July 2008

The Long Goodbye

A School of Medicine student learns a hard lesson advocating for a patient in India

By Vaani Garg, M09

This morning at 5:14 a.m. my phone rang. It was Didi from the children's center. In Hindi, she asked if I could come to the hospital. "Rahul's condition is very serious," she said.

It was dark and ominous as India seems to be in the early mornings, with few street lights lit and many random men walking aimlessly. I knew I would have to wait 45 minutes until it became light out before I ventured alone in a rickshaw through the red-light district.

Illustration: Daniel Chang

I quickly dressed in a sweater, long pants and juttis (shoes) to keep warm and waited on the main road. When I finally reached the hospital, Didi was standing outside to receive me. Rahul, the child of a commercial sex worker, had been living at Saheli, the nonprofit center where I was working, to get treatment for his illness. When his condition worsened, I was the one who had taken him to the hospital.

Didi told me that Madam, the head of Saheli, was also coming.

"I'll wait," she said. "You go upstairs."

I climbed five flights to reach the pediatric ICU, where I frantically searched for the pediatrician covering Rahul. I explained that I was a medical student from America working at Saheli, and I asked what the situation was. He began to explain.

"Rahul's condition was very serious when he arrived yesterday. He has been sick for a long time with measles, and at some point, he developed severe pneumonia. He was already very malnourished with stunted growth; he looks much too small to be five years old. We tried to give him oxygen, but he kept tearing the mask off his face, shaking his bony head side to side. He kept asking for Thumb's Up to drink. In the night he had difficulty breathing, so we intubated him. He went into cardiac arrest; we started chest compressions. . ."

At some point I realized what I was listening to. I was in the middle of the speech that doctors give to family members when a death has occurred. Still I listened with hope. "We were able to bring him back for a bit but he is so small; his condition was very bad when you brought him in yesterday. . ."

My mind spinning, I asked, "What is his condition right now?"

"He is no more."

"I'm sorry, is he dead?"


I kept agonizing over how I could have let this happen. Why did I not insist that we hospitalize him sooner, on Tuesday when I first saw him? He might be alive right now.

But we went to the doctor, and I am just a student, and the doctor changed the antibiotics and said come back tomorrow. Then on Wednesday, when I held Rahul in my arms, his heart pounding above 100 and his breaths double the normal, I pushed for him to be admitted.

We went to another doctor, and he did the same: changed the antibiotics, ordered some tests and sent us home. He even knew that Rahul had pneumonia because I told him to listen to the lungs, that I heard crackles and maybe felt a consolidation.

They are doctors, not students! How could they have let us go home? I was furious, frustrated and ashamed at the same time-furious that this occurs in America also, frustrated by the complicating factors of a child of a commercial sex worker in India and ashamed that I did not do enough to help.

I walked into the room where Rahul lay wrapped in a pink and purple fleece blanket, the tube still in his mouth outlined by some blue dye to soothe the angular cheilosis. I lay my forehead on Rahul's chest and whispered, "I am so sorry."

I felt the powerful hand of Madam on my back, urging me to control myself and pull away, but I had to tell Rahul: "I am just so sorry." I closed his eyes tight and walked out of the room.

Final Destination

Some time later, we reached a remote part of Pune by van, passing Rahul's mother and father traveling by foot to meet us. There were several small buildings, tan walls stained with betel nut and dirt, and a few families squatting on the grassy areas.

We parked at the beginning of a long ramp leading up to an open room. Rahul's father and Madam's husband removed the boy, still wrapped in the pink and purple blanket, from the van and placed him on a cold, green metal stretcher.

The two men carried the stretcher up the ramp to the room where the ceremony was to be held. Rahul's father disappeared for a while. He reappeared dressed in a simple white dhoti, resembling a thin toga split in two pieces.

He sat with a pot-bellied man wearing a smooth white undershirt interrupted only by a white string traversing his chest from one shoulder to the other hip. This string signified that he was a priestly man. Another man joined the two already seated around a small fire, bringing his betel leaf plate and mixing the atta (flour) and water within. There was a smaller leaf bowl with five long cylindrical collections of rice.

I kept wondering where and how Rahul was going to be cremated. The father stood up, taking the balls of prepared atta and rice over to Rahul, who lay on the stretcher. He tore off some rice and placed it in the boy's mouth, in his two nostrils, over his two small eyes and inside his tiny ears. He then positioned one atta-rice combination on Rahul's forehead, one beside each ear, one on his chest and one over his neck.

The father then was instructed to pick up a mutka (clay pot) filled with water and place it on his shoulder. Madam's husband was called to hit the mutka with a sharp stone, piercing a hole in the pot so that a stream of water perfectly and smoothly sailed out of the back side.

The father walked around the pale green stretcher, the water splashing on the ground behind him as he moved. Again, the rock hit for a second hole. He slowly circled again with two streams softly pouring out from his shoulder. Again, the third hit and circle. He halted back in starting position, some words spoken in Marathi, and suddenly I watched him drop the mutka.

The shattering sound shook my whole body, and my eyes shot to the small pieces of clay and droplets of water covering the ground. My guess was that Rahul was now purified for the afterlife, and the divine bodies had been awakened to receive him.

The father and Madam's husband picked up the pale green stretcher with the small bundle of pink and purple fleece and carried it away, the women wailing Rahul's name in Marathi.

I was almost thankful that they were not speaking in Hindi, their words a jumble of sounds. Still, through the look of anguish on their faces and the shrill nature of their wails I could feel the true meanings. We watched the stretcher leave our room and enter another, the final destination.

Vaani Garg is spending 10 months in Pune, India, between her third and fourth years of medical school. As a fellow of the American India Foundation Service Corps program, she has been working at Saheli, a home/treatment center for children of commercial sex workers. This article first appeared in the Spring 2008 issue of Tufts Medicine.

Article Tools

emailE-mail printPrint