So, Ija, my 89 year old mother in law had a stroke (right cerebral infarct with left cerebral bleed) last week. After 10 days spent at the hospital, we brought her home yesterday – she has been lying unresponsive in bed since last Monday morning. Obviously, this was a period of worry and frustration for us, but also of observation and reflection. A few thoughts emerged:
A) Old Was Truly Gold – It’s a truism, but the age old mantras of Clean air, Organic food and Simple living really worked. This is preaching to the converted largely, but the fact remains that urban upper middle class living nowadays is the pits. My in laws lived in a small hilly border town called Pithoragarh most of their lives. Like most hill folk of that time, they ate simple, locally grown vegetarian food supplemented with lots of dairy twice a day; woke up at 4 am and slept at 8pm, walked everywhere; didn’t overwork and didn’t party. Result – ija at nearly 90 was walking, talking, eating, bathing independently till Sunday evening – she held sway over, in fact terrorised a household comprised of sons, daughters in law, grandchildren, household help and guests. Even now, when she has been bedridden for nearly two weeks, her vitals are strong and working perfectly fine. This, despite having had two strokes some 15 years ago, losing speech as a result, and then recovering from it to regale us with many tales of her brain haemorrhage and other illnesses.
B) It REALLY is all about the people – A Hospital, just like, but even more than other service oriented institutions like schools and banks, is run by the people – it is not just the doctors, who of course are very important, but the rest of the staff. Nurses (and that entire eco system) are probably even more important than doctors. So are the ward staff, the cleaning staff, the security, the ambulance staff, the food deliverers, the Physio therapists, the admin, the cash and billing staff, the counsellors, the dieticians – the entire jing bang. Ramaiah Memorial Hospital was an example of an institution where we met excellence all around. Every single interaction with the staff, from the security guard outside the ICU, who went out of his way to check status of arrival of stretcher for MRI, and gave us numbers of key people to call; to the physiotherapist girls who not only exercised ija’s stiff neck and limbs, but also took care to give me, my sister in law and the new caregiver girl we hired, clear, lucid and reasonable instructions for her care post hospital; to the catering guy who made sure and delivered food we wanted as and when we wanted; to ambulance folks who called several numbers to ensure they were ready and waiting when ija was ready to be taken home – these micro “moments of truth” were what led to delight in customer interaction. Infact, on a previous visit to the same hospital with ija, the guard outside the dental hospital had been extremely helpful – when my husband offered him a tip, he flat refused – saying this is my duty sir. This is unprecedented in India, where most things do not work without a bribe or a bakhshish! All of this brings home the importance of training and investing in the second and third in commands in an organisation. That is the only way to make sure a system is sustainable. Leadership is very important, but so is the workforce. For example, in Ivy League colleges, the undergrad classes are really taught by TAs – but that is possible only because they admit the best/ the cream of the students. Similarly, MS Ramaiah has integrated its supply chain backwards – they have nursing training college, also medical college – so their hiring pipeline is always full (a lesson many schools and other organisations can learn).
C) But Process is King – The thing is, people with the best intention in the world, cannot make a scale institution work unless there are rock solid processes – that is the reason why large multinational corporates funded economies like India, which then entered new phases of development because of their process expertise. Ramaiah has not only the people to make even a hospital stay almost pleasurable (and certainly reassuring), its processes are also world class. They have a clear role definitions with accountability, but also supervisors with different spans of control for every job. This includes the staff who cleans and dusts every room – the cleaning supervisor actually slid open the windows to ija’s palliative care room, swept a finger on the sill in classical housewife style, and showed the smear of dust on his glove with this “a-ha” glint on his eyes to the hapless dusting guy. (Ija would have been proud)! The ambulance folks (driver/ stretcher bears) – had a supervisor too, who apparently makes sure that every ambulance experience is seamless – according to him, they fire from 10 -15 staff every day on grounds of incompetence. Of course, they also pay top salary. There are floating staff that take care of redundancy – the head of the Palliative Care Unit was absent for a couple days, but she had a second in command, and then another lady who generally adds as PR dogsbody, but acted like a great customer touch point in her absence.
