Tackling Diabetes in Old Delhi
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A modern epidemic in a historic city Tackling diabetes in Old Delhi Syed Saad Mahmood, MD, MPH The author (AΩA, Case Western each crumbling sandstone facade or Reserve University, 2010) is a resident ornate wooden doorway. Shams, the in Internal Medicine at Massachusetts home-visitnurse,afterwaitingformeto General Hospital. This essay won third finallycatchmybreath,knockedonour prize in the 2010 Helen H. Glaser patient’sfrontdoor.Fifty-eight-year-old Student Essay Competition. Mrs.Nidagreeteduswithasmilethat broughtintoreliefthehighcheekbones ut of breath from trying to andalmondshapedeyespointingtothe keep up with the home-visit Central-Asian ancestry of Old Delhi nurse, I was relieved to reach residents.1p50 Mrs. Nida lived with her ourO diabetes patient’s quarters deep threedaughtersintwocrampedrooms within historic Old Delhi. The cool carved out of a dilapidated mansion. Marchbreezemadeitswaythroughthe Focused on saving for her children’s city’s labyrinth of gullies, or alleyways, weddingdowries,shehadignoredyears helping the sweat on my face evapo- of blurring vision, constant thirst, and rate.Seeingtherowofnowramshackle a tingling sensation in her feet. Only houses, I imagined the story behind when her eldest daughter noticed an 30 The Pharos/Spring2011 ulcer on her foot was she brought to a hand-woven dupatta, or head stole. AdamsCareCharitableHospital,where ShamsandIjoinedheronathincotton- Ifirstmether,andwhereshewasdiag- filledmattresslaidonthefloor.Toshow nosedwiththe“sugardisease,”astype2 gratitude to Shams, Mrs. Nida offered diabetesmellitusislocallyknown. us Rooh Afza sherbet, a syrup of rose Mrs. Nida’s type 2 diabetes is not water and honey that I accepted while unusual.Indiahas40.9milliondiabet- making a mental note to list the drink ics,morethananyothercountryinthe “off-limits”fordiabetics. world.2 Diabetics make up a relatively higherpercentageofIndia’spopulation, Observing Mrs. Nida’s mannerisms, 12.1percent,comparedto8.2percentof I began to think about the narrative the U.S. population.3 Yet India has an of her historic city. Old Delhi truly obesity rate of 2.2 percent of the total came to life in 1639 when the Mughal population, compared with approxi- Emperor Shahjehan laid the founda- mately30percentintheUnitedStates. tion stone to establish his new capital, India’smoderndiabetesepidemicisfu- Shahjehanabad. The Mughal emperor eledbyacombinationofenvironmental hadbeengrievingafterthedeath,dur- factors, such as higher smoking rates, ing childbirth, of his queen, Mumtaz and a genetic predisposition that may Mahal,andhaddecidedtorelocatehis account for why the urban poor, like court.Afternineyearsofconstruction, Mrs. Nida, are so likely to develop the theroyalhouseholdmovedtothenew pathology. Some researchers contend city,leavingbehindthepreviouscapital, that in-utero exposure to undernutri- Agra,butnotbeforebequeathingitwith tion—thecasefor30percentofIndian aplaceinthehistorybooksthroughthe infants—canleadtohighersusceptibil- constructionofTajMahal,atributeto ity to type 2 diabetes later in life. The MumtazMahal. urbanpoorarealsolesslikelytoreceive Shahjehanabad’s centerpiece was adequate treatment since diabetes and ChandniChowk,MoonlitSquare.Built other diet-related noncommunicable by the Emperor’s favorite daughter, diseases account for 13.9 percent of JahanaraBegum,theChowk’sfocuswas India’stotalhealthcarecost.4 water—it featured a square reflecting As part of my public health cap- poolfedbyatree-shadedcanalrunning stone project at Case Western Reserve along the avenue that supplied water University,IwasinIndiatoassistinpro- to residents.11p198 Under royal patron- viding charitable hospital care for Old age,thecapitalevolvedintoboulevards Delhi’s underprivileged. The hospital of Mughal Gardens and ornate hawe- wantedtoproduceaneducationalbro- lis—courtyard mansions—with arched chure on type 2 diabetes that targeted doorways and elaborately painted ve- theuniquedietoftheirpatientpopula- randahs.AsacenterforUrduliterature tion. To learn about the dietary habits andIslamiccalligraphy,manyofIndia’s andbarrierstocareinthiscommunity, finest poets—Mir, Zauq, and even the IaccompaniedShamsduringhishome great Mirza Ghalib—composed their visitstochangeulcerdressingstwicea poems in these hawelis. In 1648, poet week.AndthatishowIfoundmyselfat ChandarBhanBrahmanproudlywrote Mrs.Nida’shome.Thoughlivingachal- that the city’s “towers are the resting lenging life of limited resources, Mrs. placeofthesun.Itsavenuesaresofull Nida had a subtle regality and a sense of pleasure that its lanes are like the of culture, as if her comportment had roadsofparadise.”1p53 been passed down through successive For over two centuries the capital generations in a once-prosperous