Domestic violence – a social impediment to health

Domestic violence – a social impediment to health

These are stories of three women who came to my clinic over the past 10 years. They came to the clinic at different points in time, one almost 8 years ago, one who is visiting regularly since the past 5-6 years and one whom I saw today. Each has a very different story but linked by one common determinant, domestic violence. Sarasu, a 60-year-old lady who I saw today in the clinic, brought back memories of Roja and Amudha from the past. The violence that they experience in their lives reflected on their health and brought them in contact with me. From a fresh MD graduate ten years ago, who was naïve to the issue of domestic violence in the lives of women, to the primary care practitioner, who suspects domestic violence in my patients very frequently now, I have come a long way. I am narrating the stories of these three women who taught me to be aware of how much violence a woman must face in order to even exist in an oppressive and patriarchal society.

Sarasu walked into my clinic with an unsteady gait, as though a very heavy weight had been placed on her shoulders for her to carry. She didn’t speak much, but uttered in a very soft voice, “Sir, my whole body is aching. I ache from head to foot all over”. She said this and went quiet. I was looking into her eyes and they were quickly filling with tears. I was quietly waiting for her to speak more. But instead of words coming out of her mouth, large drops of tears streamed down her cheeks. I just placed my hand gently on hers and waited for her to speak. She responded to the gesture and said, “My grandson beats me up every night. He is 21 years old and works in a mechanic shed. He gets drunk every night with the money he earns and comes home drunk. If I ask him for money for food, he just pushed me down, slaps me on the face, pulls my hair and kicks me in my stomach” and started sobbing uncontrollably. I was shocked and had no words. This elderly woman, so frail and weak, already a known patient with hypertension was being physically assaulted by her grandson. She then pointed out a slip of paper in her hand and continued, “Last Thursday after a bout of such beating and kicking, I fainted and became unconscious. My neighbors took me to the nearby hospital and they found that my blood sugar was very high, more than 400 mg/dl. The doctor has started me on anti-diabetes medications. So, I have come here to continue treatment with you” I was unprepared for this kind of abuse of an elderly woman at home, a very different form of domestic violence, about which I had read and heard, but never seen before. Sensing my unpreparedness with the situation, and trying to diffuse the awkward silence, Sarasu started speaking again, “I have 3 grandsons, they are my daughter’s sons. My daughter committed suicide when the youngest grandson was just 2 years old. Since then I have been bringing up these three children as my own. Now see, how this one treats me” What was most disturbing to me was that a young man could physically abuse a woman, that too an elderly woman and that too someone who had brought him up as her own son. I have seen Sarasu and heard her story only today. A lot of work remains to be done with her and her family, which I must start working on soon. But Sarasu brought back memories of two other women whom I had seen in the past.

Roja is a 50-year-old lady with type 2 diabetes. Her blood sugars are mostly very poorly controlled. During my first clinical encounter with Roja, I had found out that she had very badly controlled blood sugars for 5 years before coming to my clinic. She was on good doses of oral diabetes medications, but still, they were not working for her. So initially I had thought that it must be a form of severe insulin resistance and had planned that soon I should start her on insulin injections. The next routine three monthly blood sugar test showed that her blood sugar was so well controlled. I was surprised and attributed the success to my diligent care, to very soon realize that it was all just my self-absorbed hubris. Her next three monthly sugar tests were again off the charts. I thought I should get to the bottom of this and started talking to her about her daily routine, life at home and family. It was then the big fact hit me on my face. Roja had a very abusive husband. At the age of 55, he had a very violent sexual appetite and used to abuse her sexually and physically at home. He was home only 5 months in a year, by nature of his job as a construction contractor. The remaining 7 months, he was traveling and staying out at construction sites. I realized that Roja’s blood sugars were well controlled when her husband was out of town and hit the ceiling again when he came back home to violate and abuse her. This story opened my eyes to a very important, but often neglected fact about diabetes treatment in women. The social aspects of a woman’s life include facing domestic violence on a daily basis and this is sure to have an impact on her blood sugar control. The long term solution would be to take Roja out of the violent relationship. But from a social and cultural standpoint, it is easier said than done. Roja continues to stay in her abusive marriage till date and both Roja and me look forward to those few months when we can breathe easy about her blood sugar and overall health status.

