Nobility in theory and practice

No one is evil.

Everyone’s default setting is good, but sometimes their goodness gets corrupted by selfishness or stupidity or anger. Having a selfless and noble philosophy is a good start; but then again selfless and noble philosophies are a dime a dozen. Go to any comic book store and you’ll read how batman never compromises his belief in justice for the sake of expediency, most constitutions (but not Australia’s) are enshrined with values such as that we are all born with certain inalienable rights including life, liberty and the pursuit of happiness. But not everybody has the opportunity or the strength of will to put them into practice.

What follows are some examples of nobility in practice that I have come across so far during my time here.

I was sitting in my preceptor’s surgery today when a man who works in the hospitals blood bank came in to talk about a patient. Let’s call him Dave. Dave had a low platelet count and despite several transfusions the count was not rising substantially. Dave was financially strained and would not be able to afford transfusions for much longer. He was from a rural town and was recently forced to sell his house in order to afford treatment. He also had children and the man from the blood bank (Barry) was worried that their education and their future prospects may be being unintentionally sacrificed. Barry suggested that patients often do not reveal these concerns to their doctors unless asked and so was advising my preceptor to tell Dave plainly if he had a problem with hematopoiesis (blood cell, including platelet production). That way, he would not continue spending money on transfusions that were not fixing the underlying problem. What impressed me here was simply that Barry took the time to enquire about Dave’s personal life and then put in the effort to confront Dave’s doctor about the issue. The effort was not much but it revealed that Barry really cared for this stranger, hence, nobility in practice.

Patients come in occasionally without any family members. In India, a patient’s family does a lot of what we Australians would expect the hospital to take care of. A simple example is with drugs. Here, a doctor will prescribe the drugs, but then it is the patient’s responsibility to acquire them from an outside pharmacy and make sure that they are being taken as prescribed. With such a system patients who come in on their own are in a bit of a bind. Patients here do not wear hospital gowns, they just wear the clothes they came in with, and if they want a blanket they have to bring it themselves. We were told toady of such a patient, and before I could think of the blanket situation, my preceptor said that he had a spare blanket at home and that if the patient needed it he could have it. Again, the effort was minimal, but the thought and the offer revealed that my preceptor cared.

In an urban slum, three doctors I met have dedicated themselves to not only look after the health of their respective communities but also to act as mentors and help with social, economic, marital and other problems. Their effort is maximal and reveals thorough nobility in philosophy and practice.

It is comforting to be surrounded by such people, people who have maintained their default setting.

Work

An 18 year old boy looks after the guest house where I am temporarily staying. He works for 8 hours every day from Monday to Sunday. His parents own a small shop in the market district and after work every day he goes to sit in the shop. He is in his last year of school so while sitting in the shop he studies and after the shop closes he finishes any study that he has to do. I saw him working last Sunday and was surprised, I asked him when he takes time off and he old me that he doesn’t. He told me that days-off breed laziness.

I had that day off and I spent most of it wandering aimlessly.

My preceptor starts work at about 9 30 and works till 2 he then starts again at 5 30 and goes till about 9. He has cut down his work hours because he thinks it is important to spend some time with his family.

The junior doctors that I work with start work at about 8 and do all their pre round work before the consultants like my preceptor arrive at 9 30. They take about an hour for lunch and then stick around to do post round work after the consultants leave at 9 pm. When I asked my friend what he does on his days off he says that he doesn’t take any. He saves them up and then goes home for 4 or five days every couple of months.

I have been working the same hours of them and already after a week am feeling burned out. I come from a country where the average income is around $35 000 a year. Most people in India earn less that $2 per day.

Why?

The markets

If you want to se capitalism don’t go to Wall street, come to India. For markets to function properly economists make certain assumptions. Some of these are that everyone is rational, everyone is looking out for themselves and themselves alone, that everyone has perfect information about products and prices etc. and fourth that there is perfect competition. These assumptions are always wrong. But economists cant be bothered working out by how much so they just assume that their assumptions are true and then use these assumptions to guide public policy and make predictions. Genius isn’t it.

But yesterday I went to a place where these assumptions are more right that anywhere else I have ever seen. I asked my friend rickshaw driver to take me to Paithan Gate, the most crowded shopping district in Aurangabad, and from there I walked around without any particular purpose.

When I got to the outskirts I came across a shop called “Sham electronic repairs” (Sham is a common Indian name). I thought my non Indian friends would get a kick out of the pun so I took out my camera to take a photo. As soon as I did two cute children ran up to me and asked me to show them the picture I took. They looked at my picture and then looked at the shop and started laughing. I took a picture of the boy and showed it to him and he got all excited, but then his big sister pushed him out of the way and told me to take one of her. I took one of her and she had a similar reaction. These kids had no shoes and were literally wearing rags but they were just as happy as any other kids I’ve seen. That made me happy too.

