by Vikas Swarup
My relationship with hospitals is like that of a battered wife who keeps returning to her abusive husband. I hate to visit them. A trip to the government hospital is enough to make an atheist out of a believer. You see so much pain and suffering that it prompts the question: how can a merciful God permit disease? Yet I cannot do without them. Hospitals are the boats that move damaged souls across the river of human sickness. They provide a quarterly certificate of reassurance that all is well with Ma and the world.
By now it has become a settled routine. I take Ma to the government hospital early on a Sunday morning. They take Ma’s blood and urine. She is tested for B12 deficiency, iron deficiency and anaemia. A chest X-ray is done as well as an eye exam. Then Dr Mittal himself holds a consultation with us, armed with reports of CBC, FBS, PPBS, serum creatinine and urine culture. He gives her a good lecture on maintaining a sugar-free diet and taking her medicines regularly before renewing her prescription: glibenclamide for her diabetes, salbutamol inhalers for her asthma, diclofenac 50 mg for her arthritis and telmisartan 40 mg for her hypertension. ‘Your mother is fine.’ He usually makes a thumbs-up sign at me. ‘Bring her back after three months.’
The last three-month period ended at the beginning of April. At that time we were all preoccupied with Nirmala Ben’s historic fast. But the very first Sunday after that I am at the government hospital with Ma.
It is a cloudless sunny day outside but inside the hospital it is gloomy and grey. Most of the tube lights are fused, and it is only the sunlight streaming through the two casement windows at either end that illuminates the reception area. The walls wear the faded, neglected look of a place that has seen better days. The air reeks of sweat, loud with people. A young mother in a blue sari is squatting in a corner, wailing inconsolably. There are long queues in front of the registration counter. It takes three hours just to get a hospital card for those without clout or connections.
As I traverse the corridors to the nephrology department, the sour, chemical smell of the hospital invades my nostrils, making me quicken my steps. Dr Mittal’s office, on the third floor, is equally crowded. Most are elderly patients with chronic conditions, settled uneasily into the hard, plastic chairs inside the waiting room. Some of them give Ma curious glances, perhaps jogging their memories to check where they have seen her. Those who succeed will recognise her as the unknown woman by Nirmala Ben’s side in TV coverage of the fast.
As usual, the duty nurse allows us to jump the queue, and ten minutes later we are face to face with Dr Dheeraj Mittal. A short man in his mid-forties, Dr Mittal has the slightly unkempt look of a forgetful professor with his shaggy dark hair and rimless eyeglasses. But he more than makes up for it with his pleasant bedside manner and deep medical knowledge. He exudes confidence and competence. ‘Welcome, Maa-ji,’ he greets Mother. ‘I am told you have also become quite a celebrity, thanks to Nirmala Ben.’
‘Nirmala Ben is lucky,’ Ma says wryly. ‘She doesn’t have to endure these endless trips to the hospital.’
‘If only you could maintain a constant weight you would also be spared these check-ups. But, every time I see you, your weight decreases a little.’
‘What to do?’ Ma sighs. ‘Nirmala Ben is hale and hearty even after fasting for two weeks. I eat thrice a day and yet just cannot seem to put on any weight.’
Dr Mittal glances at me. ‘Are you aware that two months ago Maa-ji collapsed in the house, due to hypoglycaemia?’
‘Ma never told me, Doctor. I learnt about it only now.’
‘That is why we need to examine her more thoroughly this time,’ says Dr Mittal as he begins scribbling on his pad.
He orders a battery of new tests: Hba1C, fructosamine, 1.5-anhydroglucitol, microalbumin, CMP, BUN, cystatin C, C-peptide – it is the first warning sign that this checkup is not proceeding according to script.
The tests take a full day and the results a full week. As usual they go directly to Dr Mittal. I have always found it strange that test results are shown to the doctor first, as though patients cannot be trusted with analysis of their own bodies.