D) “Sung” Heroes – The Medical profession is often reviled and sometimes blessed, but it really needs supreme appreciation – How difficult is it to tell patient after patient, and caregiver after caregiver, that there is no hope! How difficult is it to go on performing a job again and again, and saving lives, despite the odds of lives getting lost in the process. I just bought this book This is Going to Hurt, an account of a doctor, who gave it up because of sad incidents. Doctors have this incredibly hard entrance exam, then they study for many many years, and then intern for many many hard hours, and then do this very very very very hard job. They have all my respect, and long may their tribe last. Despite much evidence to the contrary, and of course many malpractices, for a good doctor, medicine needs to be more a vocation than a profession/ means of income.
E) Murphy’s law is real – This insight was the result of a conversation I had with a deeply philosophical security guard outside the Palliative Care Unit. Hailing from Hyderabad, he told me he had experience of patient care at the ICU, but he had quit that department when the SARS outbreak happened. He told me triumphantly that it was now the Coronavirus that was reaching epidemic proportions, and wasn’t it a good thing he had shifted to the Palliative Care! Having explained to me the benefits of an air bed over a water bed, and the correct setting for maximum patient comfort for both, he waxed eloquent on the dollops of ghee that people of the older times would eat – that being the reason why they grew so robust. He vented about the chicken available nowadays, which were being given injections to grow from scrawny beings to 3 kg fat hens; and the mushrooms which were being manufactured in machines – and said, no wonder there are illnesses aplenty. After a longish conversation about many life and death theories, he told me that I should pray to Allah that I never be brought to the hospital in a stretcher or a wheelchair. On my saying yes, that’s what everyone hopes for, but no one has control over, he nodded sagely and said – that is correct, madam! Later, when I was going home, I met him in the elevator and asked he me – “oota aita” (have you eaten). When I asked him if he had, he told me, “duniya ka asool hai ki jab kuch nahi chahiye tou duniya poochti hai, aur jab bhookh lagti hai, tou koi nahi poochta.” A very Murphy Law-ish statement from the mouth of a security guard.
F) Ancillary services – A while ago, I watched an interesting movie called Tumhari Sulu – was a refreshing take on a middle class ambitious housewife who first, by an interesting spate of circumstances, tried being a sexy chatline host much to her family’s horror, and then, after a series of unfortunate incidents, began a catering service , supplying amongst others the radio channel she was working at. Similarly, a Hospital spawns a whole host of ancillary services. Medical supplies rental, nursing attendant supply, catering service….the whole Nursing Homecare industry is one that we saw closely. Essentially, in a world where people have the ability to pay, the gaps for services are so many – and still so difficult to fill. The global geriatric services market is estimated to be at about 900 billionish USD according to a report by GMI. As per Cyber Media Research’s analysis, in 2016, the home healthcare industry in India stood at $3.20 billion and is expected to grow to $6.21 billion by 2020. By 2050, the elderly population is likely to increase by three times to reach around 300 million, accounting for 20% of the country’s total population. There are many providers – Bangalore based Portea being a big professionally run one. But clearly many smaller ones are jumping in. After all, body shopping is something we do well. The Homecare service seems to see margins of 50% and upwards, relying on caregivers from Bengal, Odisha and Kerala, Karnataka – these are barely trained, needy girls (and I assume boys) on whom you leave the daily care of your loved ones.
G) Melanin’s Rule – Skin colour is really an obsession with us Indians (and of course across the world). The very very sweet well meaning nurses looking after ija would repeatedly say – “she is a white beauty”. I felt like quoting MLK back at them all the time “I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin, but by the content of their character”. Its another matter that the white beauty comment would have made ija very happy – she has often told me about the skin whitening afghan snow cream she used daily for skincare. I am so so happy about the recent penalty proposed on skin colour related ads. And the fact that my daughters’ generation at least is actively rejecting these racist norms.
H) The Flip Side of Influence – We Indians are so used to battling the odds to turn them into our favour in all circumstances, that we look for “Influence” always. So it happened to my husband and me when we first admitted Ija to the ICU. Feeling very lost, and unable to quite gauge accurately the true state of affairs because of our inexperience, we of course asked around if anyone had any “contacts” at the hospital. A bunch of folks responded. We were satisfied. But, the whole thing escalated – some one asked someone else and then someone else, and the matter reached the top folks at the hospital. In no time, we were called by the ICU staff and asked why we were unhappy with the service at the hospital, why we had complained, did we not get the counselling, etc etc. Caught completely by surprise, and embarrassed to the hilt, we spent many minutes clarifying that this was Chinese Whispers at work – and they were just the victims of well meaning helpers! Anyway, we got away with filling some feedback forms, but learnt a valuable lesson on not overusing resources at the wrong time.
