Death by Coconut Water Old Age Poison Senicide Severe Hyper Kalemia Thalaikoothal

 Death by Coconut Water  Old Age  Poison Senicide  Severe Hyper Kalemia Thalaikoothal  

Thalaikoothal (Tamil: தலைக்கூத்தல், lit. showering)[needs Tamil IPA] is the traditional practice of senicide (killing of the elderly) or involuntary euthanasia, by their own family members, observed in some parts of southern districts of Tamil Nadu state of India.

Methods

Typically, the person is given an extensive oil-bath early in the morning and subsequently made to drink glasses of tender coconut water which results in kidney failure, high fever, fits, and death within a day or two.[1][2] This technique may also involve a head massage with cold water, which may lower body temperature sufficiently to cause heart failure.[3] Alternative methods involve force feeding cow's milk while plugging the nose, causing breathing difficulties (the "milk therapy") or use of poisons.[3]

Incidence

Although thalaikoothal is illegal in India,[4] the practice has long received covert social acceptance as a form of mercy killing, and people seldom complain to the police.[5] In some case the family informs their relatives before performing thalaikoothal,[6] and the victims sometimes even request it.[3] However, social acceptance may lead to more egregious abuses: the issue gained a higher profile in early 2010, when an 80-year-old man escaped when he came to know of his fate and heard his family members discussing how they were going to "share" his lands, and took refuge in a relative's home.[5]

Investigation revealed the practice to be "fairly widespread "in the southern districts of Tamil Nadu.[4][5] Dozens or perhaps hundreds of cases occur each year.[3]

Response

In 2010, after an exposé in Virudhunagar district the administration set up teams of officers to monitor the senior citizens.[5][6]

Representation in modern cinema

A 2019 Tamil language movie, K.D. Engira Karuppudurai was based on the concept of Thalaikoothal where the family members of an old man who has been in coma for months plan to kill him.

Winner of National Award in 2019, Tamil movie Baaram is based on Thalaikoothal.

Old-age poison

By Lakshmi Subramanian | From issue dated November 22, 2015twitterlinkedingooglefacebook

Krishnasamy, 67: “I offered Thalaikoothal to my brother. One day, my son will do the same to me.” | Salil BeraRaniamma, 80: Was ditched by her daughter and grandchildren because she stopped getting pension. She now lives in a dilapidated house. She recently bumped into an iron gate and lost vision in her right eye |Salil BeraCrude traditionCrude tradition: Mandabasalai village in Virudhunagar | Salil BeraJanaki, 70: She knows her daughter has little time to take care of her. Her right leg and left hand, both paralysed, add to the burden | Salil BeraKrishnasamy, 67: “I offered Thalaikoothal to my brother. One day, my son will do the same to me.” | Salil BeraRaniamma, 80: Was ditched by her daughter and grandchildren because she stopped getting pension. She now lives in a dilapidated house. She recently bumped into an iron gate and lost vision in her right eye |Salil Bera

1234

? Go backOnward ?

A traditional form of senicide takes a grislier form, with the denial of old-age pension

"It [a glass of mud mixed with water] blocks the food pipe and the elderly would have to fight for oxygen" - Elango Rajarathiram, HelpAge India

Iam a burden. I don’t want to trouble you any more,” she says, hands joined in supplication. Tears run down her wrinkled face as she lifts her head to look into the eyes of her daughter, Deivanai Ponnumalai. Her words are lost in sobs, and her lower lip trembles as she wipes away the tears with the corner of her muddled green sari. Janaki Kottaichamy, 70, knows that her daughter has little time to take care of her. Her right leg and left hand, both paralysed, add to the burden. Deivanai, an agricultural labourer, ekes out a living and cannot afford her mother's medicines.

Janaki lives on one meal a day—a cup of kanji (rice gruel) early in the morning. “I don’t want to live. I know I will be killed as my daughter cannot afford to take care of me. But I want to die a peaceful death without pain. Will you help me?” she asks me. Given her condition, Janaki could soon be given a leisurely oil bath, several glasses of tender coconut water and, perhaps, a lethal injection.

Called Thalaikoothal, the oil bath is a crude ritual practised in more than 40 villages—including Mandabasalai, where Janaki lives—in Tamil Nadu’s industrial capital Virudhunagar and India’s firecracker capital Sivakasi. It is also prevalent in villages around Madurai and Thoothukudi, though to a lesser extent.

In Thalaikoothal, the body is massaged with 100ml each of coconut, castor and sesame oils, usually at dawn. After this, the person is given a cold bath and put to bed. The body temperature soon dips, often to a lethal extent. After 15 minutes, the person is made to drink a few glasses of tender coconut water and a glass of milk. This causes renal failure. In a day or two, the person catches a fever and dies.