That is what adds to the mystique of the medical profession. Doctors and car mechanics have something in common. Both work under the hood and we have no accurate way of knowing what’s happening down there, in the innards of the human body or the core of a car engine. Just as a perfectly good car can stall suddenly, our bodies can betray us in a myriad ways. So when Dr Mittal summons me to the hospital at 11 a.m. on Sunday, 24 April, I enter his office with the trepidation of a marginal student about to receive her report card.
‘Is everything all right with Ma, Doctor?’ I ask the moment I settle down in the chair opposite him.
The sombre expression on his face makes my chest start to tighten up. ‘I have always believed in full disclosure with my patients,’ he begins. ‘That is why—’
‘Please don’t tell me it’s cancer,’ I interrupt him plaintively.
‘No, it’s not cancer,’ he says.
‘Thank God.’ I exhale.
‘No need to thank God just yet. Your mother has ESRD, which is just as bad.’
‘ESRD? What’s that?’
‘End-stage renal disease, also known as chronic kidney failure. Diabetes and hypertension are the most common causes of ESRD, and your mother has both. These are diseases that affect the blood vessels and they impair the kidneys’ ability to filter blood and regulate fluids in the body. In end stage kidney failure, the kidneys function at less than fifteen per cent of their normal capacity.’
I am shocked. ‘But … but she looks fine. There must be some mistake.’
‘The test results are in front of me and they don’t lie.’ He picks up a printout and begins reeling off figures: ‘Haemoglobin six grams, fasting blood sugar eighty, PPBS a hundred and ten, serum creatinine 7.5 milligram, urine shows protein of three-plus and sugar is also three-plus.’ He takes off his eyeglasses and scratches his brow. ‘If these aren’t indicators of ESRD, then what are they?’
‘Then how come we are discovering this now?’
‘Kidney disease is a silent killer, proceeding stealthily over many years, with no signs or symptoms the patient can recognise. When detected late, as in your mother’s case, it can be fatal.’
Fatal. The word sends a chill up my spine.
‘The only way to treat ESRD is with dialysis or transplantation,’ he presses on. ‘Permanent dialysis you won’t be able to afford. So there’s only one option left to you.’
‘What’s that?’
‘A kidney transplant. Your mother needs a new kidney and quickly.’
‘And how much is a new kidney going to cost?’
‘Nothing.’
‘Nothing? How come?’
‘Because it will be yours. Or your sister’s.’
‘I … I don’t understand.’
‘Under the Human Organ Transplantation Act of 1994, only living, related donors are permitted to provide organs to a patient. This includes father, mother, brother and sister.’
‘Donating blood is one thing. But how can a living person donate an organ like the kidney?’
‘It’s called living-donor kidney transplantation. You see, the advantage of the kidney is that it is a paired organ. We have two of them. The second kidney is actually redundant, because it serves no useful purpose. In fact, some say it wastes the resources of the body. So it is possible to remove a kidney from a living person. Reasonably healthy humans can function quite well with one kidney. The only thing is, are you and Neha up to it?’
I am staring at the floor, head hanging down, trying desperately not to throw up. Nodding weakly, I ask, ‘How do we go about it?’
‘Well, I’ll need both you and Neha to come in and give blood tests. If possible, today itself. The good thing is that your mother’s blood type is AB positive, which makes her a universal receiver. I’ll just have to do a tissue antigen match and crossmatching to determine final compatibility for organ donation.’
‘And what if Neha and I are not found compatible?’
‘We’ll cross that bridge when we come to it, right?’ He smiles brightly at me, but it does nothing to lift my mood.
‘Thank you, Doctor,’ I say, my voice sounding hoarse and unnatural, and exit his office.
The waiting room outside his chamber contains a faded poster showing the main structures of the urinary system. I’ve never given it a second glance. But today it draws me like a magnet. I study the two dark, bean-shaped organs located one on either side of the spine, just below the rib cage, as though they were coordinates to some long-buried treasure. They look quite small, each no bigger than a clenched fist. Both are covered with a mesh of fibrous tissue, nerves and blood vessels. Both have ureters going into the urinary bladder. To me the left kidney and the right kidney look identical. And there is nothing in the diagram to suggest that one of them is redundant.
