The Cost of Medicine

It is obvious that the patient is dying. She is 92 years old with “multiple medical problems”—so many that my tired intern mind can barely list them on morning rounds. “History of metastatic colon cancer, diabetes, advanced dementia, congestive heart failure. . .” But the family wants everything done—so we do our job efficiently and thoroughly. The attending physician recommends an MRI to clarify the diagnosis of the patient’s sudden limb weakness, and I write the order down, then initial it. It feels routine now, this mundane ordering of expensive tests with no questions asked about cost. No more do I feel the sense of wonder and amazement that suffused me when I first started working as a physician in the United States. Like “Medical Disneyland”—as many diagnostic and therapeutic rides as you want. And no lines in this amusement park, Sir! So I ordered them all, the MRIs, the CTs, the PET scans—this was larger-than-life medicine.

But for some reason today, as I order the scan and look into the hazy eyes of this 92-year-old lady with a dying body that all these thousands of dollars will not save, I think back to the boy.

While a medical student in India, I was on call one night in the ER (or “casualty,” as it is known in India), asleep soundly in a room that I was sharing with the intern, when we were awakened by loud knocking on the door. The government hospital could not afford pagers, so the system of choice was Ramappa, the orderly, who was sent to wake up physicians whenever there was an admission. The method was a bit alarming, especially at two in the morning, but it was foolproof—there was no “but my pager didn’t go off.” I woke up with my face and scalp itching. A few mosquitoes had made their way through little rents in the mosquito net and now in the dim light I could see them hovering around, replete and sluggish.

“What is it?” the intern asks sleepily.

“One boy has come to casualty, Doctor. He feels sick and wants medicine.” Ramappa had a talent for giving us no information at all yet managing to sound like he was imparting details that were clinically crucial.

We go to the casualty where a boy sits in the corner wearing a ragged cotton shirt a few sizes too big and blue shorts, the color beaten out of them. His bony legs are dry and scarred and his bare feet do not reach the ground as he sits on the stone bench. His hair is wispy brown, his eyes sad, and his belly protrudes below prominent ribs. This small front room is used as a waiting room but also, when things are busy, as an examination room or sometimes even for minor surgical procedures. There is no door—it was never designed for one with its wide archways and open windows—and the smell of disinfectant is not as strong here in the cool night air. Moths fuss around the bright lamp on the roof and there is the soft clatter of a bandicoot scurrying along the rafters. In the adjoining room, separated from this one only by a small corridor, coarse jute rope restrains a man to one of ten beds. He is screaming loudly in a psychotic rage induced by the atropine administered as an antidote to the insecticides he swallowed earlier today.

“Love problem, Doctor,” Ramappa had told me earlier.

On another bed sits Shivarama, the other orderly, who has been assigned to watch over the restrained man.

The boy just sits there looking at the moths. Now Shivarama lights a leisurely beedi—an Indian hand-rolled cigarette—and watches us as we try to talk to the boy over the screams.

He tells us he is from a nearby village and has run away from home to the city after his stepmother beat him again for the fourth time this week.

I see bruises on his arms, his chest, and his back— black and red, they look like he has been playing Holi—the festival where people throw colored powders on each other to celebrate the first day of harvest season.

“I have sugar problem, Doctor,” he says. The intern tells me to take care of this and goes to the next cubicle— another man has just been carried in after being hit by a speeding truck.

“I was taking injections for high sugar in my blood,” he continues in fluent Hindi, “and then my mother died 2 months ago and my father married again. She has two children, so there is no money for injections now.” He looks vacantly at the red-oxide floor. “I have been vomiting the whole day, Doctor, and now I feel like I will faint.”

I examine him gently, afraid to push and prod too hard, his bones seem fragile and brittle with malnutrition. I feel his pulse—it is rapid and thready. His mouth is parched and he has the sick sweet breath of diabetic ketoacidosis.

“Do you get enough food to eat?” I ask.

“She says it is better to keep the food for healthy children, Sir. So my stepbrother and stepsister get most of the food. Anyway, it will be all wasted if I eat because very soon I will die from sugar disease.”

As I examine him, I ask him how old he is.

“Eighteen,” he says.

