Saturday, 20 June 2009

A culturally oriented Medical Consultation..

You don’t have to search for the people, those who you need to meet will come your way, thus welcomed me into her tribe, “Dr Pat Brown”, a traditional tribe of Indians living in the midst of the state of Iowa. They had been fiercely independent and resisted all efforts to move them to Oklahoma and to this day they speak their language and follow their ancient religious rites and practices.

Persistence and belief in ones culture does pay off in the end.

This is one of the many things she taught me, among our many encounters over the years. They also made me realize that just a western education (a very good one mind you, medical school in London, Postgraduate studies in Internal Medicine in Australia and Endocrinology training at Washington University and University of Miami in the USA) alone is not sufficient when trying to become a healer, because the western model is based on curing, the symptoms, parts of an individual and fixing the problem in the mechanical mode. I went back to London, did a postgraduate degree in Medical Anthropology to become a culturally competent health care provider. I hope I did not disappoint my Meskwakia friend, “Dr Pat Brown”

July 10, 2007

Chennai, as Madras is now called, has the distinction of having an airport which has not altered in appearance since I had been there last about ten years ago. It is a market in aviation antiquity, and I was to fly a contradiction in terms, a very latest model plane, made in Brasil, fitted with all business class style seats with wonderful meals served on board. An antithesis of Low Cost Airlines which are proliferating like mosquitoes during monsoon times.

They even have a lounge where attentive Dravidians, made tea for you, you could nibble on a sandwich. I surveyed the room, all middle aged or above Indians, some in their brief cases denoting their newly found status in this surging economy, an older couple talking very loudly, uncomfortable for me even a few meters away, a woman with fragrant jasmine tied to her hair feeding a baby.

Other business types, in casual Indian attire, some with phones glued to their ears and others perusing without much interest the newspapers available in the lounge.

I had my computer and was carrying all the gifts in jade I had brought in Burma, the affectionate capital with its pre colonial innocence still intact, which I had just left, the day before.

In fact I was to be on the Paramount Airways Flight at 7 45 am , instead I am on their flight 10 hours later to Coimbatore which would proceed to drop us off in cochin at around 9 pm.

I was given a good seat, 5 B, the bulkhead seat with plenty of leg room, but as luck would have it, the jasmined lady sat next to me, her girth pouring over even the business class size seats with her child ( who like most Indian children misbehave in public and demand attention, especially if they are boys, since it is boys the parents dot upon, the girls know they are neglected, now and later on.) after a few kicks from his tender feet, I looked around, spoke to the airhostess, with the unusual name of Ginny and even more unusual face, which was much more Myanmar Like( which I took to be bring good luck) , and decided I shall move to another seat with better behaved representative of Indian culture.

There was a gentleman sitting on seat 5 D, tall and somewhat quiet and elegant for his age, which I thought would be around 40. He invited me to come and sit next to him, to make the trip bearable for me and relieve the pressure on the body (physically and metaphorically) of the jasmined lady.

As the plane was about to take off, I smiled at the Myanmar Like face of Ginny and moved over to seat 5C.

Hello said my companion, and I am not given to conversations on airplane flights, considering this is my fifth flight in one week, just civil and formal.

I have had the habit of noting the flight details on the note book I carry, a moleskin book ( which Bruce Chatwin liked to write on ), this one gift from a store in Paris, from you know who, who lives in Paris!

Flight no 56 for this year, Paramount Airways Flight 334 Brasil made Embraer Jet 125 seat no 5C, Bulkhead flying form Madras to Coimbatore, flying time of 51 minutes.

Then I was making notes on the notebook, the cholera outbreak in Chennai as madras is now called, the charlatans who wait for tourists at the arrival hall to tell them that there are no ATM machines, but for a small fee of 100 rupees he is willing to change American dollars…

I was vaguely aware of the curious look of my fellow passenger but I have known Indians to be curious to the point of being rude and staring into your notebook, computers and the dress in case of women…

Are you going to Cochin?

Yes I am I replied. To be polite, added, are you from cochin?

Basically I am from Cochin, in a gentle voice, but I am settled in Madras. This ornate way of speaking English is very common in India; My name is Srinivasan and your good name? he enquired and put out his hands.

Dr Yehuda

Your country?

What shall I say... shall I tell him I live in Paris, that my heart is in Baracoa, Cuba, that I carry Australian passport, that I work with American Indians..

Easiest and more convenient in these parts, Cuba.

I was quite pleased with his next sentence...