Nerrala bazaar, means different market in Hindi, and it was the next place I stumbled across. Goats, pigs, people, cows, dogs all cramped into this tiny open space between two meanders of the river. Each product was sold by at least four different people who were all located next to each other. They each had their little spot on the ground with their products, such as fruits or clothes spread neatly on a thin sheet on the dirt. They all shouted prices and if I went to talk to one of them about price it instantly became an auction between the four. If they tried to collude amongst themselves they new that a new person would set up shop tomorrow and undercut them. Thus, there was perfect competition. All the products were there for you to see and touch and the going price was well established by the shouting salesmen, thus there was perfect information.

But the, flaws of capitalism were also clearly on display. Since there was no government interference, there were no regulations on child labor and children who seemed just old enough to talk were carrying things for their parents or putting things in bags for me. Also, publicly owned resources like the air and the environment were being grossly exploited. The stench of smoke and dust and feces was more than noticeable and the river was worse than a sewer, flowing with trash and oil, with pigs wallowing in the mud and people urinating and defecating on nearby rocks.

Nevertheless, this market feeds thousands provides a steady income for thousands more, although the environment suffers it keeps kids in school and parents in work, we just have to figure out a way to stop if from being one or the other.

Bibi ka Muqbara

It was sad to see the slowly crumbling vestiges of a once powerful opulent empire. An empire that had the extra cash to build two almost identical, massive structures on opposite sides of the country. Bibi ka maqbara was built by the son of Aurangzeb, who was the founder of Aurangabad and the son of Shah Jahan, the emperor who built the Taj Mahal. It was meant to rival the Taj, but sadly the architectural fashion of the day resulted in it being less ornate, and therefore, less appreciated in the centuries that followed. It is, without doubt a beautiful and impressive structure but sadly it is always compared to the Taj. And it always falls short and thus has always been neglected.

I strolled around the mausoleum and imagined how it would have looked when it was built, with its shiny marble designs, its ungratified walls, it’s well kept gardens and its pools filled with water. I shouldn’t be too hard on them though, it’s still commendable that a 300 year old building has been kept largely in tact. But they could have done better.
Perhaps my view was tainted because I had just lost my phone.

I was talking on it when I got into the rickshaw and when I got out it was gone, but finding out where that rickshaw driver went and how I could find him again seemed hopeless. I had a robust session of haggling with him before I got in as well so perhaps this was some kind of payback. All my numbers were in there. And worse yet I was imagining the lecture I was going to get from my parents when I told them, especially given how I had lost my phone the last time I was in India.

Without my phone I felt naked. Unable to call anyone if anything happened to me. Removed from the world. I cant remember the last time I was phoneless. It’s a strange feeling, liberating, scary and lonely all at the same time. Iv decided im going to try it for a week when I get back to Brisbane just to see how it goes.

So there I was, the sun setting, phoneless, helpless and annoyed. I took a seat directly in front of the building in between two big clay pots. It was the best seat in the house and as the sun set and shone red and yellow onto the white monument all its imperfections disappeared. I sat for about and hour and watched all the colours, first the brown of smog, then yellow, orange, red and black and finally was appreciate it as Aurangzeb intended.

So about my phone, after another haggling session to get a rickshaw back I went to the stand where I caught the original ric. Long story short, I was super lucky, the driver had found it and I eventually got it back. I paid him a bakshish (prize) of 500 rupees but realized soon after that maybe I was swindled. Did the driver take my phone in the scuffle at the very beginning with the sole intention of getting a bakshish?

Can I hold such a dim view of humanity to think that this is actually possible? I decided to err on the side of trust. It’s better to believe that everyone is honest and be disappointed occasionally than believe that everyone is dishonest. The driver, Shriram is now my driver of choice, I have his phone number, and whenever I want to go anywhere he is the one I call. It’s worked out twice so far and it seems that believing in his integrity was the right decision. Honesty 1, dishonesty 0.

unhelpable patients

There are serious downsides to being seen as gods.

As Uncle Ben said, with great power comes great responsibility, and from the patient histories I have taken, these responsibilities are often not taken seriously. Many patients in the general ward have complained that their rural doctors are not up to the mark; one was a very similar case to one I described previously in the out patient department, where a patient with a chronic lung condition was prescribed an oral drug when an inhaler was more effective. Just as insidious as incompetence, however, is laziness and corruption. Patients and doctors alike have complained that there is a chronic poor work ethic in public hospitals. An example I was given was that ultrasound machines would just lie unused for months because a small bulb had stopped working and no one had bothered to order a new one because the red tape was too cumbersome. These impressions have come from second hand sources and are probably biased so I shouldn’t be too quick to judge.

