Approaching the main hospital buildings I could hear the low murmur of many voices, though there were few people to see. Vincent guided me up a small wheelchair ramp, following signs indicating ‘OPD’ - the Outpatient Department. Despite my distinctly unstable stomach, already sounding orchestral, I was looking forward to this. Cambridge had been turning me soft, so the challenge of a rugged Third World clinic was something I relished.
It was as we rounded the final corner I almost changed my mind. The low murmur had now become an unbearable din, hitting us hard the moment we entered the patient waiting area. The place was jammed with people, an immense mass of them. There must have been at least 300. A clinic in the UK would be regarded as big if it saw more than thirty. Men, women, children, crutches, wheelchairs, even a few patients crawling. It seemed as if all humanity had descended on Padhar that day. Vincent’s advertising would have done credit to a major conglomerate, so excellent was the response.
It was impossible for me to deal with every case, particularly working through an interpreter. Hindi and Gondi are the local languages. My abilities in either tongue are appalling. An interpreter may seem a good idea but frequently loses those little nuances of expression that are so important to a doctor. Patients often tell you they are well when, in fact, they are as sick as a dog. Particularly so when they have some ghastly sexual problem. To make the best of a clinic, you have to speak the local language, preferably like a native. Clement Moss could speak six of the things with an accent that was indistinguishable from the original. I can barely speak my own.
Women struggle to be heard in Padhar, despite the heroic efforts of Vincent’s wife, Meenakshi, to raise their profile in Indian society. That first clinic showed me how far they have to go. A large, overfed woman perched herself precariously on the patient’s chair to one side of my desk.
‘Namaste - hello,’ I said, hands clasped firmly together in prayer like fashion as welcome. With this one word I had already exhausted my knowledge of the local tongue. The woman did not move. She simply looked at me - a vacant, expressionless stare, half smiling. Perhaps I had tried the wrong greeting, I thought. Never mind, there was a job to do.
‘What is your problem?’ I asked, now in English. I had given up with the interpreter as I had caught him asking a patient the World Cup football score instead of taking details of a painful hip. ‘Is it your knee?’ I added. There was a fair chance this would be so.
Vincent had known of my interest in the joint and had advertised widely.
‘Oh yes, doctor. It is her knee,’ came the reply. Only it had not come from the patient but from some distance away. I glanced around me. The consulting room was bursting with people, more than fifty in its tiny area, hundreds more milling outside. Orderly queues did not exist and appointment times were a forlorn hope. The rules were simple - every patient tried to be first. A clinic auxiliary would attempt valiantly to keep order, but was frequently flattened in the rush. Through all of this he would maintain a calm, controlled exterior, plying me with soft drinks and tea whenever I looked overcome. He was a lifesaver that man. Once a patient had made it into the consulting room, his next task was to find his way to the chair beside my desk. That might mean elbowing dozens of other unfortunates to one side. Crutches were ideal. When in trouble they could be used as spears. Plaster casts also made vicious clubs for fighting your way to the front.
So it was that day as I searched through the morass of bodies, trying to identify the voice. From somewhere in the middle of the crowd I could see a small, dark head bob up and down - jumping up on its toes, trying desperately to be seen. I could tell it was a man, not a big man, but unquestionably he was trying to attract my attention. ‘Her knee, doctor. Her knee. Pain,’ he shouted, his arm waving frantically above the heads of his fellow patients. Then, slowly, at times forcefully, I saw him push his way through the bodies to reach the side of my desk. He collected dozens of irritated glances as he moved. ‘My wife,’ he added as he breathlessly gained his destination, pointing to the large, silent, motionless creature in the chair. ‘My lady wife.’ I learned then that most consultations with women took place through their husbands. No matter that you might seek information on menstrual cycles, piles or vaginal discharge, the husband answered all.