In M Reddiapatti, a village near Mandabasalai, 92-year-old Subbama Veluchamy was recently put to sleep by her family. Bedridden for more than 40 days, she was under the care of her sister-in-law and her son’s family. One day, after a bout of diarrhoea, Subbama refused to eat or drink. This was when the family decided to give her the oil bath. However, the bath failed, and a local quack prescribed a dozen sleeping pills. These, too, failed to put her out of her misery. The last resort was a lethal injection. As her veins were infirm, the quack pricked her foot and took her life. “We all could hear her crying loudly and quivering in pain. But the family cannot afford her,” says Kasthuri, her neighbour.

26Dhanushkodi Dhanushkodi, 66: A security guard in a fireworks company in Sivakasi, Dhanushkodi is one of the few men skilled in the technique | Salil Bera

Till a few years ago, if the oil and coconut water failed, the person would be given a glass of mud mixed with water or, a piece of murukku, a savoury, would be forced down the throat. “It blocks the food pipe and the elderly would have to fight for oxygen,” says Elango Rajarathiram of HelpAge India, an NGO in Virudhunagar working to stop the ritual.

Though villagers claim they have buried this gruesome tradition, it has now taken on a silent form. Unlike earlier, when it was socially acceptable, relatives are no longer informed or invited. More shocking, however, is the evolution of the ritual. Now, pesticides, sleeping pills and lethal injections have become part of it. The local quacks prescribe Valium tablets. If these fail, the villagers call in the quack to inject a combination of poisons and a fatal dose of drugs. Death comes within minutes.

'Dr Muthuraja', who gave Subbama the lethal injection, refused to meet THE WEEK. But Kasthuri, Subbama's neighbour, says Muthuraja is the trusted man in such situations. A quack from Virudhunagar, Muthuraja usually administers lethal injections on demand. However, he insists on confidentiality as he knows the gravity and depravity of his service. Interestingly, the villagers in M Reddiapatti and Mandabasalai know that he is not a doctor or a trained nurse. “He used to be a compounder in a hospital in Madurai,” says Selvaraj, a shop owner in M Reddiapatti.

25Seeniamma Seeniamma, 97: Survived Thalaikoothal twice as well as ten sleeping pills. Having lost her sight and voice, she now waits for a release | Salil Bera

In other villages, such as Kariapatti, Ennam Reddiapatti and Vellore, pesticides are being used to kill the elderly. The pesticide Thimet 10 G, a dark granulated organic solvent, or Kurnamarunthu, as the villagers call it, is mixed in tea or water and administered.

Says 66-year-old Dhanushkodi Karupannan of Ennam Reddiapatti village: “I have done it for my sister-in-law and my father. What else can be done when they cannot fend for themselves? We cannot afford them.” A security guard in a fireworks company in Sivakasi, Dhanushkodi is one of the few men skilled in the technique. “I did it 20 years back. We don’t practise it anymore,” he adds quickly.

Another popular material is a highly-toxic tablet used to kill pigs. It costs Rs.10 and is sold under various brand names, such as Quickphos and Celphos, in pesticide shops throughout these villages. Usually, this tablet is mixed in tea given to the elderly. The death results from profound shock, myocarditis and multi-organ failure.

Dhanushkodi recently saw his relative Mookaiah take a 'pig tablet'. “He died within one hour,” he says. “His sons refused to take care of him and he had to repay loans he had taken for his daughter’s wedding. I saw him consume the tablet. But, he was helpless.” His 62-year-old relative Bhaskaran Muniyandi asks: “We know this would be our fate when we grow old, but where is the solution?”

Though the practice is ethically and legally unpardonable, one should note that it is sustained by the economic backwardness of this region. “Their livelihood has always been a question mark,” says J. Manivannan of Elders For Elders Foundation, an NGO in Cuddalore. “They are farm labourers. Both men and women work but their daily earnings can meet only one person’s needs.”

And, the state government's old age pension, Rs.1,000 a month, has recently been denied to about 80 per cent of the estimated 30,000 elders in these villages. “This was a big financial support for the people in this region as there are no big job opportunities for the elders,” says Tiruchuli MLA Thangam Thennarasu. “Despite several requests, the revenue officials have recently disqualified 80 per cent of the elders from the list of pensioners.” The revenue officials, he says, have turned a blind eye to the elders in this region, listing various additional eligibility criteria. Apparently, to gain votes, many villagers had been given the pension despite not being fully eligible. Now, they are being held to the actual criteria.

The monthly pension was the major source of money for the most of the elderly. “It is my money. It fetches me two square meals a day and a few medicines,” says Poolugu Pandi, 90, of Mandabasalai village. Paralysed because of arthritis and having lost 60 per cent of his vision, he is under the care of his daughter-in-law. But, he is now worried, as some of his relatives no longer get the pension. “Will I continue to get the monthly pension? Otherwise, where do I go for food and medicine?” he asks.