The other responsibility that I experienced first hand was the greater extent that patients involve you in their lives. Patients are much more likely to reveal social and economic problems if they respect you. As I took histories yesterday in an urban slum I would begin asking about their chest pain or their tiredness but as soon as I would ask about their home life, or other things that were causing them tension they would immediately give me the grand tour of their lives. I had women telling me about their money problems, asking me what they will do if they cannot afford treatment, a man told me about their daughter’s children and how they were willing to forgo healthcare in order to pay school fees.

A case that really affected me though, was an old woman who came in with her neighbor into my preceptor’s surgery. This woman lives about 100 kilometers away which means that it costs around 200 rupees for the two way journey. The woman complained of chest pain, had a high blood pressure and uncontrolled type 2 diabetes. She was about 60 and lived on a farm with her only son and his family. She had two daughters, but as is the custom here the daughters live with their husbands families and have very little to do with their biological parents after marriage.

She began to tell the doctor about her tiredness when she broke down crying. She told us that her son now owned the family farm and had told her that since she was no longer capable of working, she was no longer any use to him. Rather that saving any money for oneself it is the custom here that ones children will look after you in your twilight years. If they do not, well, nothing….

It was so painful for me to see this woman so utterly broken. A broken body, a broken spirit, she was worthless to her son and because of that she believed she was worthless herself. It is a fear for all of us, sometimes conscious sometimes not, that at the end of our lives we will look back and be disappointed. We are by far our own harshest critics, and self disappointment hurts more than any other. I felt great sympathy for this woman who I knew was looking back on a life that she felt was wasted; that added nothing. My preceptor and I discussed her case over tea the next day and even if she doesn’t know it, I can be sure that that woman added something new to my perspective…..

So what can we do for her? Unfortunately not much, we can reduce the prices of her medicine, we can give her a larger stock of medicines that will last longer so that she doesn’t have to make the journey into town as often. But as for her psyche, we can empathize, tell her that we will take care of her health, and show her some of the compassion that her jackass son robbed her of; but we do not have the time or the ability to do family therapy or otherwise improve her social situation. More urgent matters occupy our time, our time is already stretched to the limit and well that’s it……. I’m out of time….

Doctors are still gods in India

My hospital has used that to its advantage and placed several doctors in rural and slum areas to not only look after health but also act as mentors and community leaders. Healthcare is not holistic because our wanky biopsychosocial curriculum tells us it is. It’s holistic because people are not defined by their illnesses.

An illness is part of who someone is when they have it. But whether they contract it and how it progresses is not only determined by the nature of the illness but also the nature of the person. People are shaped by their genes and their environment. Therefore to uplift communities and improve their resilience we must focus on improving their environment. Hedgewar hospital espouses this philosophy and not only treats the ill but also runs schools, adult education programmes, micro credit schemes and preventative health workshops to uplift communities.

Gandhi said ‘Be the change you want to see in the world’. The doctors at this hospital are doing just that.


I read something else in the lunch room at the hospital that I thought would fit well here. It goes something like this.

“When I was a young man I wanted to change the world, but that was too difficult so I tried to change my nation. When I found I couldn’t change my nation I tried to change my town. But I couldn’t change my town either so as an older man I tried to change my family. Now as an old man I have come to a realization. If as a young man I had changed myself I would have changed my family. Me and my family could have had an impact on our town, and my town could have changed my nation and indeed the world.”

Fear

Sadness, loss, concern, desperation, determination, loss of hope, perseverance, courage and anger are all emotions I had prepared myself to see. But one emotion caught me by surprise. Fear. It seems so obvious to me now, but my lack of mental preparedness meant that I was caught completely off guard when I saw the face of one of the patients in our ward a few days ago. He suffers from a chronic lung disease and despite gasping for breath, oxygen was not sufficiently reaching his blood. He was straining every wasted muscle he had left, and sitting atop his fragile broken body was a face that knew that something horrible was happening. Wide eyes, fast heavy breathing, pale wrinkled face, sweating bullets clutching his sons hand with his left and his doctors with his right. His high pitched voice, speaking what he thought were his dying words, were barely audible but the message was loud and clear. “I am scared. Do something. Anything”. He survived.

Fear is something that I’ve been noticing more and more since that first encounter. A child was undergoing her first operation without general anesthetic. Putting myself in her shoes I imagined lying on a metal table in a cold room surrounded by faceless strangers covered in blue or green. Their surgical masks revealing only their beady eyes void of sympathy or emotion that knew me by number alone. Even if I yelled for my parents they wouldn’t hear me, and anyway fear had reduced my voice to a whisper.