A Luxury Called Health. A doctor’s journey through the art, the science and the trickery of medicine. Kavery Nambisan. New Delhi, Speaking Tiger, 2021. Paperback. 305pp. `599.00. ISBN: 978-9354470691.
Dr Nambisan has gained well-deserved fame from her work as a surgeon in rural clinics in Bihar, Uttar Pradesh, Tamil Nadu, Maharashtra and Karnataka and in her present clinic in Kodagu—the district from which she derives her origin. Her ethics, concern for her patients (most of whom are poor), surgical skills and the manner in which she successfully overcame the many handicaps in a series of rural public sector clinics make her a role model. The other equally admirable person who comes to mind at once is Dr Taru Jindal who worked in Motihari in East Champaran and Masarhi, both in Bihar.
Dr Nambisan has another and equally prominent feather in her cap. She is a reputed author of fiction with several acclaimed novels to her credit.
The volume under review has two facets. The principal title suggests a commentary on health—which remains a luxury for the vast majority of our countryfolk. The second is an autobiographical account of her personal experiences as she moved from her parental homes in Kodagu and Delhi to St John’s Medical College in Bengaluru as a medical student, travelled to Britain to obtain her Fellowship of the Royal College of Surgeons and then returned to serve patients desperately in need in neglected parts of our country.
The reader must be prepared to shift gears as pages are turned as Dr Nambisan moves from one to the other facet.
Her initial experience with the lives of the underprivileged and the poverty of health facilities is described in Chapter 4 when, as part of her internship programme, she lived and worked for three months in Mandya district, north of Mysore. Already she was experiencing the curiosity and kindness of the villagers as well as the lack of sensitivity in city doctors treating them. The senseless cruelty when an ayah slapped local women ‘who proved difficult’ jolted her. Fear was evident in those awaiting treatment. Even as we learn of these assaults to her senses, we see glimpses of her own, inner turmoil. ‘I had begun to defy parental control from my late medical college years…How was a young woman to break free of age-old control systems and define her own life?’ The efforts needed to pursue a career in surgery against her father’s wish are revealing.
Experiences as a medical student and later, as a resident doctor in Bengaluru and in Britain make interesting reading. Let me quote one example from a conversation between her and English nurses and doctors. ‘There was spluttering laughter when I declared earnestly that girls from India were always virgins before marriage.’ There are several other chuckle-eliciting anecdotes.
An example of shift of gear is encountered in Chapter 9 when Dr Nambisan provides a review of the history of medicine under the heading ‘Ancestor worship’. A nugget I uncovered here is the statement that Dhanvantari—deemed the god of healing in India—died from snakebite as there was no one with the skill to treat him.
Her final viva voce examination for the fellowship of the Royal College of Surgeons was made memorable by her being asked about the diseased thyroid gland. She provided details described by Dr Hilary Wade in her publications in a manner that evoked admiration in the examiner. It was only later that she uncovered the identity of her examiner—Dr Hilary Wade!
Another shift in gear is noted in Chapter 21, when she describes a few of her medical heroes—contemporary and from the 19th century. A lesson she learnt from one of her colleagues needs repeated emphasis: patients are often wiser than doctors assume. A corollary—illiteracy does not imply stupidity. On the contrary, the illiterate have, of necessity, highly developed survival skills.
It was in Liverpool that she married the young man who had been a year senior to her throughout their student days at St John’s—Dr K.R. Bhatt. Despite the fact that this marriage lasted 18 years, we learn little about him except for the fact that he switched careers to become an anaesthetist while in Vrindavan. The merest hint of what was to follow is encountered on pages 94–5. Nor do we learn anything of their daughter, Chetana.
We are, however, provided some intimate details of her beliefs. ‘I have never been religiously inclined. Perplexed by the tenets and contradictions that come with every religion, I have tried to keep a safe distance from matters holy. I live with my impiety, in closeness with religion.’
Her work in Mokama, Bihar is described in Chapters 12 and 15. An important lesson was learnt here. At an interview for doctors to work in the local hospital, the sister in charge of administration asked each applicant their caste. When Dr Nambisan objected, the sister explained, ‘We prefer doctors from lower castes. Job opportunities of this sort are limited for them, which means they are less likely to quit…’ After her second stint in Mokama, she concluded her analysis of her hospital thus, ‘…it was certainly managed very well. But the soul seemed to have gone out of it…’
Between these two stints, she worked in Vrindavan (Chapter 13). It was here that she started her literary career.
As she starts Chapter 14, we read: ‘Between the previous chapter and this lies the period when my first marriage soured and ended…’ She married poet and author Mr Vijay Nambisan in 1994. Soon after, they lived in Madras, where she worked in a five-storeyed private hospital. Her experiences shook her. The account of the young man who had suffered a road accident provides a graphic and tragic example (pp. 133–5). It is surprising that she was able to continue working in this hospital for 15 months. Almost in passing, we learnt of her brief encounters with Ms Jayalalitha and Ms Shashikala (though they are not named in the text).