27ElangoRajarathiram Elango Rajarathiram | Salil Bera

Elsewhere, Raniamma Natarasa Thevar, 80, was ditched by her daughter and grandchildren because she stopped getting pension. She now lives in a dilapidated house. She recently bumped into an iron gate and lost vision in her right eye.

Apart from economical constraints, the lack of palliative care in these villages is also a serious concern. “We would have to go to Madurai for any medical help. There are no big hospitals [here],” says Rasathi, wife of Velusamy Sangaiah, 60, who is being treated for prostate cancer. “We have spent close to Rs.2 lakh in the last one year. We got help through the government’s insurance scheme. But, what now?”

Likewise, a primary health centre or a village nurse would have helped Seeniamma, 97, who recently survived Thalaikoothal twice as well as ten sleeping pills. Having lost her sight and voice, Seeniamma lies on a steel cot in a small, dark room, waiting for a release. “I am also suffering with her,” says her daughter-in-law Karpagavalli. “We have to spend at least Rs.300 a month to get Dettol and soap to clean this room. Doctors and nurses used to visit our village and give medicines to the elders. But, these days, we don’t find them.”

State health secretary J. Radhakrishnan, however, disagrees. “Tamil Nadu is next only to Kerala when it comes to palliative care,” he tells THE WEEK.

However, despite interventions by the government and NGOs, the villagers realise they, too, will turn victims one day. Says Krishnasamy, 67, of Vellore village: “I offered Thalaikoothal to my brother. One day, my son will do the same to me.”

Most names have been changed.

KIN WHO KILL

THIS STORY IS FROM MAY 24, 2015

Kin who kill

Padmini Sivarajah | TNN | Updated: May 24, 2015, 12:39 IST

Aruna Shanbaug’s death has revived the debate on euthanasia, but a very crude form of ‘mercy killing’ still survives in some villages in south India. Here, people take it upon themselves to ‘cull’ elderly persons who are bedridden and considered a burden to the family, with something as innocuous as oil and coconut water. And though villagers claim they’ve buried the gruesome tradition, social activists say they haven’t seen the last of it yet.

“We no longer do it, but it was called ‘thalaikoothal’,” says G Anusha of Innam Reddiarpatti in Virudhunagar district. “A person who was suffering and bedridden was given an oil bath at dawn and then plied with multiple glasses of tender coconut juice, which resulted in the body cooling considerably, eventually causing high fever. In a day or two they died,” she says, insisting that the practice has now dwindled. Her neighbour Kuruvamma credits improved facilities like transport and medical support for the decline of the tradition. “I myself look after two elders in the family. We want them to live as long as they are destined to,” she claims.

Seventy-five-year-old, bespectacled Sankaramma sits rolling paper tubes for a fireworks factory. “I have to work as long as I can to be able to eat,” she says, insinuating that she literally has to safeguard her living. But then she cautiously mentions that she has known elderly people who were given thalaikoothal deaths. “But that was then,’’ she hastily adds.

Is this staunch denial really an eyewash? A social activist from Usilampatti, M P Raman, concedes that this indigenous form of mercy killing still prevails, but is kept under wraps for fear of prosecution. His words are echoed by C Radhakrishnan, senior manager at Help Age India, Madurai. “Though villagers claim it isn’t practiced anymore, thalaikoothal is more prevalent now than ever before,” he states, citing greater employment as one of the reasons. “Unlike those days when at least one member of the family was at home to look after the elderly, everybody in a household today is employed and a bedridden person becomes a big responsibility,” he explains.

Apparently thalaikoothal is no random act of extermination, but a well-oiled death ritual provoked by poverty and abetted by custom. An old, ailing individual, with an already weakened immune system is pushed over the edge with oil baths and coconut juice guaranteed to induce a fever that will eventually do the person in. And even as preparations for the thalaikoothal are under way, family will start arranging for the funeral as well.

“I came to know that invalid elders are given a final oil bath and forced to drink tender coconut juice, followed by tulsi juice and then milk (a customary predeath drink), with the relatives standing around chanting, ‘kasi’, ‘kasi’,” Radhakrishnan says. But they are not the only devices employed. In some cases, hard pieces of murukku (a savoury) are forced down a resistant individual’s throat, causing him or her to choke to death. Mud mixed with water is also used, with hopes that the watery Hemlock would cause indigestion — almost surely fatal to an already compromised body.

According to Dr N Raja, a geriatrician and private practitioner in Madurai, an oil bath followed by tender coconut juice, a coolant, results in the body’s temperature falling to 94 or 92 degrees F from the normal of 98.4 degrees F. “It can also cause electrolyte imbalance, which can play havoc with the body’s metabolism. And for a person who is already sick, it can even lead to cardiac arrest,” he says.

