The Whole Picture


In 2023, I engaged in a profound workshop dissecting the intricate interplay among doctors, healthcare systems, and wider socio-political contexts. 

This workshop, alongside other experiences during that period, served as a catalyst for a profound shift in my perspective on health.

As doctors we are trained to play within the boundaries of guidelines and pharmaceuticals. With limited time with each patient, it is easy to fall into the trap of treating the reports and images and not the patient, and the person.

As I listen to individuals’ encounters with healthcare professionals, it becomes increasingly evident that doctors often address what they perceive as the issue, rather than considering the patient’s perspective. However, the solution typically resides somewhere between these two viewpoints.Given the power dynamics inherent in the doctor-patient relationship, it falls upon physicians to bridge this gap and navigate towards this middle ground.

Unless doctors in a diverse country like India, with its myriad communities and complex cultural tapestry, tailor treatments that are culturally sensitive and contextually relevant, the effectiveness of the treatment is compromised.

Anyone can write a prescription. In current times, one doesn’t have to be a doctor to do that.The true value of our medical education, expertise, and experience lies in our ability to apply this knowledge effectively within the specific context of each individual patient we encounter.

Merely prescribing iron to someone with an iron deficiency is insufficient. It’s crucial to delve deeper and understand the underlying reasons for their deficiency. We must consider factors such as the patient’s access to affordable supplements, what iron-rich foods are available and culturally acceptable in their environment, and ensure accessibility to these resources.

Health transcends mere medical intervention. Each time we prescribe a drug, we make a choice that carries political implications. While we have the freedom to act as we see fit we should be aware of this dynamic.  

Are we prescribing the drug because its benefits outweigh its side effects? Can the patient afford it? Does the patient’s circumstances allow them to be compliant with the treatment plan? Is it actually solving the problem or just alleviating it for the time being and will reappear once the medication is stopped? Is there a practical, natural, long term solution? Or are we as doctors, unknowingly playing as marionettes in the hands of big pharma and the silent elite and setting the patient up for long term dependence on a product that needs to be paid for? 

As doctors, it’s crucial to question these dynamics, even if it’s not part of our formal training. Our responsibility lies with our patients, not the system. We must open our minds to constantly ask these questions and understand how political policies impact health.

It has also become essential to expand our viewpoint beyond the individual patient and recognize that health has social, economic, political and cultural determinants. Public policy, housing conditions, sanitation, access to clean water, employment opportunities, education, and cultural constraints all exert profound influence on overall health outcomes. Acknowledging and addressing these broader determinants are essential steps towards fostering health and well-being in communities, rural and urban, economically stable or not. 

If our primary concern is the well-being of individuals, it’s imperative to acknowledge that their health, as well as the functioning of the medical system, is intricately intertwined with larger societal perspectives of economy, politics, and culture.

Our primary duty is to prioritise the health and well-being of the patient, which is why we pursued medicine in the first place. Our responsibility does not lie in perpetuating a cycle of pharmaceutical dependence or ensuring profits for large corporations.

Especially in the current political environment, it is not enough to insulate oneself in the sanitised bubble of the hospital or clinic and pretend that we are only concerned with the patient, the lab and the stethoscope. Our ears need to hear the exposure to silica in the mines between the wheeze of lung disease, see the standing water breeding mosquitoes between the rash of Dengue, understand the family dynamics behind a pregnant mothers pallor of iron deficiency anaemia. 

Rather than simply adhering to international guidelines and prescribing medications, our obligation is to address the specific problem that the patient presents to us. If we find ourselves unable to solve the issue, it is our responsibility to be honest about our limitations and seek alternative solutions.

Is it a significant demand on each doctor? Undoubtedly. Is the current system conducive to supporting this ethos? Unfortunately, no. However, does this imply that we can simply relinquish our responsibility? I believe not. At the very least, we should endeavour to contribute to the solution.

This  poster serves as a visual narrative of our collective exploration into the root causes of healthcare crises and the need for a holistic approach to addressing them.

Titled “The Whole Picture” the poster aims to spark conversations about the broader socio-political forces shaping medical encounters and the imperative of understanding the political economy of health. It invites viewers to ponder on the interconnectedness of health with issues like urban development, displacement, and communal tensions.

As a participant of Govern-H 2.2, I am excited to share this poster as a testament to our commitment to engaging in rigorous political study and advocating for systemic change in healthcare. It serves as a reminder of the ongoing journey towards a more equitable and inclusive healthcare system, grounded in holistic principles and collective action.

To reach me for customised illustrations, poster design or concept art please email me at: illustratinghope@gmail.com.

To browse through some of my work please check the following links:

Check out my work on Behance

You can find @illustratinghope’s profile on Freelancer here.

