The Girl with the Turquoise Eye-Shadow

It was mid-December in Mumbai, a city with just one season, hot and humid. Yet the worn cotton curtains of the consulting room I sat in billowed with an afternoon breeze that sent icy fingers down my neck and up my spine, and a hollow cough rattled my chest. The Out-Patient Department (OPD) was crowded, and patients pressed in on me from all sides even as I feverishly attended to them. I had only a few minutes to assess each patient, to listen to their stories of aches and lumps and wounds, to ask quick questions while leading them to an area designated for examination at the end of the room, cordoned off for privacy by tatty curtains. Then it was back to my desk, a brief hurried explanation, a swift listing of investigations and doling out of medications, and on to the next.

I was an assistant professor in the department of general surgery at one of the busiest government-funded hospitals in the city, the same institute where I had trained to become a surgeon, the same institute where I had contracted tuberculosis in the course of my training. A six-month drug regimen cured the active infection yet, three years later, I still bore the scars of the disease. My chest was ‘weak’ and prone to ‘winter colds,’ and my air passages were hyper-reactive, making me whistle for breath. Yet bundled up in a sweater, I soldiered on, for we were always short-staffed. The hospital served a large chunk of Mumbai’s low-income population and was a national referral center as well. I was due some time off, but that day I had to work.

My next patient was a little girl accompanied by her mother. I say ‘little’ because she looked little, short, and skeletal in her slenderness with sunken cheeks and drooping curls of hair plastered sweatily on her head. She was the only person in the room besides me who was wearing a sweater yet shivering like a leaf on the peepal tree outside the OPD window. I say ‘little,’ but she must, in fact, have been over twelve years of age because children younger than that were sent to the pediatrics department. She looked familiar, but I had never attended to her before. The professor and head of our surgical unit had seen her so far. That day, though, she had switched doctors, probably because of the interminably long queue that snaked outwards from his desk, far out of the room and even beyond the waiting area.

Before I became a doctor and contracted tuberculosis myself, I had thought it a romantic disease, the very word evoking images of poets who died tragically young despite sunny sanatoriums and ethereal maidens with the rose bloom of bloody coughs upon their lips.

I glanced through her file, thick and clunky, filled with notes and reports detailing a year of OPD visits. She had tuberculosis, just as I suspected. In her case, though, it was her abdomen that was affected. This was a less common site of infection than the chest and yet not as infrequent as one would imagine when hearing the word tuberculosis. (Before I became a doctor and contracted tuberculosis myself, I had thought it a romantic disease, the very word evoking images of poets who died tragically young despite sunny sanatoriums and ethereal maidens with the rose bloom of bloody coughs upon their lips.) She had been taking the government-approved treatment regimen for over nine months now. Each month, she visited the OPD and had her prescription extended. This time, though, her mother looked determined to have her say. She spoke empathically, not allowing me to edge a word in sideways.

‘Pranali* is not getting better; she still has a fever, her tummy hurts, she’s not able to eat much, doesn’t feel like eating at all.’

I lead Pranali, along with her mother, to the examination section. As she lay down and pulled her kurta up, her concave belly was exposed, curving inwards, as hollow as her cheeks; yet when I placed my hands on it, there was a doughy softness, a pliability that one could knead. I placed the stethoscope on her belly and heard a continuous tinkle, the protest of a gurgling stream tripping over stones that hindered its free dance. This particular sound suggested a potential narrowing in her intestine.

I told them she would require admission, certain investigations, possible surgery. A portion of her intestine may have narrowed in response to the tubercular infection, resulting in an obstruction. In addition, the fever and loss of appetite signalled an active infection. Since she had been on treatment for so long, it was highly likely that the disease was ‘multi-drug resistant.’ Additional investigations would be required to ascertain this, and if confirmed, she would need an expensive treatment regimen of second-line antibiotics.

Her mother agreed to everything with alacrity, to the admission, the extra investigations, the additional expenses. This easy willingness to spend money they could obviously ill-afford showed how desperate she was to find the answers to her child’s ongoing health troubles.

