In the Bonesetter's Waiting Room (5 page)

A community meeting was to be held that afternoon on the other side of the main canal, organised by two of Dharavi's other
sanghinis
, and I wanted to listen in. Stepping once again out into the narrow slum lanes, I turned to see her husband quietly head back into the house, now emptied of children and guests.

My daughter and I took an auto-rickshaw to get to the meeting – partly because of the unrelenting rain and partly because of Dharavi's immense sprawl. As we walked from the rickshaw back into the maze we passed one of the little temple squares – the only non-claustrophobic spaces among the dark narrow lanes – and arrived at the home of Bhanuben, another
sanghini
. This time there were fifteen local women in the sparsely furnished ten-foot square kitchen-cum-living room, sitting cross-legged and taking up almost the entire floor space. As we entered, wondering where we might sit, Bhanuben, a jovial but forceful woman in her mid-forties, dressed in a sari and sporting a large bindi; and fellow
sanghini
Shirin, a much younger woman draped in a black
hijab
and
jilbab
, welcomed us in as warmly as if the room was of palatial proportions. We folded our legs into the shape of the last visible pieces of painted concrete. Shirin stood nearby, leaning in to translate in case I missed any of the discussion.

By then, the talk that had paused when I entered was once again in full flow. It had come to Bhanuben's attention that there had been several child marriages – eleven- and twelve-year-olds. Had anyone else come across this? Many of the group chipped in – it was a matter of grave concern, for both boys and girls who were leaving school prematurely to raise families. What might be done about it?

The next point on the agenda was a deeply fascinating question that wouldn't have been given a second thought in those places where mothers arranged play dates and coffee mornings, but which felt distinctly out of place in Dharavi. ‘What do you do for
yourselves
?' Bhanuben asked. ‘What makes you happy? Is it singing, is it dancing? Do you spend some time on yourselves every day?' She spoke forcefully and seemingly from a well of experience, so that, as they were raised, she swiftly, skilfully and kindly put down every protestation or excuse from the women in the group.

‘I do not have any time to do something for myself,' the young woman next to me said. ‘I am always cooking, or looking after children, or my husband. Where is there time?' She laughed at Bhanuben's deliciously ridiculous idea.

The woman directly opposite me was far less cheerful. ‘I have three children and I look after them on my own. One of them is ill. He has epilepsy. I cannot afford his medicine. I cannot find work.' It was true, jobs were difficult to come by and life was hand-to-mouth for all the women present. In state-run hospitals, a nominal charge of ten rupees (ten pence) is made for medications, but I knew from my conversations with Nayreen that even that small amount might present a choice between treatment or their children's next meal. I could see that ‘me time' was the farthest thing from her mind.

‘That is why we are meeting here,' Bhanuben said. ‘There is support. Come to Chota Sion and tell SNEHA that you are needing that medicine. We will help you. There are twenty-four hours in a day. I am not asking you for all of them. I am asking you to take half an hour for yourself. Half an hour a day to do what you enjoy. You can do that. Raise your hands if you will do that. What time of day will you make time? What will you do?'

A few tentative hands rose into the air, unsure, like weighted balloons ready to drop at a moment's notice. But the more hands that went up, the more other women were emboldened to join in until nearly everyone agreed to give it a try. ‘When I was a girl I wanted to sing,' one of the group offered her pledge. ‘I
really
wanted to learn, but my parents would not allow me. I was very angry at them.
That
is what I will do now, I can spend some time singing.' But at the back of the room, another of the women sat quietly. She looked melancholic, beyond sadness, her face devoid of expression, her eyes empty. It was the look of someone recently bereaved, though she has lost no one to death.

‘My husband left,' she said. ‘I have two children. Now my children do not listen to anything I say. They don't have jobs. I don't have a job or money …' I could see it must have felt to her as though everything was conspiring against her, and it was a heaviness I deeply related to also, having always raised my daughter on my own. She looked defeated, but at least she spoke and was listened to. I watched as Bhanuben counselled her and the group around her offered support. There was not one woman there who couldn't relate to at least part of what she was experiencing. The absence of a husband through death or abandonment, or the presence of an abusive one, was evidently a burden most had in common.