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Pravin in Nepal

prayer flags

Each day pours into the next relentlessly, it’s as if there’s only so much that 24 hours can handle. I can safely say that 25th April 2015 was the longest day of my life.

21–22 April

The bus journey from Varanasi lasted an exhausting 17 hours on treacherous road. We passed through a huge archway which read a curt ‘Indian Border Ends’, and I was finally in Kathmandu.
Suddenly I was acutely aware of the fact that it was finally happening- the lone-traveller-traveling-without-a-plan thing. I was venturing into a foreign country for the first time, about 3000 km away from home.

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Kathmandu was warmer than I had expected. The city was colourful with temples and prayer flags. The air was thick with dust. The river carried mostly sewage. But the people were friendly and helpful. They struck up conversations easily, even with me, a total stranger. I fell in love with the place, instantly.
I felt I could spend hours just looking around in the red brick and carved wood Durbar Squares, watching people — old men, college students, families — sitting and passing time.

Patan Durbar square

I struggled to pick up the language, and used the basic phrases in Nepali that I had saved on my phone. When the people I met learned that I was Indian they switched to fluent Hindi; only to be confused to find me still faltering. Being Tamilian, I have only a basic hold on Hindi, and it is as foreign a language for me as any other.

I had planned the trip such that I was to come to Kathmandu back on the last day, to take the bus back to Varanasi. I promised myself that before I went back to India, I would climb the two hundred feet high Dharahara Tower to see the magnificent panorama, and also visit the pretty little temple which I had passed by so often during my walks in the city, the one which no one seemed to go into.

23–24 April

Bhaktapur, not far from the capital, is a UNESCO World Heritage Site with red brick pavements, narrow branching lanes, ancient temples and outbursts of flamboyant woodwork even on the most modest old houses.

bhaktapur houses

 

The traditional Tibetan Buddhist art of painting called Thanka was being taught at many small schools around the square. One could, I thought, spend a lifetime trying to master these intricate art forms. The shop nearby selling these Thanka paintings had a massive yak skin canvas with concentric circles of Tibetan prayers neatly painted on it in gold.

 

I met Gyanu Maya, a 75 year old lady, who sold jewellery that she had made herself. While I bought something from her, she made small talk in Nepali, not noticing that I didn’t understand a word.gyanu maya bhaktapur

 

Each section of the town was meant for different purposes- whole neighbourhoods for people who made pottery, jewellery, carpets, paintings, etc.

I wondered how different life would be if I lived in this town, a cultural hub and an architectural marvel!

 

A bus ride took me to a village called Nagarkot, farther up in the hills. There were few tourists here.

lantang range. view from nagarkot view tower

My first glimpse of the distant snow on massive peaks was overwhelming. It was slightly worrying to acknowledge, as a student of Medicine, that just the sigh of these beautiful giants could be therapeutic.

Later I walked through the forest to Kattike, a small village that is accessible only by foot and maybe a courageous driver. I stopped at the first house to ask for water and directions. The father and son there were unwilling to talk. I tried my broken Nepali, and then there was no stopping them! I realised they were just uncomfortable with English, but were actually very friendly people. We spoke about Nepal, its economy, their food and habits. As we drew maps of our countries trying to show our hometowns, they served me their local drinks, chyang and raksi. Nyang Pasang Sherpa, the father, had climbed Mount Everest four times!

How long does it take for three people to become good friends? Three hours and some alcohol, I would say.

25 April 2015

Despite sore muscles, I made up my mind to trek to the foothills on the other side of the valley. I set out for Dhulikel, the next town, with my backpack. After three hours I realised I was lost. A helpful young man pulled up on his motorcycle, asking where I wanted to go.
I could walk on another ten hours from this place to Dhulikel, he said, but instead he could take me downhill on his bike to the direct road. I accepted his offer.the morning of 25-4-2015

He saved my life.
Nala, the village where he dropped me, was quiet and sparsely populated. Everybody seemed to be out in the fields working. Small children and their mothers were in and around the homes.

Without warning, it happened. I was hit by a sudden wave of nausea and dizziness. It wouldn’t leave! Was this food poisoning? Hypoglycaemia? My knees wobbled, ready to give way. Trees looked like they were being shaken from the roots.

It was a few moments before people started screaming. The mountains rumbled and a cloud of dust began to rise from them.

The earth quaked.

20150427_182342It felt as though a strong force was trying to pin me to the ground with its powerful side-to-side agitation. Flower pots fell from terraces. The road groaned. Bikers toppled helplessly off their machines. Before my eyes, I saw fine cracks appear in the ground.

From a house nearby, two men stumbled out onto the road, only to realise that there were children still indoors. I ran in with them and helped bring out three horrified children.