I) Self Worth vs. Humility – While sitting in Ija’s room, I was typing out a response to an urgent, important email. A young intern came in to return ija’s discharge summary paper which she had borrowed. When I asked her to place it in the file please, she said – no, I can’t do it. Im very busy. I guess I looked shocked – as she then said, we have many patients to see, and we can’t do these things. I guess she was right (my point had merely been – since you are placing it on top anyway, just open the file and place it aside) – but it reinforced an important point to me. This is about confidence in self/ or a heightened sense of one’s value – it is trait that I totally lack (I have been told several times by several diverse people the I have no ego – its not something that I am ashamed of, but neither is it something that I would necessarily teach my kids). My husband (and his brother, a senior doctor) – have it in spades. They are always about making something grand/ the big picture/ inflation/ larger than life… what have you. It stands them in good stead – my husband refuses to sign a deal with anyone unless it meats the bare threshold of valuation he has set for the company. My brother in law starts most conversations with strangers saying – do you know who I am – I was Senior Officer in so-and-so etc etc. My in laws had immense pride in being Bhatt from Bishadh, an uchcha koti brahmin; my mother has immense pride in her daughter’s accomplishments. My ex business partner smoke screened our capabilities to clients very often – saying we know/ have done much more than we actually had. Clever business? Yes, totally! Marketing? Maybe. Respect Generation guarantor? Sometimes. Good, bad, or ugly? Can’t really say. This also amplifies real or imagined slights (how did I not get a large room/ how dare the CEO not come and meet me)…but for sure, it is better than to be on the flip side of the coin. The number of conversations I have had with my daughter who is in college far away, in the wee hours of the night, to allay fears of – I have no friends/ I am not likeable/ I am dumb, is not funny. Just messes with her head, and ensures that the therapy/ mental health medicine industry is thriving. I am guessing a good state of being is confidence in self based on actual traits, behaviours and achievements; yet enough humility to acknowledge other people’s traits, behaviours and achievements. Tough balance!
J) Minimalism and Focus – This is the era of decluttering – many a preacher is giving gyan on mindfulness, on simplicity, on getting down to the basics. Celebrities are getting huge views and followerships on recycled clothing. Home schooling a big thing. Single home ownership/ single car ownership/ sharing rooms is being taught as a big lessons. No air travel/ dry shopping free months/ vintage shops are trending globally. My husband’s firm Social Alpha incubates a company called Bare necessities, which works on zero waste processes. All this, apart from urban brouhaha, is really good for the environment and just generally plain old common sense. But, somehow, the real value of paring down one’s life to the bare necessities comes when you have a loved one in hospital – all needs become wants – and all wants become don’t wants. You realise the bs about relationships is not bs. You rue the phone call you didn’t make, or the fight you did have, with parents and other friends and family. You say – God, I’ll feed a 100 children; or I’ll give up Rajnigandha, if you make my m-i-l well again. All external trappings evaporate in the face of adversity – my friend who lost her husband very young says this well – one life to live – may as well be true to what you really really want to do and what is important to you.
K) New Normal – As we now slowly get used to a bed ridden mum, we have to adjust to our new normal. At each stage, one has changes, and one adjusts. When ija first came to live with us, we made minor modifications in life style – gave up eating meat; our evening outings together as a family stopped… When my daughter went to college, a room became vacant, uninterrupted sleep became a thing of the past and the voice data usage shot through the skies. So did stress and heart medication. Now when ija is semi comatose, we have a new full time member of our household (her attendant), her room smells like a hospital, bed sores and secretion cleaning have become frequent search terms, and the mixie is being overused. This, after all, is life! As I was telling a friend who lost her dad recently, and then is nursing her mother through a stroke (thankfully mashi is recovering) while we were grieving about the loss of another friend’s mother suddenly just as she was rehabilitating her father in law, we are now at that stage of life. In our late teens, we were all only about college admissions and exams, in our twenties we were all job hunting and then partying; then it was promotions/ marriage/ home ownership/ parenthood/ their schooling/ empty nesting – and now ofcourse as our parents are all becoming geriatrics, we are seeing their illness and, eventually their end. This is, truly, the circle of life
joshsang 