Anand Bharathan

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Mathematics, Gratitude & Forgiveness-Lessons from a visiting brother-in-law

My wife’s brother came visiting us this morning. This is the first time in the last 25 years that we are getting to meet him. He spoke about his life’s journey which started as a student of journalism and blossomed into his Professorship in academia, teaching and training people in a specialty called “Instruction Technology” at Kansas, USA.

Mathematics

As I was wondering what this field is about, he explained that “instruction technology” integrates online academic teaching at schools/colleges and software technology in such a way that the “end-user” or the “intended beneficiary” (read students!) becomes the most important beneficary of the two components of online teaching resources, viz. teachers and the technology they use. It was wonderful to listen to his journey of imagining himself to be a poor mathematics student, starting a career in journalism & content creation, meeting a teacher at Singapore who inspired him to take up GRE (an exam full of mathematics!), scoring very high in maths based GRE- fully unravelling the fact that the right teacher could bring out the true potential, of even a student who imagines himself to be poor at something and showing how destiny unravels itself as one starts travelling into the “unknown”, letting go of the fear that is so characteristic of, and paralyses so many of us.

Gratitude

He spoke about gratitude as he continued. My understanding of gratitude was that it was of vital importance to recognise the contribution of other people in our lives. Something that will genuinely make them happy and encourage them to continue to help other people. I truly did not know how it worked.

Deepak anna told me that gratitude was of vital importance to ourselves as individuals. Gratitude allows us to have a photograph of the many positive events of life, as we experienced it. That life allowed us to have so many positive experiences. It shows how the person or people or a life-situation to whom/which we are grateful was so vital to our own experience of those positive moments. So, he told that gratitude is something we must show, to help ourselves first. Of course, expression of gratitude will certainly make the other person experience happiness and make her/him want to help more beings around them.

I was astonished at his very high level of understanding of how gratitude works. And, of course, immediately was filled with gratitude for him.

Forgiveness

Deepak anna also completely changed my understanding of forgiveness. I used to believe that only strong people know how to forgive others who did something wrong to them. That you could transmute your enemies to friends by learning to forgive. That we need to forgive ourselves, for our own mistakes before we could forgive others. Many such ideas existed in my mind about forgiveness- from what I read, heard and knew.

Whereas Deepak anna told that we ourselves are the greatest beneficiaries when we offer forgiveness to others. When we truly forgive someone, we let go of the burden we carry in our mind, our baggage, about them. About a bad feeling we have about them. Any bad thought or feeling about any other soul is truly a burden. A burden which is waiting to translate into a “re-action” to the harm we think that they caused us. It is so easy to for me to understand now that forgiveness is a way of easing our own burden. Of strengthening our “letting go” muscle. This will empower us to breathe easy, walk away easily from people and life-situations that have the potential to trap us into an endless cycle of harm and counter-harm.

I am so grateful for this day and for Deepak anna who took time to come visit us in his limited time in India.

Human suffering, death and healing- thoughts!

Limitations of contemporary medicine- seeing suffering & death as failure

Contemporary allopathic medicine and care process is trapped by viewing death and complications in the care process as failure. Death of the suffering humans triggers discussion and research to prevent such occurrence in future. In a way, it is the compassion and empathy intrinsic to human beings that results in such search for ‘cure’ of all or most illnesses. In a materialistic world dominated by pitiable, unquenchable thirst for acquiring more wealth, power and fame, such expression of compassion could be healing for individuals or groups of people experiencing it.

The biggest flaw in such a thinking however, is that human suffering is real and unavoidable. We are failing to make use of the first noble truth that Gautama Buddha gave us after 7 years of selfless effort towards the understanding of Truth about suffering. We are failing to make use of the entire teaching of Srimad Bhagavat Gita which speaks of unattached action as service to the Divine and as a pathway to the Divine.

Are we training doctors to accept human suffering and death?

My answer is most times, no! Most of my training in allopathic medicine did not involve a part which allowed acceptance of suffering and death. Training was mostly about identifying and curing illnesses. In helpless situations where no such cure was available, our training aimed to provide palliation of symptoms like pain that our patients suffered with. A high and worthy goal indeed!

Most of the training I experienced refused to talk about death as the inevitable consequence of life. Mortality audits we attended left an impression in my mind that death is not acceptable and must be somehow always prevented. My teachers at Nizam’s Institute, Hyderabad, Prof. Sastry and Prof. Bheerappa and my boss at CMC, Vellore, Prof. Sitaram were notable exceptions of that idea that death is not acceptable. They told us that medical care is about compassionate and best possible care of the suffering as an accompaniment during illness. And, they made us inquire about the meticulousness of the care process and not the end point of cure or death. Unfortunately, caught in the rat race to train more, I left all these exceptional teachers before they could leave the full impact of this truth on my being.

