The lampshade was swinging gently, casting a penumbra on the ceiling of the old, dilapidated World War II army barrack that served as the Health Centre to the neighbouring residents. The residents were mostly from slums and in the Delhi of late 1990s more and more slums were springing up everywhere. An old fan whirred in the background. It was the end of a long summer day.
June in Delhi can be stiflingly hot and the air, in anticipation of monsoon, can become so thick with humidity that you wish for a pair of gills rather than lungs. But, the beads of sweat on Dr Joseph’s forehead were not just from the heat and humidity. The stench from Kunti Bai’s clothes, the last patient of the day, still wafted in the air.
The condition of Health Centre was poor, as were the patients that went there. There was usually not much to offer apart from a parcha, a prescription, for this tablet or that. But people nevertheless queued up noisily and gratefully accepted that valued piece of paper. Did they have money to buy the medicines prescribed or indeed if they really needed that tablet or tonic, or was it the poverty and deprivation that needed addressing? Human brain is good at blocking out such troubling thoughts and growing up in India is often a good education in that.
In those days I would meet Joseph at the Centre every Saturday evening and we would walk to the nearby Sardar’s Dhaba that served cheap whisky and the most exquisite tandoori chicken. We were both in agreement that this was good for our soul and eagerly looked forward to those happy Saturday evenings.
Despite the stench and heat in his office, that evening, I could immediately sense that Joseph preoccupied with some thoughts. He acknowledged me with a gentle smile, “You know I have had an amazing experience today.” He went on to tell me about Kunti Bai. She had presented to him a few weeks ago with her fist pressed against breast bone, “It hurts here doctor babu.” Joseph ascertained that the pain was usually on eating solids, which seem to take an inordinately long time to pass through her gullet.
Joseph, the dedicated and ever resourceful doctor, concerned that there might be something nasty going on with Kunti’s gullet had managed to arrange a gastroscopy for free with a gastroenterologist friend of his. Much to his relief nothing nasty was found.
He reassured Kunti, “Bai its all fine. Nothing to worry. Eat regularly and all will be fine.”
Kunti’s reaction startled him. “Babu, why does it keep hurting like this,” she asked tearfully.
Joseph was used to seeing these dislocated, isolated new migrants to the throbbing metropolis that Delhi had become. Sensitised as he was to the many traumatic experiences of relocation and the distant, often demeaning, harsh realities of the daily life in a metropolis, he touched Kunti’s hands and gently asked, “What is hurting you? Why do you hold your chest like that?”
A wall of silence met his questions, but not for long. Soon tears rolled off her eyes as she narrated the story of her family loosing their land in her village. Then she had to leave her family behind to earn money and ended up in Delhi. Got married to an alcoholic, who regularly abused her.
“Could this be causing the pain?”, she asked tears still rolling from her eyes.
“Perhaps”, he replied, his mind furiously thinking which social worker or charity would be most supportive and helpful for Kunti.
“Doctor Saab, thank you. You have listened to me as nobody ever has. Thank you again for all the help”, Kunti left refusing any further help.
“I just can’t understand why she refused help”, Joseph said guiltily over the glass of whiskey. He seemed to blame himself for her refusal to accept help. It was then the cleaner from the Health Centre turned up. Predictable as we were, he knew where to find Joseph.
“Saab, I found this bag in your room as I was cleaning it.”
Joseph immediately realised that it was the ragged bag that Kunti came with. It felt curiously heavy and we could not resist the temptation to check its content. Out came one prescription after another, results of one barium swallow after another. We could find at least 3 different endoscopy results. All were normal.
The whiskey was already having its effect and the brain felt too tired and exhausted.
“Can you please take this to Kunti’s shack and return it to her?”, Joseph requested the cleaner softly.
Kunti’s behaviour was baffling and I admit feeling angry at her and sorry for my friend. My friend’s trust and care felt betrayed. It did not make sense. She had no money and was doctor-hopping. Managing to get investigations that she no longer needed. Probably also refusing help that she needed. All this to what avail?
With years Kunti receded from memory and the life went on.
Jhumpa Lahiri in her Pulitzer Prize winning book Interpreter of Maladies has a story “The Treatment of Bibi Haldar”, which brought back the memories of Kunti Bai. Like Kunti, Bibi Haldar suffered with a mysterious ailment. It is a story of a lonely, destitute woman’s life. “Apart from my X-rays, I have never been photographed,” she says. Likewise Kunti Bai had X-rays, but never had that metaphorical photograph, which might have helped to understand the person that she was. “Treatment” in the title refers both to that prescribed to cure her condition, and the way she was treated by her family and by her community. I cannot help but wonder what treatment Kunti Bai ended up getting.
There are many layers to the dialogue that happens between a patient and the doctor. Indeed, as John Launer writes in Therapeutic Dialogue there are more people present in the conversation between a doctor and patient, all struggling to make sense of each others’ stories, to the best of their ability.
It is inevitable that the stories that a patient brings to her doctor will have more players than present in the room. It can be difficult for the doctor to sift out “medical” from “non-medical” if indeed that is possible. This can be frustrating, but I think it is something to celebrate.
Iona Heath writes: “Illness begins as a subjective sense of bodily unease, an experience of the functioning of the body as being not quite right. It is often very intangible and the sense of unease arises not just from what we have come to recognise as disease but also from other forms of distress including tiredness and unhappiness, misery and grief.”
I, like many of my colleagues often struggle with what can be regarded as “non-medical.” But, I do not think that we can ever really escape that. I cannot agree with that meagre view of humanity that many people seek medical labels to have an “easy life” on benefits.
I have beliefs which may be naive and foolish. This may change over the years, but so far my years as a doctor has only strengthened my belief in humanity. At the same time I have realised the limits of my imagination, which prevents me from better understanding the conversations that take between doctor and patient.
I am still learning.