Tirunelveli N Kannan, professor of sociology, Manonmaniam Sundaranar University, says that this was an age-old practice which was not confined to any specific community. “I have heard people doing it in villages in Virudhunagar and also Usilampatti in Madurai,’’ he says. “If closely researched we may see similar practices in many countries.’’ “The issue of the person’s consent in this practice, did not rise as in many cases he or she was terminally ill and almost unconscious. No person would willingly agree to being killed, but the community as a whole took the decision on his behalf, and went ahead with it,” says Kannan. This was something that had social acceptance, he added.

LATEST COMMENT

Government should take extreme steps to stop people from doing these practices.

S Alagarsamy, 78, says he has no fear of forced death. Although age has restricted his mobility, he believes he won’t be a burden to his widowed daughter because of the free rations doled out by the state. “Mercifully the government provides us with free rice. Moreover, my daughter looks after me well, otherwise I would have feared the thalaikoothal,’’ he says.

Radhakrishnan points out that death by thailakoothal is almost always signed off by a certifying doctor as death due to natural causes — old age in their case. “The truth will emerge if these deaths are better investigated,” the NGO worker claims.

Incidentally, when Dr Raja discharges a patient in his care — one who may not have long to live — the patient’s relatives sometimes ask him if they could perform the oil bath ritual. These people usually come from places like the rural pockets of Madurai, including villages in and around Usilampatti. “I tell them that it is illegal and that it should never be done, but I do not know if they follow my counsel.”

Should a patient be forced onto a ventilator even when there is no hope of recovery? Aruna Shanbaug’s last mom...Read More

In the recent Bollywood release Piku, 70-year-old Bhaskar Banerjee played by Amitabh Bachchan expresses shock that Rana (Irrfan Khan) allowed his cancer-stricken father to be put on a ventilator. I don’t like unnatural deaths so don’t ever do that to me, Bhaskar tells daughter Piku (Deepika Padukone).

The scene has provoked much chatter on social media. There seems to be a general horror of dying hooked to machines, especially a ventilator. And yet, Aruna Shanbaug, who was in a vegetative state for 42 years, was put on a ventilator in her last days. Senior critical care specialist Dr RK Mani calls it the “ultimate outrage”.

“Why did we heap such suffering on her and not let her die in peace? We have not questioned the ethics and rationality of artificial life support when treatment is futile. In the US, the first Do Not Resuscitate (DNR) order was written in 1973 and by 1988, it had been codified as law. And they did not call it ‘euthanasia’. We might have closed the gap in curative treatment, but we are 40 years behind the developed world in end of life care (EOLC),” says Mani.

Life-support treatment requires a plethora of machines, tubes and medication, not just ventilators. Yet, ventilators have become the focus of any EOLC discussion, with a general notion that people are forced onto ventilators by hospitals driven by greed.

Quoting western studies, Dr Aniruddha Malpani, who runs a patient education programme in Mumbai, said, “Around 40% of the patient’s total medical expenditure is incurred in the last seven days of life. Yet neither the patient’s relatives nor doctors will want to discuss the futility of putting a severely ill patient on life support.’’ Most relatives don’t want to be haunted by the thought that they didn’t do enough for the patient even if it means their loved one dying in a sterile ICU hooked up to machines.

But can a patient forego intervention? No doctor can force a surgery, not even a life-saving one. That’s common law. But this doesn’t seem to apply to life support. “This respect for choice — which is not construed as the patient attempting suicide — ought to apply to EOLC, where a person or his family is allowed to choose or reject a particular treatment mode or intervention,” says Mani. Doctors can counsel extensively but should act on the wishes of the patient or family. But since the law does not articulate this position clearly, physicians tend to be apprehensive.

EOLC decisions depend on complex integrative skills that cannot be reduced solely to objective criteria, warns Dr Shivakumar Iyer, president of the Indian Society of Critical Care Medicine (ISCCM). He adds that even the guidelines drawn up by ISCCM along with the Indian Association of Palliative Care are based on factors such as comfort, needs, and universal ethical principles. The ISCCM has called for special training for doctors in communicating EOLC decisions to families and in weighing a range of factors, looking at the patient beyond clinical parameters.

Critical care specialists are unanimous that this is a decision to be taken in conjunction with the patient, where possible, or with the family, and does not require court intervention, as suggested by the Supreme Court in the Aruna Shanbaug judgement. “Thousands die every day in ICUs. Can doctors be running to court every time? The organ transplant act allows a team of doctors to declare brain death and in conjunction with the patient’s family, get consent to harvest organs and withdraw life support. A similar clear legislation is required to allow a team of doctors to decide on futility of care and EOLC decisions in consultation with the family,” suggests a senior critical care specialist.

Even today, hospitals or doctors cannot prevent a patient’s family from discontinuing treatment and taking the person home. It’s called Left Against Medical Advice (LAMA). “The family does not take the court’s permission to do it. So, to assume that families cannot be allowed to take EOLC decisions as their intentions could be suspect makes no sense. Even if they have mala fide intentions, they can discontinue treatment and take the patient home to die,” points out an intensivist.