The reality of pain, suffering and death- lack of access

Pain was always treated as an enemy that has to be controlled by all means. But, the reality of medical practice showed me that pain cannot always be treated. Use the best available pain killers and still suffering due to pain is a reality. This used to be discouraging.

I suffered intensely seeing the suffering due to persistent pain despite medicines and later, due to lack of access to medical care. It consumed me. For several years, I felt like a failure and wished death to soon visit me, instead of patients I could not care for. Every patient who needed care, but could not buy it in this world of private health care where we sell our knowledge and ability to care for our sick fellow human beings caused intense pain. The 18 years I spent training as the surgeon I became felt like fruitless use of time. I had come to become a saleable commodity rather than an instrument of healing.

I tried to switch from private health care to public health care in 2021 through a potential offer of employment at Stanley Medical College, Chennai’s liver transplant program. But, due to an act of the Divine, the plan did not materialise. I ended up working in private health care where the feeling of being a failure- a person selling skills for livelihood and not available for healing of the suffering haunted me.

A trip to Shirdi- Beginning of the healing journey

My wife introduced me to Sai Baba of Shirdi, a great Being who treated people’s illnesses as a form of service while himself living a life of extreme austerity. We travelled to Shirdi. After coming back from Shirdi, numerous Teachers appeared in life to show me what care and healing mean in truth.

The endless line of Teachers- Christ, Krishna…

An endless line of Teachers then appeared. Teachings of Saint Neem Karoli Baba Maharaj reached through Sri Ram Dass of Kainchi Ashram, who taught me that Christ and Krishna are the same! Sri Krishna Prem and Sri Madhav Ashish of Uttar Brindaban Ashram at Mirtola had left behind invaluable treasures in the form of teachings they left. Srimad Bhagavad Gita and The Kathopanishad were taught, resulting in cleansing of the mirror of my mind, bit by bit. Anger and hatred towards a system which cared and provided mostly for the ones who could pay started dissolving.

Unattached action of Srimad Bhagavad Gita in the current era

The living examples of selfless service and unattached action that Srimad Bhagavad Gita teaches so well, appeared in life. Dr. Regi George, Dr. Lalitha Regi, Dr. Ravi and Mrs. Prema of Sittilingi Tribal Health Initiative, Dr. Nandakumar Menon, Dr. Shylaja and Dr. Royson of ASHWINI, Gudalur, Mrs. Lindsay Ghosh and Ranjan Ghosh (Ranjan da) of Jan Chetna Manch, Chandankiyari, Dr. Yogesh Jain of Jan Swasthya Sahyog in Ganyari and Dr. Ravikannan and Mrs. Seetha Ravikannan of Cachar cancer hospital, Silchar made their appearances in my troubled life and gradually helped me understand that life and similarly, practice of medicine is about accompaniment of the sick and suffering and not about cure that I was trying to sell all along.

All of them showed that it is possible to do one’s best to care, to relieve pain and suffering and yet many times, fail to achieve these high goals. They showed how beautiful life becomes when selfless giving of care becomes the highest endpoint of care as a healer.

Suffering is grace

Sri Ram Dass of Kainchi Ashram says in the short movie, ‘Going Home’ that suffering is grace. When we start to understand the meaning of suffering and why it comes- a result of clinging or attachment to a particular outcome, as Buddha and Sri Krishna taught- the beginning of the end of suffering starts. Suffering for everyone of us, including the unfortunate sick humans who we care for, could become an eyeopener to the Truth of impermanence of human life. Understanding impermanence not as failure, but as a high Truth is healing.

As one of my Teachers, Thich Nhat Hahn teaches, impermanence is beautiful. The impermanence of sea water is the cloud. The impermanence of cloud is the river and the impermanence of the river is the water we drink. Impermanence of winter is the flowering season!

Let there be an end to all suffering- The Third and the fourth Noble Truths

I pray that none of you who read this suffer, at least unnecessarily, but are able to experience the grace that I experience many times. Let the Divine grace manifest as peace in each of your hearts. Let the Peace you experience become so intense and full, that each one of you becomes capable of transmitting that overflowing Peace to suffering beings around you and heal them.

Let the world around us learn that money, power and fame are so impermanent and the Peace we experience is so invaluable and can never be bought.