Women also appeared to have a raw deal in marriage. I confess to a small degree of male chauvinism. However, rural Madhya Pradesh tested even my tolerance to the full. During my first weeks in Padhar, I noticed several women were admitted as emergencies with burns. Sirpandi Bai was one of them. She had awful injuries. As I walked into her small room, away from the main hospital ward, I could smell the rotting flesh. Sirpandi was a beautiful woman, what little of her I was allowed to see. Young, no more than twenty years old, with a delicate appearance. Her normally smooth face was now lined with distress and racked with pain. Her top half, above the belly button, was fine. Below that level was a mangled, infected mess. It took all my self-control not to vomit as I pulled back the single sheet to examine her. Apart from a small area at the top of her right leg, the skin was missing from the rest of her. Bright red flesh shone like a huge, bloody beacon. Small patches of black, dead tissue hung off her in thin strands, as green pus began to seep from several areas. The bed was stained with body fluids. Not urine, but serum secreted by the exposed flesh. The sight was horrific. Full thickness, infected burns affecting more than 50 per cent of her body. Sirpandi Bai would die for sure. Worse, she had no family or friends to sit with her. She was suffering her fate alone.
Sirpandi’s crime had been to marry without a dowry following her. It had been promised, but had never appeared. Arranged marriages still exist in Indian society and are largely very successful, but a dowry is usually agreed beforehand. There is unquestionably a business element to many Indian partnerships. Within months of the dowry failing to materialize, Sirpandi had sustained her terrible accident. Some would say it was bad luck, something that Nature had decreed, but Sirpandi was not the only one. During my time in Padhar I saw this fate befall more than six young women. Rumour had it new wives would be disposed of by fire if the dowry did not follow over the marital threshold. Rumour is not always accurate, but six cases says more than bad luck. Often at dead of night, the unsuspecting victim would be thrown on to an open fire, or her flimsy dwelling set alight. Petrol could not be used as this, of course, would be obvious murder. Rotting to death is not a pleasant way to go. Sirpandi died two days later. Overwhelming infection of the raw flesh, combined with kidney failure, were more than her young frame could take. Fifty per cent is a large skin area to destroy. Even professional burns units in the West would have had their work cut out to save her. This was dahej hatya, bride burning or dowry death, in action.
Life appears cheap if you are a Gond, particularly where children are involved. Mothers become used to losing one in every four to the ravages of local disease. If you reach sixty years of age you are doing well. People have simply become accustomed to death. This was brought home to me forcibly one day, when Vincent and I went to Bhopal to meet Louise. She had decided leaving her husband to his own devices in central India was unwise. Why shouldn’t she join in the fun?
That day, early in the morning, I met her at Bhopal airport. The place is like something from a Cold War spy novel. Battered rectangular buildings, largely deserted, watched over by bored security guards armed with dilapidated Lee-Enfield rifles. Each guard looked identical. Black, macassared hair painted firmly to a greasy scalp. A neatly manicured moustache decorated the upper lip while huge, symmetrical sweat stains dampened each armpit. Sleepily they would wave people by, whether or not they were boarding or disembarking the various rickety aircraft that landed from time to time. By then I had been working in the Indian jungle for two months and was totally accustomed to Indian life. Such a scene could have been repeated throughout the land at various key installations. I no longer regarded it as strange.
I wish I had taken my camera to record Louise’s expression as she sta
ggered down the aircraft steps that morning. I could tell she was overwhelmingly relieved to be alive. The airline had supplied its oldest, tattiest, rattliest airplane to fly her from Bombay. Her image of the country had been that of guidebooks, of Passage to India, or of Plain Tales of the Raj. Properly dressed in her Jaeger tropical suit, to be suddenly faced with the real, rural thing was a major shock to her normally tolerant system. ‘Darling, where have you brought me?’ was all she could say. ‘And look at you!’ I was now truly local, looking every bit the missionary doctor. Open sandals, battered khaki trousers and tatty shirt. I was also very thin, shabby clothes hanging from a bony frame. Gastroenteritis had attacked at least four times. Weight loss was a foregone conclusion. As I hugged my wife in welcome I could see one bored security guard perk up. For a brief moment something different was brightening his day.
‘What does she see in him?’ I could hear him think.
