In the Bonesetter's Waiting Room

by Aarathi Prasad

  On the ground floor of the cardiac wing of the hospital I was shown a long, computer-filled room, the focus of which was an enormous teleconferencing screen. This was the e-health unit, where technicians analysed patient data sent in real time from areas where there was no cardiology expertise. On the screens of the myriad computer monitors were graphs and metrics of the vital signs of patients from the deep, doctorless rural areas of India and beyond. Introduced as a pilot scheme almost immediately after his hospital opened in 2001, Shetty oversaw India’s first efforts to deliver free electronic healthcare to the interior of India, where it remains difficult to attract any medical staff at all and harder still to attract the best qualified. From its site in Electronic City, Shetty’s hospital served as one of two telemedicine hubs for seven states of India, working with the Indian Space Research Organisation and Hewlett Packard for maximum efficiency. The first trials had resulted in the treatment of 10,000 patients in remote coronary care units, where basic measuring equipment can be sent for use by staff with only basic training.

  ‘We do seven hundred tele-ECGs a day now,’ the technician on duty explained to me, ‘from the interior, but also from twenty-two countries from all over the world – there are fifty-three centres in Africa, many in Tanzania, also Malaysia, Thailand, Eastern Europe, Iraq. The readings come in within a minute from equipment they keep in the hundred and thirty centres and then our doctors process and analyse them here.’

  ‘On that big screen,’ Asha added, ‘that’s where doctors connect. We run eight training sessions a month, so that our doctors can exchange information and training with doctors from around the world. It’s for their continuing medical education.’

  The healthcare and education links Asha told me about were now part of Phase Two of the Indian government-funded Pan-African e-Network project – developed to share India’s new affordable healthcare schemes as well as its specialist educational facilities with African signatory countries – Botswana, Burundi, Côte d’Ivoire, Djibouti, Egypt, Eritrea, Libya, Malawi, Mozambique, Somalia, Uganda and Zambia.

  As much as Devi Shetty is an advocate for universal health, education and equal opportunity, he is probably also one of his generation’s most dedicated patriots. As he has enthusiastically and emphatically said, ‘We believe that India will become the first country in the world to dissociate healthcare from affluence. India will prove to the world that the wealth of a nation has very little to do with the quality of healthcare its citizens can enjoy and we are going to do this within the next ten years. I have no doubt that this will become a reality, because this is the only way our civilisation will be protected.’

  And I had no doubt that what Shetty dreams of, he probably will achieve – much as he has already done in a remarkably short time. It may be that Narayana’s achievements have in part been driven by Shetty’s remarkable charisma, but I also got the distinct impression that the kind of systems that he got moving just made plain, simple sense. Shetty has a very clear and precise way of thinking about problems. Concise in his speech and disciplined with his time, his skill lies in stripping away the extraneous and getting to the heart of the matter. He thinks of healthcare in the round, rather than its constituent parts. He had envisioned a certain reality and found the most logical route to get there.

  The best solutions are often the simplest, but Shetty’s brand of simple also had sophistication. His entrepreneurship is as hard-nosed as his personal ethos is spiritual, and his work is studied closely by academics, critics and admirers alike. His methods take into account what patients really need and what motivates staff. He has harnessed mobile health technology to bring diagnosis to places where no specialist doctors are present and enabled doctors to understand the economics of their own time, encouraging accountability by sending them daily breakdowns of costs.

  Shetty aims to go to Africa when he retires. In the meantime he is trying to persuade a number of international educational establishments to set up a global medical university. He hopes it will train the massive numbers of medical staff needed in countries – India included – in which there are still simply not enough to go round. Rolling out solutions such as these, both in India and worldwide, is still a work in progress, but one that, if Devi Shetty has anything to do with it, looks destined to succeed.

  5

  Blood, Bile, Bone

  I COULDN’T HELP WATCHING the reflection of his face in the rear-view mirror as Hakim Sultan Rasool carefully pulled a barbed thorn from his lip. It bled a little as it caught the skin and he flinched.

