 "Atul Gawande")
My interview with Atul Gawande, a staff writer on medicine for The New Yorker magazine and surgeon at a hospital in Boston, begins badly. We had arranged to meet at The Lalit in New Delhi, where Gawande had arrived the night before from the US, but when I arrive a little past 12.30 for our one-hour lunch, he is neither at the hotel's coffee shop nor in the lobby. I am about to approach someone who looks vaguely like him before deciding that it's not Gawande. Could he have forgotten, I wonder, or cancelled.
Even by the standards of overachievers, Gawande juggles almost too much. He is also a professor at Harvard Medical School and its school of public health. Gawande's 2009 article on health care in two Texas towns - which showed that the less expensive health care provider was better - was cited by President Barack Obama in an address to the US Congress. The 49-year-old father of three is the director of a non-profit that seeks to bring down surgery-related deaths around the world, including India, where he is involved in an effort to bring down maternal mortality. The night before, he had posted 12 successive tweets damning the doctors who had advised the Central Intelligence Agency on its torture techniques.
I call Gawande's room and hear a sleepy voice at the other end. I have woken him up but he promises to be down in 15 minutes anyway. It turns out that The Lalit had not had a room available when he arrived at 2.30 am the night before and he had only gone to bed at 6.30 am, when a room was made ready. After years of admiring Gawande's articles in The New Yorker and wondering how he found time to sleep, I am both mortified and amused to have begun our interview by waking him up.
Gawande's 15 minutes turns out to be exactly that. We find a corner of the noisy coffee shop for our lunch. Gawande is in New Delhi to give the fourth and final Reith lecture for the BBC, a series in which he has discussed the unyielding problems of ageing and dying, as well as challenges for health care systems. Gawande reveals that he asked to do the final one from India. India is a fitting end to this prestigious lecture series; in that final talk, Gawande travels back to the land of his parents' birth to reflect on the advances in well-being that clean water, irrigation and antibiotics have brought to his grandfather's village in Maharashtra in a couple of generations. "On the one hand, my father's mother died under the age of 30 from malaria," Gawande says. "My father's sisters died in their nineties." His grandmother's early death had prompted Gawande's father to seek a career in medicine. An indicator that progress is being made in the village is that diabetes is more widespread than child malnutrition. "A small amount of prosperity has made a big difference to people's health. Yet you still have deaths from child malnutrition and diarrhoea there," he says.
We discuss end-of-life options later in lieu of dessert, but return to the paradox of diabetes and diarrhoea in rural India, of women dying from lack of access to a surgeon in childbirth in villages to Caesareans being used too indiscriminately in the country's urban hospitals. Less than five per cent of health workers washed their hands before vaginal examinations, research done in his native village in Maharashtra and elsewhere in rural India showed. A large number of mothers, bleeding copiously because of an obstruction in the path of the baby, often lacked access to a surgeon or blood transfusion because basic checks were not done as the women arrived in labour.
He points to another paradox: even as India has made substantial progress in the past decade from mothers giving birth at home to many using health care facilities, maternal mortality rates have not fallen as much as they should have. The absence of a checklist, a Gawandian innovation that is essentially a dos and don'ts of diagnostic systems and basic hygiene, is one reason. In Uttar Pradesh, simple ideas like having the cleaner leave a bowl of water behind in facilities with no running water after he cleaned the room or using hand-sanitiser helped reduce maternal mortality. In Delhi, he cites World Bank research that showed that patients at primary health care centres complaining of chest pain typically spent less than three minutes with doctors, nearly all of whom neglected to check their blood pressure.
I am already running out of time; a man from the BBC has arrived. I ask Gawande about his latest book, which weaves together his father's fight against cancer and that of his daughter's piano teacher into a narrative that questions the "hubris" of modern medicine in prolonging people's lives, even 'curing' them, when they suffer from terminal illnesses. Both Gawande's father and his daughter Hunter's piano teacher opt against last-ditch operations or chemotherapy in favour of seeking help from hospice workers to live as normal a life in their last days at home. "People who have a conversation (about end-of-life options) usually opt to go home," Gawande says, pointing out that these patients are happier and live longer than those in hospitals. "That means, on every matrix we are failing." Gawande's father left the hospital and stayed home, hosting dinner parties while managing his pain medication for the tumour that had started in his spine. His father lived long enough to see him deliver a graduation address in his hometown's Ohio University, so buoyed by pride that he abandoned his wheelchair on the day.
I tell Gawande that my father also had that important conversation soon after he was diagnosed with Stage IV pancreatic cancer five years ago - he was adamant he wanted no chemo, while specifiying that he wanted to be buried with my mother's wedding sari. He spent his last couple of months at home with his sons, reminiscing, watching old movies and having friends and relatives over.
Reading Gawande's book has helped me appreciate the wisdom of such choices, I say. Gawande is running a half-hour late for his date with the BBC, but this humane journalist-philosopher-doctor has a question. He has heard getting morphine even from hospices is a huge problem in India; what was my father's experience?
Later that evening, Gawande delivers the BBC lecture that is broadcast worldwide. His mother, Sushila, a retired paediatrician, is in the audience. The talk begins with his grandfather and ends with a hospice in Delhi for poor people where an eighty-something woman, rescued from the streets with maggots in her wounds, finds a sense of purpose helping out in the kitchen. Like his book, it is a masterpiece.
Atul Gawande's Reith lectures on The Future of Medicine are available online at the BBC website. http://www.bbc.co.uk/programmes/b00729d9