By the time I finished with OPD and went to the wards for rounds, Pranali’s abdominal scan was done. I discussed the images with the on-duty radiologist. We scrolled slowly through the black and white images, looking carefully for the potential block. I tried to convey the findings to her parents as best I could, using simple Marathi words that a layperson would understand. Although my drawing skills were as rudimentary as a toddler’s, I tried to illuminate my explanation with an illustration, making scratches on a rough sheet of paper with a ball-point pen. A pair of parallel squiggles represented the small intestine, while a pair of curly brackets stood in for the right colon. I drew a small circle at the junction. This was a natural point of narrowing but also the hub of active abdominal tuberculosis. I pressed in the pen’s point, making the walls of the circle thicker, the centre smaller. The disease had thickened the walls of this junction, narrowing the lumen to a pin-hole. She would need surgery to remove this diseased obstructed intestinal segment. We would send a sample from it to a private laboratory that specialised in growing the notoriously hard to cultivate tuberculosis bacteria and assessing which antibiotics a particular strain was susceptible to. Again I emphasized that significant expense was involved in this specialised testing, one that I could not waive off or subsidise since it was outsourced. But they were quietly acquiescent.

Performing surgery is a strangely intimate task. You cut through the layers of flesh that cloak a human being and plunge your hands into depths that, in the ordinary scheme of things, were never meant to see the light of day. Surgery is violence, cloaked in respectability by need, consent, and anaesthesia. The surgeon has to armour herself in a confidence that often borders on a god-like arrogance. We wear our armour so often and so closely, it sometimes fuses with our skin, becoming the facade we present to others as much as to ourselves.

Later that evening, I performed the surgery, cutting through the thin wall of her abdomen quickly; there was no spare fat to obscure my view. Her intestines were studded with tiny pearly grains called tubercles. They gleamed palely in a cloudy fluid produced by the inner lining of the abdominal cavity in reaction to the florid infection. Large lymph nodes glared angrily red. I confirmed the blockage and tied off the vessels feeding this part of her gut. Then, snipping the bowel off on either side, I handed over the specimen to the nurse. I sewed the two open ends of intestine to each other in order to recreate a functional passage, then sewed her tummy shut. I separated and labelled the samples to be sent to the private laboratory myself, to avoid any errors.

I saw Pranali off to the recovery room and reassured her parents that the surgery had gone off as well as expected. Then I took myself off duty. I was on leave for the next fortnight. I hoped the rest would give me some respite from the cough that echoed hollowly in my chest and the chill that had settled in my bones.

I returned to work, my health restored. Pranali and her parents came in for the follow-up visit. We removed her sutures and looked at her reports. The biopsy result was unsurprising, confirming tuberculosis. The report I was waiting for was the one from the private laboratory. It would identify the strain causing her disease and the antibiotics it was susceptible to. The final result would take a couple of months. In the meantime, we started her on a cocktail of potentially useful second-line drugs.

From then on, she came to OPD every month with her mother. They would now wait in the queue for me. They had shifted loyalties, likely because I was younger, also a woman and chattier, but also quite possibly because of the mystical bond that is a by-product of surgical intimacy. As the reports came in, we tweaked her drug regimen. Each time she looked healthier, her weight steadily increasing till she was finally in the healthy range for her age, her cheeks filling out.

One day, towards the end of her treatment course, she came to see me with her mother and a young woman I hadn’t met before. Pranali looked shyly proud as she held hands with the lady. Her curls gleaming glossily, turquoise eye shadow shimmering on her eyelids, she introduced me enthusiastically to her new sister-in-law. Her older brother had just gotten married, and his wife, her bhabhi, was her new best friend. Her sister-in-law seemed gently amused by her eagerness, lovingly indulgent towards the child, and interested in her treatment. Pranali’s mother, wearing a bright purple-pink saree, looked relaxed for the first time since I had met her. Her happiness at her daughter’s health and son’s marriage had temporarily smoothened out the care-worn grooves on her face.

As Pranali’s treatment course drew to a close, she developed an abdominal bulge. The surgical scar had stretched open; there was a gap in the muscle edges below them. She had a hernia, not uncommon among patients operated on for abdominal tuberculosis. They were often so poorly nourished that their healing was compromised. She would need surgery to fix the hernia. I assured them that this surgery was not as big a deal as her previous one; it was only a matter of bridging the defect and bringing the edges together again. As a precautionary measure, though, I advised her to get another abdominal scan done. It would give me additional details about the hernia and confirm that the tuberculosis had cleared up completely.

