Death is not a switch. One is not alive one moment and dead the next. It is a biological process. His father taught him the four-point 1968 Harvard Committee definition: total unresponsitivity, no movement or breathing over a period of at least an hour, no reflexes, and, in the absence of severe hypothermia or central nervous system depressants, a flat encephalogram for twenty-four hours with no measurable change. These are standard evaluations for death.
To say, then, that this young man is dead is a lie. He has suffered a clinical death. His heart has stopped, and his respiration is nil. If they were in Delhi, Dev could put him on an artificial respirator to compensate for his collapsed lung. He could compress the boy’s heart and keep the blood circulating. He could continue transfusions, more blood, more oxygen. It is possible to come back from clinical death. He has seen it. He has done it.
But Dev also knows he should have checked for the vein rupture before repairing the gallbladder and liver. No one would blame him, though, not in the heat of emergency. Not when two people were required for suction. Perhaps if his and Dr. Ferrell’s positions had been reversed, Dr. Ferrell would have done the same. Who can say for sure?
After the point after which no revival is possible comes biological death, usually about four minutes after the clinical death. Brain activity ceases completely. Electrocerebral silence.
The nurse gathers the operating equipment — the scalpels, the hemostats, the clamps, twinkling stainless steel objects — to be boiled. Dr. Ferrell removes his face mask. His breath is audible, a low, stuttering grunt. Dev stares at the patient’s face. At any moment, he will witness his biological death, irrevocable proof of failure.
Yet even after biological death, cellular death has not ensued. This is the basis of organ transplantation: not everything dies all at once. An excised kidney, for instance, continues to produce urine with a perfusion. It becomes a matter of keeping the tissue from necrotizing before it has been transplanted. This young man could have been a wellspring: corneas, pancreas, blood. Too many here have died of acute renal failure, after their crushed muscles flooded their kidneys with myoglobin. The dialysis unit of the Renal Disaster Relief Task Force has been delayed. In the meantime, medical workers have sent out the word: if your urine turns dark, seek help immediately. But the afflicted stay silent, as if accepting suffering were the same as minimizing it.
The nurse asks, — Can I aid you?
Dev shakes his head no. He yanks off the gloves with a single motion, before the blood can stiffen. The nurse holds a garbage bag for him. His fingers are damp, slightly slick. The boy’s skin is still warm to the touch. His core temperature won’t drop noticeably for at least an hour.
A waste, a terrible waste.
An act of nature he can understand: the unknown forces of the universe are blameless. But this — this was intentional. A conscious act of evil. He should have suspected the trajectory of the bullet. Maybe given another unit of blood. The nurse had it in her hands. Perhaps Ferrell had other ideas for resuscitation; something he’d learned at a conference while Dev ossified in clinical practice. But he had stopped, and now the boy continues to die multiple deaths.
The boy’s comrades wait outside the tent for word about his condition. The sun casts their silhouettes against the thick canvas. This death, unlike the others, cannot go unremarked upon. This is grounds for an international incident, and Dev will be caught in its midst.
A grim duty, this knowledge.
But he has delivered unhappy information many, many times before. One grows accustomed to it. Back in Delhi, he once treated a kabari who had contracted HIV. His wife had sought help for him; she hadn’t even known of HIV until one of the other ragpickers told her. She reeked of filth, and the admittance staff refused to let her enter the clinic. She was barefoot. It had taken her most of the day to walk there. Dev wondered if the man had contracted HIV from a prostitute, but in his line of work, scavenging through people’s refuse, he may have been pricked by a syringe.
The next day, Dev and Preeta, the prevention-outreach worker, traveled to the Ghazipur landfill where the man worked. All eighty acres of it rose from the ground like a cliff face. The people here were ants, picking through the wreckage for whatever could be collected and sold. When people threw something away, this was away. The stench made Preeta gag.
Slum camps ringed the area, each specializing in a product: tangles of wire, bales of clothing, dizzying arrays of nuts and bolts and small shards of metal. But all Dev could see were iterations of death. Families leaving cooking fires burning, allowing the carbon monoxide to suffocate them in their sleep. Split-off timbers waiting to impale; crushing hulks of concrete balancing precariously overhead; rust-flecked metal cables promising tetanus.
The wife brought Dev and Preeta to a hovel, a latticework of bamboo poles and a roof of rewoven basket thatch, patched with plastic bags. The man was covered by a thin blanket with a Jet Airways insignia stitched in its corner.
He’s wasting away, the wife said.
The man had Kaposi sarcomas on his arms and shoulders, cancerous craters. His wife, too, was most likely infected. Her son, sporting a dirt mustache, ran up to Preeta and offered her a bent earring. He was no older than six. The woman instructed her son to settle down, and he went back to shredding plastic bags and stuffing the scraps into a larger bag. (Five rupees a kilogram, Preeta later told him.) The boy, too, might have been infected. He was severely anemic, malnourished.
Can you give my husband medicine? the wife asked. She clinked coins in her hand, surely no more than a few rupees. Please, she said. She held up her savings. Her hand was nicked and cut, the thin scabs crosshatching her skin. All she had were a few paise. Not enough, even, to buy the dust at the bottom of a pill bottle.