Shirin, who had been translating for me, had also experienced this at first hand. Extremely eloquent and clearly very well educated, she had been forced to move out of the marital home with her children after her husband had remarried. Without support from the community group, she would not have had the courage to reclaim the space in her house and regain stability for her children. That was what made her want to do the same for other women who felt powerless, or were in the depths of depression. ‘I am alert and keep my eyes open for women [in crisis], motivate them to ask for help. Abandoned women whose husbands have remarried; women and girls being harassed by the local boys. I am proud of myself to be a
sanghini
,' said Shirin. With Bhanuben, she encouraged women to attend meetings for emotional and social support and to train for skilled jobs.

When Bhanuben wasn't finding women in crisis, women in crisis were finding her. She would always answer a knock on her door, whatever the hour. Her social work came later in life, twenty-four years after she dropped out of school, aged twelve. She married at sixteen and then began working as a domestic cook, which provided her husband and in-laws with their only income. She always dreamed of studying again, but didn't know how to. Her husband's family was very conservative and in their community it was taboo for a woman to go out wearing even ankle jewellery, or even to wear it indoors if it could be seen by other male relatives.

When Bhanuben finally made the decision to do something for herself – as she encourages other women to do – she was ridiculed by the local council of elders. When the social work done by her team of women started to produce results, they were condemned by the men of the community and their husbands were openly taunted for ‘not having control over their wives and letting them do such work'. But still her work continues. Bhanuben, a born leader, if not a force of nature, was adamant that it should. ‘Joining SNEHA was like being reborn, and in the same way other women should also reinvent themselves.' Her community group now has over a hundred members who educate and support others in matters of violence and women's rights. The men of the local council who once ridiculed her now respect her. And many of those husbands who were abusive or addicts have also turned up for counselling at Chota Sion.

Back at the hospital, Nayreen Daruwala was cautiously pleased at the community's progress. ‘It has snowballed; people are referred by family and friends. Counselling is slowly becoming part of the culture. Even some men in Dharavi who have had counselling are referring abused women and their abusers to the centre now.'

But there is still a long path to travel, and its direction is one that excites Nayreen. ‘Mental health is
so
tied up with violence here. Psychiatrists in Mumbai won't accept this. They hold only a genetic and physiological viewpoint about mental health conditions.'

I found it incredible that Nayreen and her team were having a hard time getting psychiatrists in the main Sion Hospital to acknowledge a relationship between violence and the development of mental illness in women. Through SNEHA's recent interventions – creating the beginnings of a women's outpatient department and offering counselling services for survivors of violence – Nayreen still hopes to highlight this association to the medics.

Clearly, many of the women who will go to SNEHA's outpatient department for counselling will improve over time because of psychological therapies – the 160
sanghinis
now serving Dharavi are evidence of that. ‘Almost every woman we interact with have faced some form of violence, either in their homes or in the community,' Nayreen told me. Not all of them require psychiatric drug-based therapy, but by highlighting an association that most Indian psychiatrists do not currently acknowledge, the hope is that more women who need it will have access to medical help. This is also crucial to changing the culture of how women are treated both medically and socially. From in-laws dispensing tablets to psychiatrists who will not, changing that culture of second-rate treatment for women will mean getting an acknowledgement that women who are depressed in Dharavi are not just ‘mad', or a write-off to be divorced or abandoned. It will be a recognition that violence and its psychological or psychiatric effects are no longer acceptable or invisible; that women can and will be treated, and in many cases not only improve but also themselves become powerful agents of change.