Four years after the “landmark” judgment allowed “passive euthanasia”, no one has appealed for this option. “Thousands of people might have wanted to forego life support treatment but the process laid down by the court is unwieldy and unworkable. Of what use is a law that cannot facilitate, but only hinder, appropriate care of the dying?” asks Mani.

Nothing passive about euthanasia

Currently, euthanasia, defined as the administration of a legal drug by a physician as an act of mercy at the patient’s request, is an option in only Netherlands, Switzerland and in Oregon in the US.

What is allowed by law in India, thanks to the Aruna Shanbaug judgement of the Supreme Court, is “passive euthanasia”. It is an obsolete term because euthanasia is a specific act and there can be nothing passive about it, say doctors.

The Indian Society of Critical Care Medicine and the Indian Association of Palliative Care have drawn up a detailed end of life care policy after studying guidelines from across the world. It is meant for patients dying with an advanced life-limiting illness. It lists procedural guidelines to limit inappropriate therapeutic medical interventions and to improve the quality of care of the dying within an ethical framework and through a consensus involving doctors and the family/patient.

The updated policy was published in September 2014 but not too many doctors are aware of its existence. The foregoing or withdrawal of life support is still done “discreetly” and is a privilege available to a few who can reach a medical centre with doctors sensitive to the needs of patients and their families.

In southern India, relatives sometimes quietly kill their elders

Indian men in the village of Innamrediyarpatti, from left: pipe fitter Ponnusamy, 67; retiree Dhanushkoti, 63; farmer Kalimuthu, 60; and textile mill worker Michael, 62. Even as India debates the morality and legality of euthanasia, three districts in the southern state of Tamil Nadu have been quietly carrying out their own version of it.

Indian men in the village of Innamrediyarpatti, from left: pipe fitter Ponnusamy, 67; retiree Dhanushkoti, 63; farmer Kalimuthu, 60; and textile mill worker Michael, 62. Even as India debates the morality and legality of euthanasia, three districts in the southern state of Tamil Nadu have been quietly carrying out their own version of it.(Mark Magnier / / Los Angeles Times)

By  MARK MAGNIER, LOS ANGELES TIMES

JAN. 15, 201312 AM

INNAMREDIYARPATTI, India — Michael headed for work at a textile mill, leaving his wife, children and infirm mother at home in this impoverished part of southern India. When he returned a few hours later, his mother’s body was propped up in a chair surrounded by villagers and decorated with flowers, poisoned by his wife with a potion in a local form of mercy killing known as thalaikoothal.

Three decades later, he harbors no ill will toward his wife. “My mother had been sick and in pain for 20 days and wasn’t eating properly,” said Michael, 62, who like many southern Indians uses one name. “I was thinking of doing it myself. It was time, and there wasn’t enough food to go around.”

Even as India debates the morality and legality of euthanasia, three districts in the southern state of Tamil Nadu have been quietly carrying out a homegrown version for decades, or centuries, depending on whom you ask.

The practice in one small corner of India has declined under the spotlight after a high-profile 2010 case and growing opposition from elderly rights groups, but dozens, even hundreds, of cases of thalaikoothal, or “head pouring,” occur quietly each year, people say.

“Some call it euthanasia,” said Rajeshwar Devarakonda, social protection head at HelpAge India, a civic group focused on elderly care. “Others call it homicide.”

Although it can take various forms, a common approach is that once an elderly relative becomes seriously ill and the family can’t afford to care for the person, a date is set. Often relatives are called to say goodbye or even participate. The victim is given an oil bath, a head massage perhaps involving cold water and an exceedingly large amount of green coconut milk, leading to death.

Reducing a sick or frail person’s body temperature can bring on heart failure, said Dr. Raja Natrajan, a geriatrician, while drinking excessive liquids can induce renal failure.

In a variation, victims are force-fed cow’s milk and their noses pinched shut — an act called “milk therapy” — resulting in “breathing problems,” said S. Gurusamy, a sociology professor at the Gandhigram Rural Institute.

Thalaikoothal — traditionally for those 50 and older who become incapacitated, although younger people who become very ill are also targeted — is as natural as a birthday or wedding, some say. “It’s just the cycle of life,” said Kalimuthu, 60, a Peraiyur village farmer with a white, receding hairline and a wispy mustache.

Despite community claims that it’s used only in terminal cases, social acceptability has resulted in abuses, care experts said, as impatient family members “hurry things along” to gain control of the estate, sometimes with the help of compliant doctors or quacks who substitute poison-laced alcohol or pills for coconut milk.

“Nowadays, because of their assets, young people sometimes want thalaikoothal done even if it’s just a cold or minor sickness,” said Elango Rajarathinam, Virudhunagar-based director of Elders for Elders Foundation. “Old people are definitely scared of this practice. You can see the stress on their faces.”

Occasionally, those targeted get wind of it and flee.