The pain of practising as a doctor selling ‘care’ in India

This is not an isolated event. This is an everyday event, illustrated through the example of what I experienced yesterday as a doctor practising in private sector health care of India. I go through this painful experience and still practice as a doctor within a system of care that I disagree with, because only when you are an insider, it is possible to be aware of the situation, speak about it and do what is possible within the system while still calling for it (as well as myself who is an essential part of it) to think if it is capable of transformation into a kinder version, rather than the profit-higher-than-anything version that it is currently.

A 68 year old man came to the clinic with his wife, son, daughter-in-law and his 10 year old granddaughter. He ran a small grocery shop at Tiruppur, a nearby town. Small grocers are essentially a subsistence business, in which consistent hard work provides just enough money to run the family. Money comes in only as long as an individual is able to run the business. Usually, no reliable saving is possible.

Abdominal pain for a month led to diagnosis of a malignant mass in the pancreatic head with involvement of a major blood vessel close by. He said he was never ill in all his adulthood, a true blessing in these times. Pain was disabling and gave a constant reminder of the life-threatening cancer that was slowly consuming his body. After a detailed review of records and review of the CT scan images, I told him that he had a locally advanced pancreatic head cancer and that this cannot be surgically removed. At least not upfront, as the first step of treatment.

He would need to undergo a special method of intervention called endoscopic ultrasound scan guided biopsy, a method to obtain a small amount of tissue from the mass in the pancreas to see what type of cancer it is. Simultaneously, by a procedure called ERCP (Endoscopic Retrograde Cholangio Pancreaticography), a stent needs to be placed in the bile duct that was being obstructed by the pancreatic mass, causing jaundice. Based on the type of cancer, he will need preoperative chemotherapy (neoadjuvant chemotherapy) that may or may not result in reasonable shrinkage of the tumour. If there is response alone, a surgical removal of the pancreatic mass would later be possible.

Then came the selling part of the care. In fact, it had begun as soon as they stepped inside the hospital where my clinic was. They had to pay a fee of INR 500 (INR five hundred only) for this consultation to happen. That was the cost paid to even see me!

Fear of suffering and death

Now that he knows that he has an aggressive tumour in pancreas in which all treatment is but a way of buying little extra time, rather than any scope for healthy longevity, he was a broken man. He cried in front of me and in front of his entire family. Fear of death and suffering is so real. I tried to console him saying that we will guide him well, keep him as pain-free as possible and help him go through this difficult phase of life.

Pain of the cost of care

When his family asked about expenses for this care in my private sector practice, I told them that the initial endoscopic procedures, biopsy and stent placement for jaundice could cost around INR 3 lakhs. I could see an unpleasant surprise in their eyes and body language. I advised them not to borrow for care and that the same care is available at Government Mohan Kumaramangalam Medical College Hospital where all such facilities are available. His family showed the usual lower middle class hesitation in considering care in a government system. Fear of apathy in the care process (though not always true) and fear of government sector not matching up to private sector in the procedures themselves were showing up in the conversation that followed. These are the common fears that push our patients to borrow beyond their means to provide private health care for their relatives.

It is better to be poor -the middle class suffering

The poor are spared. They have no choice but to reach out to government sector health care. The upper middle class are usually insured for private health care and the rich (though really few in number anywhere in India) can buy Indian health care anywhere.

**Private health care and medical tourism- “so-called” pride of India**

India’s private health care is being praised as high in quality and very affordable compared to that available in Europe, the UK or the USA. Indian governments, whether the Union government or the state governments, take pride in offering low cost, high quality care for foreign nationals in India’s growing private health sector. Such hospitals and doctors are seen in high esteem by the political class and business class of India. But, for vast majority of Indians, who are either lower middle class or poor, access to such care is lacking.

Political expediency, not the real solution- Public insurance giving private care

Poorly conceived programs like public-private partnerships and provision of high cost health care in private sector for certain illnesses in private hospitals are advanced by governments which seem to have no awareness of where the root of the problem lies. It looks politically expedient to do such showmanship than provide real long term solutions by strengthening the public sector. All government insurance programs, whether they are PMJAY or CMCHIS of government of Tamil Nadu, put public money mostly into private sector hands and further weaken the public sector health care.

Talking about cost while children listen

I was looking at the patient’s granddaughter, a child who was 10 years old, wondering what she will think of this conversation as. What does it teach her? That we are able to sell a care process to a suffering man at the weakest moment of his life! What values are we (including me) teaching this young girl about life? We are probably showing her at a tender age that money is more important than anything to go through life. Is this the value we want to pass on to our next generation? Question loomed making me silent and withdrawn after they left my office.

