic courtesy: helping an elderly person. Subsequent days have offered many more occasions to see such deeds that makes me feel privileged.

Our health care system should be able to provide such an opportunity for our students too. A clinical care area where a patient will be treated with dignity and respect will demand the same from a novice student who has all the good intentions of being a superior doctor. Patient care where patient's interests hold supreme will indeed prime the malleable minds of our young doctors to hold up to that standard. Clinical care is where all the real action of education starts, in my opinion. There are no stronger lessons than seeing things being done. Concepts are abstract, they belong to the realm of imagination. We deal with breathing lives, deeds do matter. 

Unfortunately, it is a sad realization, our institutions do not currently have much emphasis on improving patient care. Our educationists are quite fired up when it comes to talking big syndromes in class rooms but when it comes to taking care of small details in patient care (which carry a huge implication for patient outcomes), they are listless, absent and sometimes abhorrent. You will see sleek classrooms in many of these institutions, but they will have crammed up all their patients in a space where breathing is difficult. This needs to change. It is not good. 

Access and Quality

In the 1960s, China saw a phenomenon of "barefoot doctors." Named after barefoot farmers in southern China who worked at the paddy fields in a commune and also practiced medicine, these were farmers who underwent short-term training of three months to a year and delivered basic health services to the community.  This offered decentralized basic health care services which focused on prevention and was sustained locally. 

Despite quite a low per capita income, China achieved infant mortality rates comparable to developed nations by the 1980s. 

Although, there were concomitant social and economic progresses, many people credit improved access to basic health services provided by barefoot doctors for this phenomenal reduction in infant mortality rate. Carl Taylor writes in Reaching Health for All: 

      "The Chinese experience shows that with equitable distribution even the simplest
       and lowest-cost health measures can have great impact. It is more important that
       care at community level be readily available to all with no barriers of cost or 
       social constraints than that it be of the highest quality...."

This should be an illuminating lesson for our policy makers who seem so hung up on coercing doctors to stay in remote areas, as if the presence alone of half-hearted doctors in these desperate places is going to solve all our health woes. This experience suggests that what we actually need is ensuring unimpeded access to basic health services. And this is best provided by locals who receive short-term targeted basic healthcare delivery training. 

While Mr. Taylor emphasizes access over getting obsessed with high quality care at community level, it does not mean that quality of care is a dispensable luxury. As much as our community suffers from access issues, our so called tertiary care centers suffer from quality issues. And, I think, lack of quality in these higher centers is as much of an issue as access is for the communities. 

Few days ago, my father asked if I knew anyone at Tribuhuwan University Teaching Hospital (TUTH). One of my villagers had brought his daughter to the emergency room there and knowing that I was around, he was trying to check with my father if I could put in some words to the doctors in that hospital. First off, I do not know many people at TUTH. Secondly, why should one seek relations when there may be tens of other patients who might be going through the same process of patient care? Still, I half-heartedly called one of my friends at TUTH, just to satisfy my father, and asked him to see if he could ask a resident in the emergency room to check on that particular patient. 

Two days later, when I arrived home in the evening, I found the patient, her father and her cousin camped at my living room. They had left the hospital against medical advise, one of the notorious LAMAs (Left Against Medical Advice). Frustrated, father explained his dissatisfaction thus: 

They were in the emergency room, a place akin to goat shed (in his own words). Nobody seemed to know what was going on with her. Students poked on her eight times drawing tube after tubes of blood as if the sole purpose of her presence was to offer a  practice opportunity for these students. They were told that she needed blood and she needed to be admitted. Somebody told she would need a bone marrow biopsy; another person told she did not. After less than a 1/2 of the first unit of blood was transfused, the catheter clogged and blood was not transfused for several more hours. When asked why the catheter got clogged and blood was not running, they were told an inexperienced person had put in a catheter. So what is the purpose of staying in the hospital, if she is not getting the treatment and is a subject of experimentation every step of the way? That's why we left the hospital. 

I flipped through a sheaf of medical documents. She had gone there with a feeling of weakness and shortness of breath. During evaluation, her hemoglobin was found to be quite low at 6 g/dL (normally it is around 12). All other testings were normal. 

I can imagine of a rich academic discussion that might have happened amongst the doctors participating in her care. A senior doctor must have asked, "What's the cause of isolated anemia with normal WBCs and Platelets?" An apt among the herd of the learners must have purged out a list of differential diagnosis astonishing the less well-read ones. To that list, the senior doctor must have added some sharp criticisms or comments. Everyone must have been quite appeased by such a rigorous academic exercise, ready for a round of momos, tired  by the effort of recalling data that are normally transcribed in the books. 

But what of the patient? 

She left the hospital with hemoglobin of 6 g/dL. This condition is perhaps not acutely life-threatening, but a teenage girl leaving a hospital in critical condition is a big failure of the system. We tend to blame patients for these kind of failures: LAMA is a patient responsibility, what can a doctor do? We say. But if this person was my daughter, I would have done the same. Perhaps piqued by such repetitive lame arguments, Paul Farmer, a doctor of deeds for the neediest, had a simple thing to say about such non-compliant patients: 

      "The only non-compliant people are physicians. If the patient doesn't get better, it's your
       own fault. Fix it." (In: Mountain Beyond Mountains)

Dr. Farmer is talking about a patient who is not getting better despite some efforts and is asking for increased effort. But we are talking about owning some responsibility for at least critical and acute care. 

Barefoot doctors seem like an attractive option for basic healthcare in our communities but it does not justify footless doctors in our higher care centers. More than that, apathetic hospital administration that leaves patient care to the devices of mob dynamics needs to realize that its somnolence is a reason for much agony.