How is your president? Is he feeling better? Very few people except a few American Indians ever enquire about the well being of our beloved Comandante, Jefe, Fidel Castro

Now I was a bit more inclined to talk to him. He is well. We engaged in a conversation about Cuba, Kerala Communism (the only place in the world to elect communists in a free election and continue to do so), and the levels of education.

I am going to cochin just for one day for business. He said. I work for Cognizant which meant nothing to me, but turned out to be a popular software firm. I build the buildings in which they operate and I am in charge of new buildings and they are building a new one in Cochin that is the purpose of my short trip for the day. While there I would attend a temple where my ancestors had worshipped.

The conversation got around to economy surging, the Indians always proud of the positive aspects of this upward surge and without analysis, echolalic in their adulation of individuals who have done well, blaming those who didn’t do well to their own inability to harvest the technological landfall.

They are dying for the wrong reasons, I said. The Indians have a very high rate of Diabetes, they have heart attacks at a young age, and they ape the westerners without thinking, like to take on the lowest form of the western culture without understanding the philosophical basis of the western mind. All show and no sound no depth and only death at an early age.

You seem to travel a lot, Rangoon Singapore Paris Cuba Miami London, do you like travelling?

Yes I do

What is your business? I am not a businessman I told him, but a doctor but with a strong and peculiar interest in the effect of culture in the health of a people, more than the individual the society in which he lives.

When I saw you at the airport, I had the feeling that I need to talk to you. Do you mind if I ask you some questions? I hope I am not disturbing you.

For the past one and half years I have been a diabetic.

That news came as a shock to me. He looked fairly young and also not fat and looked fit and well for his age.

I have high blood pressure also

As if he wanted to surprise me more?

What is this diabetes? The doctors just told me to take medications and I do it but no one has explained anything to me. They told me it is hereditary and father had diabetes for eleven years before his death and my mother has diabetes for the past fifteen years...

He kept on adding more and more to my plate

The insatiable appetite of a medical anthropologist

My father died about one year and couple of months ago

Where shall I begin?

As a doctor or as an anthropologist?

Since I was going to ask him questions that a doctor might not ask him, I had to explain why I was asking such questions which he might think are irrelevant to the condition.

He is asst manager in charge of constructions, and he lives about six kilometres away from his work. Until last year he used to go there by bicycle or at times he used to walk the distance. He had been a star basketball player appearing at state level championships.

And he has been a lifelong vegetarian. He never smoked nor drunk alcohol.

This is getting intriguing. Doctors among you might want to find an aetiology for his diabetes and blood pressure, he won’t find it in his weight, since he does not look obese, and where did his blood pressure come from? How did his diet harm him or protect him?

According to traditions, he had gotten married at the age of 25 to a girl from his own caste, and has a four and half year old daughter. They live together in a house with his mother and his younger brother who is 22 years old who weighs 110 kg. he referred to his younger brother as overweight.

So far no biomedicine had entered the conversation. I knew this was going to be a long conversation.

First of all he had certain conceptions about diabetes. You got it from your parents, and you took medications prescribed the doctor and it went away.

So I had to give him information, carefully, not to antagonize his own belief systems but to let him see what he believes in and convince him from a scientific and social point of view that the nature of the disease he has.

A 30 year old hardworking young man with diabetes and Blood pressure.

Even before they told me I had diabetes, I had the feeling that I had high blood sugar, going back may be 3 years, at that time blood sugar was around 150-160 and was told by the doctors that “borderline”

What is this borderline? Is it a feeble attempt to hide behind your ignorance about the cultural aspects of your disease by making the numbers have significance within the medical context?

There is no such as “borderline”. I told him. You don’t become diabetic overnight, one day you don’t have diabetes and the next day you have diabetes. It is a metabolic alteration which happens over a long period of time.

When someone is pregnant, we don’t say, you are “borderline” pregnant, you are either pregnant or you are not. In case of diabetes, it is something that reflects the change In the metabolism of the body over a period of time...

But what causes this change in metabolism?

By this time, he had told me more about his family. He was born into a family of Brahmins, who had been priests at the temple adjacent to the royal palace of the maharajahs of Cochin in mattanchery. His father was in business and had relocated to Madras.

So far, nothing, no clues why this young man who is athletic and eats pure vegetarian food and who weighs 100 kg to his 6 foot 1 inches frame should be diabetic?

As we were taught in England during our clinical clerkship days, if you wait long enough the patient would tall you every thing.

That is what happened in this case with mr srinivasan.

