The Lancet Student

Latest blog post:Monsoon in Dharavi

This blog was submitted by tukaram on 1st July 2015.
Tagged with India, internal medicine, student

Last week I was informed about Ganeshan's demise by his son. He had type 2 diabetes, obstructive airway disease due to post TB sequelae, and coronary artery heart disease with compromised left ventricular systolic function. He was recommended to undergo a coronary artery bypass graft 7 years ago which he had declined due to economic constraints. 

We first met when I was a junior resident in internal medicine at one of the busiest public hospitals in Mumbai in 2005: full of enthusiasm and excitement as this was the preferred residency position for fresh graduates. Localising neurodeficits, diagnosing murmurs, interpreting ECGs , examining peripheral smears for malarial parasites, stool for Vibrio cholera were favourite exercises amongst residents. Ganeshan ran a vadapav (popular and cheap street food in Mumbai) stall on the footpath near hospital entrance which was popular among residents to relieve hunger in busy days/nights of emergency. He had a '4 at the cost of 3' offer exclusively for residents.  My hospital was just a stone’s throw away from Asia's largest slum, Dharavi. Inhabited by over a million residents like Ganeshan, this also was the capital of all tropical infections like tuberculosis, malaria, dengue, diarrhoea, leptospirosis etc. Ironically, the major five star hospitals in the city of Mumbai where most Bollywood celebrities are treated is just 10minutes drive from Dharavi. With 'apparent' global control over third world problems, textbook coverage of these diseases was shrinking and we often had to resort to the archived older editions of the textbooks. We used to call Dharavi a 'reference text book of tropical medicine'. Before joining residency here, monsoon for me was the most awaited pleasant rescue from a hot, and dry summer, a time to go for trecking, and have fun with friends, reading (and sometimes composing) popular poetry relating rains and love etc. I never knew that those 3 years of internal medicine residency were going to change my impression about monsoon forever. 

Monsoon for residents the meant wards flooded with patients, and more patients finding places on 'floor beds' than the designated cots. I barely used to manage to make passage for myself in the ward at 4am in the morning recording patients’histories, vitals, placing cannulas, collecting blood etc. One day of fever, hemoptysis on day 2, and respiratory failure and death due to alveolar haemorrhage had become a common scenario. The number of patients requiring ventilatory support far exceeded the available facilities. This epidemic (that latter turned out to be leptospirosis due to L. icterohaemorrhagiaeL. bataviae, L. tarassovi ) took a huge toll of life that included children, young men and women. 2005 left permanent mark on me as physician. 

There was always a severe crisis of beds (including floor beds) during monsoon that was quite anticipated. Many of the surgical wards used to be vacated for these patients with all their routine surgeries postponed indefinitely. But the most senior physicians and junior residents alike were left clueless by the disproportionately higher admission rates of noninfectious problems unrelated to the monsoon during this same period. Some of our senior colleagues had even postulated the possible role of 'infectious trigger' to explain this peculiar phenomenon. I found that really interesting and decided to take it up as my research project. I started interviewing these patients, recording their history, examination findings, and lab results in detail. I prepared the protocol for the project, and was about to submit it for approval when truth revealed itself.

I was interviewing Ganeshan and his family when he was admitted for acute exacerbation of COPD. By this time I was familiar with entire family and had even visited his 'home' once on occasion of his son's wedding. When I gave him the background of my project, he wished to disclose to me something relevant to my project on the condition that it would be kept secret. Most dwellings in Dharavi are 6 by 6 feet "kachha rooms" occupied by an average of 5-6 family members. Except for children, all other family members would find adjacent footpaths as their bed in the night. Monsoon not only floods these roads and footpaths but also their houses - one of the family members is required to throw out the flooded water from inside the home all the day and night during heavy rains. We used to always ask fever victims (as per released guidelines for febrile illness) about "history of wading through rain water" - without even imagining that here "rain can also wade through their houses"! At this time hospital wards were the only shelter for people residing here. Stable diabetics would skip their insulin dose, asthmatics would skip their inhalers, patients with heart failure would skip their diuretics, antianginals and would land up in the casualty with acute exacerbations for admission. 

This opened my eyes to the major social interactions that need to be respected when one evaluates and treats poor. William Osler’s teaching "Listen to the patient, he is telling you the diagnosis" was taught to me most practically by Ganeshan.