Medical student narratives for understanding Disease and social order in the third world

- Rakesh Biswas MD, Asst professor, Medicine, Manipal teaching hospital, Pokhara, Nepal

- Binod Dhakal MBBS student, Manipal teaching hospital, Pokhara, Nepal

- Gaurav Raj Dhakal MBBS student, Manipal teaching hospital, Pokhara, Nepal

- R N Das, MD, Asst professor, Medicine, Manipal teaching hospital, Pokhara, Nepal

- JS Nagra MD, Professor, Community Medicine, Dean, Manipal college of medical sciences, Pokhara, Nepal

Email: rakesh7biswas@hotmail.com

E-mail: rakesh7biswas@hotmail.com

Eubios Journal of Asian and International Bioethics 13 (2003), 139-142.


Illness is deeply embedded in the social world, and consequently it is inseparable from the structures and processes that constitute that world. For the practitioner, as for the anthropologist, an enquiry into the meanings of illness is a journey into relationships (1). It was our aim to document that journey. We collected data on individual patients in a narrative format as opposed to the traditional format of case reports. The different medical student narratives incorporate social issues ranging from single mothers, alcoholism and child labor. The first two narratives are in a story format by the students and are self explanatory whereas the last by their teacher [who also considers himself a medical student (2)] is more of a traditional case report which needed a discussion. Names and situations have been changed to protect individual privacy. The usage of English hasn't been corrected purposefully as it reflects the way it is handled by students in this part of the world.

Story 1

"You must have seen a lot of deliveries by now, you are in third year, aren't you?" my mother asked me with extreme sense of pride in front of my relatives." Yeah mom but we will see all of them in final MBBS",I tried to coax her. Whenever I was on vacation my mother always used to throw a couple of questions regarding my subject and I on the contrary always used to spin off ,digressing the matter to somewhere or the other. It seemed to me as what Einstein would say , a lone ostrich trying to bury the head in the sand of physics(the subject of my interest) to protect myself from the evil quanta of medicine!In fact I never wanted to become a doctor but as bad luck would have it there was no way to escape from the entrapment as a poor fellow in the event horizon of black hole.....

Time passed on. Finally I managed to reach the Final MBBS and the much awaited day (of course not mine ) arrived, that is the day of labour room posting. My spirits had already sunk. Nonetheless I had to attend the thing at least to tell my mother about the process of giving birth and interventions by mankind. We were made into groups of two and posted in one of the regional hospitals of the country. My other friend was a brilliant chap with tremendous interest in the subject; I was feeling ashamed of myself to protect the unnecessary ego that has crept into me over the years. On the way I was engrossed in Steven Weinberg's "The First Three Minutes" that tried to lessen my frustrations to some extent. We reached the hospital at 8:00 clock and the whole night we had to stay there seeing and conducting deliveries if lucky enough. We entered the first stage room which welcomed us with unfashionable furnishings and peculiar odour. I was feeling happy to see the empty beds but the sleepy intern insisted us to wait for somebody may show up soon. We came back to the examination room and waited. On wall there was something written in nice handwriting which I thought belonged to some religion:
From the unreal,O lord lead me to the real
From the darkness,O lord lead me to the light
From death O lord lead me to immortality

Oops! the futile reassurances!! How could one deny death, which is inevitable? Exasperated, I again opened the Weinberg's book and tried to enjoy the dances of muons and kaons. After one hour a fat lady came accompanied by her husband. We took her to the examination room. The intern asked me to examine the lady while he was busy writing the sheet. I tried to behave as if I was a good doctor( not a student)and started to do the general examination followed by abdominal. I put my hands on the abdomen but could elicit nothing when I suddenly realized that the lady's sweetheart was giving me a hostile look from outside. Seeing this my buddy told him to go out for a while and latched the door from inside. Finally the intern finished the examination and she was to be taken to the first stage room and to be started on intravenous line. Two sisters came, one carrying an IV set with her. They asked me, "Will you try?" I hesitatingly said," Okay" I gave a prick but the blood didn't come, again pressed hard but the lady made a painful cry "Aaa...". I was searching for other point but the sister who now knew my condition said sarcastically, "The lady is delivering soon". I found myself sweating. Within a few minutes she was taken to labour room where I could hear the sisters shouting in chorus,"Push" "Push" "Not in the neck, push down". Sounded to more like the bard Cacofonix to me and, I wish I were Fulliautomatix to stop them. Finally the lady delivered a male child knowing which she shed few tears of happiness.