‘Wouldn’t you like to know,’ I was tempted to reply. Contrast in marriage is a good thing. I have always been suspicious of dating agencies that match like with like. It sounds terribly boring to me.
With Louise and me firmly wedged into the back of the hospital’s white, battered Volvo, Vincent drove steadily south towards Padhar. It was a single-lane road, more a track, full of potholes and hazards. You officially drive on the left in India, but it can take several days in the country to work that out. Blind corners, subsidence, fallen trees and reverse cambers are everywhere. Unlicensed lorry drivers, high on ganja, marijuana, try desperately to control their overladen charges, many of which physically capsize en route. This occasion was no exception. The Bhopal-Padhar road, if it can be called such a thing, is a lesson in survival. Should you meet anything coming in the opposite direction, you accelerate, hoot, flash your lights and generally play chicken. Then, in the final millisecond before disaster strikes, one of you steers from the road into the surrounding jungle. Vincent handled this alien driver’s environment supremely well. You have to be brought up in the land to understand it. It was he who broke the silence, as Louise and I sat rigidly in our seats, back-seat driving incessantly. Our white-knuckled hands gripped tightly on to anything we could find.
‘Oh no!’ he exclaimed. ‘I don’t believe this. Look! There! On the road.’
I peered through the chipped, dirty windscreen of the rattly Volvo. Dust was everywhere. Several hundred metres to our front I could discern the shape of a pile of rags on the roadside.
‘What about it?’ I asked, it’s only some rags. Perhaps they will be collected later.’ I strained to make more of the shape as we lurched closer. Louise and I both realized what it was simultaneously.
‘Oh God!’ she cried, ‘it’s a body!’ A body it was. Splayed across the road, its head split wide open and crushed. Brains stained the irregular dirt while the rest of the corpse was untouched. I had heard of it happening before, though had never seen it. Tired tribesmen, recovering from the rigours of the day, would lie by the side of the road to sleep. At times, no traffic would pass for at least an hour, so they would be lulled into a false sense that all was fine. Slowly the head would drift from roadside to road itself. The next lorry, driven by a man equally tired and possibly drugged, would run over the tribesman’s head, squashing it hedgehog flat. The man was as dead as they come. Instinctively I wanted to stop, if nothing else to remove the corpse from the road. But then I remembered — this is India, and in India you drive straight past, even if you do have a car full of doctors. There was nothing to be done for the poor fellow anyway.
Water contamination is a major cause of disease in rural India. As in my jungle SAS years, human or animal faeces can easily find their way into the water supply. Gastroenteritis - gut rot - is the result. Padhar is remarkable in this respect, as water can safely be drunk from the taps, thanks to the foresight of Clement Moss and the ongoing slog by those who followed him. It is not easy to keep water drinkable in such regions. However, it can give a false impression of the situation outside the village, where drinking from a tap may be asking for trouble. Most travellers, not that many venture as far as inner Madhya Pradesh, arrive in India armed with sterilization tablets, filters and assorted items to keep waterborne disease at bay. Human nature being what it is, regular use of such things is difficult, particularly if you are in the land for more than a standard holiday fortnight. To expect a Gond tribesman to use them at all is unrealistic - he will not. Clement solved the problem by drilling deep into the dusty soil to take water from several hundred feet down. Such tube wells, being so deep, are difficult to contaminate, given even the most unhygienic tribesman.
Despite these efforts, gastroenteritis is everywhere. Travel by Indian train any day around dawn and you will see hundreds of locals striding purposefully across the fields to their favourite rural spot. In their left hand they will carry a small aluminium pot of water. This is their equivalent of loo paper and explains why you do not eat with your left hand in India. For that matter you do not touch anyone with your left hand either, as this can easily be taken as an insult. How many times have you eaten with your hands and noticed food stuck under your fingernails? The same is true for human excrement. Once you realize it, there is strong incentive to keep left and right hands separate on the Indian subcontinent.