By the time I reach home, my mind is thoroughly confused and spinning with worst-case scenarios. Ma is in the kitchen as usual, preparing lunch. She doesn’t even bother to ask me about her test results. She has conditioned herself to believe that death is inevitable and no amount of antibiotics will stop it when her time comes. It is just one last desire, one final hope that keeps her going. ‘All I am waiting for is to see my two daughters get married and settled,’ she has told Nirmala Ben innumerable times. ‘After that I can die in peace.’
Neha is engrossed, as usual, in herself. When I enter our room she is preening before a mirror, imitating Priya Capoorr’s iconic pose in Love in Bangkok. ‘I have decided to apply for the Miss India contest, didi,’ she informs me. ‘A voice may have its ups and downs, but there is no doubting a beautiful face. After all, a rose is a rose is a rose, isn’t it?’
‘Can you for once think of something else besides beauty pageants and modelling competitions?’ I rebuke her. ‘Dr Mittal has got Ma’s test results and he says she has end-stage renal disease. She needs a new kidney.’
‘A new kidney? So where do we buy it from? Big Bazaar?’
‘It’s not a joke, Neha. You can’t buy a kidney: you can only donate it. Dr Mittal has called you and me for a blood test to see if either of us can be a kidney donor for Ma.’
Neha recoils as though I had slapped her. ‘Kidney donor? Are you out of your mind, didi? There’s no way I’m giving my kidney.’
‘Fine. Then you go tell Ma that she is about to die.’
At least I shame her into coming with me to the hospital. We go past the reception, and head straight to the clinical laboratory on the first floor.
The lab nurse is a middle-aged, sour-faced woman in a stiff, starched, white uniform, who has already received her instructions from Dr Mittal. With cold-blooded efficiency she locates a vein in my inner elbow region and is poised to pierce the skin with her hypodermic needle when my cell phone rings. It is the Red Cross, calling to remind me of World Blood Donation Day on 14 June. ‘The blood centre is running low again on the Bombay blood group,’ the duty clerk informs me. ‘Would you care to come in for your quarterly donation? We can even send a car to bring you.’
I marvel at their timing. ‘Sorry,’ I tell the clerk. ‘I am in a hospital right now, about to give blood for my mother. I cannot help you out this time.’
The nurse gives me a disapproving frown and guides the needle into my vein. I have given blood many times before but somehow this feels different. As the dark, crimson liquid begins to fill the syringe, I am filled with a nameless dread, a shape-shifting monster that takes the form of my worst fears. The sample will soon be tested, when it will whisper its secrets, reveal its antigens and antibodies. And I know deep in my gut that this is one test I would be happy to fail.
Neha, who has never given blood before, is fidgety and nervous when her turn comes. She bites her lower lip, clenches her hands and avoids looking at the syringe. The moment the needle enters her skin she begins hyperventilating and complains of feeling weak and dizzy. ‘Don’t be a drama queen,’ the nurse shushes her and continues to draw blood. Neha endures the procedure with gritted teeth, glaring daggers at the nurse, and throws up immediately afterwards.
Once the blood is drawn, there is an agonising three-hour wait for the results before Dr Mittal calls us to his office.
‘I have good news,’ he says, addressing me. ‘The HLA test has yielded a perfect six-of-six match for Neha and a half-match, that is three-of-six match, for you, which is just as good, because the partial rejection can be overcome through the use of immunosuppressive drugs. And the crossmatch for both of you is negative.’
‘Negative?’ Neha, who has been gripping the seat rest, suddenly unclenches her hand, a quick flicker of relief crossing her face. ‘That means we are incompatible with Ma’s blood group, isn’t it?’
‘On the contrary it means that there is perfect compatibility. In this test, we mix white blood cells from the donor with blood from the recipient. If the white blood cells are attacked and die, then the crossmatch is “positive”, and it means the recipient’s immune system cannot accept the donated organ. But if the crossmatch is “negative”, then the donor’s antigens are compatible with the recipient’s. Both your and Sapna’s blood is compatible with Maa-ji’s and both of you are capable of donating your kidney. Now it is up to you two sisters to decide who loves Mother more.’
