P. Ravi Shankar
Lalitpur, Nepal

Krishna was dead. I was relaxing on the porch of my quarters next to the primary health center when Krishna’s relatives brought me the news of his demise. Though I was sad, I also felt a sense of relief.

Krishna belonged to a poor family of agricultural workers eking out a precarious living in a ridge top mountain village, a two-hour drive from Kathmandu, the capital. The pine-scented air, the whispering winds, and the clouds rolling in during the monsoon enveloped the village in a healthy chill. In autumn and winter, the snowcapped Himalayas provided stark contrast to the crystal blue northern horizon. The village had prospered over the years, recently becoming a major attraction for tourists and residents of the valley.

The economy was booming. Tourists brought in their dollars and euros; domestics, their rupees. Many impoverished peasants marched in from the surrounding countryside and distant villages in search of work. The shantytown, where they often settled, was hidden from the sight of tourists in a deep side valley, about a 20-minute walk away. At the same time, new multistoried concrete houses painted in garish colors slowly replaced the simple stone and red clay plastered houses; recently constructed hotels with Doric columns and massive arches appeared adrift in the rustic atmosphere. The forests at the edge of the village were cleared to accommodate the growing population.

The increasing wealth demanded medical care and facilities for the residents. The private medical business was booming. In a village of about 20,000 people, there were two large pharmacies, a private hospital with X-ray and other diagnostic facilities, and three private doctors. On-call medical coverage was provided to the hotels, or “lodges,” as the locals called them. The private hospital and the clinics were sparklingly modern. Glass and chrome covered the well-maintained facilities, which were staffed by smartly turned out receptionists and public relations representatives, who took care of patients and their families. The process was efficient, smooth, and painless—but expensive. Two private laboratories competed for patients offering commissions to doctors or health workers for patient referrals. With an increasing number of tourists staying in the village, the scent of money was in the air.

Harboring a slightly dilapidated air against the backdrop of snow-covered mountains, the poorly maintained government run health center building consisted of a small stone house with four rooms: two large rooms, which could accommodate four beds; a small room for surgical procedures; and another containing a pharmacy and basic laboratory. Poor people from the village and the surrounding countryside swarmed the center; patients’ relatives often camped near the stone platform surrounding a magnificent banyan tree on the center’s grounds. The middle class and the well-to-do, however, stayed away. Over the years government-provided medical care had been stigmatized—perceived to be of low quality and provided by surly, unfriendly staff.

Even the village poor preferred to first visit private doctors, only coming to me after they had exhausted their money. I was a young, newly-established doctor, but—like in many Asian countries where increasing respect came with age—their avoidance of the government center for the more “established” doctors in private practice presented serious problems. In the private system, both rich and poor were preyed upon. The commission system was going strong, often resulting in unnecessary and expensive diagnostics and treatment. Almost everyone was involved—even two paramedics working in the government health center had clinics in the village. The exploitation of the poor was the most extreme. Many had to pawn their jewels and heirlooms, even selling their small plots of land to pay for treatment. A last resort, the government health center’s patients suffered mainly from diseases of extreme poverty: tuberculosis, infectious diseases, HIV, and AIDS.

The descendant of a prominent Kathmandu family tracing its lineage over 300 years of history, I often benefited from the wide political connections of my father, a prominent businessman. As in medical school, he arranged for me to do my two years rural service in this “cozy” village near Kathmandu. Uncomfortable with this meddling, I settled in to life at the health center, exposed to the extremes of wealth and poverty nonetheless. At the time of Krishna’s death, I had been in the village’s government health center for over a year.

When Krishna was brought to me, he was dying from lung cancer. An agricultural worker, he tilled and harvested the fields of rich landowners. Now in his late forties, he was a gaunt, prematurely-aged man with a stoop, lurching about on two pencil-thin legs. Already having spent his meager funds at private hospitals, pharmacies, and laboratories, he came to us with X-rays showing extensive involvement of both lungs and metastasis. Confirming the findings, we realized that Krishna had less than six months to live. The private hospital had recommended chemotherapy, but the drug was expensive. The two courses a week he required would have cost about 30,000 rupees ($360 US), a major hardship for a family that earned a dollar a day. His family would soon have to sell what little they owned and borrow money at exorbitant rates of interest to treat someone who was beyond help.

I was happy the family had brought him to me. In the government health center, while cancer drugs carried charges, other medicines and hospital services were free. Needy patients also qualified for small 50,000 rupee grants and funds from other charitable organizations to help cover costs. In the long term, the financial support would greatly alleviate the economic strain on Krishna and his family. But most importantly, we could help Krishna and his family make decisions that would allow him to spend his last days in peace.

As doctors we have been conditioned to do everything humanely possible for our patients, even those who are dying. I had a hard time convincing myself that it would be best to allow Krishna to die in peace surrounded by his loving family. Remembering the words of a close friend and physician—who often advised the family of advanced cancer patients to care for them at home—I found strength. There was still hope for the living. I could spare them the unnecessary expense, which would surely leave them destitute and indebted for life. The family was resistant at first, willing to spend their last paisa, but they eventually understood. Heeding my advice, they took Krishna home.

I am not recommending the denial of treatment to patients with cancer—especially if there is reasonable hope that the disease can be treated aggressively. But when disease is beyond cure, is it worth spending a family’s last resources and indebting future generations? I often visited Krishna to comfort him and medicate his pain. During my frequent visits, we became quite close. He had many good qualities: love for his family, honesty, and a basic dignity and simplicity. He died two months after we met. In the end, his family still had some money left after the funeral expenses to serve them as capital in the expensive business of living.