Gastroenteritis can be a killer and is one of the commonest causes of childhood death in rural India. Padmi, a lovely two-year-old girl, was a typical example. Her mother, a Gond tribeswoman living twenty kilometres from Padhar, had carried her through the jungle once she realized all was not well. I can see the mother now, head covered, bowed with worry, searching frantically for assistance at the hospital gates. She was not crying, which I have never seen a Gond do, irrespective of circumstance. They are a fatalistic lot. In her arms lay Padmi, a tiny creature despite her two years. The child’s skin was so wrinkled, when I pinched it between finger and thumb it did not spring back. It stayed there in a heap, like some tiny mountain. Padmi’s eyes were sunken, sparse hair straggled, arms dangling limply towards the ground. With each irregular breath, her whole body seemed to jerk. Anyone could see she was dangerously ill due to gross loss of her body’s water - dehydration. Cholera kills this way. The stuff pours out of the patient so persistently they cannot make it to the loo. Special cholera beds have been designed with conical holes in their centre. Patients lie flat on their backs, watery diarrhoea pouring forth until either death or cure intervenes. As treatment, all you can do is to replace what comes out.
Padmi was desperately sick and needed rehydration rapidly. It was her only chance. If gastroenteritis is treated sufficiently early then rehydration solutions can be given by mouth. In Padmi’s case, she was beyond this. She was so ill she would not have the strength to swallow. Rehydration by intravenous drip would be needed. Ignoring local protocol, I grabbed the mother by the arm. The woman still tightly hugged poor Padmi’s limp frame, as I force- marched her towards the children’s ward. The hospital did not have bleeps, Louise was visiting villages in the countryside and most of the medical staff had gone off for the afternoon. I was sure Padmi would be better treated by the medical side; it was not an operation she needed. I knew also how difficult it was slipping a drip needle into a dehydrated baby’s veins. So dry has the patient become that blood vessels shrivel up and disappear. Paediatricians — children’s doctors - and that included Louise, were brilliant at finding veins that no one else could see.
I had marched the mother only twenty yards when I realized we would not make it to the ward. Padmi’s body gave a soft grunt and her back arched alarmingly in her mother’s arms. Then, in an instant, she died. Her eyes, dry and covered with a transparent sticky film, were half open. It was too late. Resuscitation, I thought. I’ve got to resuscitate. I reached out to grab the little body from her mother to lay it on the ground. There I could at least begin heart massage. But the mother refused. Quietly, very sadly, head still bowed, she turned from me. I stood transfixed as she walked away, Padmi’s body in her arms. The now
lifeless head flopped up and down as she carried the once lovely girl into the surrounding jungle. I have no idea where she went. Human tragedy is everywhere in Madhya Pradesh.
One French couple stand out in my mind. They had volunteered their services to work in Padhar for several months, before going onwards to a mission station elsewhere in India. Very bravely they had turned their backs on everything at home, setting out to make a new life among the poor of India. They brought with them their small child, aged only eighteen months. Predictably, and unfortunately, the little boy developed gastroenteritis. With medical parents able to deal with the problem before it got out of hand, there was fortunately no risk to the child’s life. It did mean copious nappy changes for several days. This was not a problem - until it came to the Chief of Police.
It was Vincent’s idea. Always keen to promote Padhar in the eyes of both the world and Indian politics, he makes strenuous efforts to maintain contact with various authorities both in and outside the country. It is one of the secrets of his success. During my time in Padhar, and I have returned there six times over many years, I have treated politicians, social bigwigs and influential businessmen, as well as the poor and impoverished of the land. Money from the well-off is always used to treat the poor. It is an excellent, Robin Hood style arrangement and something other health systems should notice. Late one evening, eight of us paid the Chief of Police a visit at his official residence twenty kilometres away, in the town of Betul. Louise had not joined us. However, the French couple, and their little boy, did form part of the group. At the residence, Vincent ensured I was seated next to the police chief who, within seconds, was discussing the ups and downs of medical care in the area. The remainder of the group sat patiently and quietly, listening to us talk.
Knife Edge: Life as a Special Forces Surgeon Page 27