Her move after the second stint in Bihar was to Vijay’s home state—Kerala. Described in the short Chapter 16, it describes the problems in a small, privately owned rural hospital and the encounter with the ‘uncouth, lumbering giant’ who was the son of the owner and contributed to her decision to move on.
Chapter 17 is titled ‘The rural hospital’ but it also contains a revealing description of the treatment of her mother in ‘one of the best hospitals in Delhi’. The hustle and bustle in such hospitals is conducive to tragic errors. Dr Nambisan was fortunate in being able to prevent a disaster in her mother’s operation for swelling of the thyroid gland (p. 152).
Dr Nambisan’s descriptions of simple, rational and inexpensive steps that can make any hospital an oasis are, unfortunately, neglected by those designing five-star hospitals. The fundamental principle—hospitals exist for patients—is honoured only in the breach. Hellish experiences for many poor patients are inevitable consequences.
She describes her own experiences in rural centres with equanimity. ‘I have been assaulted by a drug addict, threatened by criminals, solicited by drunks, abused by idiots who think they have the right to exclusive treatment, belittled, abused, flattered and offered genuine gratitude. The occasional moments of mirth more than make up for the darker moments.’
Her description of ‘Unbanked direct blood transfusion’— deemed illegal by some—is worthy of study (p. 157). The footnotes on this page enable the reader to gain a rational perspective.
The poet Kamala Das came to her rescue when she and Vijay were at a loose end. She got them posts at the Tata Tea Hospital in Munnar. Having lived briefly in the guest house of this reputed organization in that salubrious hill station, I understand well their experiences during their stay. Since they stayed there much longer, they also saw the officiousness that marred relationships between ‘high’ and ‘low’ society in that rarefied atmosphere.
An eye-opening experience during their stint in Lonavala (Maharashtra) was related to the faith placed by the poor in injections, intravenous fluids and ‘instant’ remedies. (See pp. 173–5 for examples.)
Lessons are also provided on how the poor cope with serious illness (pp. 179–84), the concept of the well-to-do of ‘the lowest common denominator’ (pp. 186–7), jobs that kill (Chapter 26), interpersonal relationships and the ill-consequences that follow mishaps in them.
A not-to-be-missed gem is found early on, in ‘Prologue’ (pp. 12–13). Full of enthusiasm at lessons she was learning on healthcare in Britain, she wrote three long paragraphs on a light blue aerogramme costing five pence and posted it. I can imagine the constructive suggestions in them. The reply was, at once, characteristic and saddening. I will not rob you of the thrill of reading Dr Nambiar’s account but can understand the smile on her father’s face when she narrated it on her return to India. He knew full well the egotism behind that rude response.
Remaining respectful of her choice on what to narrate to us, the readers, I cannot help wishing we could have learnt more of her parents, siblings and her first marriage from her. As it happens, we must glean with difficulty. A rare note on her father, Mr C.M. Poonacha, is to be found on page 31 and in the footnotes on this page. Another glimpse of him can be obtained on page 94. Such accounts, redolent of propriety that is scarce in high-ranking persons, can be salutary. Apart from the note on her mother’s operation on her thyroid gland that was almost botched up in Delhi, we gain another glimpse of her at the age of 90, when she broke her hip. The surgeon was astonished by her good health, which resembled that of her two sisters. Their older brother died at the age of 102 years. Perhaps the fermented wines commonly used by Kodavas helped (p. 219). On page 205, we note that her grandfather’s great grandfather was honoured by a statue in the heart of the town of Ponnampet, where she eventually set up practice. (In the footnote here, she cautions us: ‘It is always better to take everything you hear or read about the antecedents of my people with an ample measure of salt.’)
As with the footnote above, others too are noteworthy. Consider her experience as a girl in high school: ‘I used to shed tears over the romance of the medical world in novels. I read those touching, at times over-sentimental worlds of A.J. Cronin, Richard Gordon’s madly aberrant tales of doctors’ lives and the veterinary tales of James Herriot which are as much about animals he treated as they are about the people who own them’ (p. 96). Another example: ‘Once at the bedside of an aged man the boss said, in all courtesy, “Mr. B…I have to put my finger up your back side… I hope you don’t mind.” “Oh, that’s all right”, came the quick reply. “Just be sure you don’t leave it behind” ’ (p. 160).
I could go on and on but I can already sense a frown on my editor’s forehead so will end with the most poignant chapters in the book (29 and 30). I withhold any observations on their contents for Dr Nambisan deserves your total attention as you read them. It is not from Dr Nambisan but from other sources that I learnt of Vijay’s eminence as a poet all over India. This fact alone makes these chapters invaluable.
