|Painting by Nisar Ahmed|
I seldom see patients without an appointment, which for an initial patient can take up to an hour, often longer. Fortunately for this couple, the booked patient rang in to say he could not come because of some transport problem, so I was able to see them.
“Doctor saheb- we have come from very far. We have seen many doctors in many cities of Pakistan. They have all done many tests and have given many medicines. The doctors told us there is nothing wrong with her and she must see a ‘nafsiyaati’ (psychiatrist) doctor. So we saw many nafsiyaati doctors as well. But nothing seems to have any effect on her. Then someone told us about you, so we are here. Your receptionist has given us time after one month, but can you please see her today as we have come from very far and cannot stay in Karachi.”
They came in and sat down. As her husband spoke, I could sense her gazing at me intently. What was going through her mind? Was there fear or doubting of me in her eyes?
“Yet another doctor . . . yet another repetition of the symptoms . . . yet more tests . . . yet more medicines . . . yet another fruitless consultation . . .”
Her husband spoke for about ten minutes, reeling off her symptoms in a well-rehearsed manner. Strange, I thought. She is the one with the symptoms but he is speaking for her. But then this is not unusual in the strongly patriarchal Pakistani society. I asked her if she spoke Urdu. “Yes” she said. I requested the husband to step out and let me speak to her on her own.
Alone with a female resident and myself, she sat back in the chair. I could see she was feeling more relaxed. She had her head covered with a veil and had fine sculpted features.
She started by telling us about her symptoms: the constant headaches, aching shoulders and neck, weakness, poor sleep, worrying all the time, irritability, lack of interest in things around her and in life generally.
“How long have you had the symptoms?” I asked her.
“Four years or so.”
“What happened four years ago?”
“My eighteen-year-old son was shot dead . . .”
She was the middle of three children, with an older brother and a younger sister. Her father was a well-to-do jeweller and a respected man of his community. She studied up to seventh grade when she was married off—barely thirteen years old. She wanted to study further but her marriage and children ended that.
She was now forty-three, had eight live births, four miscarriages and two still-births. Her mother died when she was twenty-six and is buried in Iran, where her married sister and remarried father also live.
I asked her what happened to her son. She told me he had an altercation with her son-in-law, who was also her husband’s nephew. The altercation kept simmering until one evening the son-in-law turned up at their house and shot her son.
She had rushed to the hallway when she heard the gunshots and saw her son lying in a pool of blood. He died on the way to the hospital.
The son-in-law was arrested but was never charged with murder. Her husband’s family put pressure on them to forgive him. After all, he was her husband’s nephew, and crucially, he was married to their daughter.
Pakistan’s fractured judicial system, its still existent archaic tribal laws, the value of human life in Pakistan, highly patriarchal attitudes, and the compromised status of women in society had all coalesced to get the killer off the hook. He was soon released and the lady’s daughter remained married to him—divorce being out of the question. Every time she saw the son-in-law, the image of her dying son appeared in front of her eyes. The image continued to haunt her dreams, and she frequently woke up in a panic fighting for air.
As I tried to process and make some sense of her narrative, she threw another emotional blow. She had not seen her mother for over ten years before she passed away in Iran. She had never been to her grave, as her husband refused to let her go to visit her sister, who he thought was a bad influence. She wanted to grieve and get closure but had not been allowed to.
We sat there silently—her sad and fearful eyes, now wet, challenging me to respond to what she had laid down in front of me—in front of this big doctor, in this big hospital, in Pakistan’s biggest city.
I scanned my training, my qualifications, my research papers, my book chapters, my grants, my national and international presentations, my positions, my titles.
What did they all mean to this lady and her problems—problems that had been framed for so long as “depression” and “anxiety” and “somatoform” and “conversion” and “psychosomatic” and “PTSD” So many doctors had placed so many labels that it was virtually impossible to reframe them and give her an alternate explanation. She had brought a thick folder filled with prescriptions of every brand and every class; antidepressants, tranquillizers, mood stabilizers, anti-psychotics. Someone must have felt she was delusional, having all these complaints and numerous tests covering every system in her body. But it was also a testament to her ongoing symptoms and her desire to seek relief from them.
“Doctor,” she said after a long pause, “do something that will make me forget everything and give me peace of mind.”
As I looked at the long list of medicines she had been given, a pharmaceutical company advertisement I had seen years ago in a psychiatry journal suddenly resurfaced in my mind. Spread over two pages, it had a quote from Shakespeare’s Macbeth on one page:
“Canst thou not minister to a mind diseased;
Pluck from the memory a rooted sorrow;
Raze out the written trouble of the brain;
And with some sweet oblivious antidote,
Cleanse the stuff’d bosom of that perilous stuff
Which weighs upon the heart?”
and on the other page was a line: “We are working on it . . .”
Very clever, I had thought at the time.
The pharmaceutical industry has certainly worked “on it” and has come up with some incredible “stuff” over the years.
Except that none of it seems to have worked on her.
And of course, no “stuff” can ever work on her, or million of others like her who suffer from similar symptoms. For we neither understand the cause of their “mind diseased,” nor is there any “oblivious antidote’”that can “cleanse’”that “which weighs upon the heart.”
Pakistan’s equally fractured health system, the lack of exposure to mental health in medical education, the corrupting influence of the pharmaceutical industry, and an over-reliance on the biomedical model has created a culture of “a pill for every ill.” A culture that makes physicians reach for the prescription pad even before patients have finished relating all their symptoms. Each medicine and each prescription given to this lady seemed to represent an insult thrown at her by physicians: “How dare you come with these aches and pains when there is nothing to explain them? Take this and be off.” This appeared to be the unspoken message as she had been handed each prescription.
So I asked her, what did she think could ease her troubled mind?
“Doctor saheb, I have taken every medicine the doctors gave me but nothing has worked. My son can never come back to me. My daughter has three small children and has to stay with her ‘qaatil’ (murderer) husband. She has no choice. I have to accept him for her sake. But please tell my husband to let me go to my sister and visit my mother’s grave in Iran. That will bring peace to my mind.”
There is a wonderful aphorism in medicine: “Listen, listen, listen. The patient is telling you the diagnosis.” This has been all but lost in this cacophonic age of instant communication and multi-tasking, an age where physicians neither have the time nor the ability to listen to patients’ stories. It is much easier and safer to hide behind the sacred pages of the DSM manual and ICD codes, to diagnose a condition such as “major depression” and prescribe medications for it.
Is that what the patients want as well?
Actually, many do not want the prescriptions, and for many the medicines will not work anyway. Many want their stories to be heard. They want to be listened to and understood, and for physicians to help them come to terms with their fears and apprehensions, their guilt and trauma, their pain and suffering.
Many want us to practice slow medicine.
As she and her husband (whom I had called back in the room to explain what may he happening and how we need to address the problem) gathered their papers and got up to leave, I caught her eyes again. She gave me a brief smile.
It was at that moment I knew I had made a connection with the troubled lady with a weight upon her heart.
MURAD MOOSA KHAN, MRCPsych, PhD, is Professor of Psychiatry at the Aga Khan University in Karachi, Pakistan. He is the principal investigator of Karachi Suicide study. His research interests include suicidal behavior, mental health of women and elderly, and medical ethics.