Over the centuries, many physicians have written poignantly in both fiction and non-fiction genres about life, suffering, and hope. These have inspired many health professionals to follow a career in medicine. Cutting- edge medical research published in prestigious medical journals is important, but it is the true human stories that resonate with our lives that continue to fascinate.
Here is a short, heart-rending story entitled Food for Thought from Mumbai by Sunil Badve that first appeared in the Annals of Internal Medicine (2005; 143-149). This short essay not only evokes deep compassion but also reveals today’s stark reality of medical practice in South Asia against the background of poverty.
“ In August 1996, I joined Lokmanya Tilak Municipal General Hospital (LTMGH) located near Asia’s largest slum, Dharavi in Mumbai, India, as an internist–house officer. Initially, I had a difficult time managing the huge workload. One of the central tasks of the house staff was to discharge as many patients as possible on pre-emergency days to make room for the many anticipated admissions on call days. The house staff who kept their ward census in single digits were most valued. Those who failed to do this invited reproach from the registrars.
One day, the hospital admitted a middle-aged worker with fever, who responded to anti-malarial treatment and was soon fit to go home. In the morning of the pre-emergency day, I filled out his discharge forms. However, during my evening rounds, I found him still sitting on the hospital bed. I told the patient that he had been discharged and should leave. I admit I was quite rude to him. The poor man didn’t argue. I left to attend to other patients, completed my evening rounds, and began to see the new admissions.
Then I witnessed something unforgettable. While the discharged patient sat on his hospital bed, his two small children quietly hid beneath the bed and shared a lip-smacking meal—the hospital food meant for their father. It was obvious from their faces that these children seldom enjoyed such nutritious food. Soon after, the gentleman went home with a satisfied heart and his children with full stomachs. My heart sank. I was stunned to see that this poor man had overstayed his visit just to feed his children on a day that he could not earn his daily wages because of hospitalisation.
That day I learned a lesson not found in Harrison’s Principles of Internal Medicine: that I was fighting not malaria or any other disease, but the deadliest affliction known to humankind: poverty.
Now, years later, I walk the well-appointed, air-conditioned corridors of P D Hinduja National Hospital in Mumbai, a privately run, state-of-the-art facility located just three miles from LTMGH. But I am still reminded of poverty—for example, when our kidney transplant recipients stop taking immune suppression or when patients with end-stage renal disease stop dialysis because of exhausted financial resources. It is a bitter fact that many patients in India prefer to receive inadequate treatment or even stop treatment and die rather than sell their property and burden their family, even when they have a treatable disease.
Now I understand the meaning of the words of wisdom told by my mentor, Bharat Shah: “What is adequate [treatment] is not practical, so what is practical has to be adequate.” As I think back to 1996 and remember the poor man and his two hungry children, I wonder: Do the best practice guidelines and treatment recommendations published in renowned journals really apply to our poor patients?