52 Seeing the whole picture

The Blind Men and the Elephant: When a group of blind men were shown an elephant, each touched different parts of its body. One said, 'It is like a rope'.

Others disagreed and said: "No! It is like a thick snake." "No! It is like a tree trunk." "No! It is like a fan." "No! It is like a spear." "No! It is like a wall."

The guide with a normal vision then told them, "You are all partly right but wholly wrong" and described to them the size and parts of the elephant.

Kannan, a 56-year old toddy tapper, went to a heart care centre for advice. Of late, he had developed chest discomfort while climbing tall palm trees to collect toddy. He had adapted to this disability by climbing on dwarf palm trees and delegating the tall trees to his son. On testing, he was found to have blood flow problems in the heart (ischemia).

Dr Shankar, a heart specialist of the centre, suggested that it is better to ask Kannan to stop climbing trees and manage his cardiac symptom with medications. A surgeon disagreed and asked Shankar, "What will he do for living?" "Why, he could sell some eatables in front of a toddy shop. He won't have symptoms then."

The surgeon laughed derisively and said, "We should do our best for this case. In

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similar cases, Western literature clearly says that surgical treatment is better than medical treatment. Only surgery can put him back on his job of toddy tapping." Some others agreed with this line of thinking. Anyway, they were badly in need of cases for coronary bypass surgery; an expert surgeon was due to arrive shortly to operate on cases and boost the image of the cardiac centre.

Kannan was operated and sent home. He came for a checkup ten weeks later. Dr Shankar spotted him and called him to his consulting room. "Kanna, How are you?", he asked. "Doctor sir, by God's grace, I have survived the operation and I am fine." "What do you do nowadays? Do you climb trees?" "No, sir, how can I do that?" "But, you were operated upon so that you can again climb tall trees once again and tap toddy."

Kannan replied, "Sir, you have spent so much money on me, operated on me; you have kept me in intensive care for two days and given me a new lease of life. I have had a rebirth. My life is now so precious. I can't risk it by climbing trees. I do not even climb the dwarf trees anymore."

Dr Shankar was bemused. "Then how do you earn a living?" he asked Kannan. "Sir, I sell salted peanuts in front of a toddy shop."

Comments

Dr B. Lown, the co-founder of International Physicians for the Prevention of Nuclear War, for which he got the Nobel Peace Prize, writes, "The focus of the (health care) system as it has become an industrial behemoth, has shifted from attending to the sick to guarding the economic bottom line, putting itself on a collision course with professional doctoring” (Lown B. 1996).

When economy of the health industry is the priority, holistic approach takes a back seat. After all, six "blind specialists" groping on different parts of a case generate much more income than a holistic physician identifying the whole problem with a proper perspective.

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Hippocrates said, "I would like to know what type of person has a disease more than what type of disease a person has.” This sums up holistic perspective concisely. The 'life world' of a person influences the disease, the care seeking process and even the healing process. Yet it is ignored by most physicians.

In a tertiary care setting, disease orientation is the norm and person orientation is the exception. Professionals like Dr Shankar, are gently told that they belong to 'family practice or something like that' and eased out of tertiary care setting.

This is a very unfortunate development especially in the third world. I have seen many persons with acceptable quality of life sacrificed at the altar of hi-tech disease care.

I have also seen asymptomatic teenage girls with small or medium sized "holes in the heart" undergo open heart surgery to close the holes. Left alone, these rural, semi-literate young women from orthodox families would have got married, settled in life, produced children and may or may not get into late complications after the age of forty. They could have been followed up and if necessary, operated later around the age of thirty years. But they are treated like young women in the West and therein lies the problems they face in their life-world.

Scarring them on the chest wall and the hospitalisation stigmatises them in their community. Some do not get married and continue to be a "family-burden.” Some others get married only to be scolded and sent back when the husbands discover the scar and the details of a heart operation concealed from him before the wedding. These young women also return to their parents and end up as a "family burden.” It is only a fortunate few who are well settled in life after undergoing such surgeries. Meanwhile, the heart centre will claim that 95% of the cases are "successfully treated" because, success in their paradigm means a well closed "hole in the heart".

Should we focus on the hole in her heart or the whole of her life is a fundamental and complex query which needs a holistic approach. Hi-tech assembly-line medical care does not usually allow such debates. This has to be done at the primary care level by the family physician. If holistic perspective of a case suggests that a tertiary care procedure is not warranted, then such a case should not be allowed to enter the assembly line of a tertiary care facility. This is an ethical obligation expected of holistic primary care physicians.

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Where are such physicians? If you find one, engage him/her as your family doctor for life. Such a person will not trick you but treat you in a wholesome manner.

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Trick or Treat - a survival guide to health care

An insider's account of health care delivery system today. This book is meant to help the reader be aware of various tricks played on gullible persons seeking health care; to help women be aware of gender related risks in hospitals and know how to avoid harassment; to help activist learn to discuss the pros and cons of multifaceted health care issues; to help health professionals see the current health crisis from the client's viewpoint and learn to avoid litigation; to help administrators understand the complex nature of health care related problems and realize how synergy and co-operation among the key players of health care is necessary to improve the current dismal scene.