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Vijay Gopichandran

As I sit to write this, my hands are trembling. These fingers have danced over this keyboard for the past 5 months only to key in names, addresses, phone numbers and details of patients with COVID 19, to submit reports to the state government. These fingers which have the habit of completing words which begin with ‘me…’ as medicine, now complete any word starting with ‘p’ as positive by force of habit. So much of my routine life changed due to the pandemic and all things associated with it. Nowadays I leave home by 7 AM. So, my most precious morning writing routine has taken a beating. I return home on some days by 7 PM, some days even later, so my evening writing is also gone. Though I would not call myself overworked, I do not get any time to think, reflect and write, as most of my time is occupied in COVID 19 related work. So, I am glad, that I am writing this blog after a huge hiatus. I don’t know how this blog is going to pan out. I have not organized it in my head. I am just typing my thoughts as they emerge.

This past Sunday, I went to my rural clinic after a long gap. Inter-district travel has now been permitted after a long lock-down period and I immediately took the opportunity to go to the clinic. The gate leading to the clinic was open. There is a slope from the road down into the clinic portico. The portico leads to the front door of the clinic, which was also open. On either side of the portico are stone slabs for patients to sit and wait. The portico has a big old almond tree and a few young neem trees. These trees provide a nice shade and as I entered the gate, slid down the slope to enter the portico, I was greeted by patients who were waiting outside seated on the slabs, the concrete platform over the water sump just adjacent to the well and even on the wall surrounding the well in the portico. Nothing had changed in the clinic. I expected many drastic changes given the pandemic situation and all the government regulations. I expected that all people would have their masks on, nobody did. To avoid crowding in the waiting room, I expected circles to be painted on the floor to maintain physical distancing, but people were standing shoulder to shoulder. I thought the crowd would be less as people would fear hospitals, but it was like any normal day, the entire clinic buzzing with people of all ages.

This whole scene was a complete surprise for me. My thoughts flashed back to my hospital in Chennai. I have gotten used to not seeing any face, or any smile in the past 5 months because of the mask. As I enter the hospital campus, it is difficult nowadays for me to acknowledge the greetings of other staff. Previously I used to flash a broad smile in acknowledgment, but my mask prevents me from doing that nowadays. So, I have resorted to joining my hands in a “Vanakkam” gesture or lifting my palm to my forehead in a salute, or touching my heart and bowing in respect as appropriate to the staff who is wishing me. People who visit the hospital in Chennai are themselves so self-aware that they maintain arm’s length while talking to me or even asking me a question. I have young patients who refuse to sit on the chair on which a previous patient sat, refuse to have their blood pressure checked with the same cuff, and ask for my stethoscope to be sanitized before I use it on them. I had started getting used to this new normal, that the scene in my rural clinic took me by surprise. If anything had changed in the clinic, it was me. I now have a lot more grey hair than the last time I had come to the clinic 5 months ago, and I had a white mask covering my nose and mouth.

Slowly adapting myself to the contrast, I started seeing patients. Most of the patients who had come were my routine patients. The very first lady was an elderly woman, who has been seeing me for her high blood pressure for over 4 years now. She is a petite lady who has lost most of her teeth and wears a brilliant bright smile on her face every time. She has a high-pitched squeaky voice and we usually have a nice conversation whenever she visits. We talk about her husband’s health, her goats, her son, daughter in law and grandchildren. She walked in with the support of a stick. I have never seen her walk so slowly and with the help of a stick before. The usual bright smile was missing. Worry and concern was drawn all over her face.

“hi, paatti, How are you? Long time no see…” I said

She smiled, but a lot less bright than usual and said she was well. I have noticed one remarkably interesting phenomenon about patients visiting my clinic. They are never used to being asked “how are you?” during a hospital visit. The usual doctor’s interview in this part of the world starts with “what trouble do you have?” or “what brings you to the hospital today?” or some such statement inquiring about the illness. So, they are taken off-guard by “how are you?” and they always respond “I am fine” by force of habit. Then they pull themselves together and start narrating how they are not fine. Something similar happened to this paatti (grandma in Tamil).

“I am fine. How are you my king?” she said. She always referred to me as ‘her king’ (en raasa).

“you don’t look that well paatti. Tell me what the matter is?”

“nothing like that. Suba, who is from my village, who came here this morning, told me that you have come. So I came running to just see you before you leave.”

It was already 3.45 PM and I was almost 1 hour and 45 minutes past the clinic closing time. It had rained that morning and the roads were damp and muddy. She had walked all of 3 kilometers with her limp and her walking stick, as fast as she could walk, just to see me. I was overwhelmed with emotion.

Suba is the community health worker associated with our organization and hails from the same village as this paatti. Just this morning, she had narrated the story of how almost everyone in the village had lost their jobs in nearby garment export companies due to the lockdown. Initially during the months of May they had received half salary even though there was no work. But slowly even that salary had stopped. Almost everyone in the village was now eating one meal a day with whatever food support that is provided by the government.

I applied the blood pressure cuff on her right arm and started inflating it. She sat quietly and watched me as I measured her blood pressure. She had lost so much weight. Must be the low food intake. The corners of her mouth were cracked and her lips were chaffed. She was probably not getting any vitamins.

“you have lost too much weight. Aren’t you eating well?” I asked, just to make her talk to me about her difficulties and her hunger.

“I am eating OK.” She said and went quiet again.

I was wondering why she is not opening up to me? Why is she so quiet suddenly? We used to talk about every small silly thing in the past. What has happened now? Has she given up on life? Has she gotten so used to not eating well and not having money for the past 4-5 months that she doesn’t feel like talking about it? I think that apathy happens often. We face a difficulty, it is hard for a few days. Then we get used to it and we find it odd to even talk about it. I could see the elderly lady was just comfortable being there in my clinic, being examined, being cared for. After that she got up and said, “from now you will come every week right? Don’t forsake us like that. You know we all don’t have anyone else but you” and she walked away slowly. Those words hit me like a bullet on my forehead. My mind flashed back to my hospital in Chennai.

I have been doing triage of patients every day in the morning over the past few months in my hospital. Patients come to the hospital and they all pass through our team first. We inquire about their problems and we triage them into those who need to be seen in the COVID 19 unit, those who can be seen at the triage area and sent home from there and those who need to be seen by the various departments in the hospital. The other day there was an elderly lady accompanied by her son. She came because she was feeling light-headed for the past few days. I examined her blood pressure and it was remarkably high. I started her on blood pressure medications and asked her to come back after a week. Her son was upset. He said,

“my mother has never been diagnosed with high blood pressure before. I don’t believe you”

I called another colleague of mine to countercheck the blood pressure and he concurred with me. I gave the son that information and said she needs to be on the drugs.

“I want to see a more senior doctor than you. I am not convinced.”, he said, and he walked away taking his mother with him.

I flashed right back into my rural clinic from these thoughts. The contrast was too strong for me. The inequity was glaring. Women of similar age from two different places, both with hypertension, and such a strong contrast in presentation. While one from the village was deprived of any health care and was solely dependent on an inconsistent source, the other one in the city had the choice of doubting the diagnosis and seeking a second and even a third opinion. I don’t know which hurt me more – the feeling that the paatti in my rural clinic was so deprived, or the blatant disrespect for my reasonably sensible diagnosis by the son of the elderly woman in my hospital. As I sit here typing this blog, I know that these disparities are only expanding and becoming wider by the day. I wish I had some answers. I am searching.