Mundane work load! The disgusting cry,the dirty birth passage and bloody field ,I suffered with bitter melancholy.I saw the devilish faŤade of humanity behind those glitteriness of getting child and rearing up which made me more suffocated. Next day I went again but with lost zeal a small amount of which I had had the previous day. The beds were full with different crying facies. The intern asked me to assist one, I agreed(again driven by ego) and put on the gloves. After sometime in one lady the baby crowned and was taken to the labour room flanked by the sisters. We followed them.

The lady was short, in her twenties and seemed to be economically deprived from her physique and attire.She did not do much efforts to push as others and much to my surprise she gave a big blow to the intern's hand when he wanted to put the finger inside."I f so why did you come here?" the intern shouted.The lady delivered a female child assisted by me.Her face became expressionless; no signs of satisfaction which I had seen in each and every mother after delivery since yesterday.She sniffed instead and dabbed the corner of the eyes turning her head to one side.The moment became unfathomable.

I came back to the examination room and tried to concentrate on Weinberg's book but every moment my thought went with the lady and every moment I was haunted by a question,"Why she did not want to deliver?"I saw the lady being taken on a trolley outside , she was later accompanied by an old man and a small lady.From the room I could hear some murmuring reassurances,when somebody in the crowd shouted,"Unmarried!"

A moment of silence........... I threw the book and rushed towards the crowd to understand the situation where they told me that the lady whose delivery I conducted was infact unmarried. Her boyfriend after having nice time with her married somebody else and the poor lady could find shelter with nobody than her dear old father.I even met her father(a short man with shabby attire) who on my biggest bewilderment was ecstactic on having a grand child.He promised me to leave no stone unturned to bring up the child!Such a noble idea!! Such a candid thought!!!I sat impotently and watched him,an indomitable symbol of love and humanity."There is no fear in love but perfect love casteth out fear".....I learned a new lesson.

Life would never become same for the lady and her father who had to undergo all embarrassment and humiliation to bring up the illegitimate child in the midst of so called civilized people. And so would be mine. I felt ashamed of myself of being quite oblivious to the world in which I play ,live everyday!........ Thoughts changed from funny quarks to human sentiments,from Heisenberg to Hutchison and Osler and from equations to care and service to humanity!My heart filled with both joy and excitement when I began to hover into the world where mountains haven't been climbed and cosmos hasn't been probed by me.......not yet.

Ave , my dearest mother!
Binod Dhakal, Final year medical student

Story 2

..........he left school around class eight. I asked him why, I never did get the reason. The only thing I learnt from him was that he was getting tired of the same old routine and his continuing disinterest in books. There was a wink in his eyes, he must be avoiding my queries...but I had work to do and so I proceeded.

Jigme is 27 years of age and unemployed. His built is that of a lightweight boxer and there's a certain charm to his face that would drive any girl crazy. Dressed in an orange T-shirt and a blue jean trouser, seated on a chair opposite me, answers my questions with no apprehension. It took me very little time to build a rapport with him and this made my task less arduous. I lean closer to him, there's a distinct smell of alcohol in his breath ; I was closer to my diagnosis of the case.

Jigme has a stepfather who is very different from his father. He regards his own father with disgust, a person whom he tries to avoid thinking of, an alcoholic who would spank his mother every other time of the day. He still recalls the iron rod leaving a scar on his right cheek, thanks to his father. He would feel sorry for his mother and there would be ideas hovering in his mind about getting rid of his so-called father....there was a moment when he even attempted to hit him but something compelled him to stop. A year later his father expired...Jigme was happy for his mother.