The third story is that of 28-year-old Amudha, who was the wife of Mari, a 35-year-old autorickshaw driver. One day Mari brought Amudha to my clinic with a cut on her forehead and a bruise on her left arm. I had sutured Amudha’s wound. Mari was so kind, loving and caring and he had literally carried Amudha off to the auto and driven her off to their home after the treatment. About 2 months later he brought Amudha again with a similar laceration on her hand. While I was suturing this wound, the social worker from the village where Amudha and Mari live, walked quietly into the procedure room and spoke to me in a low voice. She said that it was Mari who was beating up Amudha blue and black and pretending to be so kind and nice. I was shocked to face the reality behind this situation. Here I was thinking that Mari was a doting husband and Amudha the loving wife. But the true story was that Mari was the domestic monster who was injuring Amudha. After suturing the wound, I did not think it was right to send Amudha back with her husband. In front of the social worker, I asked Amudha whether we can inform the police and have this issue handled by them. Amudha refused immediately and vehemently. She said, “this is a private issue between husband and wife. Please don’t spoil my life. I am having a good life with my husband” The social worker also agreed with this line of thinking and I was helpless. I walked out of the clinic reluctantly, letting Amudha go with her husband back to her life of violence. I heard from the social worker that a few months later Amudha was admitted to the government general hospital in an unconscious state with intracranial bleeding following a violent attack by her husband when he had held her by her long hair and banged her head against the large slab of concrete used for washing clothes. At this point, the police had intervened and arrested Amudha’s husband. But very sadly, the very next week after Amudha’s husband had been sent off to the prison, her own father-in-law had tried to enter her home at night and rape her. So Amudha had run off from her husband’s village to her own parents’ home with her children, where another distant cousin of hers had started approaching her with sexual intent. After hearing about this incident, I started wondering if Mari, despite being a violent monster, was a more agreeable evil compared to the others in her life.

All three women, Sarasu, Roja and Amudha, had the violence of different forms in their lives. The violence was presenting a serious problem to their health. The violence in the lives of these three women is physical, sexual and psychological. In many instances, the violence is not so dramatic, but slow, steady and persistent, that it wears away the energy, confidence and will to live in the women who suffer it. The violence is compounded by the social context in which the women live.

I have met and interacted with several non-governmental organizations which work on prevention of domestic violence. In fact, I have visited some of the domestic violence prevention cells in hospitals, the crisis centers, helplines and other interventions. All these groups are doing a great job of helping women in distress. However, one thing that really stumps me is the fact that a large portion of women like Sarasu, Roja, and Amudha is always outside of the protective net of these organizations. When Roja is ready to face the violence of her husband for decades, with just silent tears and mute prayers for a solution, and when Sarasu has resigned to her fate and karma, and when social pressures subject Amudha to prefer a violent husband to a life without him, how are these women even expected to approach a helpline? Some of these NGOs have outreach workers in emergency rooms of hospitals and they train doctors working in these emergency rooms to suspect, identify and report domestic violence. But then what next? We are again left with Rojas, Amudhas, and Sarasus of this world who would rather remain with infinite forbearance than raise a voice against the social norms which justify domestic violence. I know I did not make a huge difference in the lives of these women. But, all three of them taught me the omnipresent nature of domestic violence in the life of women. Now whenever I see a boy in my class referring to his peer girl in a disrespectful manner, I know I need to stop the young man immediately and tell him to change himself. I also know that I need to treat my women colleagues with respect to create a respectful environment which these young men will see and learn from. I know I can champion the cause of equality of the genders, talk about it in my classes, raise discussions and debates and create a healthy dialogue. These steps may not immediately impact the lives of my patients, but I believe that in the long run, it will create a bunch of men with healthy attitudes and respect for women.