Flesh and Bone

It was early July in 2014. The heat of June still hung over the city of Delhi, but it was tempered by the stirrings of the impending monsoon. Although it was an El Niño year, and the monsoon could well be delayed or depleted, or both. I am not sure why I am writing this, because the weather was the last thing on my mind as I watched my father-in-law shrink on his hospital bed. Papa’s shrinking was gut-wrenching and visible: it was an every day diminishing over the past month as if his body was being erased, little by little, by an inept child, unable to get his proportions right. Papa’s toes that peeked through the sheets were scrawny and stubbled; his arms and legs were singing hymns to the Gods — haath paanv kirtan kar rahe the — as he would have put it; the beautiful surgeon’s fingers that he used to hold elegantly aloft, away from his body, as if showing off a particularly precious piece of jewellery, lay still, thinned and elongated like an antique Chinese calligraphy brush-set. But it was his face that held my attention the longest. His face, hidden behind the ventilator, was hollowed out, and his cheeks were the concaves of the Head of a Roman Patrician from Otricoli. But unlike the thoughtful, albeit slightly garrulous, vitality that the sculpture emanates despite being carved out of cold marble, Papa’s features were dulled and receded almost to the point of being blanked out.

Papa was in the terminal stage of his colorectal cancer. And he was starving. It was not the starvation that the deprivation of food causes. It was the starvation that occurs so frequently in cancer patients that it has its own nomenclature: cancer cachexia.

The word ‘starvation’ has Proto-Germanic origins. It comes from sterbanan which literally means ‘become stiff’ or ‘die’. Cachexia — pronounced with a ‘K’ sound ‘kakhexia’ — on the other hand, has Greek roots. It comes from kakós meaning ‘bad’; and héxis, broadly meaning ‘habit’ or ‘state of body’. But despite its more benign origins, cachexia is much more insidious than ordinary starvation, that is if starvation can ever be called ‘ordinary’.

“There has been no improvement in his condition”, I heard the doctor say. “I think we can stop the TPN.”

TPN. “Total parenteral nutrition”, I said to myself. Fluids that were being administered straight into Papa’s veins to provide the nutrients that he needed.

“Does that mean we will stop feeding him? Will we starve him to death?”

In deference to Papa’s condition, the hospital had relaxed its strict visitor-time-and-numbers policy, and the room was full of people; some of whom I knew, most of whom I didn’t. I had been at Papa’s bedside for the last seven hours, and even in the midst of my grief, I could feel the beginning of the exhausted peckishness of the first stage of my own starvation. Which, I knew, was very different from Papa’s.

In someone like me, starvation is not a linear process. Most healthy humans have a series of physiological and metabolic defences that work in tandem to keep them alive for as long as possible. And while the amount of time a person can survive without food differs from individual to individual, with many external factors determining it, there are still essentially three stages of starvation; all of which are all well documented. For about the first six hours after we have eaten, our body digests the food to produce glucose. This glucose gets easily absorbed in our blood and is carried to our muscles and liver, providing the energy to function. If we have eaten more than what our body immediately needs, a part of that glucose gets stored as fatty acid for use in the future when food may not be as abundant. After those first six hours, most of the glucose gets used up, and the body begins to need food again. (That was the peckishness I had felt. If I were to have eaten then, my body would have been satiated and gone through the same digestion-glucose-fatty acid cycle once more).

However, if we don’t get any food for the next 24-48 hours, the fatty reserves are used for our energy requirements. This phase of starvation is called ketosis, and it lasts for about three days. If food is still not available, we enter the third phase of starvation called autophagy — which translates to ‘self-devouring’. The body begins to feed upon itself. The muscles begin to waste away. But the human body adapts very quickly to this new phase and adjusts its functioning to stay alive for as long as possible; the metabolism slows down to perform only essential functions, and the cell breakdown to fuel its critical energy needs, too, does not happen haphazardly. The body systematically decides which cells to break down and which to save so that we have the maximum chances of remaining alive. If during this time, there is no onset of any immune-related disease due to the severe lack of vitamins and minerals, we can sustain ourselves for quite a long period of time without food. We might become severely lethargic and barely be able to function, but we can survive. And if, after prolonged starvation, food once again becomes available in the required quantity, the recovery is fairly quick, often with very little permanent damage.

But Papa’s cachexia, I knew, was different.

“No, no,” the doctor was saying. He was young and looked a little tired. But he was a trained oncologist, so he probably confronted such relatives and made such decisions every day. “The patient is already starving. His body is unable to utilise any nutrients that we are providing him. There is no absorption.”

This conversation was taking place over Papa’s bed. He was a doctor too, but he had no voice in the matter. There was no reaction from him. There had been no reaction from him for a long time now.

Cancer cachexia is a multifactorial syndrome characterised by a marked loss of body weight, anorexia, asthenia and anaemia. ‘It is the most common manifestation of the advanced malignant disease, leading to death,’ the paper I had read about cachexia had said clinically. I knew in terminal cancer cachexia, the patient does not go through the stages of ordinary starvation. The lack of nutrient intake is often caused not by the absence of food but by the inability of the body to ingest it. Like in the case of typical starvation, the body begins to cannibalise on itself to fuel its energy needs, but it loses its ability to slow down the metabolism. The wasting away of the muscles is, therefore, quite rapid. And since the body is unable to digest and utilise food, giving it more nutrients serves very little purpose. It does not reverse the effects of starvation.

“But we can’t shut down his feed. We can’t starve him. If we stop giving him food, we are cutting out his most primal connection to the physical world. We will kill him. We can’t do that!”

Papa had always been a gentle, non-confrontational man whose mood swings are a part of family lore, although I saw very few signs of them in the time I had known him. With me, he was mild-mannered, and although occasionally startled by the rumbustiousness of his two grandchildren, had always been a willing accomplice in their role plays. His sense of humour, too, was legendary, and I had seen plenty of signs of that. His Hindi was old-fashioned and suffused with Urdu words, and his humour had the lilt of a self-effacing Harishankar Parsai. But the quiet had settled inside him for a long time now. Emotions had bent and faded, and now his outlines were being slowly erased. As the conversation swirled around him, as the doctor, the family, the litany of well-wishers spoke of him and for him, as decisions were made about him, he lay with the TPN still attached to his body.

Weight loss in cancer cachexia and starvation have different mechanisms. Weight loss in cancer patients is due to equal loss of both adipose tissue and skeletal muscle mass, whereas, in starvation or in anorexia nervosa, weight loss is mainly from the reduction of fat, and only a small amount is from the muscle. I remembered the words from the scientific paper I had read about cachexia as I drove back home, and it was perhaps the first smattering of the monsoon rain that made my muddy windshield opaque.

Deliverance. That night, I wrote.

Deliverance
It didn’t matter
The seconds, the minutes, the hours, the years
The syringes, the monitors, the jabs, the tears
The wrinkling, the smoothing, the parchmenting of skin
The fatigue, the indifference, the occasional balefulness of kin
It didn’t matter
Because he had gleefully discovered on the sly
Inside the mould-mottled room where he was made to lie
Unable to even move his head without the aid of the long-drawn sigh
Twinkling lights and tree-lined path: the secret getaway that no-one could spy

I tucked the piece of paper under my bed. And I prayed to no particular God, appropriated by no particular religion, but to nature and to the atom and to the first strands of life itself.