Jigme is a Tibetan refugee living in the heart of Pokhara...Ghorepatan Refugee Camp. His parents weave carpets and make Tibetan necklaces for a living. His elder brother is a monk in the monastery; two of his sisters are married. I had asked him whether he ever wanted to become a monk...he never did like the idea of becoming a monk..it just did not fit in his lifestyle!

Everything about Jigme is superb except that he wakes up with a bottle of alcohol, he eats alcohol, he sleeps alcohol and he talks alcohol. It began in standard eight, among his circle of friends with the first sip, which transformed into a stepping-stone. Alcohol, ciggarettes and sexy girls were his motto for the rest of his life. Somewhere along the line he got into marihuana, doping cigarettes and hashish. With encouragement from his friends he even experienced the ecstasy, euphoria of injectable drugs. Without any hesitation he pulls up his sleeves and shows me the puncture marks. His hand drifts into the pant pocket and takes out a dark ball...."you want some?" I avoid the question.

What about girls...he has had numerous sexual relations...condoms became routine only three years ago. I ask him why...he tells me that three to four years ago he had not heard about HIV, plus they were creating a hindrance with the feel. There's a sly smile on his face gesturing me to indulge into it.

"I am my own Doctor,malai tha cha malai ke garnu parcha tara.....",it is the but that stops him. He wants to call it quits, earn a living and ama ra buwa lai sukkha dina chahanchu....His aim in life is to own a Mercedes Benz C class.......here we have something in common between us. I try and counsel him, inform him about the need to reform his lifestyle, to avoid alcohol progressively, avoid sharing the same syringe, keep a distance from the deliriants and somniferous agents and use a condom. Not that he is unaware of the dos and the don'ts..i repeated it to emphasize the facts that make a difference in life. I encourage him to enroll into a rehabilitation center or seek professional advice from a psychiatrist. Maybe seek a job to keep him busy. It is the psychological dependence that has to be got rid off, the physical dependence can be taken care of later.

I try to give him the boost, build up his confidence a bit.

Jigme nods his head and listens to me. I don't know how much of it he has imbibed. What I see in front of me is a healthy young man...waking up in the morning....offering prayers to the Dalai Lama.....heading for his work with a gleam in his eyes.......happy with life and at peace with himself.

In the end of my session with Jigme, I thank him for presenting me the facts and reality of life, we shake hands with each other and bid farewell. The last I caught sight of Jigme was in our mess eating lunch.

Jigme was the case allotted to me during our clinico-social case in community medicine university exams during our 3rd MBBS. He was an alcoholic and my task was to counsel him. If Jigme mends himself and adopts a healthy life then I would have achieved my objective. Sometimes miracles just happen.

Gaurav raj Dhakal
Final mbbs student.

Story 3

We have come across a patient of alcoholic cirrhosis with complications of portal hypertension developing at the age of 21 years. We attempt to present below a report not only unique to an individual but also compare the scenario of alcoholism in the developed and underdeveloped world. Social problems of child labor and easy alcohol access perpetuate alcoholism and its antecedent problems in the form of a vicious cycle which continues to plague the third world.

Case-Report

A 25 year old man working as a hotel waiter in Bharatpur, Nepal, was admitted to the district hospital Bharatpur with the chief complaints of abdominal distension since the last 3 years. He was a regular drinker by the age of twelve. His mother abandoned him and ran away with another man when he was 6 years old From the age of 12 he was forced to work as a daily wage earner by his father. He was employed in a factory manufacturing country liquor where he had easy access to drink. Since then he started drinking 250 ml of spirits daily and would occasionally consume 2 bottles of 750ml each. At the age of 21, he had an episode of massive hematemesis and malaena for which he received 6 units of blood transfusion. Soon after hospital discharge he continued drinking for another year until he was readmitted to the same Hospital with ascites. He has undergone repeated paracentesis ever since. He also had an umbilical hernia due to ascites which burst spontaneously and was subsequently managed with regular Betadine dressings.

