Grappling with cultural identity is a common struggle among children of first-generation immigrants. Growing up in the United States with Indian parents who were open to Western culture allowed me to develop the ability to navigate two cultures. Everything from the food I eat to the way I speak my native language, Telugu, is weighted with American influence. Though I recognize that my dual identity allows me to present alternate perspectives in the classroom, it often calls into question with which culture I identify. Instead of being at peace between two worlds, I have struggled to find a sense of belonging.

A recent study abroad course in India showed me that palliative care's central themes of acceptance and silence can bridge science-driven medicine with humanism in healthcare. On a personal note, the course allowed me the distance to step back and evaluate my Indian-American identity. My experiences with palliative care allowed me to make connections between what I previously saw as separate influences in my life into a more integrated story of how I can live as an Indian-American.

Many people have asked me why I chose India, my birthplace, to study abroad. My situation was hard for others to imagine—the idea of me, a generally confident person, struggling to consolidate multiple cultural identities. The desire to reconcile my two worlds, combined with the kind touch that I observed in palliative care spurred me to apply for a three-week course to Kerala, a state in Southern India. The course was facilitated by Pallium India, a palliative care organization that provides clinical services, education, and advocacy throughout India. An interdisciplinary team of faculty comprised of a pharmacist, physician, and nurse, along with Dr. M.R. Rajagopal, widely known as the father of palliative care in India, led the course.

My experiences in Kerala were different from previous trips to India. It didn't dawn on me, even after arriving at the airport, that I was traveling to India without my family for the first time. When visiting the Napier Museum to marvel at statues of ancient Hindu deities, it wasn't my parents explaining their significance to me, but rather, me explaining their significance to my classmates. I'd never dreamed of going to a Hindu temple without my mom, but I did exactly that when I went to Trivandrum's famed Sri Padmanabhaswamy Temple. On this trip, people treated me like I was Indian rather than American. When visiting patients’ homes, ordering at restaurants, or during any sort of interaction with the public—even with a group of my classmates—locals would address me in Malayalam when I am almost as American as my classmates! The previously well-defined Indian-American lines in my life quickly became blurred and I soon became very confused. In a last-ditch effort to interpret my confusion, I looked inward to understand how I became interested in palliative care.

At around age 15, I started volunteering at a cardiac unit in my hometown. I was a shy volunteer who stuck with stocking supplies and tidying up rather than tending to patients. One day, while cleaning a wheelchair, I heard crying and hushed voices in the room next to me. I pretended to wheel the chair back to its place, but I was curious to see what all the commotion was about. A quick glance through the door revealed a physician sitting on the bed, holding her patient's hand, simply being present. She was not saying anything to the woman, and likewise the patient said very little while the family was quietly weeping in the background. The image of the physician sitting on the patient's bed, holding her hand stuck with me as I finished high school and went to college. This experience coupled with my continuing exploration of healthcare greatly influenced my decision to take this course.

During the course, each day a handful of students would accompany a Pallium team (e.g. a nurse, a driver, and often a physician) on home visits around Trivandrum and neighboring villages to attend to patients in need of palliative care. The students not visiting homes attended rounds on Pallium's inpatient unit. Every day I observed difficult situations caused by late-stage cancer and chronic illness. What intrigued me were the similarities in which Indian and American physicians interacted with their patients.

About a week into the course, I met a patient who was struggling to breathe. Her chest was rising heavily up and down and her mouth was agape. She made an agonizing moan with every exhalation…but what struck me most was that she reminded me of my own mother. Everything from the shape of her face, the small bindi she wore, to her short stature reminded me of my mom. It pained me to watch the physician pry open her eyelids to inspect her pupils and partially remove her clothes to auscultate her lung and heart sounds when she was clearly hours away from death. The physician's actions angered me. However, as I passed this patient's room later, a glance through the door revealed again a physician seated by the patient's bed, holding her hand, gazing at her closed eyes. I saw the same sight I had seen as a hospital volunteer—only this time it was halfway across the world. A short while later, I heard that the patient passed away. Although it was painful to watch the woman struggling for air, the physician's kind actions somehow helped me witness her suffering.

Palliative care's impact was illustrated in the home visits around Kerala, but also areas where I would have never suspected. After a long day of home visits in Poovar, a coastal fishing town, we stopped to get oranges at a fruit stand. I reflected to my youth when I would observe my grandpa's bargaining. He was always insistent on haggling to get a good price, so I felt like I needed to follow suit. I was determined to bargain even though I didn't know Malayalam or local fruit prices. After failing to get a good price at the first stand, we stopped at another stand a couple blocks away. The stand was run by a tight-lipped elderly gentleman who argued that ripe oranges were 100 Rupees/kilo and unripe ones were 60 Rupees/kilo. Thinking that he was trying to cheat me, I cursed under my breath in my mother tongue of Telugu, when he interrupted me…in Telugu, “Na bharya chanipoyi padhi samvatsaralu ayyindhi”—“it has been 10 years since my wife has passed away.” As he was speaking in broken Telugu, my world stood at a standstill. All the chaos behind me: the cars, auto-rickshaws, buses, voices, all blurred because at this moment, I was only focused on this gentleman. He talked about how his wife died of lung cancer and how he felt like he must remarry as he couldn't bear the pain of living alone. I quietly smiled to myself and asked him why he was sharing such a personal story with me, a stranger who cursed at him five minutes prior. He awkwardly pointed to my Pallium badge. We talked for another moment about his life as he finished bagging our oranges. I smiled and left the old man be…and got a great price on the oranges.

Defining “health” based on medical diagnoses provides a narrow perspective into a person's life; but connecting with patients on an emotional level has the power to widen our perspective. This humanistic approach bears universal value; it explains how I observed the pose of physicians sitting at a patient's bedside 8,000 miles apart. It explains why palliative care physicians recognize the importance of providing comfort to their patients when delivering difficult news. It also may explain my experience at the fruit stand. It could have been chance that I wore my badge, but what compelled the vendor to propel the conversation to an intimate personal story? I believe it is palliative care's emphasis on “listening” that resonated with the shop owner when he saw my badge. His genuine experiences with palliative care led to a unique moment that involved me as an active participant in his grief process.

What I have learned from this experience is that certain universal themes exist in medicine. Through palliative care, I've found the little things like silence, acceptance, and listening genuinely impact one's health. Palliative care is a specialty unlike others in its emphasis on humanistic care. Traveling to India without my family made this trip different. Although my Hinduism was present in the temple and my grandfather's lessons guided me, this family-independent trip helped me become more comfortable with my dual identity. The image of the physicians sitting at bedside, seeing my mom in the patient's face at Pallium, and the unexpected encounter with the fruit vendor bridged two worlds. So how can I say that I feel a sense of belonging between two countries 8,000 miles apart? I found myself belonging in a world where India and the United States intersected for me through palliative care.