I was very close to my father. One morning he felt nauseated and my mother insisted on his going to the hospital and there they admitted him and later on we were told that he had suffered a second heart attack and had passed away. My father suffered from diabetes and high blood pressure, his first heart attack was at the age of 59. I feel very guilty about my father’s death. I don’t think we were being told the truth about his condition. There may be some negligence involved. It was raining heavily and I was very involved in my work and for two weeks I couldn’t go to the pharmacy to get his medications and he may have gone without medications for two weeks.

His eyes welled up and tears began to flow. I miss him so very much, he was always there for me, and he was in business so he could teach me the ropes of the trade. I could ask him questions and he was such a good guide to me.

Unresolved grief.

In the last year, since the death of your father, have you kept a check on blood sugar and blood pressure?

They were always running high, on the average the blood sugar was 230 and the blood pressure was 150/90. and they remain so.

How to talk about grief resolution in this Brahmin man, who is climbing the ladder of success?

I enquired about his religious habits. Brahmins are very ritualistic, do rituals at home and at temples, follow certain dietary restrictions and fasting. Do you fast? I asked him, No I was told it was not good for a diabetic to fast.

One thing I found out was that the education regarding Diabetes or other health matters is very poor in India. The information that is available in the newspapers, their main source, is uncritical. There is a lot of emphasis on food, when the food is fresh and of good quality. Here is an educated man who is very nearly ignorant about Diabetes which he might have had for about five years, diagnosed for about a year and half, uncontrolled and a prey to the complications of the disease at an early age.

After I was diagnosed with diabetes, I felt week. I couldn’t hold or lift up my baby. The walking became difficult and doing chores was becoming a task. I was told It was due to diabetes and no explanation was given. And no treatment prescribed. He had fallen off his scooter recently and had a problem with his knees and was receiving treatment in the traditional manner, similar to traction therapy.

I was not impressed with the care given to the patients by the doctors in private hospitals in India, from the few stories I have heard. When making money becomes an objective, the noble aspect of healing goes by the way side.

I was very fond of the food prepared for me. I realized that I need to cut down on the size of my food, instead of taking three handfuls, I decided to eat only one handful of food per occasion and I have already lost 5 kg in weight. I also eat lots of green vegies and was told not to eat fruit because of the sugar in them. I drink about 8 bottles of water per day and I think it is helping my diabetes.

What this man needs is a good diabetes education...

He kept on bringing his conversation around his father. Only in the recent years, did his father bring him back to this ancestral temple, and since then he had come back many many times to pray there. Also since the death of his father, during Saturdays and Sundays, he piles up his family in the car and visits the various temples near madras.

Spiritually he seems to be okay

The diet is very good, with minor modifications could even be excellent.

Rituals are being followed.

What other holistic aspect is missing? In this puzzle of a young man with diabetes?

He longer bicycles to work, but instead drives there. While at work, where he has to supervise 20 people, he is under a lot of stress. He finds the stupidity of men difficult to forgive, and find the inability of people to comprehend, very irritating. For him Day is day and night is night and finds it very difficult to comprehend why people have to question whether bright days are actually days... not in an existentialist fashion but in an ignorant fashion.

He was always sensitive in this fashion, even before he started on this particular job.

So the second aspect of the holistic view, inability to accept frailty in others and internalizing that anger and frustration.

I began to talk about Buddha with the thought of finding out about his charitable disposition and also about finding ways to discuss ways to calm his mind in front of the human frailties.

All of us are born frail and then we gain merit in the eyes of others by doing good deeds. Instead of getting annoyed at the people at their frailties, it is better to understand them and forgive them, in that way you would begin to feel better rather than being hurt and carrying a burning fire inside you. Also remember, many of the people in India, especially those with limited ambition or limited chances to achieve their ambitions are very passive aggressive and they succeed in irritating others.

He listened eagerly and paid attention to the words. He is of charitable disposition; he likes to be of help to the old people, and younger children which he considers his service to the people. So yet another, rung in the completion of the treatment plan for him

Rituals compatible with his culture

Humanitarian work among the people he likes.

Now to work on resolution of his grief. Here I briefly prayed to my teaches, the American Indians for help, as they have helped me to resolve grief in two severe episodes in my life.