Neha and I look at each other, and then look away. The air in the room grows dense and oppressive, weighed down by the gravity of the situation and the hospital’s ominous ambience.
Dr Mittal senses the palpable tension between us. ‘I know it is not an easy decision. That is why I want both of you to think about it carefully and come back to me in seventy-two hours. That’s three full days.’
We walk home in silence, not knowing what to say or do next. It is a new challenge to both of us, something we have never faced before. The only ground rule we agree on is not to breathe a word about this to Ma.
* * *
That night, as I lie in the dark, I can hear Neha tossing and turning in her bed. And I know she is thinking the same thought as me. All our filial love and affection has eventually come down to this bizarre predicament: whom do you care for more – your mother or your kidney?
It is a question I wish no daughter should ever have to answer. For it has the potential of pitting sister against sister, laying bare the hidden weakness of the soul. Every anxiety, every doubt, every foible and pretence waylays me in the street of indecision. Every selfish desire sprouts in the garden of my fear.
I occupy myself by researching ESRD and kidney transplants. The kidney of an adult human, I learn, measures ten to twelve centimetres in length, contains one million nephrons and weighs approximately 150 grams. I trawl the Internet, seeking inspiration from those who have donated kidneys to their loved ones and are still leading happy, healthy lives.
Neha spends her time researching the opposite, marshalling arguments against donation. She holds whispered conversations with me when Ma has gone off to sleep. ‘Donating a kidney is not like giving your iPod to a friend,’ she says. ‘It is a major surgical procedure and carries long-term health risks. After the operation you can forget about playing any more sports or doing physical activity. Besides, I don’t even buy the argument that the second kidney is redundant. God forbid, but if something were to happen to me one day, say an accident or some serious disease, the second kidney would come in mighty handy.’
There is some truth to what she says. My research reveals that people with just one kidney tend to suffer from a few problems later in life. Some have high blood pressure, others a condition called proteinuria, which refers to excessive protein in the urine, and a third category has been known to suffer from a reduced glomerular filtration rate, which basically means that the single kidney is no longer as effective in removing wastes from the bloodstream.
‘After knowing all this, you still think we should go ahead with kidney donation?’ Neha demands.
‘We don’t have a choice. If Ma
doesn’t get a new kidney, she dies,’ I respond. ‘Blood demands a price. Love demands sacrifice.’
‘Then you make it,’ she says with characteristic bluntness. ‘I have to appear for the regionals of the Miss India contest. I can’t go looking pale and unhealthy. Besides, you are the eldest in the family.’
Neha has hurt me before; now she is trying to backstab me. I can feel the knife of betrayal twisting up my insides. And it fills me with utter disgust. ‘Why? What special favours have you all done me?’ I erupt in virtuous anger. ‘Where does it say that the eldest has to suffer for everyone else? I gave up my dreams, I cut short my studies, and now you are forcing me to even cut open my body?’
For once Neha is dumbfounded. She takes an involuntary step back, her eyes wide from disbelief. Then a gasp of contrition escapes her lips and she falls down at my feet. ‘Forgive me, didi,’ she cries, clutching my legs. ‘I take back my words. After all that you’ve done for me, how could I be such an ingrate? I don’t deserve to live.’
It is enough to make me break out in tears. I raise her up, mumbling, ‘We’re in this together, stupid.’
We cling to each other, two scared souls trying desperately to gather the courage to do one brave thing.
* * *
When the moral instinct for filial love collides with the primal instinct for self-preservation, the first casualty is decision-making. We try to postpone the inevitable by immersing ourselves in the mundane routine of life. I religiously go to my job, Neha to her college. At night, closeted in the same bedroom, we hardly speak to each other, suffocated by our anxieties.
For forty-eight hours we remain in deadlock, tense with uncertainty, torn with irresolution, like a jury unable to agree upon its verdict.
It is Neha who suggests a way out of the impasse on the third morning. ‘Let’s toss, like they do in cricket. Heads it is me. Tails it will be you. Okay?’
