February marked what I consider my brief and incomplete spiritual tour of India. While spending some time with a college friend in Delhi and enjoying some familiarity after my months of constant travel around India, I quickly grew restless. I stayed in Delhi as I waited for a response from my contact in Jaipur, an anesthesiologist and found of the palliative care department at the Bhagwan Maveer cancer hospital. She had confirmed that I could spend at least two weeks with her earlier in the year, but now my emails and phone calls were met with silence. As I grew tired of waiting, I decided to head to Jaipur anyway–it was only a four-hour bus ride from Delhi. More calls and emails telling her I had made it to Jaipur…more silence. After spending a few days sight-seeing in Jaipur, I again grew tired of waiting and went to the hospital, more or less uninvited. I had to show several people the name of the doctor I was looking for, before a security guard kindly guided me to the palliative care office. It was a tiny room, and everyone stared at me when I entered. It makes me laugh when I look back on it now…the surprised doctor was nice enough to spend an hour of her time with me, answering my questions. After we were finished talking, however, she dismissed herself and told me to email her if I had any other questions. I was so confused; had she not emailed me a month prior telling me she’d be happy to have me work with her at Bhagwan for several weeks? I felt pushing myself into this palliative care department would not benefit me further. With a language barrier present, I have often found that what I can get out of shadowing is very dependent on what the medical provider is willing to put in. By choosing to move on from this experience, however, I was met with several unplanned weeks of my Watson. In my hostel that evening, a group of Argentinian travelers were discussing going to Pushkar, a nearby town with the only Brahman temple in all of India. Considered a sacred city, it is a popular pilgrimage site for Hindus. I decided I would catch a bus with these travelers the next day to see what this sacred city had in store.
When I arrived in Pushkar, I quickly realized that not only was Pushkar a religious site, it had also grown to be a popular tourist destination. I was surprised by the number of tourists and perhaps even more by the number of clothing stalls that lined the streets. While initially I resented being surrounded by other travelers who thought I was just like them, I came to realize that spending time with other travelers actually allowed me to relax. Instead of worrying about where I was going to eat dinner, contacting new doctors, or planning my travel to my next palliative care institution, I could spend my free time pondering some of the more spiritual and existential questions inherent in some ideas of a good death. In some ways, it felt freeing just to be a traveler in India, rather than a researcher. I spent one afternoon in Pushkar crouched on a wooden stepstool surrounded by beautiful fabric in a merchant’s small shop. He had offered me a chai for the small price of a conversation. I sipped on the scalding tea while he explained his views on the meaning of life.
“God put us all on this earth to be nice to each other. Luckily, God put me here in this beautiful place. It’s easier to be nice to people in a beautiful place. All the other merchants here, they just want your money, but I try to learn from the many worlds that come here. Tell me about your home and your country. What do you think is the purpose of this life for you?”
I honestly didn’t have answers any of his questions. What could I tell him about my country, a place that I started to view less and less favorably with each month spent outside of it? What is the purpose of this life…does my life even have a purpose? These thoughts circled my head as I took my evening walk around Pushkar Lake.
After a few days in Pushkar, I eventually made my way to Rishikesh. While visiting the “Yoga Capitol of the World,” I took a week-long yoga course, which included a daily two-hour class about yogic/Indian philosophy. In Varanasi, I wandered through the ghats along the Ganges River. I saw shaved heads as a sign of mourning, bodies being burned, and sadhus covering their bodies in the remaining ashes. Varanasi had a mystical feel, and I learned about the great lengths families will go to try to ensure moksha, or salvation, for their dying loved ones. For those who travel to Varanasi to die, breaking the rebirth cycle is of paramount importance. I was curious about the so-called “death hostels” found in Varanasi. By chance, I ended up meeting a woman from the US who was doing some research at these death hostels. After learning more about these hostels over coffee, I decided that I did not need to go watch for myself. I would have felt too intrusive, even with another American at my side. Learning about how to care for the dying is one thing; watching people die is another. Varanasi was one of my favorite cities in India. It truly had a hectic, spiritual energy that I did not realize would prepare me perfectly for the days to come.
