The old man and his grandson

Recently I started serving in a rural clinic in Tiruvallur district, about 40 KM from Chennai. I like the ambience of the clinic. It is spacious, well ventilated, well illuminated and clean. The staff is very friendly. Any patient who comes there is made to feel at home. The consultation chamber is a big 20 feet by 20 feet room with my table and chair in one corner. There is a clear 15 feet distance to traverse to reach my table from the door to the room. Yesterday as I sat in that room seeing patients, an elderly gentleman walked slowly through the door. He was accompanied by a young boy who was holding his right hand. The old man had a wooden stick held in his left hand to support himself while walking. He had a prominent limp as he walked across the room to my table. The young boy was full of energy, but he tried hard and wore a serious look on his face as he accompanied the older man. The old man was focussed on me and was looking at me with full attention as he moved across the room. The boy was restless and he was seeing all around avoiding eye contact with me. 

"Please come and take your seat" I said to the old man. 

"It is my knee. It is paining very badly and I am unable to walk" the old man was shouting at the top of his voice. Elderly people who have reduced hearing often are unable to regulate the volume of their speech and end up shouting without actually intending to. He was wearing a thick pair of glasses which made his eyes look small and distant. He was staring into my eyes, but I felt that he could not see clearly, because despite the keen look his eyes did not connect with me. 

"When is the pain more? Is it more during the day or at night when you are lying down to sleep?" 

The old man looked at me and then shifted his gaze to the young boy. Then he looked back at me, 

"Sorry doctor, I cannot hear properly. Please tell my grandson. He will help me understand" 

I turned to the young boy. He did not wait for me to repeat the question. "He complains of pain throughout the day. Morning and night he suffers from pain" 

I moved my chair closer to the old man. "Sir, let me examine your knees carefully" I slowly and clearly spelled out into his ears without shouting. Often elderly people who cannot hear well, read lips and can follow if we speak slowly and clearly in a low pitch. This simple gesture greatly encouraged the man and he smiled at me and agreed to have his knees examined. Both the knees let out creaking noises on movement. They were both degenerated and severely arthritic. 

"I will give you some pain killers for now. We may have to work on some physiotherapy for your knees" once again I spelled this out slowly and clearly into his ears. He understood and nodded his agreement. 

It was a Monday morning and I was surprised to see the young boy in the clinic on a school day. "Why are you not in school?" I asked the boy. 

"If I go to school, who will bring my grandfather to the hospital?" Mixed with a maturity way beyond his youth, I could also sense sadness in the young boy's voice. 

It is not often that we see such beautiful relationships between grandparents and grandchildren nowadays where a young grandchild takes responsibility for the health and wellbeing of the grandparent. I learned that the grandfather was a labourer at a nearby brick kiln. They had immigrated from a nearby district and had come for the manual labour in the kiln. 

"I was unsure of how we were going to make it when both his parents died in a terrible road accident 5 years ago." said the old man with tears in his eyes. The child was orphaned in one stroke and the two of them are the only support for each other. The old man, despite his aging body and frail physical condition was trying hard to somehow put some food on their plates. They would work in this kiln for a few months and then move to another one. The boy did not have a permanent home, school or social circles. 

After giving medicines for the elderly man, I sat down to talk to the boy. He was walking barefoot and there were multiple lacerations, blisters and wounds over his feet. When I asked him about it, he dismissed them saying these are common among people who work in the kiln. The young boys and girls (who have come to live in the kilns with their parents who are laborers there) who have nimble bodies and small hands are preferred to run in and out of the kilns through the high temperatures to carry small objects in and out. They are not officially 'employed' in the kiln. They get to go to the local panchayat school. But they also have to help out in the kiln. He said there are many other boys and girls like him in the kiln who have such burns and blisters due to the heat. 

Long after the clinic was over, I found myself thinking about this old man and his grandson. The boy, all of 13 years, had grown into an adult with care giving responsibilities. The injustice of this whole situation broke my heart. I was helpless. I was thinking of all possible ways in which I could help this boy regain his adolescence and support the old man. There was no situation in which I could see them both together and living in comfort. The boy had to go to residential hostel for education and the old man to a care home for the elderly. Neither of them were ready for such a separation. The separation would be inevitable, and may have to be negotiated slowly and carefully. Sometimes the complexity of medical practice is not just the biomedical challenge, but the social challenges like these, which need a sensitive and compassionate approach.