Fiction: Of doctors and doctors

- Neera Kashyap

Dr Kamath pried two fingers beneath the rubber tubing of his stethoscope to lighten its weight around his collar. Despite notices in three languages stuck on every wall of his two-roomed chamber instructing, 'Only two patients allowed in doctor's room', there was a crowd. He felt its pressure in the weight of his stethoscope and in the sweat caught beneath its steel. There was no electricity again and Swarup had not opened the window nor started the generator. As things stood, both light and air were blocked by a family that stood before the window in huddled apprehension. Ever since his return to his hometown in the heart of a cluster of large villages, the smell of the generator's diesel oppressed him most, more than the smell of his patients' fears - patients who wished to trust him but weren't sure if they could.

Flanked by two younger men, the old man before him coughed deeply, his body quivering with the impact. His kurta was unbuttoned to the waist, a copper amulet alive to every tremble in his chest. Kamath gestured him towards the patient's chair, then felt his pulse. How long have you had this fever? One month, replied one of the men accompanying him - both younger replicas of the old man. Kamath motioned for silence, gesturing them to back off. They did, colliding into people behind them.

Kamath looked into his patient's eyes. "Do you cough up phlegm?" he asked gently. The old man hesitated, nodded.
"What color?" continued Kamath.
"First white, now dark yellow. I feel pain here when I cough," he said, rubbing his chest.
"Breath is short? Hmm. I will use this stethoscope to examine your breathing. Take deep breaths." He heard the abnormal crackling sounds in the chest he had been looking for. He took the man’s blood pressure. Swarup had entered and was driving people out but the replicas moved swiftly towards the doctor’s desk.

One of them spilled the contents of a file full of ECG strip readings onto the table. Kamath stared, uncomprehending.

"But this is for the heart", he said, almost to himself.
"Yes. The doctor said he needed an ECG every three months from a proper place. He said there was less blood going to his heart."
"Which doctor is this?"
"Allopathic doctor. Like you, Sahib. His clinic is in the main market, near the bus stand."
"And what did the lab charge?"
"Rs 500, Sir. Lab in Nasik, recommended by the doctor, same one."
"I see," said Kamath, after a pause. "An ECG in any good lab should cost Rs 150, maximum Rs 250. Your father does not have a heart condition. He has an infection in the lungs. We need to find out what it is. He will need a lung X-Ray and some blood tests. Please get these done from any reliable local lab, no need to go to Nasik or any big town."

The old man coughed raspily. He unrolled his kurta sleeve and held his arm out for an injection. Kamath, by now used to the villagers' pleas for injections, ignored him. The sons stood their ground, demanding at the very least, some medicines.

"I cannot prescribe medicines till I have the test results", said Kamath ringing the buzzer for Swarup who sailed in with another patient complete with family, the one huddled next to the window lunging towards his desk. For a moment, Kamath looked at them unseeingly. His own medical fraternity, he thought. He had seen patient prescriptions where steroid injections were administered first, ending in no conclusive diagnosis, but in a list of medicines. A poor farmer with uncomplicated hypertension was being sent to a city cardiologist for regular ECGs. A private hospital nearby used ultrasound as a money-spinner, charging desperately poor people Rs 1000 for each unneeded scan.

The patient before him was a girl in her teens. She lay immobile in her father’s arms, eyes shut. The mother hung to her husband’s side, eyes wide with alarm. She held up the girl’s salwar to reveal two brown punctures on her lower leg, red swellings all around. Kamath had seen non-venomous snake bites which had mainly involved keeping the patient calm as he administered first aid. He took a closer look.

There was a discharge from one of the holes. He felt a swelling in the lymph nodes behind the girl’s knees. His sharp volley of questions revealed that she had stepped on a snake in the paddy field and got bitten; it was a snake – she had seen it, the mother urged. This happened 18 hours ago. When her swelling and dizziness increased, they took her to their local doctor.

“What doctor?” asked Kamath.
“Family doctor. In the village. He gave two injections and some tablets.” The mother emptied a small brown envelope, large multi-colored pills rolling out onto her palm.