Following my time in Varanasi, I finally was ready to return back to the medical side of my project. I decided to visit Dr. Dam’s clinic near Bokaro, a small city in Jharkhand close to the West Bengali border. I had contacted Dr. Dam through a long email chain beginning with a Davidson connection. In our initial emails, he warned me that Kosish Hospice would be very different than anything else I would see in India. He also invited me on a spiritual sojourn through the Himalayas, but unfortunately, we were unable to go in the cold, winter season. Regardless, I was pleased to have the opportunity to meet this intriguing man and visit his rural hospice center. I did not realize before my arrival, however, that Kosish really was not a functioning hospice. They ran an outpatient clinic only on Sundays, meeting the medical needs of almost anyone from the nearby villages. Kosish also ran an after-school program for the village children, where the children were welcome for a snack and a place to finish their schoolwork with the assistance of two community workers. Kosish also provided the children with a meal 2-3 times a week. The funding for the foods and the salary of the community workers came directly out of Dr. Dam’s pocket–he was still a practicing anesthesiologist in the city of Bokaro. Dr. Dam’s hospice practice is informed by the idea of total pain. Total pain is comprised of four components: physical, spiritual, psychological, and social. Because of the lack of resources in these rural villages, the care provided is less about treating physical pain, and more about addressing social pain by reassuring elderly patients that there is still someone nearby who cares. While Kosish is only open on Sundays for outpatient visits, the community workers are responsible for home visits during the week. I had the privilege of shadowing Anbika, one of the community health workers, as she walked from house to house within two villages, inquiring if there was any older family member who may need medical attention. She refilled blood pressure medications, checked temperatures if needed, and listened to the patients and their families. She knew everyone in the community. I just kept thinking to myself I can’t believe I’m here right now as I followed her through the village. Dr. Dam taught me that death is not always a bad thing; in poverty-stricken villages, death is often welcome as it means one less mouth to feed.
One evening, as I sat outside and read, the only two residents of Kosish Hospice summoned me to look out the window overlooking the nearby creak. The elderly couple had been rescued from the streets of Kolkata, and Dr. Dam offered them a place to stay in exchange for some help with the after-school children. The old man spoke English, but his hearing was horrible, so we still struggled to communicate. He usually just talked at me about India in the 1950s or various different gods while I nodded, often not quite sure what he was talking about. That evening, however, he had something to show me.
“See those people over there?” he said as he pointed to the fire on the bank of the small river. I nodded, as I always did.
“It’s a funeral. They burned a young man’s body tonight. I know he is young because there is no singing. They are silent and solemn. It was a sad loss. If he had been old, it would have been a celebration of his life. But he died too soon.” I nodded again.
Dr. Dam also taught me about the healing power of ritualism, and he told me stories of spiritual rituals he would perform for his willing patients. I never had the privilege of witnessing one of these rituals, but he shared a lot of his writing about his experiences with me. I enjoyed reading his work while sitting at the empty hospice in what honestly felt like the middle of nowhere. It was a week that felt like a lifetime, and a week that challenged many if my beliefs about the purpose of palliative care.
After leaving Kosish, I traveled through Kolkata to make my way towards Guwahati for the 20th Indian Association of Palliative Care Conference. Here, I had the pleasure of seeing Dr. Dam again, as well as the majority of the other doctors I has met throughout my stay in India. The conference was the perfect conclusion to my time in India, and I found myself listening to many conclusions that I had already made, although perhaps with better language. Because my time in the palliative care world has been brief, I do not always have the best vocabulary to describe what I am seeing or experiencing. At the conference, however, I learned many words and phrases to help me articulate my big takeaways from both the conference and my own experiences. Respite care is a hugely unmet need for palliative care all across the world. Two major life commonalities are caregiving and suffering–most of us will experience both before we die. Suffering often needs to be validated, and only then can it start to be alleviated. Palliative care is a revenue-destroying specialty, so its expansion is often met with pushback. Even within the field of palliative care, doctors who focus more on spiritual needs and less on narcotics are sometimes looked down upon. It is a field with tremendous barriers, but also tremendous potential. As I finished my time studying in India, I was still met with so many questions. I feel as though I have not been able to digest everything I have seen and learn. It may take some time to process what I have seen, and I think it will take even more time to fully form the right questions.