  A few minutes earlier, he had asked our driver to make a sudden stop – one of many we would make on our early morning forage out towards the more rural landscapes outside Hyderabad, along roads that connected the old city with the new airport. This time, we had pulled up outside a one-roomed house, its once vibrant blues bleached over the years by the burning sun and and pristine whites stained by the monsoon rains. The front door was shrouded in a tattered curtain and, where there might have been a path to it, what looked like a grave covered in fleshy shards of aloe vera blocked the way. To one side was a low-growing cactus, its flat leaves bordered by spikes and flanked by an infantry of razor-sharp bristles. Hakim Sultan Rasool picked up a twig, wrapped it round one of the plant’s prickly pear fruits and twisted hard. A sliver of a woman’s face appeared, peering through the curtain. She made no objection to us being on her land and instead watched as he broke the fruit open and offered me a look at its oozing crimson flesh. ‘The fruit is used to make a syrup,’ he explained, ‘for chronic tuberculosis. And I use Aloe in a formulation that works till second grade carcinoma.’ He pointed to the ‘grave’. ‘After that it doesn’t work though. But people don’t know this medicinal value. It’s growing right in front of them, but they don’t know.’ He paused to swallow the pulp of one half of the cactus fruit and as he felt its sharp prick tossed the other back under the plant.

  As we travelled on, the hakim, my Urdu translator Ramal Alwi and I passed littered undeveloped plots in small roadside towns, sparsely scattered mosques and homes and more wooded areas. As we went, Rasool pointed out the trees, shrubs, flowers, berries and barks he experimented with in his medical formulations. There were flowers used to treat rabies, the milky sap of leaves for the purification of blood, plants for jaundice, enlarged lymph nodes, palpitations, bronchitis, ulcers and first-stage uterine carcinoma. Occasionally, he ate a flower or leaf, ‘Only because I know how to eat them,’ he told me. ‘Hm. This one is very bitter,’ he said, swallowing it anyway. ‘I recognise the plants by smelling, tasting and looking at their structure. In old areas of Hyderabad we can easily find these plants, but in open building plots being developed in other parts of the city they see them as weeds and destroy them. Here, in the rural areas, whoever knows about these plants as medicine, they will use them. Har plants medicinal hain – I think all plants are useful. Even if I show you some plant and say it is not medicinal, someone else might know what to use it for. I only take plants from here in an emergency, because they get polluted this close to the city. But see, in such a small area I’ve shown you, we’ve already identified nearly twenty medicinal plants. In the jungle there are hundreds. For my medicines I collect baskets full from the wild. Since I was eight years old I’ve been going out to the Warangal forests with my grandfather and father, I learned their formulations from them and I also experimented.’

  As an example, the hakim pointed out another delicate shrub, growing close to the ground. As we bent to inspect it, he told me that its leaves are known to be useful in certain sexual disorders. Based on that, and by experimenting with different combinations of formulations using the plant, he’d been able to help people who come to him with gonorrhoea and syphilis.

  ‘Does it work?’ I asked.

  ‘All treated successfully,’ he affirmed. ‘Effective hai. In one month the syphilis is gone.’

  In India, ‘hakim’ is the title that doctors of Unani medicine (the ‘U,’ of AYUSH) ar
e popularly given. As well as the decades-long apprenticeship in his family (of which he is the fourth generation) and with the other hakims in his five-year training at Unani medical college, Hakim Sultan Rasool used a large, beautifully illustrated volume of a 200-year-old text, bound in peacock blue and filled with painted depictions of plants and their descriptions in Urdu, that lay on his lap as we drove. The Kitab Rehnumae-Akhakheer, authored in an area of what is now Pakistan, was one of his trusted references: it details medicinal plants of the subcontinent and their indications, as well as their counterparts from other parts of the world – sometimes as far afield as Saudi Arabia and Greece.

  The herbarium that Hakim Sultan Rasool used, and the medicines he formulated, were based broadly in a tradition known as Tibb-e-Unani: tibb being the Arabic word for medicine and Unani from the Persian word for the ancient Greeks. To India’s close Islamic neighbours, Greece was known as Yunanistan and Greeks were called Yunani. Technically, the Arabic word Unani translated as Ionian – the eastern Greek-speaking people of Asia Minor, an area close to the island where Hippocrates was said to have been born. As well as being the name of the people, Unani was what their medicine came to be called on the Indian subcontinent.

