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.

 

 

 

 

The Headache Poem

(A poem by Dr Siddharth Warrier)

 

I went to a doctor for a headache; he

After much examination said,

‘It seems you suffer – what is clinically

Known as an aching head.

 

But before one makes such daring claim,

One ensures there’s no mistake!

For a head that ‘hurts’ is not the same

As a head that has an ‘ache’.

 

Your head can burn, your head can break,

It can poke or prick like a pin;

If you knew all the ways your head could ache,

Then your aching head would spin.

 

I’ve known of heads that have been said

To stab, and split and shake.

Indeed, you must be glad, your head –

Does nothing more than ache.

 

Some last for hours, some for days,

Some stay and others spread;

Some aches head off in different ways,

Others quietly lie in bed.

 

The Aam aadmi calls it a ‘sardard’,

The middle class say ‘my head is paining’.

The South Bombay folks love a fancy word!

They announce – my head is migraining.

 

For some, the headaches are a measure –

Of all the tensions in their lives!

Some blame it on blood pressure,

While most others blame their wives.

 

All doctors claim an urgent need,

To name which ache is which.

The only thing they haven’t agreed

Is how to name the bitch.

 

Even the neurologists are peeved,

Is it a symptom or a sign?

As a general physician, I’m relieved

That headache isn’t mine.’

 

‘Stop! This is a miracle!’, I said,

‘And surely there’s no mistake!

You’ve left me so confused, my head

Has forgotten how to ache!’

 

– Dr. Siddharth Warrier

A Neurosurgeon’s Fix

Guest writer, Baba Yogesh reviews Paul Kalanithi’s ‘When Breath becomes Air

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We breathe. We inhale air, with gases in proportion to those in local atmosphere, and we exhale breath which is the inhaled air but with a little less oxygen, some more carbon dioxide, humidified, and cleansed of all particulate matter. This process of breathing results in a personalized change in the quality of air that we breathe out, our breath. From a medical point of view, at no point in one’s life can breath become air. Then does the title imply the breath under scrutiny belongs to a person whose life has ceased to be? But then, how can a person who isn’t alive breathe? This latter pedantic quandary notwithstanding, the original motive of the author, Paul Kalanithi, who wrote the book titled such, probably was to signify death. Death in general, and his impending one in particular.

Paul was a neurosurgeon-scientist. He studied medicine at Stanford, and his research involved electrical stimulation of brain regions with intracerebral electrodes. Paul started college with the question, ‘What makes life meaningful?’ a philosophical timeless Gordian knot we all have wrestled with. Quite unlike many, Paul sought answer to it with literature.

“I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion.” He saw literature as a fertile source-material to study life. He felt that only the vague intricate complexity of classical writing can encompass the similarly qualified concept of life and its meaning. He majored in English and Biology. He further went on to do Masters in English literature on ‘Whitman and the medicalization of personality’. But after masters, he felt caught in a catch-22. In his words,“If the unexamined life was not worth living, was the unlived life worth examining? ”

Convinced that to truly answer what makes life meaningful, one needed to experience life at the crucial juncture where it could possibly be stripped of meaning, he turned to medicine. His transition into neurosurgery is well-reasoned and captured in,“Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?”

In this book, Paul writes about his life as a surgeon and how he grappled with the complexities involved in patient-care, informed decision, long work-hours, and the unfortunate objectification of patients. And its written with a personal touch such that at no point does it get preachy or overtly verbose. And in the second half, Paul writes about his descent from a care-giver, to a patient diagnosed with stage-IV lung cancer, grappling with the reality of being struck down in his prime when he was at the peak of his surgical career, with life looking up bright ahead. Paul writes about how he dealt with it, accepted it, curiously went through the Kubler-Ross model for 5 stages of loss in reverse, and faced his own mortality and the question of the meaning of his life, up close.

The book ends abruptly. Paul died, in February, 2015. And in the end of the book is an epilogue by his wife, Lucy, who remained by his side all along. She writes how its possible to love a person, as deeply as before, even when the person is no more. Its a book thats personal, humane, and heartrendingly tragic. But then, so is life, often times. If you are a doctor, or anyone who was ever interested in what life and living is all about, here in this book is a perspective that will remain with you for a very long time.

Love Happens.

Decoding medical school. The first of a series by Smriti.

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I’ve been meaning to write about the journey of the practice of medicine, and I realise it will be incomplete without a general overview of the course and its materials.

Medicine is actually the most colourful amalgamation of pure sciences there is. For example, these are the subjects we study in MBBS.

First year is the most descriptive answer to the question ‘Who am I?’ It starts with anatomy. This involves a complete dissection (theoretical as well as practical) of the human body. Concrete distinctions are made as to what is a nerve, a vein, an artery. Anatomy tells us the complete structure of the human body.

Now we come to the functional aspect. This is physiology. Here we learn how anatomical distinctions are not absolute, and how organs work together so that the body operates as one individual.

We also learn biochemistry- actions at a cellular level which enable the body’s structure and function to work.

Second year is about everything that can go wrong.

Pathology- what happens when structure and function misbehave.

Microbiology- how bugs can affect us, from single cellular viruses to complex segmented roundworms.

Pharmacology- the science of drugs and their interaction with humans.

Forensic medicine and toxicology- violence, poisons and a miscellany of ugh stuff.

The last two years is spent studying the practical sciences- what to do with a cataract, how to help with childbirth, when to treat a disease with drugs and when to operate on a patient. We spend more time in the ward than in the classroom.

This is followed by a year of interning in different departments, where the job description can involve anything from ordering food for the residents to doing minor surgeries singlehandedly.

Somewhere, in these five and a half years, (if you’re lucky) love happens. It may be in the form of a spark on a quiet day in the library, or it may be a gradual allurement over the years.

And just like that, you know what you want to do. All your life. For me, it was internal medicine.

Dr. Smriti Khanna

Movement

The clock strikes 11.
She shuffles in, pallu balanced on shoulder, swaying as she walks. Goes to the corner bed, lovingly picks up his left foot, and starts rubbing vigorous circles into his sole.

‘Open your eyes, beta. Let’s go home.’

He lies in bed, unmoving.

Oils his hair. Asks whether the nurse has given him enough milk today. Insists on adding more salt to the liquid feed we euphemistically call lunch.

The clock strikes 12. After many requests from the ICU security, she leaves, her glance lingering on him as she goes.

She sits outside, waiting for the clock to strike 11 again.

Hello there.

Smriti writes. Our project has said its first words!

 

I started my journey in medicine as a fledgling, and, after 10 years, I still feel like one. This in no way diminishes the magnitude of what I have gone through and learned. When I joined MBBS, it was more a case of drifting into it rather than an active decision.

I didn’t know when I joined medicine that I would come to love it with such fierceness, or that it would become a philosophy as much as a vocation. I didn’t know what subject I would take as a subspeciality, or what lifestyle I would have as a doctor.  As many people from the medical fraternity will tell you, medicine can consume your life and your mind. Most doctors have only doctor friends, talk only about medicine at the dinner table, parties or social gatherings.

I still don’t know where I’m going. Medicine is a long winding road, or a strict master, whichever metaphor you prefer. It is also a fulfilling voyage and a scintillating life lesson. But above all, it is a passion, and a way of being. Every doctor has his own way of practising medicine, which he extrapolates to how to live.

Gayatri and I met in St. Johns Hospital, Bangalore, 4 years ago, and bonded over our love for second hand books, comfortable silences and general silliness. This blog is as much a culmination of our conversations over the years as is it a working commentary of what goes on in our heads when we see patients get better, or die, or hang precariously in between.

These are the things we have thought about.