Kamath felt the venom rise in his throat. He lowered the girl’s legs and turned her to her left. He snapped at Swarup to bring him soap solution and bandages, washed the wound and covered it loosely with sterile gauze. He gave the girl a tetanus shot in the arm; she did not flinch. Her breathing was labored but her tongue mobile. There was no time to waste on taking her blood pressure. He scanned his mind for the name of the medical officer at the district hospital – someone he had met at a block-level immunization camp. They had exchanged numbers and goodwill. He may not have saved his name on his phone under ‘Doctors’. This meant time would be needed to search through his entire contact list to recall his name.

He turned to the father. “This is a bite from a poisonous snake, the poison has spread. It should have been treated in a hospital within four hours. With anti-venom… with an injection that is not plain water but has medicine that kills the poison.”

Kamath’s voice did not soften even as the mother shuddered and the father stood frozen. “You must leave for the district hospital immediately. Only they will have the doctors and supplies to deal with this. When the injection starts working, she will recover fast. But the doctors will have to keep watch for some time,” he added.

Kamble. Dr Kamble’s name came to him in a flash. He was listed on his phone under K. He must move it under Doctors, thought Kamath, the call to him going through quicker than he had anticipated. Kamble’s response was immediate and reassuring. Details were given: 14 or 15 years old; snakebite; purulent; local thrombosis; edema in the legs; lymph nodes affected; breathing labored but upper airways clear.

Kamath accompanied the family to the waiting van outside, directing the mother to keep the girl’s legs lowered so the poison did not travel up. As he slid the van door shut, the girl opened her eyes and looked at him, her gaze unclear as if she saw him but through a cloud. He stared at the dust raised by the vehicle as it rattled off on the potholed road. As he re-entered his clinic, the diesel smell made him gag. The waiting room was full: people sprawled on chairs, humped in clusters, slumped on floors, a baby crawling towards his chamber. Swarup was leaning against a wall, picking his nose. Two delicate punctures swam before Kamath’s eyes ringed by soft red swellings.

“If any of you have come to me after seeing a quack, leave. Leave, I tell you,” he shouted. People stared but nobody stirred. Swarup cleared a way for Dr Kamath’s return to his desk, handed him the girl’s form to sign with the consultation fee of Rs.200. Kamath thrust the money into his drawer, slammed it shut and cursed as his fingers caught in the drawer.

The house was dark when Kamath returned home. His father frequently forgot to keep a light on for him, one of the many indicators that he – a heart patient - needed him much less than Kamath had assumed he would after his mother’s death. The void his mother had left remained unfilled by his return home. He realized that his father’s responses to his biannual homecomings had really been his mother’s responses – filled with gladness. He felt little gladness now as he sensed his father’s days spent waiting… waiting for her to appear… somehow… waiting for his own body to go. He tried to defy this waiting by intensifying his own activity - attending every cultural event the town offered, dropping in on relatives, building bridges with district officials. Finally, there were just the walks along fields beyond town that held his interest, work at the clinic absorbing him increasingly. He switched on the light – the single tube light shone blue, hanging at an angle, the screws at one end long gone.

He opened the window of his room. The stench of uncollected garbage from the lane below assailed him. He picked out two volumes of textbooks on Internal Medicine from a shelf till he found the section on Snakebites. There was much more he needed to learn about the diseases he came across increasingly here - thyroid dysfunction, ischemic heart disease, scorpion stings, snake bites, tetanus. Then there were diseases like hepatitis which he learnt with time were also directly caused by quacks using unsterile needles and syringes. Or indirectly - through overmedication, the hope being that by giving a range of pills, something would work.