Others just accept their fate, experts said, even requesting thalaikoothal, less because they’re ready to die than because society makes them feel worthless.

Ponnusamy, 67, a pipe fitter in a green shirt and purple dhoti, a type of sarong, recently suffered two heart attacks, leaving him worried about more than his ticker.

“I trust my wife wouldn’t think like that,” he said, gazing over the infertile landscape at two bullocks with decoratively painted blue horns. “If my family tried thalaikoothal on me, I’d ask why. If they didn’t answer, I might resign myself to it.”

The history of thalaikoothal is hazy, but some say it started before the British Empire when a prince helped his ailing mother-in-law die peacefully. Others suspect it began as recently as the 1950s, a response to a rising population and poor local economy.

“India’s very good at making up stories,” said Devarakonda.

Underpinning thalaikoothal is a society that’s seen extended families gradually replaced by nuclear families, placing less social value on the elderly.

Although women’s status in India is often low, men are more frequently the victims of thalaikoothal, experts said, in part because assets are generally in their names, providing an incentive. Also, daughters-in-law who provide most elder care are reluctant to assist men, given social taboos. In addition, some perceive men’s housekeeping skills as limited in male-dominated India, leaving them seemingly dependent.

“An old man can’t even make his own tea or take care of the grandchildren, while older women remain useful,” said Devarakonda.

Many people feel they’re just relieving someone’s suffering, added Gurusamy, who sees thalaikoothal as more a family decision than a moral concern.

“You can try anything, but it won’t stop thalaikoothal,” said Dhanushkoti, 63, a retiree in Innamrediyarpatti. “In our culture, if there’s a problem in the house, the family, not the government, handles it.”

Rather than fighting entrenched culture directly, activists said, they’re trying to improve underlying social and economic conditions through education and calls for improved palliative care. Elders’ health often deteriorates for very basic reasons, they said, including untreated bedsores that lead to severe infection and, ultimately, thalaikoothal.

The gradual spread of pensions, however modest, is also helping. “If you’re dead, you can’t bring a pension in,” said Rajarathinam. “Now families have an interest in keeping you alive.”

Activists have created about 500 elder-empowerment groups to confront neighbors suspected of planning thalaikoothal and are teaching children to act as community watchdogs, although these measures aren’t always effective.

As several men in their 70s gather in the Innamrediyarpatti community hall for a self-help meeting, most acknowledge that they’ve never prevented thalaikoothal and would be reluctant to do so.

“If I try and stop someone, they’ll just say, ‘Then you take care of the old man yourself,’ ” said Kalimuthu, a group member. “What can I say? I can’t afford to keep him.”

Euthanasia is illegal in India, but right-to-die groups have conducted seminars, launched media campaigns and petitioned courts for changes.

The Supreme Court in a landmark case two years ago — in which a woman remained in a vegetative state for nearly four decades after being raped and asphyxiated — paved the way for families or direct caregivers to withdraw life support.

Police and officials in Tamil Nadu have largely turned a blind eye to thalaikoothal. In 2010, however, the practice hit the headlines when a 60-year-old man died suddenly and his nephew Asokan accused a hospital janitor of offering injections, using skills she’d picked up watching doctors. She was suspected of being involved in several similar cases. Officials ultimately released her, saying there was no evidence because the bodies had been cremated or buried.

“It’s a police coverup to hide this disturbing practice,” said Asokan, a trade union official. “Elderly need better care, and this hideous practice should end.”

As some people justify thalaikoothal on cultural grounds, others are outraged.

“Who has the right to take a life?” said Kannan, 45, a betel nut seller rolling leaves at a small stand. “We don’t need to kill them. This is murder.”

mark.magnier@latimes.com

Tanvi Sharma of The Times’ New Delhi bureau contributed to this report.

Thalaikoothal: the crude ritual killing of the elderly in India

By Pastor Paul

Thalaikoothal, the crude ritual practice of geronticide or involuntary euthanasia of the elderly and infirm, is still practiced in parts of India. In a sense it resembles leading a lamb to slaughter, except no knife is involved. In more than 50 villages of the districts of Virudhunagar, Mandabasalai, Madurai, Thoothukudi and Theni in the Tamil Nadu State, the favored practice involves an oil bath

Even in some regions otherwise praised for a vibrant culture encompassing all walks of life, the ritualistic practice is often accepted as an innocuous norm.

When a family is unable to bear the burden of an elderly, they kill them off. Many of the strongest hearts would cringe at the methods used.

A group of elders gather outside a village corner shop. At times thalaikoothal is practiced even with their consent

A GROUP OF ELDERS GATHER OUTSIDE A VILLAGE CORNER SHOP. AT TIMES THALAIKOOTHAL IS PRACTICED EVEN WITH THEIR CONSENT

The most common practice involves first giving the person an oil bath. The body is massaged with 100 ml each of coconut, castor and sesame oils, usually at dawn. After this, the person is given a cold bath and put to bed. The body temperature soon dips, often lethally. After 15 minutes, the person is made to drink a few glasses of tender coconut water and a glass of milk. This causes renal failure. In a day or two, the person catches fever and dies.