I began to tell him the story. I used to work with a doctor, kind and compassionate and truly dedicated to his work. One February morning I was told that he had been killed in a light plane crash in North Dakota. I was shocked and unable to accept the loss of my friend. After the event, at the mention of his name, my eyes would well up and I felt like crying. It went on for months. And I felt very sad at the loss of such a capable doctor and also a good friend of the American Indians. But the persistent effect upon began bothering me and I talked to my American Indian teachers. His spirit has not left you and you must tell the spirit to leave you. Go to an open area, preferably under a tree; offer his spirits the food he really liked in life, and talk to him. Tell him that it is time for him to go on his journey. I did that and I felt very comforted by the act and from then on, I noticed that, even though my affections for him had not decreased in any way, my tearing decreased. While I was telling him this story, sitting at the comfortable seats of this brasilian made jet, flying over the cloudy skies of south India, I felt the deep nostalgia for the presence of my friend coming up and my own eyes welling up and in response his tears also began to flow.

At that moment I knew I had made contact with him and that my therapeutic efforts would be successful.

I suggested that he should do the same, take his fathers favourite food and go to a secluded place and talk to him. Tell his spirits to go on their journey and that he will always remember him as the most important person in his life, but he has to go on with his life. He agreed to do that. A Jewish boy telling an American Indian ritual to a Brahmin from an old family!

While on the matter of rituals, I told him that he should continue with his rituals at home and at temple, and that he should pay attention to his humanitarian aid work among the elderly. He was very pleased about that.

I decided to explain the various phases of Grief to him and that he was still in denial about his father’s death and that he has not accepted it well. I explained to him at length about various aspects of grief. He was surprised such explanations existed.

Indian educational system is one of the poorest in the world (that does not mean brilliant individuals don’t do well despite the system), and it does not allow people to delve into metaphysical and tangential, philosophical matters. What they call philosophy is the repetition of what has been written in their holy books, much like a fundamentalist Christian arguing a contemporary social theme, saying it is written in the bible.

I wanted to shift gears, to make light conversation, to give my own mind a little relief, from this constant conversation, now going through a stop over of the plane at the airport in Coimbatore and the plane taking off to the nearby destination of Cochin. As expected, the skies were cloudy and filled with rain.

I used to eat a lot of potatoes. I like spicy food, use green chillies. Use sunflower oil for cooking. He eats freshly prepared food every day and now that he has reduced his quantity, I think nutritionally he is on the right road. I told him about chemicals in the food but since he is a Brahmin who does not eat what they consider contaminated food, I would imagine he is free of the chemical burden the average Indian is exposed to.

Could this man have type 1 diabetes? Brahmins in India are genetically close to the Europeans (in fact they refer themselves as Aryans, like Hitler used to, and in fact Brahmins are genetically closer to Europeans than they are the native Dravidians of south India). The fact that he has never had diabetic ketoacidosis in his five years of hyperglycemia (years estimated by me, even though the diagnosis was made only one and half years ago) was comforting. I checked his neck for Acanthosis Nigricans and there were traces of it in his neck. What helped me was this bit of information: his brother, who is 22 and weighs 110 kg, has Acanthosis Nigricans. Of course, Srinivasan did not know what it was, but he said he had noticed dark markings in the back of the neck of his brother and told him to clean it better. So the brother is hyperinsulinemic and insulin resistant there is a good chance Srinivasan himself is hyperinsulinemic and insulin resistant.

He began checking his blood sugar early in the game but gave up when his machine gave up after just ten readings. The home glucose monitoring machines and the strips are truly one of luxury here in India, the prices are close to the average salary of workers for the month, and there is no scheme whereby they can get a machine free or strips free. How lucky are the patients in the developed world, where we do our best to educate our patients with multipoint approach and give them machines and strips. Not that it results in better care, perhaps relating to the lack of attention to the social matters.

I explained to him the Indian paradox. When the country was extremely poor and the able men and women had to seek their fortune elsewhere, the country experienced no chronic health problems the kind affected in the western world. Now with economic reforms, and worldwide surge in their demand for software expertise, the country has created a rising elite of people, with it has come chronic diseases such as Diabetes and High Blood Pressure and Coronary Heart Disease. What is amazing is that this has happened in such a quick fashion, within the span of ten to twenty years. In an effort to imitate the west, the young of the country is donning the western clothes (usually borrowed from the lower levels of the western society) and priding themselves with eating and drinking western style junk food. The fact that men under 30 are getting diabetes and that men under 40 are dying of heat attacks are worrisome. In fact Indians are dying for the wrong reason, which we can term, Death by Future Shock.

I hope to work on this theme later on, with some investigative journalists from Questfeatures in Cochin in Southern India.