He felt nothing but disdain for the Ayurveda-Unani-Homeopath varieties who wouldn't stick to their own medicines, taking wholesale to modern drugs. But his skin crawled at the thought of the ones who were totally unqualified - compounder varieties, medical shopkeepers, lab technicians, medical reps - who had a field day treating people any which way they chose. Children dead through uncontrolled diarrhea or dead through injections given for 'chicken pox'. Dead either way. Or people diseased - in ways that baffled him. Their illnesses would delay cure as test reports brought to him showed inconclusive results, patients readily losing faith in him. Kamath thought of the girl with snake bite. If he hadn't alerted the parents to the emergency, they could have well gone doc-shopping. There were enough allopaths in town who, for a fee, would even offer consultations to patients of quacks, including surgeries. He would speak to Dr. Wankhede about the quacks scene in the district. As district medical officer, he had gotten Kamath to help run two preventive health campaigns. Kamath's eyes drooped. The girl had opened her eyes. The cloud in her eyes had derailed his day. The garbage stench deepened with the night’s humidity.

He reached his clinic early the next morning. Swarup had not yet come in and the place was a mess. Dented plastic bottles and empty snack foils lay strewn on the dusty floor. The toilet door was wide open, sending out a putrid smell. Kamath ignored everything but his need to get Dr. Wankhede on the phone. The news was grim. The remoter villages were rife with quacks as most health centers and private doctors were concentrated in larger blocks. Quacks had their 'chambers' in village shops but also came to weekly village bazaars because of the crowds. The Medical Council's legal jurisdiction extended only to allopaths - all of whom had to register with the State Medical Council. It had no powers over the Indian medicine varieties nor over quacks.

"You mean if I see a pretender doing his nonsense, I can do nothing?" asked Kamath.
"You can, if he is an allopath," said Wankhede. "You can report him to the State Council. Those fellows will send your complaint to the district Chief Medical Officer who will investigate, then report back to the Council. A doc who hasn't registered or has a fake degree or has some malpractice charge can be fined or his license revoked with a closure notice. Everything against him but nothing against these other guys. Why, Kamath? Something happened?"
"No, no. Just want to kill these other guys," laughed Kamath, embarrassed by how close his answer felt to the truth.
"Some hope from Delhi, though. Delhi Medical Council has managed to amend its Act to catch these rascals, fine them 20 grand or jail them for three years. Non-bailable. But before all that, he is sent a show cause notice to close down his clinic. When he complies, a compliance report is sent to all the top fellows - deputy commissioner of police, Health Secretary, district medical chief. Last year, the Delhi Council issued show-cause notice to more than a hundred of these rascals. Seventy clinics were shut down and more than 50 FIRs acted upon. Our State Council is preparing to do the same."

The news did not fill Kamath with cheer. He had been waiting to text message Kamble. He wrote and re-wrote his message to make it sound casual: 'What news of the snake-bite patient I sent you? Regards, Dr. Kamath'. Kamble's reply came after two hours: 'She died early morning.'

Kamath closed his clinic and spent the day behind locked doors studying the locations of the remote weekly bazaars in the region.

The bus that took Kamath to the weekly bazaar hurtled over a national highway. Long stretches of cotton grew in black soil on either side of the road, compact cotton balls peeping out of sturdy green stalks. The bus stopped often to pick up villagers en route as they waited in groups on the main road. On reaching the bazaar it emptied out, colorfully dressed passengers jumping off with brisk purpose.

The bazaar was in full swing. The stalls were mostly in the open but some had roofs made of cloth, plastic or bamboo. Everywhere things were being sold - on the ground, on raised mud platforms, on bicycles and poles, from the back of trucks, tempos and horse-drawn carts. Sellers shouted out their wares: vegetables, meat, grains, utensils, pressure cookers, steel furniture, locks, farm equipment, batteries, readymade garments, shoes, cosmetics, toiletries, bangles and bindis.... voices renting the air.

Stalls were arranged product-wise - vegetable vendors, grain sellers, cloth merchants and others all sitting together in their own long rows. Cows, goats and hens waited morosely to be sold. Singularly distinct was a herbalist selling roots and herbs from discolored jars, a dentist, a palmist, a tailor and a repairmen before whom people stood anxiously waving broken umbrellas and torches, utensils and stoves, watches and keys. A man wheeled his cycle slowly through the melee shouting, "Rat poison, rat poison, rat poison. 25% zinc phosphate. Guaranteed to kill rats... your grain sacks will be safe, your clothes will be safe... like never before."

