A Passage in India
"It's cooler this morning," I said to Seema, as we left the hospital grounds en route to our home visits.
It was a bright and bustling morning in Trivandrum, the capital of India's southwesternmost state, Kerala. A third-year resident in family medicine, I had come here to work with the staff of an Indian nonprofit devoted to advancing palliative care services across India. Seema was a young, newly qualified junior doctor who had only recently joined the organization. We were traveling with five others--our driver, two nurses and two nursing trainees--into the mountains east of Trivandrum for the day.
"We don't really speak about the weather like you do," Seema gently chided. "In the West you spend lots of time talking about the weather." As I silently ceded her point, she consoled me: "I think you have more variety to your weather. Here it is only hot, very hot, or cold and rainy. Most people carry an umbrella because it's useful in any of those cases."
I counted the passing umbrellas as our van carried us into the foothills on our way to Palode, a village where we would hold a small outpatient clinic before making home visits.
After the clinic session, Seema looked tired. I asked what she was thinking.
"Sometimes I feel frustrated that we can't do more for our patients," she said. "Doesn't this frustrate you?"
Of course, I thought. It frustrates all of us.
A bit tentatively, I asked, "Have you heard, Seema, about the idea of bearing witness?"
She shook her head.
"It's the idea that just being present with someone can be healing," I went on. "In the Bronx, where I work, lots of our patients suffer from sicknesses and social ills that we can't do much about. Sometimes, just being there is doing something; sometimes it's the best we can offer." Perhaps this notion was merely a salve for my feelings of helplessness. Still, I hoped that it was true. Seema's answer was silence--whether thoughtful or skeptical, I couldn't tell.
After lunch, we were joined by a beautiful ten-year-old girl named Paadini. A member of her school's health club, she aspired to be a doctor and sometimes accompanied the palliative-care team on home visits.
As we drove deeper into the mountains, Paadini sang quietly to herself, and Seema told me about the patient we were going to see.
Diagnosed at forty-eight with breast cancer, she'd had a left radical mastectomy and multiple rounds of chemotherapy and radiation therapy. The treatment had been unsuccessful, likely because of her late diagnosis--common in a country where most people don't have access to primary care or the money to pay for it.
The woman's alcoholic husband had left her years before, but had returned home a month or so back, Seema said. "He had nowhere else to go, and she could not, as his wife, turn him away." He'd recently been found lying dead in the road. The woman's son worked nearby, but was rarely home; a few months back, her daughter had fled with a boy. The patient, bed-bound and fed twice daily by a seventeen-year-old neighbor, was essentially alone.
The road's jagged asphalt gave way to red dust. We passed government-owned bamboo and acacia farms, abandoned bus shelters and a painted cement statue of Shiva--the giver and taker of life--with his blue skin, dreadlocks and trident. Crossing over a fast-flowing river, we reached the patient's small village and stopped to buy biscuits and bananas to bring the patient.
We parked the van and descended into a shallow valley of rice paddies and palms. Led by Paadini in her pink dress, we walked single-file through the lush, green landscape to the sound of a gently trickling stream and goats bleating in the distance. Around us, white cranes swooped into placid ponds filled with blooming lotus flowers.
As we scrambled up a steep rise to a small, dark mud-brick home, an eager puppy on a chain barked piercingly, announcing our arrival.
Our patient lay in the open front porch, naked except for a stained white sari blouse and the bright pink blankets that covered her. Eyes closed, she moaned quietly, grimacing between shallow, rasping breaths. Her head, covered with short wisps of hair, lay awkwardly on the pillow. Her cheekbones jutted over sunken cheeks, her lips were dry and cracked, her exposed arms were wasted.
On a bench a package of steroids, unused since the team's visit a week back, sat next to a tin of watery rice porridge--her unfinished breakfast.
Responding to our greeting, she seemed confused. She'd tried to bathe that morning, she said, but had fallen in the pool--an event that had actually taken place two weeks before. She complained of being in pain, and she looked it. When she rolled over, I saw bits of dry feces caked to her thigh. She seemed very close to death.
Hoping to relieve her pain and breathlessness, I asked Seema, "Can we give her morphine?"
"No," Seema answered. "None of her family are here. If we give her morphine and then something happens, her family will say that she was fine when they last saw her and blame us for making her worse. Our hands are tied." I suppressed a flash of anger. There must be something we can do.
We crushed the steroid pills into the rice milk, and the nurse spooned it into her mouth. We tried and failed to take her blood pressure; her weak, thready pulse told us that it was very low.
As a team member called the woman's son on a mobile phone, we sat on a mat next to the woman's bed. Looking around, she locked her eyes onto mine, then reached for my hand.
I clasped her hand in mine, and we sat for several minutes, looking at each other. As I had many times in my brief medical career, I moved past my own discomfort by acting as I thought a good doctor would. And though I wouldn't generally use these words, I think that I prayed for her. I also wondered how she understood this strange situation, and wondered who was comforting who more.
"She doesn't know us, but she knows that we're here to help her, " Seema said.
An idea occurred to me. Turning, I caught Paadini's eye.
"She's very sick, Paadini," I said gently. "Maybe it would make her feel better if you could sing her a song." But Paadini shrank back shyly.
The son arrived, doe-eyed and bewildered. Seema explained that his mother was very close to death; that she needed to be cleaned and to have someone stay with her. The son promised to take care of these things.
Bending down, I took the woman's hand again and smiled. Then Seema did the same.
Our earlier conversation came back to me. Our presence may be the best thing we have to offer.
We left and walked back through the forest.
I thought about how much suffering the woman had endured. I hoped that our presence had meant something to her. Quietly, I wished that her pain would go, that her breathlessness would cease, that she would die peacefully and soon.
Up ahead I could hear Paadini, leading us out of the green valley with a song.
Epilogue: The following week, I learned that the women had died within an hour of our visit.
About the author:
Justin Sanders is a graduating family medicine resident in New York. "I'm grateful for the enthusiastic encouragement about my writing that I've had from a thoughtful mentor in my residency program. When not working, I like looking at contemporary paintings, cooking pizza and reading The New Yorker."