Lessons from a young woman with blood vomiting

Mrs. Keerthana a 24 year old woman and mother of a 1 year old kid, suddenly started vomiting large amounts of blood as she was feeding her child in chawl they lived in Mumbai. Her husband, a daily wage labourer in Mumbai took her to a hospital near by where she was stabilised, was diagnosed to have “Extrahepatic Portal Vein Obstruction (EHPVO) and then given a referral to see a senior multi organ transplant surgeon at a private hospital in Mumbai. She was also diagnosed to have Protein-C deficiency, a condition that leads to excessive and unwarranted clotting of blood vessels in her body. In her case, portal vein that takes blood flow to liver was blocked. They were scared of the expenses that will ensue. They knew that one of the city’s public funded corporation hospitals, KEM hospital would offer them care at no cost. But decided to travel to the comfort of their home town, Salem to have the family’s support in this difficult time.

Keerthana’s family knew, Dr. Devaprasath, Pediatric Cardiolgist of Sri Ramakrishna hospital where our team serves in Coimbatore. He called up to ask if there is a surgical procedure that would help and to say that they cannot spend much.

When we saw her in our clinic, we saw a thin built woman who desperately wanted to live and was very scared that another episode of such blood vomiting would kill her. EHPVO, from which she was suffering occurs due to blockage of a large blood vessel called portal vein which drains blood from spleen and intestines into the liver. This blood vessel supplies 80% of blood inflow to the liver. Portal vein’s blood carries nutrients absorbed by intestine and insulin/glucagon produced by pancreas to the liver. When this vessel is blocked, blood from spleen/intestines goes back to heart via alternate channels in our oesophagus and stomach. These tiny blood vessels are not designed to carry that much blood (about 1.5 litres/minute) and so rupture causing blood vomiting.

Our medical gastroenterologist, Dr. Murugesh promptly performed an upper GI endoscopy for Keerthana and found large, high risk oesophageal varies with signs of recent haemorrhage (SRH). He performed endoscopic variceal band ligation (EVBL), a procedure that would help prevent another immediate episode of blood vomiting. Our clinical assessment informed us that she will benefit by an operation called “Proximal Spleno Renal Shunt (PSRS). In this operation, we remove the spleen, mobilise the splenic vein from the pancreas (to which it is closely adherent) and connect the splenic vein to the left renal vein (which takes blood from left kidney to the heart). The operation will decompress the portal blood flow into the left renal vein thereby preventing further episodes of blood vomiting. Alternate option is to perform endoscopic procedures repeatedly over several months. Such treatment will not allow Keerthana to undergo recovery quickly and will mandate multiple hospital visits, sometimes with only an incomplete recovery. In our practice, we believe that PSRS provides a highly reliable one time surgical procedure for this condition, allowing patients to return to their job/place of work/reunion with family very quickly. We have seen that PSRS operation results in reduction of costs as it is a one-step procedure. The alternate endoscopic treatment is associated with repeated hospital visits, tests done every time, multiple procedures/their associated costs and loss of working days for the patients and their family members who accompany them to hospitals.

The operation would cost a substantial sum of money for this poor family. We advised them to go to the surgical gastroenterology service of Government Stanley Hospital at Chennai where the operation could be done free of cost. But, Keerthana and her family told us that this was their last destination. They were tired and sick of running around. They were scared of the long waiting times in government systems. And, we knew that she had a surgically curable condition. We accepted her for the operation which was successfully performed by our team. Lead surgeon for this operation in our team was Dr. R. Jayapal, whose training at AIIMS, New Delhi gave him a substantial exposure to this rare operation. The hospital supported her by waiving all fees for all the operating surgeons and taking only the bare minimum cost needed to care for her. Keerthana made an uneventful recovery and has now been discharged from the hospital.

We spoke to her family to ask as to how they managed to pay the bills that were minimum due for the hospital. They had borrowed money for 60% interest! We were able to return about 20% of the sum paid by them luckily.

Lessons we learnt

Private health care is expensive. I increasingly find a lot of private hospitals and doctors working there who understand and support the plight of patients who are financially marginal.
People chose to undergo operations in private sector not because they can afford them, but for many social reasons, that include long waiting time.
They borrow substantial amounts of money for care.
Interest rates for borrowing are obscene in our country even in year 2023. In Keerthana’s case, interest rate was 60%.
Family would take about 2-3 years to repay this money.