Another method is to massage the elder’s head with cold water, causing a sudden drop in body temperature. Unable to handle the change, the individual often suffers cardiac arrest.

Should these procedures fail, a third way would be give the person a glass of mud mixed with water, or force a piece of murukku, an Indian snack, down the throat.  Being difficult to swallow, suffocation and death often ensue.

Another popular method is to administer a highly-toxic tablet used to kill pigs. It costs 10 Indian rupees and is sold under various brand names, such as Quickphos and Celphos, in pesticide shops throughout the villages. The tablet is usually mixed in tea and given to the elderly. The death results from profound shock, myocarditis and multi-organ failure.

Pesticides, sleeping pills and lethal injections have also become part of it. Or, a local quack may prescribe a too-high dose of valium. A survey carried out to study the practice in Tamil Nadu reveals there could be as many as 26 different ‘acceptable’ ways to kill the elderly. 

older man looking down b&w best smaller.jpg

In the village of M Reddiapatti in the district of Virudhunagar, 92-year-old Subbama Veluchamy was recently ‘put to sleep’ by her family. Bedridden for more than 40 days, she had been under the care of her son and her sister-in-law’s family. One day, after a bout of diarrhoea, Subbama refused to eat or drink. This was when the family decided to give her the oil bath. However, the bath failed, and a local quack prescribed a dozen sleeping pills. These too failed to put her out of her misery. The last resort was a lethal injection. As her veins were infirm, the quack pricked her foot and took her life.

“We all could hear her crying loudly and quivering in pain. But the family cannot afford her,” said her neighbor Kasthuri.

Though villagers claim they have buried the gruesome tradition, it has now taken on a silent form. Sometimes, the elderly themselves consent to it, in which case everything will be done with full preparation. Relatives are often told the exact date, as if some marriage ceremony were to be held.

Kannaki, 65, lives with her daughter Malar on one meal a day—a cup of kanji (rice gruel) early in the morning.

“I don’t want to live," she says. "I know I will be killed as my daughter cannot afford to take care of me. But I want to die a peaceful death without pain.”

She knows her daughter has little time to take care of her. Her right leg and left hand, both paralysed, add to the burden. Malar, an agricultural laborer, ekes out a living and cannot afford her mother's medicines.

“Will you help me?” she asks her daughter, hands together in supplication. “I am a burden. I don’t want to trouble you any more.” Tears run down her wrinkled face as she lifts her head to look into the eyes of Malar. Her words are lost in sobs, and her lower lip trembles as she wipes away the tears with the corner of her muddled green sari. 

Given her condition, Kannaki could soon be another victim of thalaikoothal.

As justification for the killing, some offenders say the practice enables the old to be rid of their suffering. Others say they do not have the means to take care of their parents.  The truth could be anything, including ownership of property. A higher number of the elderly victims are men who usually have the property in their names, which does somewhat validate the ownership angle.

Although illegal in India, the practice has long received covert social acceptance as a form of mercy killing. The government finds itself helpless to interfere in any practice of a society fiercely divided along religious, caste and traditional lines. So no one complains and doctors often cite the reason for death as natural causes; no one is arrested for this crime. Since society accepts it as normal, there is no hue and cry. Entire villages can stand united behind those who carry out this procedure. 

With the diverse ways there are now to kill the elderly, the ritual has spawned an unorganized crime sector involving middle men and quacks known as vettiar who claim to be siddhans (indigenous medical practitioners) and doctors. Because of the gravity of the act the quacks engage in, hesitatant villagers refuse to divulge more details about them. Furthermore, this happens right under the nose of law-makers and police.

Though the practice is ethically and legally unpardonable, one should note that it is sustained by the economic backwardness of this region.

“Their livelihood has always been a question mark,” says J. Manivannan of the Elders for Elders Foundation, an NGO in Cuddalore. “They are farm laborers. Both men and women work, but their daily earnings can meet only one person’s needs.”

State health secretary J. Radhakrishnan, however, claims that the government of  Tamil Nadu “is doing its best for palliative care.”

That this form of murder is socially acceptable says a lot about the evil lurking in a society that appears perfectly civilized and chest-thumps about its ancient history. To the hoi polloi in the villages and towns where thalaikoothal is practiced, it is considered merely part of ‘the cycle of life’.

Even activists trying to end the barbaric tradition tread carefully. They have taken the indirect route of educating the masses about how to care better for the elderly instead of telling them outright that their practice is nothing less than demonic. Bibles for Mideast ministers in the region, attempting to end the barbaric practice by teaching the value of a soul through the love of Christ.

