Thread by @TheRealDoctorT

The following story is based on conversations I’ve had with a colleague who provides dialysis to impoverished patients in the Indian subcontinent.

I can’t stop thinking about it.

This is a fictional story, based on a stark reality that thousands of patients face every day. 1/

“There's an old adage," he said, "translated from the ancient Coptic, that contains all the wisdom of the ages -- "Life is life and fun is fun, but it's all so quiet when the goldfish die.”

- Beryl Markham, “West with the Night.” 2/

The decision he has to make is always the same. How close to death is he willing to get, before he can part with the money for dialysis?

The dilemma is always the same. Where will the money come from? Who will provide for his family?

Amir has kidney failure. 3/

He lives in a country where the average cost of a dialysis treatment puts it out of the reach of 90% of the population.

The recommended amount of dialysis is 3 times a week, at a minimum.

Amir can only afford to go sporadically, once he and his family have raised the money. 4/

They live in poverty, and more than once Amir has pondered just running away to die somewhere and saving his family the burden of his dialysis.

But he can’t leave his wife and children. Life is already cruel enough to them.

And he’s scared of dying.

He is 38. 5/

And so he tries his best to limit his fluid intake. He already doesn’t eat much, and he’s losing even more weight.

He works as hard as he can and saves every spare bit of money.

And he measures the depth of his breaths.

They slowly get shorter, and shorter.

Air hunger. 6/

Eventually, usually after a few days, he is gasping for breath. His lungs are filled with fluid his weakened kidneys cannot excrete.

There is no charity dialysis unit in his province. The closest unit to him is a journey of several hours.

He makes the journey when he must. 7/

Where he lives, 80-90% of kidney failure patients will stop going to dialysis within 6 months due to the financial strain it places on their families.

They will die, and their families will be left destitute.

Amir doesn’t know the statistics.

But he is living them. 8/

He makes it to the dialysis unit today in the nick of time. His breathing is labored, and his skin glistens with a thin sheen of sweat.

As he sits in the chair and starts the treatment, he tries to slow his breathing, to calm down.

Sometimes it works, sometimes it doesn’t. 9/

The dialysis unit has a goldfish bowl that sits on a ledge by the nurses.

It is the focal point of every patient’s gaze.

Amir often stares fixedly at the goldfish as it “bloop bloops” its mouth, and flits to and fro.

He envies its gills, its underwater breathing. 10/

Mona is the nephrologist covering this dialysis unit.

Her work weighs on her heavily.

She tries to remain detached from the suffering she sees every day, to grow numb to it, but she is an empathic soul.

She is fully aware of the futility here.

A bandaid on a gaping wound. 11/

She says hello to Amir, a young man who has been on dialysis for several months. He shows up twice a week, at most.

He thanks her profusely for the dialysis, as always.

He is kind.

She charts his vital signs, and sees that his dry weight is dropping.

Malnourishment. 12/

They talk briefly. She always tries to keep the conversations short.

There are many patients, and she has learned that the better she knows them, the more her heart will break when the day comes that they stop coming in.

He asks her about the goldfish. “Why the fish?” 13/

She smiles, looking up at the goldfish bowl. “I don’t know. I suppose they’re peaceful. They don’t pass judgment. They just swim.”

Amir nods, his breathing getting a little more comfortable now as dialysis progresses. He smiles in return.

She looks back to him. 14/

“Did you know, Amir, a goldfish will grow as big as its bowl?”

Amir’s eyes widen. “Really?”

Mona nods solemnly.

Amir contemplates this, then asks, “So, in the ocean, whales are just goldfish?”

She laughs. “Not quite that big. The ocean isn’t a bowl.”

He smiles warmly. 15/

Mona moves on to see other patients.

Amir is left to his thoughts, and the quiet beeps of the dialysis machine.

He looks at the drab walls of the dialysis unit, the cramped close quarters.

He wonders, if he didn’t have kidney failure, if he had money, would he grow? 16/

The truth is his bowl will never grow bigger, and his water will never be pure.

He is tired.

He knows where this path leads.

He watches the goldfish as the hours pass. His mind is at peace, while his heart learns to let go.

“I’m not afraid,” he whispers to no one. 17/

As he finishes his treatment and gets up to leave, Amir asks the doctor if she can grant him a request.

Mona’s brow furrows. Amir has never asked for anything.

“Doctor, my family is very poor. Could you please check on them someday? Just to make sure they are okay?” 18/

Mona understands what he is asking, and why. She nods faintly.

Amir smiles, relieved. “Thank you. For everything.”

Mona has said farewell to many patients. It never gets easier.

“You can come back Amir. Even if you can’t pay. We will find a way to take care of you.” 19/

Amir nods, and bows his head in gratitude. Then he turns and walks out into the night.

His breathing is clear and easy, for the last time in his life.

Mona sits down behind her desk and writes her last notes for the day. She blocks Amir from her mind, for her heart’s sake. 20/

The days pass, and turn to weeks.

Amir never returns, as Mona knew he wouldn’t.

She rounds on the patients as she always does.

One day, she realizes with a start that the goldfish is floating in the water, motionless.

She takes the dead fish out, and wraps it in paper. 21/

That night she buries it in the dirt behind the dialysis center. She doesn’t know why, but she feels compelled to do this.

The goldfish was the focal point of a thousand gazes, a thousand unfulfilled wishes.

Something deep inside her finally unlocks.

And Mona weeps. 22/

She weeps until her tears run dry, on her knees, in the dirt.

And then she exhales deeply, and slowly puts the armor back over her aching heart.

The next morning, before she goes to the dialysis unit, she decides to take a village detour.

She has a promise to keep.