  Widely considered the basis of modern medicine, the theories surrounding health and disease in ancient Greece are thought to originate with Hippocrates, the fourth-century BCE philosopher/physician known as ‘the father of Western medicine’. Hippocrates was from the island of Kos, just off the coast of Asia Minor (present day Turkey), which was the centre of Ionian Greece. Hippocrates organised the workings of the body according to the balance of four humours – crucial bodily fluids including blood and what he called black bile and yellow bile and phlegm. According to Hippocratic theory, any imbalance in the humours could result in disease and therefore balance was essential for maintaining a healthy body and mind. Although the modern ‘germ-theory’ medicine which eventually evolved after humoral medicine is – of course – very different, in some ways Hippocrates’ understanding of disease was fairly modern, in that his diagnoses, in contrast with what came before were based on the idea that diseases had natural, physical causes, rather than supernatural ones based on evil forces.

  Hippocrates’ reasonably scientific approach to health wasn’t adopted universally, however: fast forward nearly a thousand years to medieval Europe and you’ll find a period lasting around eight centuries in which scholarship, education and literary pursuits largely disappeared in favour of religious instruction by the Christian church and scientific medicine had firmly re-dissolved into supernatural belief.

  It would not be until the twelfth century that European medicine would develop again – though when it did, it emerged because of the existence of a vast wealth of texts written in Arabic, that had in turn been translated from ancient Greek. In 661 the Umayyad Caliphate headquartered in Syria (but stretching from Afghanistan in the east to Spain in the west and encompassing Georgia, Turkey, Cyprus and northern Africa) began developing what has come to be known variously as Islamic, Arabic, or Greco-Arabic medicine. The Arabic scholars knew Hippocrates as Boqrāt, or Eboqrātis, and honoured him as the ‘first codifier of medicine’.

  For around the next 700 years the work of Hippocrates, Aristotle and Galen were used and expanded, with learned texts filling the libraries and medical schools from Córdoba in the west to Alexandria, Persia and India in the east. During that time, philosophers, mathematicians, physicians – the scholars of rising Islamic culture in the Arab world – sought good copies of ancient manuscripts. These scholars also translated classical medical texts from India, China and ancient Greece. Reflecting the broad geographic spread and cultural centres of Islamic rule, many texts were translated from Greek to Syriac and then into Arabic. When, over time, some of the original Greek manuscripts disappeared entirely, the new, post-Dark Age European intelligentsia were able to benefit from the Arab translations of medical and philosophical writings after Islamic Spain was reconquered. There, in Toledo, European scholars gathered to translate some of these Greco-Arab manuscripts into Latin, the language of the learned in medieval Europe. In this way, knowledge derived from Arab scholars who built on Greek and Eastern traditions also informed the development of what became Western medicine.

  But even before Europe of the Middle Ages turned away from the Greek model of medicine, there seems already to have been significant sharing of medical knowledge and healing plants between Asia and Europe, via the Arab intelligentsia. There is likely to have already been a long-running medical and scholarly exchange between West and East, between Egypt, Greece, China and India that might explain the ancient echoes of each in the others’ understanding of health and sickness, anatomy and the treatment of disease. It is difficult to know exactly when this started, though there is archaeological evidence that by around the second century BCE, medicinal plants with an Indian origin were already in established use in Europe.

  In 1974, archaeologists from Italy’s Experimental Centre for Underwater Archaeology uncovered a shipwreck near the remains of the Etruscan city of Populonia, along the coast of Tuscany. The ship was dated to 140–130 BCE, a time when Populonia was a key part of the sea-trade route between the Western and Eastern worlds. It had been headed for Pisa or Marseilles, loaded with cargo from the East – glass cups from Syria or Palestine, pitchers from Cyprus, wine amphorae from Rhodes, ink-wells, lamps from Asia minor and ceramics from Athens. Its origin seems to have been Delos, a tiny island at the centre of the Cyclades, set in the centre of the Aegean. Delos was at the peak of its prosperity when this cargo was heaved aboard: honoured by the Greeks, Romans, Egyptians and even the Persians, Delos was the legendary birthplace of Apollo and Artemis, and in spite of its minuscule size (less than three and a half square kilometres), at that period in time its 25,000 inhabitants lived in a hub of international commerce, at the epicentre of the Mediterranean slave trade.