2

Bollywood Bodies

ACROSS THE BRIDGE
over the Mithi River, a fifteen-minute drive west of Dharavi will take you past yet more expanses of temporary, tarpaulin-covered makeshift homes populated by families who cannot afford even to live in the mega-slum. In contrast, the Bandra Kurla Complex, a carefully planned quarter of Mumbai reminiscent of Seoul or Abu Dhabi, feels, as a colleague working in Dharavi described it, like entering ‘an off-world, like in science-fiction books'. BKC, as it is popularly known, has wide roads, towering office buildings clad in mirrored glass, five-star hotels hosting pool parties, swanky pizza restaurants and the American Embassy, set behind metal fences more than three times the height of the average Indian.

Bandra Kurla is also home to the Asian Heart Hospital, a large, multi-speciality health complex built, like most of the surrounding neighbourhood, only a decade or so ago. Offering everything from robotic surgery to neurology, orthopaedic to dental and cosmetic surgery, it is the hospital equivalent of a luxury hotel.

I was there to meet Dr Satish Arolkar, serving president of the Indian Association of Plastic Surgeons and the man responsible for introducing India to liposuction and, back in the 1980s in the days before silicone implants, breast enhancement by fat graft. In the intervening years, Dr Arolkar would tell me, once Mumbai had overcome its initial qualms regarding the vanity and drastic nature of aesthetic surgery, it had forged ahead and never looked back.

Data from the International Society of Aesthetic Plastic Surgeons make it hard to disagree: India is certainly at the centre of a worldwide boom in cosmetic surgery. In 2011, out of the 15 million people who resorted to plastic surgery to enhance their looks, 466,231 were Indians. That puts India well within the world top ten by number for a range of procedures, the most popular being breast augmentations and liposuction. In 2011 alone nearly 25,000 women had breast enlargements, a further 13,561 had breast reductions and 9,000 more had their breasts lifted to correct sagging. And it wasn't just women: around 8,000 men also had their ‘man boobs' surgically reduced. A total of 41,628 people underwent variations of the liposuction procedure which Dr Arolkar had introduced to India around thirty years earlier, while another 15,000 had tummy tucks.

As these figures suggest, plastic surgery in India is huge: 2015 estimates put the worth of its overall cosmetic surgery industry as Rs460
crore
– around £70 million – which is set to rise to over £17 billion by 2019. As I went up to Dr Arolkar's office I passed publicity posters featuring world-famous Bollywood stars. Styled with an uncharacteristic seriousness, the actors were there to give a well-loved face to the very advanced – and very expensive – surgical offerings of an industry which is now nearly as important to Mumbai as their own.

I was immediately struck by how Dr Arolkar's career had been shaped by a unique combination of clear-sighted ambition, serendipity and an open and creative mind.

‘I wanted to do surgery all along, even at university,' the doctor, a slight and kindly man in his sixties, began after apologising for not offering me tea, something that is apparently not allowed in consulting rooms, even if you happen to be a top surgeon. ‘In the second year of med school I'd do minor things – biopsies, for example,' he continued. ‘Then I started getting interested in scar formation. At that point I met a friend at university – he was from the school of arts – [who] had been developing prostheses through carving and sculpting in silicon rubber.'

Dr Arolkar's admiration for his friend's creations was palpable, and the excitement with which he spoke seemed to dissolve the intervening decades. ‘He had made a finger that was so realistic,' he continued, ‘it had hairs and pink nails – it looked just like a living finger.' For much of his early career, his medical expertise was put to use for charity and he spent a large part of his free time applying his new-found skills to those disfigured by diseases such as leprosy or severely injured in accidents. In some cases Arolkar had almost miraculous success – a man whose arm was caught in a printing machine and crushed up to the elbow, for example, had the damaged limb's basic function restored and was able to return to work.

The impact made by Dr Arolkar and his team during their periodic and unpaid stints in deprived agricultural and industrial areas was profound, allowing people to return to their communities or support themselves after injuries which a few years before might have been career ending. And they worked hard, completing up to 500 hours of surgery per visit, usually at night. There was often no electricity, no autoclave for sterilising surgical equipment and little to eat. ‘We only had boiling water for sterilisation,' he told me, ‘and I brought my own tools. When there was a power cut, we would hold a torch up and continue.'

