Tackling Diabetes in Old Delhi

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-visit nurse, after waiting for me to General Hospital. This essay won third finally catch my breath, knocked on our prize in the 2010 Helen H. Glaser patient’s front door. Fifty-eight-year-old Student Essay Competition. Mrs. Nida greeted us with a smile that brought into relief the high cheekbones ut of breath from trying to and almond shaped eyes pointing to the 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 three daughters in two cramped rooms within historic Old Delhi. The cool carved out of a dilapidated mansion. March breeze made its way through the Focused on saving for her children’s city’s labyrinth of gullies, or alleyways, wedding dowries, she had ignored years helping the sweat on my face evapo- of blurring vision, constant thirst, and rate. Seeing the row of now ramshackle a tingling sensation in her feet. Only houses, I imagined the story behind when her eldest daughter noticed an

30 The Pharos/Spring 2011 ulcer on her foot was she brought to a hand-woven dupatta, or head stole. Adams Care Charitable Hospital, where Shams and I joined her on a thin cotton- I first met her, and where she was diag- filled mattress laid on the floor. To show nosed with the “sugar disease,” as type 2 gratitude to Shams, Mrs. Nida offered diabetes mellitus is locally known. us Rooh Afza sherbet, a syrup of rose Mrs. Nida’s type 2 diabetes is not water and honey that I accepted while unusual. India has 40.9 million diabet- making a mental note to list the drink ics, more than any other country in the “off-limits” for diabetics. world.2 Diabetics make up a relatively higher percentage of India’s population, Observing Mrs. Nida’s mannerisms, 12.1 percent, compared to 8.2 percent of 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- mately 30 percent in the United States. tion stone to establish his new capital, India’s modern diabetes epidemic is fu- Shahjehanabad. The Mughal emperor eled by a combination of environmental had been grieving after the death, dur- factors, such as higher smoking rates, ing childbirth, of his queen, Mumtaz and a genetic predisposition that may Mahal, and had decided to relocate his account for why the urban poor, like court. After nine years of construction, Mrs. Nida, are so likely to develop the the royal household moved to the new pathology. Some researchers contend city, leaving behind the previous capital, that in-utero exposure to undernutri- Agra, but not before bequeathing it with tion—the case for 30 percent of Indian a place in the history books through the infants—can lead to higher susceptibil- construction of Taj Mahal, a tribute to ity to type 2 diabetes later in life. The Mumtaz Mahal. urban poor are also less likely to receive Shahjehanabad’s centerpiece was adequate treatment since diabetes and Chandni Chowk, Moonlit Square. Built other diet-related noncommunicable by the Emperor’s favorite daughter, diseases account for 13.9 percent of Jahanara Begum, the Chowk’s focus was India’s total health care cost.4 water—it featured a square reflecting As part of my public health cap- pool fed by a tree-shaded canal running stone project at Case Western Reserve along the avenue that supplied water University, I was in India to assist in pro- to residents.11p198 Under royal patron- viding charitable hospital care for Old age, the capital evolved into boulevards Delhi’s underprivileged. The hospital of Mughal Gardens and ornate hawe- wanted to produce an educational bro- lis—courtyard mansions—with arched chure on type 2 diabetes that targeted doorways and elaborately painted ve- the unique diet of their patient popula- randahs. As a center for Urdu literature tion. To learn about the dietary habits and Islamic calligraphy, many of India’s and barriers to care in this community, finest poets—Mir, Zauq, and even the I accompanied Shams during his home great Mirza Ghalib—composed their visits to change ulcer dressings twice a poems in these hawelis. In 1648, poet week. And that is how I found myself at Chandar Bhan Brahman proudly wrote Mrs. Nida’s home. Though living a chal- that the city’s “towers are the resting lenging life of limited resources, Mrs. place of the sun. Its avenues are so full Nida had a subtle regality and a sense of pleasure that its lanes are like the of culture, as if her comportment had roads of paradise.” 1p53 been passed down through successive For over two centuries the capital generations in a once-prosperous pre- prospered as a center of trade, hosting colonial metropolis. During each visit, coronations and, later on, even the early Mrs. Nida sat with her back straight and marriage of a young boy who would her henna-dyed hair neatly bundled in grow up to become India’s first prime