  A thriving population of that size would have needed many doctors, one of whom might even have been aboard the ill-fated ship: among the cargo lay a range of ancient professional medical equipment, including an iron probe and a bronze vessel for bloodletting or pain relief, and something even more remarkable and rare: hundreds of tin and wood pyxides – small cylindrical vials – were found close to what had been a locked box. This too may have belonged to the ship’s doctor and was perhaps his medicine chest, because inside one of the tin pyxides were five tablets, some still miraculously dry after 2,000 years of submersion. Chemical tests showed that among their ingredients were high levels of zinc compounds, known to have been used to treat disease in ancient times. The samples were then sent to a geneticist – who was sceptical, at first, that any intact plant DNA would have survived. But it had survived, and it later emerged that the DNA identified in the pills belonged to radish, celery, wild onion, oak, cabbage, alfalfa, carrot, yarrow and hibiscus.

  These were all plants described in early Greek medical texts – including those attributed to Hippocrates – as ingredients used to treat gastrointestinal disorders, as well as a host of other conditions. The first-century Greek physician Dioscorides (whose De Materia Medica had been translated into Arabic by Ibn Juljul in Córdoba) described wild carrot as a diuretic used to treat colic, wounds and poisonous bites. Yarrow, which stops bleeding, was, mythology tells us, the same plant the legendary hero Achilles used on the bleeding wounds of his soldiers. And from tracing its genetic ancestry it looked as though the hibiscus in the tablets might have originated in India. Dioscorides’ volumes on herbal medicines, written between the years CE 50 and 70, also listed other plants specifically marked as originating in India and detailing their uses as medicines in the Greek corpus, including: cardamom, spikenard (a valerian relative), cinnamon ointment, incense (kostos), agarwood, a myrrh-like resin called bdellium, aloe and indikon, or indigo from Indian reeds.

  Well before Dioscorides’ time, and certainly by 140 BCE, India had, of course, long made contact with Greece. Alexander the Great
had arrived with his armies around 200 years before that; as a result, the Indo-Greek Bactrian kingdom annexed Taxila – a university town in the Punjab that was internationally renowned for its medical school. Under the reign of Emperor Ashoka, who ruled over almost all of the subcontinent between the years 269 and 232 BCE, famous rock edicts were commissioned to detail the emperor’s provision of hospitals and medical treatment (along with public health initiatives such as wells and trees) for both humans and animals within his domains. These extended from parts of present-day Iran and Afghanistan into India’s east and deep south. But he also delivered these ‘among the people beyond the borders’, as far as the southwestern seaboard (Kerala), into south India and further on to Sri Lanka, as well as to the dominions of Antiochus Soter ‘the Greek King’, whose lands bordered Ashoka’s in the east and continued to Syria and Turkey in the west.

  Lost when some of the carved stone edicts were smashed over the millennia, the names and dominions of three further foreign monarchs with whom Ashoka had influence are now unknown, with the only surviving remnant naming one of the Ptolemies of Egypt, thought to be Ptolemy II Philadelphus, whose lands included parts of Egypt, Palestine, Lebanon, Turkey and Greece. As well as medical knowledge, Ashoka also stated in his edict that ‘Wherever medical herbs suitable for humans or animals are not available, I have had them imported and grown.’ The likelihood is that the sharing of medicines across a broad geographic region that included parts of the Greek world also meant the sharing of medical knowledge and expertise between East and West. Through the transitions of emperors and gods, conquests and cultural assimilation, this tradition of knowledge exchange dating back millennia saw a direct continuum into the religious and political flux of Hyderabad in the Middle Ages.