On examination he was cachectic, had a prominent scalp infection and also had mild icterus.There were prominent veins over his abdomen with a loud umbilical venous hum. He had a haemoglobin of 5g/dL,a total leucocyte count of 1800 and markedly reduced platelets on smear suggestive of hypersplenism. His serum bilirubin was 3.6mg/dL with an unconjugated fraction of 2.4mg/dL,serum albumin was 2.1g/dL and globulins were raised at 4.5g/dL.His HBSAg (Virutex/latex),Anti-HCV(dot blot Assay) and HIV(ELISA) were all negative. Ultrasound abdomen showed an irregular liver surface with portal vein measuring 14mm apart from free fluid. He had been living in the Hospital (officially as an out patient) since 3 years depending on the Hospital for his food ,shelter and intermittent paracentesis. Endoscopy services are not available in the Hospital and sclerotherapy or variceal ligation was not possible. He died of a massive variceal upper gi bleed 2 years back.

Discussion

This patient highlights the social problems posing substantial challenges to health care in the third World. Child labour was forced upon our index patient at an early age and he also took up alcohol early because of easy access to liquor. Inspite of legislative enactments prohibiting employment of children below the age of 14 years(section14;Civil rights act,2012,Nepal),the 1981 census,Nepal, showed that 4.5million or 60%of the child population in 10 to14 age group of Nepal is economically active.(ref 3:UNICEF1992).The sale or offering of alcoholic drinks to persons below 18 years of age is illegal according to legal restrictions on production, sale and consumption of alcoholic beverages in Nepal

( ref : 4 Madira Niyam haru 2033).However, alcohol use has been in Nepal since time immemorial. Social tolerance to alcohol use is quite high and so far alcohol has not been taken seriously either by the Government or by any social organization. Production, sale and consumption of alcohol is ever on the increase and it could be taken as the number one problem drug in the country(ref : 5 Shrestha et al 1992). These factors contributed to the early onset of heavy drinking in our index case and he developed cirrhosis at the age of 21 years. His dependence on alcohol was such that he didn't stop drinking even after the first episode of haematemesis and malena for which he was transfused 6 units of blood. After continued drinking for another year his social and financial supports gave away.

Following this he was converted into a total dependant on the hospital partly for his regular abdominal paracentesis and partly for 2 square meals a day, effectively falling into the vicious cycle of poverty and social-physical debility. Developed countries such as the United States have dealt with their alcohol problem with periodic enforcement of strict prohibition like the one, which lasted from 1920-23, and the incidence of alcoholic cirrhosis reached an all time low. The death rate from the condition fell to half its 1907 peak and did not start to increase again until the amendment was repealed (ref :6 Musto et al 1996). The time is ripe for Nepal to embrace strict enforcement of its prohibition laws for minors.

References
1) Kleinman A. The illness narratives. New York: Basic Books, 1988
2) Biswas R, Always a medical student, Student BMJ, 11, feb 2003,pg41. http://www.studentbmj.com/current_issue/reviews/41.html
3) Children and Women of Nepal, a situation analysis, UNICEF Nepal Publications 1992.
4) Madira Niyamharu (2033) Nepal Niyam Sangraha, Khanda 4.(KA)2040, Ministry of law and justice,HMG/Nepal,pg132-38.
5) Shrestha N.M.(1992) Alcohol and drug abuse in Nepal, British Jl. of addiction 87, 1241-48.
6) Musto D. F. (1996) Alcohol in American History, SA 274( 4),pg 64-69.


Go back to EJAIB 13 (4) July 2003
Go back to EJAIB
The Eubios Ethics Institute is on the world wide web of Internet:
http://eubios.info/index.html