Is there hope left for humanity?

Patients have become consumers. Doctors are service providers. If we blind ourselves to the business aspects of healthcare, then it is only at our own peril. When the insurance companies come, they need certain criteria to be met before your hospital is given the contract. When the maintenance contracts are signed, there are cold blooded calculations to be made by large transnational companies on the other side.

 

No effective modern Radiology manager can be blind to these realities. No idealism, only social and production material relations seem to be left.

 

Who will ship the Helium? And in whose name?

While balancing the questions regarding shipments, tools, engineers, logistics and also ‘entertaining' the ‘In-Germany-I-did-it-like-this' Neurosurgeon (how much of this is recurrence-how much residual and what happened to the far lateral parasagittal sections), one should try to retain one's humanity.

 

"In whose name will the shipment be made," came the query. They can be pretty nasty at customs at times.

 

"Where is the bursitis-collection in front of the trochlea which your colleague has written about in the report ,' a senior retired HOD-Orthopedics put the Elbow MRI films in front of me.

 

Keeping a working list is one of the tools which I have found very useful over the years, when dealing with multi-disciplinary inputs from clinicians of different specialties and managers.

 

So you think you have problems?

However, if you think that you have problems, then here is a narrative, conversations over the years with my friend Ibrahim Gambhari.

 

 

The photograph given with this blog is one which I keep on my reporting desk.

 

 

Whenever I feel overwhelmed, irritated, hopeless, useless (Mid-Life Blues...Meine Zindagi Mein Kya Kiya...What did I do in/with life) I just look at Ibrahim, his smile and my troubles seem petty.

 

When one comes in touch with such persons, one is reassured. There is still some hope left for humanity.

 

Not everyone has become a cynic (do not become like me)

 

Here is the final of the three narratives.( I am a Believer, Pals forever have been presented in previous two blogs) which changed the way I look at medicine, radiology and life.

 

Preparing for Ramadan

This page is dedicated to Ibrahim Gambhari a noble carer of his mother and a living example of a value system which is getting rarer.

"I am coming to you with my mother" Ibrahim rang me up. That was last year, before Ramadan. His mother has been bed ridden for over five years. She has severe spinal canal stenosis and is not able to stand or walk. He has taken care of her needs and has with great care and difficulty prepared the papers to enable his mother to have advanced surgery in Europe.

"She is old now" I tested him a bit to see for his resolve, one day. But there was not a glimpse of hesitation in him.

"Why should you sell off your ancestral house which had taken a generation of efforts to acquire? Do consider the implications which that will have on your family-your son in the future" I asked him one day, again trying to test his resolve and also seeing whether there are any chink in his mind-set which would try to grasp at any half-excuse for not going ahead with this difficult and costly therapy for his 85 year old mother.

"My mother's toes are more important than the house which I sold. Her pain has to be relieved. And if anyone deserves to gain from the money of that house which I sold it is my mother, as it was she who cared for my father, looked after the family and enabled us to acquire that property in Tripoli, around half a century ago." The family is originally from Al-Baida, in Eastern Libya and Ibrahim has worked himself up through this western Libyan capital city, having studied in Switzerland and stayed in Malta. But those were different times.

"At present I am unemployed" he answered one day, when I tried to probe him into what his source of income was, how he sustained himself and his family and looked after the ever increasing costs of medical bills. While many people try to flaunt their wealth, job-status, position, it takes character to admit humbly-I am unemployed. The strongest man, is he who stands alone.

There is no health care insurance system in Libya, just as in many of the underdeveloped countries. At such times people fall back on traditional social security networks, extended family, ancestral properties and it is not easy.

He brought his mother before Ramadan last year. And now this year's Ramadan month is approaching fast. In the past year, he has been through a lot. When I first saw his mother's scans I thought, this was a hopeless case, and from whatever experience I had in my decade long work in this field made me think that he should just try some conservative treatment.

But I was wrong, as I have been proved wrong many a time, by courageous and resourceful relatives and patients who stretch the limit of conventional teaching and experience through something which is called the Human Spirit. He is a strongly spiritual person, prays regularly, has seen the world, but has not let his knowledge convert him into a cynic, like many of us have become in today's material world.

The next time I saw Ibrahim after his mother's scan last October was not for his mother but another relative of his, who was young and had incidentally been diagnosed as having cancer of the breast.
"Is the report correct, doctor" he asked me.

The mammogram showed the lesion clearly and I told him not to waste any time. He went to Lebanon, and got the treatment and returned in a month, ready to follow up his mother's case again.

That is Ibrahim. Like a marathon runner, he will keep on and on, with planning, precision, and deep resolve. Never have I heard him curse his ill-luck. Always smiling. He told me of his earlier trip to Zurich.

"The doctor told me not to pay his charges now, and clear off only his hospital stay bills if I did not have enough for the present" he told me. (Incidentally, this Egyptian origin Neurosurgeon practicing in Switzerland is also named Ramadan.
I first came across Professor Aymen Ramadan in a conference 4 years ago, when he rendered the most beautiful and simple explanation of the Glasgow Coma Scale I have ever come across, helping me to reach a bit further from the tunnel-vision-view-box limitations of a radiologist)

When the twin sharing room in which his mother was staying with a Swiss lady was getting a bit crowded due to the visitors which his mother Lutfia was having, he was shifted to a suite.

