A. Mark Clarfield, MD, FRCPC, Dept. of Geriatrics, Soroka Hospital, Ben Gurion University of the Negev, Beer Sheva, Israel.
Most of us enjoy stories. They instruct, inform, involve and, above all, entertain. Who cannot remember sitting on a parent's lap listening to one. For those of us with enough mild cognitive impairment to cloud recollections of our own youth, surely we can see how much our children and grandchildren appreciate a good yarn. The telling of tales goes beyond the Brothers Grimm, television and the movies, full of (usually awful) stories that continue to attract our attention and empty our wallets.
In medicine, "the narrative" also has great appeal. We take a patient's history, after all, and we have long been told by Sir William Osler that if we let the patient tell us her story, we will come to diagnosis sooner rather than later.
The journals also have caught on to storytelling. The British Medical Journal, Annals of Internal Medicine, Canadian Medical Association Journal and Journal of American Medical Association each offer, respectively, a "Personal Column", "On Being a Doctor", "A Room With a View" and "A Piece of My Mind" in every issue. Of the big five, only the New England Journal of Medicine is still too grey to offer such a column.
Novels also have dealt with medical and doctor-related themes: Thomas Mann explored tuberculosis in "The Magic Mountain", Sinclair Lewis the life of the physician in "Arrowsmith" while Samuel Shem's "House of God" caricatured the life and loves of the harried and harassed house staff. In our field of geriatrics there have been only a few gems. In "The Stone Angel", for example, Margaret Laurence tells the tale from the perspective of an 90-year-old woman.
One of the best books addressing the theme of aging that I have read in many years came off of the pen of Canadian writer Rohinton Mistry. His most recent endeavor, "Family Matters", addresses the many issues of aging through the device of a mildly dysfunctional lower-middle class unit in Bombay. Just shy of 80, the protagonist, Nariman Vakeel, is a Parsi widower and a somewhat powerless patriarch of the family. As long as he is healthy, his stepdaughter Coomy agrees to look after him, not altogether distinterestedly, given that she lives in his house. However, while healthy he really needs very little care.
That being said, Coomy, a most embittered woman, worries constantly lest he fall and do himself an injury. His biological daughter, Roxana, a much sweeter person than her older stepsister, tries to avoid conflicts over their shared pater familias.
"I can't believe my eyes."
"What is it, wrong colour?" asked Roxana, for her sister was superstitious about such things.
"Think for a moment," said Coomy. "What are you giving, and to whom? A walking stick? To Pappa."
"He likes to take walks," said Yezad. [Roxana's husband]. "It'll be useful".
"We don't want him to take walks! He has osteoporosis, Parkinson's disease, hypotension--a walking medical dictionary!"1
All is stable until the old man, suffering from the abovementioned diseases but with absolutely no cognitive impairment, falls and breaks his ankle. Here we are let into the world of Indian medicine--harrowing for members of the lower-middle class who cannot afford health insurance and will not stoop to suffer the care under the terrible conditions of the almost non-existent public health service.
Nariman does spend two days at the Parsi General Hospital for a brief admission to have his ankle set and a cast applied. On his first (and only) night in hospital, Mistry describes the old man's thoughts:
He did not mind being alone. The wardboy on the night shift was an older man, much older than the dynamic day fellow. Early sixties at least, thought Nariman, and wondered if his shaking hands were also due to Parkinson's or something else. He made up for the imperfection of his hands with the perfection of his smile. A smile of enlightenment, thought Nariman, so like Voltaire's in old age, in the portrait that graced the frontispiece in his copy of Candide.
And how did one acquire such enlightenment, he wondered, here, in a grim ward, collecting faeces and urine from the beds of the lame and the halt and the diseased? Or were these the necessary conditions? For learning that young or old, rich or poor, we all stank at the other end?2
On returning home, at first Nariman is cared for by Coomy, but she is clearly not up to the task, neither emotionally nor physically. At first, Coomy and her ineffectual brother Jal tried to move Nariman onto a commode whenever necessary. But it is too much for them. A decision is made to utilize a bedpan and urinal which Nariman "
as though they were the vessels of salvation."3 Coomy continues to have trouble coping. As she rightly muses, "It was ridiculous
that with so much technology, scientists and engineers still hadn't invented a less disgusting thing than a bedpan. 'Who needs mobile phones and Internet and all that rubbish? How about a high-tech gadget for doing number two in bed?'".3
The book goes on to tell the tale of how difficult it is to nurse an old man at home with a fracture and Parkinson's disease. And yet, in Mistry's India, there seems to be a glaring lack of any kind of formal services. Gerontologists in wealthy North America inform us that up to 90% of the care of the elderly is borne by the "informal sector". If that is true, then in India it must be 99.99%.
The story is indeed a bleak one, although written with great sensitivity, clarity and beauty. From it we learn how lonely illness can be for an older person and how humiliating and frustrating, especially in the face of a profound absence of expert medical and nursing help.
The book also underlines another theme: how difficult it is for the poor of the world, especially in the less developed countries, to cope with the sick elderly. As well, a novel like "Family Matters" illustrates the universality of the challenges and problems of age-related disease, and how the fate of most of the world's elderly, when they do fall sick, is thrust entirely into the willing or not-so-willing hands of an immediate family. In most parts of the world, for the majority of older persons, there is simply no other choice. Through Nariman's story, Mistry lets us in on this not so well kept secret.
- Mistry, R. Family matters. Toronto: McClelland and Stewart Ltd., 2002, p. 32.
- Ibid, p. 56.
- Ibid, p. 75.