The ground was still shaking violently, so the only possible gait was a drunken stagger. Even when the shaking subsided, the earth underneath it continued to groan. Later I was told that the earthquake had lasted fifty-five seconds. That was the longest minute I have ever lived through.

Looking up at the hillside I had just biked down from, I saw it covered in a cloud of dust; rock, boulders and sand roaring downhill. I could see no trace of the houses I had passed on my ride down.20150505_110423

I spotted people who had been working in the fields running back towards the village. So far I had seen no casualties. But the earth wasn’t still. Every few seconds it rumbled and shook, though less strongly.

Rather than move on to Dhulikel, I decided to wait in an open field till the tremors had stopped. I sat there for an hour but the rumbling didn’t stop. My muddled brain tried to calm me down, saying that earthquakes like this were common in the Himalayas. Later I learned that the last ’quake of a similar magnitude was in 1934, eighty years in the past.

I didn’t know what to do, so I continued walking. I passed a small town called Banepa, where the highway showed cracks. People were all standing outside their houses. A few mud-walled buildings had been reduced to rubble, some windows had shattered and the shops were shuttered, but people did not look worried. Some were even excited.

Every time there was a tremor, though, the downed shutters would rattle hard, and the women would squeal in a loud chorus.

I reached Dhulikel four hours after the earthquake. Here too, just a few mud houses had crumbled, but public transport was overflowing with people. I realised later they were trying to get to the hospital. Everybody was out on the streets.

 

I bumped into a pair of Turkish tourists, father and son, who had found a taxi, and urged me to go back to Kathmandu with them. I told myself I could come back once the tremors stopped. Despite a highway full of cracks, it took only an hour to get to Kathmandu.

In the city, broken pavements and streets made it difficult to walk. When I saw the number of people waiting in front of the hospital, I realised that this was a much bigger calamity than I had thought. People were searching for kin in the rubble, ambulances were rushing bleeding victims to hospitals. They were the only vehicles on the road, other than the overcrowded buses.

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I got out of the taxi and started walking towards the nearby government hospital. Mobile networks were down and the entire population seemed to be out on the streets, a mass of people sobbing and running around helplessly. Darkness fell, and only the occasional passing ambulance lit my way.

At the hospital, doctors, nurses and medical students were doing the best they could, as they moved from one patient to the next. They were short on supplies. And the injured and sick were still pouring in.

I met one of the staff, told them that I was a doctor and I could help. I shifted patients for scans, took blood samples, then went around adjusting and checking the intravenous fluid lines.

At some point I was assigned to an eight-year-old boy who needed a CT scan of his head immediately. There was only one elevator and it could accommodate only one stretcher at a time. We could not wait, so we piled three or more patients on to each stretcher. The little boy was laid down alongside a frail old lady.

Upstairs in the scan room there were a dozen people waiting on wheelchairs and trolleys. They took one look at our crowded stretcher and let us pass into the imaging room. When the staff asked whether I was this boy’s brother or father, I realised that his mother had been left behind downstairs.

The boy’s scan was soon done, but the old lady still had to get hers. I had to get the boy downstairs, back to his mother immediately, but there was no spare stretcher. Against everything I had learnt in medical school about moving patients with head injuries, I lifted him and carried him in my arms. His misshapen head rested softly against me, and his blood started to stain my shirt. After a few moments he began to get agitated, tugging at my shirt. I stood there helplessly, not knowing what to do and wanting to cry.

Back in the casualty ward I saw another boy, sitting on a bed crying. He was Indian, twelve years old and named Pappai. He was playing near his uncle’s home in Kathmandu when the earthquake hit. A collapsing building had fractured both his ankles. He was brought to the hospital by an ambulance and had no idea where his family was. He was terrified. All I could offer was a little consolation and a few carrots I had in my bag.DSC_0087

I was beginning to wonder where I would go myself. I couldn’t work in the hospital any more. I was near collapse myself and needed some rest, and there were enough medical staff at the hospital. I promised Pappai that I would come back and see him after a few hours and would make sure that he found his family. Luckily he remembered his father’s phone number. His father was in Kolkata.

I returned to the locality where I had stayed in Kathmandu earlier. Everyone was out in the open. I went to the locals, who heard my story and took me in, gave me their water and biscuits and the entire back seat of their car to sleep in. They sat inside their cars all night.

Miraculously, someone’s WiFi was still working! I read frantic messages from friends and family, and managed to send some replies. I asked one friend to contact Pappai’s parents in Kolkata.

The constant anxiety kept us awake the whole night. The car shook for a good ten seconds with each aftershock, even if it was just a brief tremor.

26 April 2015

The next morning I left my luggage at a Christian convent and returned to the hospital. There were still people on the roads, though luckily the tremors were fewer and weaker.