The Pharos/Spring 2011 31 A modern epidemic in a historic city

About the author I grew up in cities across India, spent a few years on the Red Sea coast, and consider New Delhi as my home. It was a pleasure exploring the tranquil U.S. Midwest as a college student and then medical student at Case Western. Now longing for the organized chaos of New Delhi, I recently moved to Boston, where I can once again relive the hustle and bustle of a global metropolis. As I begin my Internal Medicine residency at Massachusetts General Hospital, I hope to still be able to carry on my love for reading. Perhaps inspired by conversations with my grandfa- ther, a recurrent subject choice is the biographies of the leaders of South Asia’s freedom struggle. I am grateful to the Thomas M. and Janet S. Daniel Fellowship for funding my work in Old Delhi. 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, twined with that of the empire, the me- now dubbed Old Delhi. In 1947, the city she began to share her family’s story. tropolis began to decline with the fall was the scene of some of the worst tur- Her forefathers had been the official of the dynasty to Great Britain. After moil of India’s partition into the newly cooks to the fourth Mughal emperor. the failed First War of Independence established state of Pakistan as this erst- The family had thrived while serving in 1857, the last Mughal emperor was while unified nation achieved indepen- the royal household, but like the city exiled to Burma and the city finally lost dence from Great Britain, fueling the fell onto difficult times when the royal its royal patron. Like Shahjehan, the final mass exodus of affluent residents.6 family was exiled. Mrs. Nida’s ancestors British Raj also wanted a new capital Left behind were those too poor to went from preparing stately cuisine to of its own. In 1912, Sir Edwin Lutyens migrate, who today constitute some of toiling in the warehouses and facto- was tasked with creating a “New” Delhi modern India’s most underprivileged ries that encroached on the abandoned southwest of the defeated city. Lutyens citizens. The city’s current residents, buildings. Her people had endured the created Imperial India’s capital by much like our patient Mrs. Nida, are purges following the failed First War of blending Indian and Victorian archi- mostly day-laborers, unable to obtain Independence, as well as the communal tectural styles.1p84 With the shrinking medical care and living in congested turmoil of India’s partition. She was a metropolis already in decline, and faced slums or rusted tin huts in the shadows survivor who seemed to not mind the with the draw of Lutyens’s “New Delhi,” of mansions from yesteryear. hardships, but proudly carried with her

32 The Pharos/Spring 2011 Aerial view of Chandnee Chauk, Delhi, circa 1857. Bettmann.

the knowledge of her roots. in time for the wedding. Once again sit- References Befitting her family history, it was ting regally on the cotton mattress, she 1. Dalrymple W. City of Djinns: A Year Mrs. Nida who introduced me to the gave her final approval of the brochure. in Delhi. New Delhi: Penguin; 2004. local diet to help me create a diabetes- I congratulated her on the upcoming 2. Chan JCN, Malik V, Jia W, et al. Dia- related educational brochure for Old wedding and waved a final goodbye. As I betes in Asia: Epidemiology, risk factors, Delhi’s residents. I learned about vari- left, I was acutely aware that many other and pathophysiology. JAMA 2009; 301: ous high-sugar dishes, such as papay, a residents of Old Delhi would not be as 2129–40. popular daily tea-time snack. Mrs. Nida fortunate as she: the Indian Council of 3. Yoon K-H, Lee J-H, Cho JH, et al. Epi- also helped me to understand that the Medical Research estimates that diabe- demic obesity and type 2 diabetes in Asia. residents of Old Delhi were unfamiliar tes causes 109,000 deaths per year.7 As Lancet 2006; 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 current inhabitants are overwhelmingly Trends in diet, nutritional status, and diet- one-time treatment. With her input we likely to succumb to diseases fueled by related noncommunicable diseases in China compiled a brochure to fill these knowl- poverty and lack of awareness. But I and India: The economic costs of the nutrition edge gaps. Our brochure listed the local also felt a sense of hope, inspired by the transition. Public Health Nutr 1998; 1: 5–21. diet and divided food habits into three 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, educational brochure. On my last walk lins, 2002: 10. and food to be avoided. Also listed were through the gullies, I paused at what 6. Wolpert S. Jinnah of Pakistan. New inexpensive and traditional therapies for remained of Chandni Chowk. Suddenly Delhi: Oxford University Press; 2006: 344. reducing hyperglycemia, such as eating able to see remnants of the royal avenue, 7. Mohan V, Pradeepa R. Mortality in soaked methi (fenugreek) seeds. I began to appreciate even more the diabetes mellitus: revisiting the data from As Mrs. Nida’s treatment slowly pro- poet Ghulam Khan’s optimistic words a developing region of the world. Postgrad gressed between each visit, so too did on his home city: Med J 2009; 85: 225–26. our educational brochure. During my final days in the one-time royal metrop- It is like a Garden of Eden that is The author’s address is: olis, I dropped off the completed Hindi populated. It is the foundation of the Bulfinch Medical Group (WAC-5) language brochure for her approval. eighth heaven.1p53 Massachusetts General Hospital Mrs. Nida was busy preparing for her 15 Parkman Street elder daughter’s marriage, and very Now sharing Mrs. Nida’s pride in Old Boston, Massachusetts 02114-3117 pleased that her foot ulcer was healing Delhi, I could not agree more. E-mail: [email protected]

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