Wow. I am actually in disbelief that six months of my Watson have passed. I have spent this quarter of my year in various parts of India: Bangalore, Calicut, Manipal, Goa, Pune, Mumbai, Delhi, Jaipur, and I am currently writing from Pushkar. While in India, I have embraced a much more peripatetic approach than while in Quito– I have not stayed in any one place for longer than two weeks. I have worked in hospitals, hospices, palliative care centers, and attended several conferences focused on palliative care or the dying process. Although jumping from place to place has left me feeling like a lonely nomad at times, it has helped to keep my work interesting and has allowed me to connect with many insightful individuals.
When I first arrived in India, I regretfully was a little out of my journaling groove. I took diligent notes during my days at Karunashraya hospice, but in the evenings, I felt too exhausted to process my new surroundings. I used jetlag as an excuse, although in retrospect, I was perhaps avoiding confronting how overwhelmed I actually felt. Many people I meet ask me about culture shock. At the time, I denied its existence– “It’s not as different as I expected,” I would say, and I would mean it truthfully. India hasn’t been as different as I expected, both in daily life and in the approaches to palliative care, death, and dying.
I have spent a lot of time over this past month rereading my project proposal. What exactly was it that I initially had set out to learn, have I answered that question, and if not, what have I learned instead? As I look back on my proposal, I feel like I am seeing into the mind of a younger, more naïve self. Why did I expect there to be such a large disparity in how we approach death based on cultural and religious differences? At the risk of oversimplifying, when it comes down to it, most people are afraid to die. There are a select few people and communities in this world who I think are truly at peace when it comes to facing their own death. Even the incredible doctors I have worked with usually avoid thinking of their own death, instead focusing on the deaths of their patients, alleviating the suffering of others instead of preparing for their own. As I reflect further, isn’t that what I have been doing, too? During my Davidson Watson committee interview, Dr. Campbell asked me if I ever thought about my own death. I knew my answer should be yes, but it was not. I had spent a lot of time thinking about death, yes, but how had I even begun to prepare for mine? Recently, I started to reread Tuesdays with Morrie. Morrie repeats several times, “Everyone knows they’re going to die, but nobody believes it.” Even after spending six months studying death and dying, I still can’t say that I truly comprehend the fact that I am going to die.
As I acknowledge the limited understanding of my own mortality, I feel I am able to better understand death as a truly universal experience. At least from my own experiences, being Catholic or Hindu or Muslim does not guarantee any particular approach to death. Some people take more comfort in their God than others–I believe a lot of others turn to God during this time almost as a last-ditch effort to make some meaning out of the life they have lived. Dr. Nagesh, founder and director of Karunashraya Hospice in Bangalore, and the doctor who basically has become my personal mentor during my time here in India, is very aware of our spiritual vulnerability and susceptibility as we approach our death. Due to this fact, he intentionally keeps Karunashraya as a secular institution, believing that a patient should not be tempted to embrace a new religion or God in hopes of salvation. While my questions about the influences of religion have changed, there is one question about death that has become constant: can we really die a good death if we haven’t lived a good life? I hope my next six months will guide me to truly internalize this thought.
Allow me to return to the idea of culture shock, and now admit with certainty that I was a bit shocked when I first arrived in India. Although not as different as I expected, it was definitely still different. As I prepared to visit my first hospice center in India, Dr. Nagesh helped me arrange accommodations just across the street. On my first day of work, I realized that “just across the street” was nowhere near as simple as it sounded. After closely following a group of students as they weaved around the cars, I safely made it to the other side. I nervously looked back over my shoulder at the insane traffic I had just darted through, already feeling anxious for the return journey to my hotel. With time, I learned how to fearlessly walk through the streets of India. I learned that staring is typical. I learned how to eat with my hands, how to shower with a bucket, and how to address people as sir, madam, or ma’am. Many people here speak two, three, or even eight languages, and doctors use English as a secret language when talking about patients at the bedside. I’ve learned that people are often fascinated by Americans and want to know about “Trump’s country.” I’ve learned that India is a fascinating mix of subcultures, and because of my travel throughout the country, I have gotten to experience a unique sampling of these subcultures.
Although not as different as I expected, cultural differences persist surrounding death and dying, too. Collusion is a commonplace issue that every doctor I have met has had to learn how to navigate. How can you have productive end-of-life conversations when the head of the family refuses to share their sick relative’s diagnosis? Many patients are not aware of their diagnosis, let alone their limited prognosis. Some smaller villages still have strong stigmas surrounding cancer, believing it is contagious or that it is a result of bad karma. A counselor I worked with at TATA Memorial Hospital in Mumbai explained how she feels her Muslim and Christian patients often have an easier time accepting their diagnosis than those of a Hindu faith. She thinks it is easier for patients to accept God’s plan instead of grapple with what they have done to deserve their illness, from a karmic viewpoint. I have read about Hindus who believe that suffering at the end-of-life is a necessary part of the reincarnation cycle, but I have not seen this in practice. Hindus must be cremated. Muslims believe burial rituals must happen as soon as possible, which can create problems when deaths occur late at night. Many other religions exist within this country: Sikhs, Jains, Buddhists. Doctors try to be sensitive to the religious and spiritual needs of their patients, but within large hospital settings, it is often difficult to ensure these needs are met.
India has been a whirlwind. I am not sure exactly what inspired me to extend my stay here, but somehow, I felt that I had more to learn. As I am planning my last several weeks in India, however, I can feel that it is soon time to go. After three months, I am finally beginning to feel comfortable here. I will relish in this feeling in these last few weeks, but then it will be time to challenge myself once more. From India, I plan to travel to Bhutan, immersing myself in the Buddhist spirituality of this small neighboring country of India. Following my short stint in Bhutan, I will travel to Jordan, where I will work with a nurse developing a home palliative care initiative. I have learned a lot about the development of palliative care here in India, and I have learned that these deep conversations about spirituality, religion, and the meaning of life, can often only be reserved for patients and families who have met most other end-of-life needs first (think Maslow’s hierarchy of needs). I expect to see a similar pattern in Jordan, where palliative care is very much still in the development phases. Although I have not been experiencing such intense differences based on religion, I think it will still be worthwhile to explore palliative care development in one other culture. After my time in Jordan, I will spend some time in England and/or Spain. While India has provided me with an understanding of palliative care development, I expect palliative care in the UK to be like the finished product. It is here that I will be able to explore the social side of death more, learn about the emerging roles of death doulas, visit some atypical funeral homes, and attend several (hopefully many) death cafes. My Watson has been full of ups and downs, but I can look back on my experiences so far with an overwhelming sense of gratitude. As I look forward, I feel nothing but excitement and curiosity, although I am reminding myself not to get too eager. Can you die a good death if you haven’t lived a good life? Maybe these next six months will shed some light on the good life part, too.
Submitted to the Watson Foundation as my second quarterly report