Kamath spotted the quack's stall from a distance. His was brick, the back wall bearing the red-cross sign as qualification. People entering his stall came directly to him, dismounting from buses and auto-rickshaws, tractors and ox-drawn carts, even bicycles. Kamath took his stand at the edge of the crowd, deftly moving about to get a clear view.

The quack was middle-aged with dark curly hair that stood up in spikey waves, defying the oil he used to quell them. His skin was dark with sunburn, eyes small and quizzical, a nose that looked flattened out by a blow. He wore several colored necklaces beneath his stethoscope with beads twisted around both wrists. Kamath saw him hand two ORS packets to a woman with a child and a strip of two tablets. She handed him a 50 rupee note. He said that was fine. She turned away, satisfied.

The quack knew the next patient by name, knew too the two older men accompanying him. He felt the patient's pulse with eyes closed. "Why, Prabhat? How did you get fever? You must have been counting out your corn in the hot sun. Then drinking cold water straight after, no?" The patient nodded sheepishly. The diagnosis was pronounced as heatstroke. Prabhat was given six tablets from different unlabeled bottles lined up on the table and administered two injections from two vials with the same needle and syringe, no sterile swabs used. The needles were dropped into a rusting oil canister and the syringe into a tray half-filled with water in which bobbed other syringes. The quack absently squirted out water from the syringe with one hand as he pocketed his fee with the other, injections being charged extra. He chatted cheerily to the older men, "How is your father, huh? I must pay him a home visit - no charge, just social," he laughed. "And you, Prabhat - when are they getting you married, huh? Look at your face - full of acne. Rub lemon juice. Pimples will go and all these pimple marks. For the fever, see me again in my village shop after two days." His wide grin flattened his nose further. A backslap for Pratap meant it was time for the next patient.

She looked like a newly married woman who wore a glittering sari and spoke through her pallu. Only the quack understood what she said. He addressed her husband with his diagnosis: "She has eaten too many sweets in the last few days. That's why all this stomach ache and vomiting." From his many bottles he tossed out colored tablets: two pink, two white and two dark green, asking her to take one of each twice a day. He also added six tablets from a popular Ayurvedic brand of liver pills. She, too, had to see him after two days. For liver pills, charges extra, he said.

A bus had arrived and a group made its way hurriedly to the quack's stall. A man was carrying a girl in his arms, the woman beside him plainly distraught. A stir of recognition ran through the crowd. Up close, Kamath saw that the girl's feet were swollen. The quack got up slowly, his body stiff. The crowd parted to make way. The woman and the quack confronted each other for a long moment. Her body convulsed with sobs. She sprang forward and fell at his feet. When she finally looked up, her face seemed possessed: "You could not save my son, the fever took him… God’s will... but you must save my daughter. She has been bitten by a snake... by Nag Devta Himself. Only you can save her... I know… I know this time you will."

Dr Kamath was thrown back by the surge of the crowd. He backed out a few yards and crashed into the rat poison seller, wheeling his rounds on his cycle. Flailing his arms for balance, Kamath landed flat on his back in the mud. The rat poison seller grinned, pointed to his bottle in a hand raised high and said, "You want? 25% zinc phosphate. Guaranteed to kill."

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Neera Kashyap has worked on health, social and environmental communications. As an author, she has published a book of stories for young adults titled, ‘Daring to dream’ (Rupa & Co.,2003) and contributed to five prize-winning anthologies published by Children’s Book Trust. As a literary writer of short fiction, poetry, essays, story/book reviews and creative non-fiction, her work has appeared in two poetry anthologies published in the U.K. (Clarendon Publishing House and The Poet) and in several South Asian journals including Papercuts, Kitaab, Mad in Asia and Out of Print & Blog. She lives in Delhi.

Setu, March 2020