Prevent tobacco use initiation

This anecdotal narrative beautifully drives home why efforts should be on preventing initiation of smoking or tobacco use.

- He used to smoke around thirty beedis a day; began smoking since the age of fifteen
- The big toe of his right foot turned blue, which graduated into pain and burning sensation in both        legs
- The pain became nearly constant; he stopped going to work

- His five toes were amputated, the family's strained financial condition was further strained
- His wife was frantic about the future of their two daughters

He was dark and swarthy, around five foot four. His posture was slightly stooped and the muscles of his upper arm and torso were becoming flabby. His hair was unkempt and he had stubble on his face and neck. He was around thirty-five but looked older and had streaks of white in his hair. Three toes on his left foot and two in his right were missing. The ring finger of his left hand had darkened and was ischemic. He had severe pain in his arms and legs for which he was hospitalized. 

We were third year medical students and had to present his condition to our professor for discussion. Raveendran (not his real name) used to work as a manual laborer in the Thrissur district of Kerala. He was a hard worker and used to make enough to maintain his family (wife and two daughters). Manual labor is relatively well paid in Kerala and he had built a small house on a plot of land. They were originally from South Kerala but had settled down in Thrissur (central Kerala). Raveendran was a heavy drinker and used to smoke around thirty ‘beedis’ (a thin Indian cigarette filled with tobacco flake and wrapped in a leaf tied with a string at one end) daily. He had been smoking since the age of fifteen. 

About two years ago he noticed the big toe of his right foot turning blue. Soon he began having pain and a burning sensation in both legs. He found working in the fields difficult. Initially the pain came infrequently and ceased when he sat down. Gradually the distance he could walk before he had pain decreased. 

He was diagnosed as suffering from thromboangitis obliterans (Buerger disease) at the medical college hospital and warned to strictly stop smoking. It was a sad story. Raveendran tried to quit smoking but never succeeded. His condition got worse. The pain became nearly constant. He stopped going to work. The family’s economic condition got worse. His house and land were mortgaged to pay off the accumulated debts. He developed gangrene in his toes and five toes were amputated at the hospital. The family started selling off their assets. The neighbors were supportive at first but eventually stopped providing support considering Raveendran’s stubborn refusal to quit smoking. His wife started going to work but could not work the entire day due to her husband’s condition. He was often hospitalized and had to undergo amputations, further straining the family’s resources. 

When we met her the lady was in tears. She had two daughters and was frantic with worry about the family’s future. We tried counseling Raveendran to quit smoking. He was apologetic and aware about the damage smoking was doing to him and his family. But he could not quit. We met the family off and on as we progressed through medical school and then they stopped visiting. 

What had happened to them? We lacked a system of tracking families in their homes. A few of us visited his village but the neighbors told us the family had suddenly left one morning. Where were they and what had happened to them? I often wonder.

The author Dr P Ravi Shankar is Professor of Medical Education and Chair of the Curriculum Committee at the Xavier University School of Medicine, Aruba, Kingdom of the Netherlands.  

Courtesy: Hektoen International