She would be the youngest patient for whom I had performed a hernia surgery. So as I awaited her next visit with the report, I waded through my pool of resources, seeking ways to repair her hernia that would grow along with her. I was determined to offer a repair technique that had the least chance of recurrence as well as one that would not interfere with possible future pregnancies.

When they returned a couple of weeks later with the scan report, it showed a collection of pus on the right side of her abdomen. Worried yet clinging stupidly to unlikely hope, I sent her to get the fluid tapped, and we ran some tests on it. The results confirmed what I suspected but did not want to accept. Once again, she had active tuberculosis. It was highly likely that this strain was now resistant to all the drugs she had taken so far in her first two treatment courses. This meant additional expensive tests and the likelihood that she would require a third-line treatment of even more expensive medicines.

It was as though the tuberculosis had been lying dormant until it was revealed by the investigations. Pranali, who up until now had been the poster girl of post-tuberculosis thriving, began to decline rapidly. She was always feverish, had lost her appetite, lost weight she could ill-afford to lose. It was a cruel reversal, a mirror image of her recovery process, like a time-lapse video run backward. Naturally, she was no longer cheerful. She became irritable and querulous. Each time I heard the whine in her voice, reminiscent of a much younger child, it tugged at my heart. How hard it must have been for her to go through this a third time! Her parents were subdued in their disappointment but remained quietly compliant, getting investigations done, making sure she took the medications as prescribed, following up on the referrals to tuberculosis experts that I wrote for them.

One day her mother pulled me aside and asked in a whisper if there was a chance that Pranali’s form of tuberculosis was contagious; could it spread, she wanted to know. Her new daughter-in-law was expecting, and they were worried about her and the unborn child contracting tuberculosis. I don’t remember what I advised them, but this seemed to mark a turning point, a shift in their focus from their child to their grandchild. They kept up their best efforts for Pranali, but they no longer seemed hopeful of her recovery.

I saw Pranali only twice after that. Her parents ran out of money for further treatment. Her father came to see me, and I drafted many letters for him detailing her treatment journey so he could do the rounds of charitable organisations seeking funds. Even after he stopped visiting the OPD, he would call to update me about her fast-declining health. He once mentioned that Pranali spoke of me often; she wanted to meet me, but she was too weak to come to the hospital and wait in a queue; would I visit them at home? I promised to visit. I had every intention of fulfilling my promise, even buying a tin of chocolate protein biscuits for her, but as the days passed, I didn’t go. I allowed myself to get caught up in the drama of my own life, and as the calls grew less frequent, I allowed myself to forget my promise.

One late January afternoon, I was in my bedroom doing some paperwork. The long slanting rays of the sun lit up the room with a warm glow. When my mobile phone rang, and the caller ID showed it was Pranali’s father, a strange reluctance to answer seized me; part guilt, part fear. Yet I forced myself to take the call, assuming a false-ly cheery tone, the words promising an imminent visit on the very tip of my tongue. Before I could speak, her father brokenly informed me that Pranali was dead. She had succumbed to the disease. His words were a slap of cold water, shocking me awake. Pranali was dead; that brave, giggly teenager was gone! She would never hold her unborn niece or nephew in her arms, never go shopping with friends, never grow up, or marry, or try for a child herself.

Every surgeon has a graveyard that they visit. It is filled with the names and faces and sundry details of those who died on their watch, the patients they could not save. These visits are holy, restoring the surgeon to full humanity. These visits are essential, snatching her from the jaws of god-like arrogance. This graveyard is where she can shed her armour and sink to the damp earth and sob, weep, wail, shriek. I visit mine often. Pranali’s tombstone is where I linger the longest. I assuage my guilt at not visiting her that one last time by ensuring she is not forgotten, by keeping her alive in my thoughts and through my words. I picture her at her healthiest and most hopeful, that turquoise eye shadow shimmering iridescent, like the wings of a peacock butterfly. Her season was as short as a butterfly’s, but that doesn’t mean she didn’t matter. She mattered to me, and I remember her. Perhaps that is all the meaning that life holds, that we touch each other’s lives as gently and deeply as the butterfly kisses a flower before it flits off to the next.

*Name and certain details changed to protect the identity and maintain confidentiality.