He hurriedly went to the reception to find out why this has been done and who will pay the extra money.
"I am working on a budget" he told the reception anxiously.

The Arab way of taking care of their sick and elderly, the "chai" which they have together, herbal tea with lovely scents, the small table with embroidered cloth on it and the sisters would huddle together, and one of them would cut and peel the green Libyan apples from Baida (Eastern Libya-Jebel Akhdar-The Green Mountains) all formed part of the healing process.

"If my patient does not get the proper atmosphere she will not heal properly. It is part of her culture to have family with her. No routine visiting hours for her. Let the family stay. I am preparing her for a major surgery. Let her have the family atmosphere which she is used to," the senior neurosurgeon had told the reception and nursing sisters. He had also requested that no extra charge should be taken for the suite.

The Swiss lady who was sharing the room had been dropped at the car park by her son and her husband had come in the evening for a brief half-hour before he caught up with his busy schedule.

Lutfia had her family with her. Some extended family who were in Europe were also there to visit. There is a difference in the cultures of Libyan Arabs and Europeans and there are many similarities with the value systems in the Indian subcontinent. But I think Ibrahim is the key person in all this. He has organized the whole thing,kept his family together, borne the expenses and most importantly had a spirit of caring, acceptance and support for his mother, without which the whole thing would have not been possible.

"I know of many partners who pass away within a year or two of their spouses passing away" I told him one day. Life long partners find it difficult to continue in the world after their spouse passes away and there could be an element of feeling unwanted.

"No! My mother is not unwanted. She is very much wanted" Ibrahim said firmly, his greying hair a bit unkempt from the whole day of running around. He had been to the courier office to send the CDs of the MRI scans to doctors in Europe.
His mother does not feel unwanted. She is very much the living spirit of the family. These are values of love and care which she must have inculcated in Ibrahim when he was a child and which now his young son must be seeing and imbibing.

"I have to be in Europe before the month of Ramadan" he told me anxiously. "I have been preparing for this for many years."

"But consider the general condition of your mother" I countered.

But he will have none of this "rounded medical advice".

"Doctor, even if you are right, I want to give this one chance to my mother. I will be able to sleep in peace and it will not be on my conscience that I did not try."

As a thought-experiment, try spending a morning imagining that you are such a carer-eg trying to expunge the smell of soiled sheets from your clothes, while awaiting a visit from a neighbor, who said he would "sit with her' so you can catch the bus into town, and , like a guilty hedonist, play truant from your role as nurse for a few sanity-giving hours of normal life. You wait. No one comes.

It is all we can do to spend 2 minutes on this thought-experiment, let alone a morning-or the rest of our lives. We need to be aware of the strategies we adopt to avoid involvement with the naked truth of the shattered lives, which like a tragic subplot, stand behind the farce of morning surgery or out-patients, MRI rotations or Doppler nuances in which we hear ourselves forever saying in plumy complacency...

"Kaiph Halek, Shino Moor, Hamdulillah, (How are you, Thanks to the Creator)
They parrot these words mechanically without even caring to wait for the answer
"And how are you today Mr. Ibrahim...your mother, I know..marvelous how you manage. You are a real support. Let me know if I can do anything."

We pretend to be busy, we ensure that we are busy, we surround ourselves with students, with white coats, and a miasma of technical expertise-we surround ourselves with anything to ensure that there is no chink through which Mr.Ibrahim or Mr.Sami can shine their rays of darkness.

Poor Mr.Ibrahim. Poor Mr.Sami. Poor us!

To be frightened of the darkness, panicking at the thought that we might not have anything to offer, or that we might be called to offer up our equanimity as a sacrifice to Mr.Ibrahim.

How dare one little grain upset our carefully contrived universe?

Respite care, medical charities, meals on wheels, laundry services, physiotherapy, transport, day care centres, clubs for carers, visits from district nurses or from a nurse specializing in chronic disease will go some what to mitigate Mr.Ibrahim's problems.

As ever, the way forward is by taking time to listen.

But the best thing you can ever offer is the unwritten contract that, come what may, you will be there, available, often ineffectual , but incapable of being alienated by whatever the carer may disclose to you.

Sami, Attabib, Ibrahim are some of those noble carers who form the essential part of the medical team, without whom, the best of technical scientific care cannot realize it's full potential.

 

Notes and acknowledgments

1. Concepts of this essay have been inspired by Care for Neurological Patients-Oxford handbook of Clinical Medicine.
2. Apart from the persons named in the essays, conversations with a Bulgarian staff nurse Nelly, who cares for patients with dementia helped me develop my concepts
   "Mummy I have taken my medicine" is how some old demented patients for whom she cares ring up their long-dead mothers, she explained to me one fine afternoon, further helping me to try and improve and come out of my selfish, petty, tunnel vision-view box world.

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