The self-deprecating ‘Afterword’ (p. 304) is fittingly brief. As we read this volume, while we witness Dr Nambiar’s deep sincerity and valour, I failed to find any trace of deception or cowardice.
Department of Neurosurgery, Jaslok Hospital Mumbai, Maharashtra, India
How to Practice Academic Medicine and Publish from Developing Countries? A practical guide. Samiran Nundy, Atul Kakar, Zulfiqar A. Bhutta (eds). Springer Nature, Singapore, 2022. 465pp, price not mentioned (Open access). ISBN 978– 981–16–5248–6.
When I was a postgraduate student in the 1980s, there was little to be found to help a young postgraduate practise academic medicine, leave alone conduct research efficiently and write his or her thesis in the expected manner. Some of the guides were equally clueless about what constituted a reasonably well written thesis, or if they knew, were unwilling to share their knowledge. That scenario has changed completely, and any postgraduate can choose from a wide range of ‘how to’ books describing every aspect of a thesis, from selection of the topic right until it is published. And so, when I first read the title a groan escaped my lips… oh! no, not another one. That was only till I looked at the name of Professor Samiran Nundy and asked myself why would he want to write a book to add to the overflowing number of titles on the topic? I casually glanced at the contents and the moment I went through them, I knew that this was something very different. Drs Samiran Nundy, Atul Kakar and Zulfiqar Bhutta were motivated to write this book as a response to try and address some of the reasons for the poor quality and quantity of research coming out of South Asia. In ‘Why this book?’ the three editors make a compelling case for the need to practise academic medicine in letter and spirit and to ask questions that need to be asked and answered in our context, if we do not want the dismal status quo to continue.
The book is 465 pages in length and is compiled in such a manner that whether a reader is a novice or an expert, they will be equally drawn to the manner in which all the topics are presented. Going through its contents has been such a pleasure, for even a jaded academician like me, as the book is written in an appealing fashion, in simple English sans jargon whenever possible and explains complicated concepts in a manner that is easy to understand. I am always partial to cartoons and a bit of humour interspersed in textbooks wherever possible. This book has superb cartoons, one in each chapter to break the monotony and also a small apt quote at the start of each chapter. Perhaps the most attractive aspect of the book is the fact that each chapter is arranged like a lesson. In fact, anyone who has to take a lecture on any of the topics can simply use the chapter as its sole reference point. The flow of the chapters, the questions posed and answered, the simple schematic representation of the concepts all point to the fact that there has been meticulous planning in constructing each and every chapter.
As we know academic medicine goes far beyond research methodology and scientific writing, and the book does not disappoint. In the early chapters of the book there is a lot of information suited for mentors and young faculty members of medical colleges. The authors do not hold back in listing the woes of medical research in developing countries. However, they also provide a clear direction for those who are willing to listen and act on advice.
The book is divided into ten parts with each part having one or more chapters. The part on ‘How to plan a study?’ covers all aspects of research methodology including biostatistics and the ethical aspects of research including research misconduct. The part on ‘How to write an original research paper?’ describes almost everything one needs to know about scientific writing. Though I use the qualifier ‘almost’, I could not think of anything that has not been described and discussed in these chapters. The chapters on statistics have been set out brilliantly, starting from types of data to calculating sample size to interpreting statistical tests. The ‘How to write other journal articles?’ part covers all types of articles including case reports, reviews, etc. The book also gives tips on poster presentation and oral presentation which I am sure someone preparing for a presentation will want to read and follow.
As one who is interested in medical education I was happy to see the part on ‘Education, planning and execution’. This describes various aspects of teaching–learning, from bedside clinics to e-learning, various assessment methods and a beautifully apt piece on how to prepare a lecture. The section on ‘How to conduct a journal club?’ was such a refreshing read as I have personally witnessed journal clubs that are a far cry from what is intended in one. I only hope that those who read these sections act on the wisdom that is offered in the book. It is obvious that the deep understanding and knowledge of the plight of academic medicine in our country has urged the authors to do something about it. The chapters on medical records, clinical audit, clinical trials, etc., are like the icing on the cake and clinicians in the many medical colleges will definitely benefit by the simple guidance provided in the book.
The only aspect of the book which disappointed and mildly irritated me was the foreword by Richard Smith, which to me lacked focus and seemed rather lackadaisical. Try as I did, I could not find any aspect of the book which I could criticize or felt could be presented better. I would certainly endorse this book for all doctors, whether they are in academics or in private practice, as there is something here for everyone. It is an inspiring work of erudition, written by three people who have a deep understanding, insight and an overall comprehension of the layered, nuanced and often paradoxical issues academicians have to deal with on a daily basis in this part of the world. I would encourage every faculty member, postgraduate and library to own a copy as it certainly is a value addition in this area of scholarship.
All India Institute of Medical Sciences Sijua, Patrapada Bhubaneswar, Odisha, India