But though the work was gruelling, and undertaken in desperate conditions at a time when cosmetic surgery was still a novelty regarded with some suspicion in India, the hundreds of hours Dr Arolkar and his small band of fellow student doctors put in were valuable in more ways than one.

‘In the meantime, I was earning a living as a surgeon in Mumbai,' Arolkar continued. ‘Most of my work was to correct hare lips and cleft palates as well as reconstruction following leprosy. At that time, plastic surgery was considered unusual here in the city – you have to be very vain, people said, to do it. It actually took a long time for aesthetic surgery to get into the limelight because it was seen as something unnecessary. So in 1982 nobody really knew what cosmetic surgery was in India.'

This was all set to change, however, and Arolkar's experience would stand him in good stead, as would the ‘phenomenal' teaching he received from Dr N. H. Antia, then a leader in plastic surgery who had trained under the famous Sir Harold Gillies. Gillies is known as the ‘father of plastic surgery', a visionary surgeon who both pioneered reconstructive surgery techniques on soldiers wounded in the First and Second World Wars and performed some of the first sex-change operations. As attitudes shifted, Arolkar and his small band of specialist colleagues were in prime position.

As Dr Arolkar was talking about the scarcity of plastic surgeons in India even as recently as thirty years ago, I couldn't help thinking how ironic it was that the very first plastic surgeries were performed in ancient India. A form of rhinoplasty is thought to have been invented by an Indian surgeon in around 800
BCE
. Though it had already been adopted in a modified form in medieval Italy, the ‘Indian nose' came to the attention of British medical professionals and public only during the days of the East India Company. Late in 1794 a curious letter was published in the
Gentleman's Gazette
, a popular London magazine. Signed only ‘B.L.', it seems to have been sent from India by an artist, Barak Longmate, who had made an engraving of an Indian cart driver called Cowsajee. Longmate recounts the tale of this former employee of the East India Company who made the error of being captured and imprisoned by Tipu Sultan, the King of Mysore, a region then much coveted by Britain. Already allied with the French East India Company, Tipu Sultan bore a particular grudge against the British, who had broken a treaty to support his father against the neighbouring Maratha kingdom. With British soldiers and their allies, especially Indian ones, Tipu Sultan was famous for showing no mercy and – even though he had been pensioned by the East India Company after the last Anglo-Indian war had ended two years before – Cowsajee, who unfortunately for him also happened to be Marathi, had his right hand amputated and his nose cut off by Tipu's orders.

Barak Longmate's letter to the
Gentleman's Gazette
recounts how Cowsajee lived without a nose for about a year. He may well have been saving up from his pension during that time because at the end of the twelve months he travelled to Puna to see a surgeon about having a little cosmetic work done on his face. The British doctors who were able to observe the procedure, in which a living graft of skin was cut from the patient's own face to reconstruct the missing nose, were apparently appropriately impressed.

The procedure that Cowsajee underwent – a version of which was still being used by Antia at his Mumbai hospital's Tata Department of Plastic Surgery in the 1980s – would have been developed certainly before 250
BCE
and probably around 1500
BCE
, when it begins to be obliquely alluded to in ancient texts. It is detailed in the world's oldest written manual on surgery, the
Sushruta Samhita
, which derives from the work of Suśruta, an Ayurvedic physician who may have worked in Varanasi in 1000 or 800
BCE
. Suśruta had emphasised surgical training as an integral part of medical education and as the most important part of Ayurveda, an ancient professionalised medical system in India. His
Samhita
, widely thought to have been written down around 600
BCE
, painstakingly documented preoperative and postoperative care, diet and surgical indications and contraindications of various diseases such as bowel perforation, hernia, obstetrical injuries, anal fistulae and fractures of the arms and legs. Suśruta developed and applied plastic surgical techniques for reconstructing noses, genitalia and earlobes, among other things, and it is in his work that we first find a description of the ‘Indian nose'.