After going through psychological, social and cultural aspects of the person it is time to talk about the biomedical aspects of the disease. This is obviously not a failure of the islet cells of pancreas to secrete insulin but a failure of insulin to work very well, the insulin resistance here is enhanced by the immense stress to the body, created by his work and also by his emotions. He is taking something called Glymerpride; it is an oral hypoglycaemic agent, 2 mg once a day. Obviously this has not done the trick of lowering his blood sugar which is always over 200. his medication for blood pressure control is Amylopres AT, which I would guess to be amylodipine extended release 80 mg, which is also not working very well since his blood pressure in 150/90. Since kidney protection is very important I would have preferred him to take ACE inhibitors, but I thought that I would gain his confidence before suggesting medication changes.

So what about therapy? It is all well and good to talk about the matter, like the medical anthropologists with PhD degrees do at conferences but effect no care nor cure, but we are physicians and we have to bring the relief to the patient some of which involves medications. In India, pharmaceuticals are easier to come by; Dr Reddy is a familiar name in the drug industry.

This is my outline of treatment for this young hardworking Brahmin man from Madras

Since he was already tuned to meditating in the past, I would like to continue to do meditation. He has done Yoga in the past. I recommended that he read the various asanas in the book called Yoga and Diabetes and practice them. With traditional modes of therapy, whether Yoga or Ayurveda, they have to be done in a regular pattern, not just one here and another there, the same applies to exercise to our patients in the west. I recommended meditation and yoga on a daily basis

He knows very little about Ayurveda. I suggested that he find an ayurvedic doctor and undergo massage and herbal oil treatment at least once a week.

To follow rituals at home and at temples. To follow his humanitarian work with the elderly. To work on his grief about his fathers death, by rituals and concentration and thinking and talking.

Start to use the bicycle as he did before. On a daily basis. On days without rain I suggested that he go to work on the bicycle, 6 km each way. He agreed to that.

Now to complete the task, the 25 % of the care for the patient with diabetes, the biomedical aspect, the work of the MD, the endocrinologist. I had an accucheck Aviva home glucose monitoring machine with me, but for some reason it had stopped working during this travel. I would have gladly given it to him (thanks to Kari Johnson, Roche Representative in Omaha Nebraska). It is available here in India as well. He is to check his blood sugar, one in the morning and once in the afternoon two hours after his food. He is to note down what he had eaten and other matters that might affect his blood sugar. After one week of such intense keeping of the notes, he would understand what are the things, food, exercise or stress, emotions, that increase his blood sugar. And he can modify it accordingly. After a week he can decrease the frequency of blood sugar monitoring.

I set the following limits

Fasting Blood sugar has to be below 100

Random blood sugar has to be below 160

I also told him that would like to see it lower in the future, in the range of 90 and 140

The Blood pressure has to come down to 120/70.

I will read about these medications, especially glimerpride, on the internet and find out about the dosages. My feelings are that he would need to take, perhaps even twice a day.

The plane had already landed in an already deserted but elegant cochin international airport, gateway of the young slaves to the Arab world. It was raining as expected; this time of the year, there is rain each and every day for about three months.

The luggage came out soon enough through the modern conveyor belt, compared to the antique one in madras, we went out of the terminal and there was a car waiting for him. He kindly agreed to take me to my hotel in Fort Cochin, It would be out of the way for him, since his hotel was in Edapilly, in between the airport and the city of Ernakulum and my hotel was all the way over in the south in the cochin peninsula, across the backwaters. But it was night and raining, the roads deserted car comfortable and air conditioned, and a doctor patient interaction of the finest quality.

This my dear friends, is what Yehuda Kovesh Shaheb MD, an Australian jew, trained in Endocrinology in the USA, and Medical Anthropology in London, whose heart is in Baracoa, Cuba and whose body is firmly grounded in Paris, France did over three hours of travelling in south India, on a monsoon day.

When we arrived at Ballad’s Bungalow, a 250 year old, past residence of the Bishop of cochin, my friend the manager of the hotel, Densal Beny was waiting to greet me and it was truly a nice welcome back to this ancestral territory of myth and memories.

I thanked in my mind’s eye, someone who is close to my heart, who on this day is attending a course at a hotel within stones throw away at the Red Square in Moscou, Russie...

Follow Up Note

Since our initital encounter, this gentleman has waited for me at Cennai airport for the late arrival of flights from Paris three times and i have met his family and have visited him at home and shared lots of good time and laughter together.

Also, i spent the day with him at Louvre and share a meal at Krishna bavan at rue chapelle, when he was visiting Paris for business related to his work.