The hospital seemed much less chaotic. There were no more ambulances rushing towards the hospital, and no more patients waiting on gurneys. With difficulty I found the eight-year-old with the head injury; he was in the ICU. The wards were crowded, with injured people in every corner. I couldn’t find Pappai at all, and the nurses had no idea about him.

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So I headed back to the convent, intending to set out for another hospital. On the way back, I passed the Dharahara Tower I had so wanted to climb. It took me a while to realise that the tower wasn’t rising above the trees. Someone told me that it had collapsed, killing 180 people. My blood froze for a second, thinking about the people inside who would have been walking up the spiralling stairs and felt the weight of the tower crashing down towards the earth. I could only hope that it was a quick death.

The army grounds nearby were littered with tents and each tent was packed with people.

 

It looked as though the staple food of the Kathmandu Valley had changed overnight to biscuits and raw instant noodles. Most people were living in the open.

And then it began to rain.

I remember seeing a young mother and her small daughter hugging each other, crying quietly, as if they had nobody left, nowhere to go.
Now — again! — shop shutters began to rattle loudly, and people began to scream. Another earthquake, this time for what felt like thirty seconds.

I sat down on the road, unable to control my knees.

I watched a four storey building no more than twenty feet away shake wildly, ready to fall in my direction. For the first time I was scared I would die. I don’t remember how I got back to the convent.

At the convent I was given a room. There I sat on the floor and, without warning, found myself sobbing uncontrollably.

 

 

 

 

My philosophy of medicine 

    

 
This is it. This is the thought that started this blog. 

One evening, coming back from work with all the self doubt and insecurities that comes with being a freshly passed out doctor being thrust into the unfamiliar surroundings of a new hospital, new guidelines and rules, I realised that I had become ‘institutionalised’. I was too used to following orders, protocols. Sure, I had been taught how to examine, diagnose and treat, but the algorithm of a large 1500 bedded hospital had lulled me into working at an (almost) spinal level. 
As I worked through the first few months of my ICU tenure in this 200 bedded hospital, I learnt that I would have to come up with my own algorithms. I learnt that its not about being right all the time, but being wrong the least number of times. 

And I made my own rules. As I’m nearing the end of my ICU stint, and going into more unfamiliar surroundings (again!), I realise now more than ever that what I need to take with me, apart from my knowledge of medicine, is my philosophy of medicine. 

This is how it goes:

1. First, do no harm. 

2. Do not prolong life when chances of survival are bleak. 

3. Involve family on ventilator decisions early. 

4. History, history, history. 

5. Constantly read. Ask for help. Choose only after knowing the available choices.

6. Empathize. But don’t let it cloud your decision making.

7. Worry. About patients, treatment decisions and how much of what you’re doing will work. It helps.

8. It is necessary to be impatient to get work done fast and get fast results. But it also necessary to be patient in order to give the patient time to respond.

9. Consider this. You are imposing western standards of practice, western philosophies of life, family and social norms on an environment which may be of eastern mindset or western mindset or a mix of both. So take your time. Learn how to go about things the cautious way, the aggressive way, the respectful way, the minimalistic way, the least painful way.

10. Make your own protocols. 

11. Put the patient’s wishes above that of the family’s.

12. Question everything. Patients, colleagues, current medical guidelines, the sensibility of medical decisions, and the rationale behind applying textbook (or trial) conclusions to individual case scenarios.

13. Think about what you don’t like in the current medical scenario you are working in and what you want to do to change it. It is as important to know the solution as it is to know the problem.

Fifty Shades of Brave

Every backache has a story. 

Actually, this is only a partial truth. Every patient has his or her story of their affliction. But its the ones with the low backache, where both diagnosis, and treatment are dependent on listening. 

So many of them are women. Some actually have medical causes for their pain, like a vitamin deficiency, or osteoporosis. But the treatable cause is only a fraction of the problem, and there always is the real, yet abstract element of loneliness, or a diminished feeling of self worth, or world weariness, that manifests itself in these very nagging, painful symptoms. It is an established fact that depression, a disease of the mind, can have signs of the soma (body). 

  

There will the old Mohameddan lady who has ‘bone breaking back pain, mungi (pins and needles) sensations down her legs, and constant thakaan (fatigue).’

There will be the otherwise sprightly maushis in my hospital who keep asking me what’s wrong with them, why do they keep getting tired, why are they plagued with this backache?

And I know, when they come to me, that my most important job is listening. Tales of children now grown up and busy. Their experience of the daily drudgery of existence. Stories of domestic violence, of a life spent in seva- of the in laws, the kids, the husband. How they handle two jobs and whatever other hardships life throws at them.

So I listen. At times like these, I am thankful for my dual roles of being a woman, and a doctor, because both these roles bring with them that very essential quality- patience. 

And I wonder. Can being a woman be such a thankless job?