Deepavali induced pressure on patients

 

Deepavali is a complicated time of the year. It is marked by overcrowded textile shops and shopping centers and the inordinate traffic jams on roads. People from all over Tamil Nadu try desperately to get buses and other transports to reach their hometowns to be with their family for the festival. When I was growing up, we used to carry boxes and baskets of sweets and savories and visit friends and relatives wearing our new clothes. An essential part of Deepavali would be elaborate discussions on the new sarees and dresses that were worn on that day. Today there are very few visits to friends and relatives, but these are replaced by photo ops which are shared on social media. 

 

Deepavali has always been a commercial festival. As a child, I remember the social gradient in school, when all children would be allowed to wear and display their new clothes on the day after Deepavali. The dresses, the designs, the colors, the shine of the clothes would be so different for different people. Belonging to a middle-class family where clothing and appearance were not given much priority, the most shining and good quality dress in my wardrobe would be the school uniform. Everything else was essential simple clothes. My brother and I would get the same shirt and trousers because it was just a large bit of cloth bought and stitched into two shirts and trousers. I remember one Deepavali, the Physical Education teacher commented on my brother and my clothes as “cheap”. It did not even bother us those days. But the difference between us and the other upper-class boys and girls in the school who would wear fancy designer clothes with shining shoes was hard to ignore. Though we were the bottom of the social rung in that upper class school, we did not realize that being in that school itself was a huge privilege. We were never exposed to the life of our contemporaries in government schools, compared to whom we were royalty. There was a kid whom we knew, the daughter of our rickshaw puller. She used to come and play with us at our home. Parameshwari was a very cheerful and happy kid. Our parents would buy her similar clothes as us during Deepavali. But we had no clue what things she had to go through in her government school. At some point when my brother and I were progressing to higher secondary school and careers, Parameshwari dropped out and most probably got married. We did not stay in touch beyond that. 

 

We also had to bring sweets and snacks from home and share it in class. The standard Deepavali fare in our home would be Rava laddoo (a type of sweet balls made with sugar and milk of wheat) and Thenkuzhal (a type of savory made from rice flour deep fried in oil). It was not anything fancy, and our parents would pack a small quantity in each of our boxes. But then others would bring big boxes and bags of sweets of different varieties and distribute it to everyone. Sweets made of dry fruits like cashew nuts and almonds were a rarity those days in middle class households. But the rich kids would bring them and flash their richness! These differences were not lost on me. I always knew Deepavali to be a commercial festival that widened social inequities. 

 

I had work on Sunday prior to Deepavali and was in my rural clinic seeing patients. I had a very strange encounter with a middle-aged lady who had come to get treated for her knee pain. Mrs. K walked into the clinic with a dark red saree with bright green floral patterns on it. She had oiled hair that was parted in the middle and with a bright dot of vermillion applied on the parting. I have observed an interesting practice in middle aged women in our area. They mix up a little talcum powder with turmeric powder and apply it all over their face. When talcum powder is mixed with turmeric powder it attains a lemon-yellow color. The mixture when applied on the face gives a very faint yellow tinge to the skin, which is neither the traditional yellow hue of turmeric nor the white color of talcum powder. When I first saw it, I got confused, but then one of my patients clarified it. Now I know what the lemon-yellow color means, and it doesn’t confuse me anymore. Mrs. K had this lemon-yellow hue on her face and had a huge red vermillion dot on her forehead. 

 

“Vanakkam…” she greeted me with a broad smile and sat down. 

 

“Vanakkam, please tell me what brings you to the clinic?” I asked. 

 

I am used to some patients telling me long drawn stories about their illness, sometimes starting from several weeks ago, capturing every significant milestone one by one and arriving to the actual complaint. Mrs. K had a long story too, but it was not related to her illness at all. She was talking about preparations for Deepavali. I wanted to be polite to her and so kept listening for some time. The story started from saving money in a local mutual fund where she had to invest 1000 rupees each month for 12 months. At the end of it just before Deepavali, she would get rice, lentils, sugar, jaggery, cashwes, spices, crackers and some clothes that she could use for the celebrations. She then spoke about her son and daughter studying in the city and how they are arriving only on the day prior to Deepavali. The story went on and on. At one point, I started losing patience and said, “Can we talk about what is the problem for which you have come today?” 

 

“Ohh that…sorry I completely forgot. I want you to give me something for my knee pain so that I am fit for celebrating Deepavali with my family tomorrow. Whatever medicine you give should work so well that I should be able to prepare all snacks for my kids and enjoy firecrackers with them. I should also be able to walk to my neighbors’ houses in my new saree so that they can see it. Also, I should not have any side effect. Your treatment must be quick and must last throughout the day tomorrow and the day after.” 

 

Something about what she said did not sit well with me. I am not sure if it was her tone, her demand to ‘fix her knee pain quickly’ for Deepavali, or the way she was explaining what she wants. I was very close to telling her off by saying “this is not a mechanic shed where we service cars and motorbikes” or some such rude thing. But I controlled myself. My mind was confused. We talk about incorporating patient preferences in treatment and shared decision making. I have spoken about this in my classes when I was a teacher. But I was not at all prepared for what Mrs. K asked me to do. On one hand my understanding of osteoarthritis of the knee and its treatment prevents me from making such unrealistic promises of ‘fixing her up’ for Deepavali. On the other hand, that is precisely what Mrs. K wants, that is the ‘patient preference’. I understood that Mrs. K was not wrong in expecting this and demanding it from me. It was my job to tell her what is realistically possible. I sat with her and explained that such magic remedies are not available, and we discussed going on some pain killer medicines and long-term care with physiotherapy. Mrs. K was very unhappy with me. I was sure that she was going to go to some other physician nearby with the problem. I have seen how local practitioners bombard patients with high doses of steroids which can magically reduce the pain temporarily but harm the health of the patient in the long term. Mrs. K would probably consider me as someone who did not satisfy her requests. But I had a job to do and to do it properly. 

 

Commercial festivals like Deepavali not only widen social inequities, they also put pressure on patients to quickly fix their problems and be ready to participate in them. This was the first time I encountered this Deepavali induced pressure on people with chronic conditions. Everyday there is something new to learn in primary care.