The fountain of youth for this boy is disease and malnutrition— his growth stunted and his development arrested, he looks about twelve.

I check his blood sugar. It is 664. I cannot check his electrolytes because the lab has run out of supplies tonight. “My sugar is high, no?” He looks at me. “If I did not have the disease I could drink sweet, sweet juice every day isn’t it, Doctor? My mother used to give me the juice of fresh oranges sometimes, before she died. . . .”

I nod absently, worried about his condition. He is obviously in urgent need of fluids and insulin. “I am going to take him to the ward to get him admitted,” I call out to the intern. There is no one to help us with a stretcher so we walk to the adult ward, the boy shuffling next to me in exhaustion and thirst. When we get to the ward, the clerk tells me the ward is full. I can see, over his shoulder, people crammed into every available bed, some accommodated on mattresses in the narrow corridors.

I decide to take the boy to the pediatrics ward. “Say you are sixteen,” I tell the boy. I know admission criteria are strictly enforced and only patients under eighteen years of age are admitted.

“How old are you?” the admissions clerk asks the boy.

“He is sixteen,” I tell the clerk. “No, I want the boy to tell.”

The clerk glares at me, then turns to the boy again. “How old are you, I say?”

“Uh . . .” His big black eyes are wide with nervousness and fear of this big-city clerk and big strange hospital building.

“Answer my question, I say!” the clerk points a pen at the boy, irritated by this delay in the proceedings.

“I am eighteen, Sir,” the boy says softly.

“Then no admission. Sorry Doctor, you are bringing adult person here, we can’t admit him. He is adult,” the clerk says pointing the pen at the boy again.

I know that here, in these aging government hospitals that take care of India’s poor, bureaucracy reigns supreme. But I am angry with the clerk for enforcing petty rules when someone’s life is at stake.

“Listen here, this boy needs treatment soon, otherwise he will definitely die. There is no place in the adult ward and that’s why I brought him here.”

But the clerk shakes his head again. “No, no admission here, he is adult.”

“I don’t care if he is an adult!” I say, feeling frustrated and powerless. “If you don’t admit him I will speak to the medical superintendent and tell him that you denied admission to a critically ill patient.”

“You can speak to medical superintendent, he will say the same thing,” the clerk shrugs. “Either the boy will die, Sir, or if I admit him then the next child will die because we won’t have any place in wards.” He looks at the boy a little more sympathetically. “What can I say, Doctor, there are always more people than beds here. Sorry.”

We walk back in silence toward the casualty, which is near the main gate of the hospital. The long, paved road is quiet, the darkness punctuated by soft lamps on the side. There are occasional sounds of crows—they are waking up and soon it will be morning. The boy walks slowly, not talking, now and then wiping snot from his nose with a sleeve of his long ragged cotton shirt.

When we get to the gate, I hand him all the money I have in my pocket—50 rupees—about $1. He knows this will be enough only for a day’s supply of insulin, but his eyes light up and he takes the money with a soft “thank you.”

There is nothing else I can do. I watch him make his way through the big iron gates, past the waiting rickshaws outside. He waits for a bus to lumber past and then carefully, painfully, crosses the road. I watch him until he disappears into the shadows.

I feel sad and dejected and this surprises me. I see disease and suffering all the time—every day people die for lack of money for medicines and tests. So this unaccustomed sorrow feels strange, but, like a long forgotten blanket, it begins to comfort me. Any feeling, even sorrow, is a respite from the numbness I wasn’t even aware of until today. Then I realize that the soothing warmth of my sadness comes from this boy’s despair. The selfishness of this confuses and disconcerts me, so I put it out of my mind and head back to the room to get some sleep before Ramappa knocks on the door again.

Later that day a body is brought to the morgue by a police constable.

“We found him outside lying in the gully, Sir. It seems he drank many glasses of juice in that shop outside. Where he got the money from, I don’t know, poor beggar.”

I look at the boy. His legs are still scarred and his body is still bruised, but with his eyes closed and the smell of oranges clinging to him, he seems, finally, at peace.

Now, I sit in this air-conditioned ward next to shiny computers and smooth new tables. I try not to think of the boy as I order this test for a 92-year-old lady with a dying mind and a dying body, a $2000 test that would buy lots and lots of insulin.