pre- prosperedasacenteroftrade,hosting colonial metropolis. During each visit, coronationsand,lateron,eventheearly Mrs.Nidasatwithherbackstraightand marriage of a young boy who would her henna-dyed hair neatly bundled in grow up to become India’s first prime The Pharos/Spring2011 31 A modern epidemic in a historic city About the author Igrewupincitiesacross India,spentafewyearsonthe RedSeacoast,andconsider NewDelhiasmyhome.Itwasa pleasureexploringthetranquil U.S.Midwestasacollegestudent andthenmedicalstudentatCase Western.Nowlongingforthe organizedchaosofNewDelhi,I recentlymovedtoBoston,where Icanonceagainrelivethehustle andbustleofaglobalmetropolis. AsIbeginmyInternalMedicine residencyatMassachusetts GeneralHospital,Ihopetostill beabletocarryonmylovefor reading.Perhapsinspiredby conversationswithmygrandfa- ther,arecurrentsubjectchoiceis thebiographiesoftheleadersof SouthAsia’sfreedomstruggle. Iamgratefultothe ThomasM.andJanetS.Daniel Fellowshipforfundingmywork inOldDelhi. Shah Jehan on Horseback. Attributed to Bhag. © Francis G. Mayer/CORBIS. minister.5 But with its fortunes inter- residents began to abandon what they As I continued to visit Mrs. Nida, twinedwiththatoftheempire,theme- nowdubbedOldDelhi.In1947,thecity she began to share her family’s story. tropolis began to decline with the fall wasthesceneofsomeoftheworsttur- Her forefathers had been the official of the dynasty to Great Britain. After moilofIndia’spartitionintothenewly cooks to the fourth Mughal emperor. the failed First War of Independence establishedstateofPakistanasthiserst- The family had thrived while serving in 1857, the last Mughal emperor was whileunifiednationachievedindepen- the royal household, but like the city exiledtoBurmaandthecityfinallylost dence from Great Britain, fueling the fellontodifficulttimeswhentheroyal its royal patron. Like Shahjehan, the finalmassexodusofaffluentresidents.6 familywasexiled.Mrs.Nida’sancestors British Raj also wanted a new capital Left behind were those too poor to wentfrompreparingstatelycuisineto of its own. In 1912, Sir Edwin Lutyens migrate, who today constitute some of toiling in the warehouses and facto- wastaskedwithcreatinga“New”Delhi modern India’s most underprivileged riesthatencroachedontheabandoned southwestofthedefeatedcity.Lutyens citizens. The city’s current residents, buildings.Herpeoplehadenduredthe created Imperial India’s capital by much like our patient Mrs. Nida, are purgesfollowingthefailedFirstWarof blending Indian and Victorian archi- mostly day-laborers, unable to obtain Independence,aswellasthecommunal tectural styles.1p84 With the shrinking medical care and living in congested turmoil of India’s partition. She was a metropolisalreadyindecline,andfaced slumsorrustedtinhutsintheshadows survivorwhoseemedtonotmindthe withthedrawofLutyens’s“NewDelhi,” ofmansionsfromyesteryear. hardships,butproudlycarriedwithher 32 The Pharos/Spring2011 Aerial view of Chandnee Chauk, Delhi, circa 1857. Bettmann. theknowledgeofherroots. intimeforthewedding.Onceagainsit- References Befitting her family history, it was tingregallyonthecottonmattress,she 1. DalrympleW.CityofDjinns:AYear Mrs. Nida who introduced me to the gaveherfinalapprovalofthebrochure. inDelhi.NewDelhi:Penguin;2004. localdiettohelpmecreateadiabetes- I congratulated her on the upcoming 2. ChanJCN,MalikV,JiaW,etal.Dia- related educational brochure for Old weddingandwavedafinalgoodbye.AsI betes in Asia: Epidemiology, risk factors, Delhi’s residents. I learned about vari- left,Iwasacutelyawarethatmanyother and pathophysiology. JAMA 2009; 301: oushigh-sugardishes,suchaspapay,a residentsofOldDelhiwouldnotbeas 2129–40. populardailytea-timesnack.Mrs.Nida fortunateasshe:theIndianCouncilof 3. YoonK-H,LeeJ-H,ChoJH,etal.Epi- also helped me to understand that the MedicalResearchestimatesthatdiabe- demicobesityandtype2diabetesinAsia. residents of Old Delhi were unfamiliar tescauses109,000deathsperyear.7As Lancet2006;368:1681–88. with the symptoms of type 2 diabe- a city past its zenith, Shahjehanabad’s 4. Popkin BM, Horton S, Kim S, et al. tes and believed that it needed only a currentinhabitantsareoverwhelmingly Trends in diet, nutritional status, and diet- one-timetreatment.Withherinputwe likelytosuccumbtodiseasesfueledby related noncommunicable diseases in China compiledabrochuretofilltheseknowl- poverty and lack of awareness. But I andIndia:Theeconomiccostsofthenutrition edgegaps.Ourbrochurelistedthelocal alsofeltasenseofhope,inspiredbythe transition.PublicHealthNutr1998;1:5–21. dietanddividedfoodhabitsintothree resilience of Mrs. Nida and the chari- 5. Frank K. Indira: The life of Indira categories: food that could be eaten table hospital that had invested in the Nehru Gandhi. Great Britain: Harper Col- freely, food that required moderation, educationalbrochure.Onmylastwalk lins,2002:10.