The details of the operation were as follows: a pattern corresponding to the size of the nose to be repaired was cut from the leaf of a creeper. The template was then used to cut a similar shape from the cheek. The cheek skin was sutured with a sharp needle and cotton thread over where the nose would have been. Incisions were made where the nostrils would be and the outer skin was turned in. Two tubes (stalks of the castor oil plant) were inserted into the new nostrils to allow normal breathing and prevent flesh from hanging down. The newly attached cheek flesh was then dusted with three plant-derived powders called Pattanga, Yashtimdhukam and Rasanjana (liquorice, red sandal-wood and barberry) that had been pulverised together. Finally, the nose was enveloped in cotton and several times sprinkled over with pure, refined sesame oil. When the flap of skin removed from the cheek had successfully healed over, any excess skin was removed and tidied up with some final trimming and suturing.

This use of the cheek flap later developed into the similar forehead-flap method that Barak Longmate documented: ‘This operation is very generally successful,' he wrote. ‘The artificial nose is secure, and looks nearly as well as the natural one; nor is the scar on the forehead very observable after a length of time … This operation is not uncommon in India and has been practised from time immemorial.'

Unsurprising, then, and perhaps almost inevitable, that thousands of years of experience in aesthetic plastic surgery, a fast-growing cadre of Indian cosmetic surgeons and Bollywood role models willing to embrace the modern Western fashion for self-enhancement should combine to place Mumbaikars at the forefront of India's cosmetic surgery boom.

‘The culture changed totally,' Dr Arolkar continued as we carried on talking over a delicious lunch in the strictly vegetarian hospital canteen. ‘[Now] people come and say, I want a little tuck here, bigger lips – it's swung like a pendulum the other way. I have been president of the Indian Association of Plastic Surgeons since 2013, though they've now reduced the term to two years because this field has become so popular.' But, as he went on to say, success has brought its own problems for the industry. ‘Because of this there are also now a lot of quacks coming up who are not trained in surgery at all … so insurance premiums and claims are both rising. Regulation is almost absent. We do have a consumer court and a civil court – and technically anyone can go there and complain, but really we need advisory medical bodies and councils to review this.'

Worryingly, an estimated fifty-five per cent of rhinoplasties conducted by reputable Indian plastic surgeons are repairs to those that have gone wrong in the first instance, having been carried out in unregulated, often illegally operated small-town clinics by unqualified practitioners. A 2011
Times of India
investigation found that patients were often discharged within a few hours of being operated upon. Without regulation, competitive pricing means that, for many patients, the sole determining factor in where they choose to be operated on is cost.

For patients who do pick the wrong surgeon, the consequences can be severe, even fatal. A famous Tollywood (Telugu) actress, Aarthi Agarwal, who was refused liposuction by her Hyderabad surgeon went ahead with the procedure in America. She died, aged thirty-one, of respiratory problems soon after. Aarthi's Indian surgeon had turned her down because she had very little fat under the skin – which is what liposuction is supposed to deal with. The procedure is not appropriate either for removing large amounts of body fat or for treating the ‘skinny-fat' phenomenon: the sort of mid-waist fat that is internal, wrapped around the organs, and common in Indians, stemming from either genetics or the pre-natal environment. Add to that the change in many Indians' diets to high-calorie foods, an increasingly sedentary lifestyle and the decline of the perception that big is beautiful and it becomes clear that the demand for liposuction will probably escalate further still.

In the absence of regulation, Dr Arolkar believes the onus has to be on would-be patients to assess their doctor's credentials before going under the knife. ‘They also need to be aware of complications,' Dr Arolkar told me. ‘But either way the risks of dissatisfaction are high, because now some people don't really know what they want. They say they want to become more beautiful, but they don't know what they want to change! Sometimes I think, actually, you need a brain change, because I've seen people who were asking the impossible.'