July 02, 2016 Bibles for Mideast Comment

180

Coconut water has become an increasingly popular sports

drink because of its natural ingredients, electrolytes, and

mineral content. Marketing has focused on the product’s low

levels of fat, calories, and carbohydrates while promoting

health benefits that are as-of-yet unproven. Coconut water,

when consumed in excess, has been noted in case reports to

cause severe hyperkalemia.1

 We present a case of a 42-year-old

otherwise healthy man who presented to our emergency

department following an episode of exertional syncope after

consuming multiple servings of coconut water.

Case Presentation

A 42-year-old black man without any medical history presented to our hospital after a syncopal episode. He was playing

tennis outdoors all day in temperatures in excess of 90° Fahrenheit. He reported drinking a total of eight 11-ounce bottles of

coconut water throughout the day. He experienced the sudden

onset of lightheadedness and was witnessed to have lost consciousness. He did not experience any significant head trauma

and regained consciousness almost immediately. Afterward he

complained of generalized weakness and lightheadedness.

He was brought to the emergency department by ambulance. There he was noted to have a blood pressure of 67/45,

a regular pulse in the 50s, and a temperature of 36.3°C. On

examination, he was disoriented and his skin was warm.

There was no jugular venous distention. Lungs were clear to

auscultation. Cardiovascular examination disclosed a regular

bradycardic rhythm without any murmur or gallop. Point of

maximal impulse was not displaced. Abdominal examination

was benign. There was no edema on examination of the lower

extremities, and his distal pulses were present but thready.

ECG demonstrated sinus arrest with a junctional escape

rhythm at a rate of 51 beats per minute, a high take-off of coved

ST-segment elevations resembling a hyperkalemia-induced

Brugada pattern and peaked T waves (Figure [A]).2

 He then

had a prolonged pause associated with altered mental status.

He was paced externally with consistent capture, and atropine

0.5 mg was administered intravenously. Subsequently his

intrinsic sinus rhythm returned with normal AV conduction. A

temporary transvenous pacemaker was placed.

Subsequent laboratory evaluation disclosed a serum potassium of 7.8 mmol/L, blood urea nitrogen of 22 mg/dL, and

creatinine of 2.1 mg/dL. Initial creatinine kinase was 1615

U/L with a normal MB fraction and troponin. He was admitted to the cardiac care unit for rhabdomyolysis, acute kidney

injury, and hyperkalemia. He was aggressively rehydrated

with intravenous fluids. The hyperkalemia was treated with

calcium gluconate, albuterol sulfate by nebulizer, sodium

polystyrene sulfonate, and intravenous dextrose and insulin.

During his hospital stay, he remained in normal sinus rhythm

without any further significant arrhythmic or hemodynamic

events. His potassium down-trended to normal levels and his

renal function improved (Table I in the Data Supplement).

Repeat ECG showed sinus bradycardia and memory T-wave

inversions secondary to recent pacing (Figure [B]). He was

discharged in stable condition on day 3 with close follow-up

planned with his primary physician and cardiologist. He was

also instructed to avoid coconut water, remain well hydrated,

and avoid excessive exercise in the extreme heat.

Discussion

Coconut water has become a popular oral rehydration solution in the United States and Europe, in part, because of marketing and celebrity endorsement. The makers of coconut

water purport health benefits that have not yet been verified

by clinical trials. Marketing materials claim that the drink

prevents kidney stones, lowers cancer risk, and strengthens

the immune system.3

 Coconut water is a hypotonic solution that is more acidic than plasma. It contains high concentrations of sugars and potassium, with lower amounts

of sodium, chloride, and phosphate. There have been documented cases of the use of coconut water as an intravenous

solution in developing countries where saline solution was

not readily available.3

When consumed in excess, coconut water has been shown

in case reports to cause severe hyperkalemia.3

 Eight ounces

of coconut water contain ≈600 mg of potassium. One popular

brand has as much as 690 mg per serving (Table II in the Data

Supplement). The suggested adequate daily intake of potassium for an adult without chronic kidney disease is ≈4.7 g

per day.4

 Our patient, who drank 8 servings of coconut water

within a short period of time would have ingested ≈5.5 g of

potassium. In combination with acute kidney injury and rhabdomyolysis, his potassium level was life-threatening.

(Circ Arrhythm Electrophysiol. 2014;7:180-181.)

© 2014 American Heart Association, Inc.

Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org DOI: 10.1161/CIRCEP.113.000941

Images and Case Reports in Arrhythmia

and Electrophysiology

Received August 5, 2013; accepted December 6, 2013.

Department of Cardiology, New York Hospital Queens.

The Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.113.000941/-/DC1.

Correspondence to Justin Hakimian, MD, Department of Cardiology, New York Hospital Queens, 56-46 Main St, WA-200, Queens, NY 11355. E-mail

drjhakimian@gmail.com

Death by Coconut

Justin Hakimian, MD; Seth H. Goldbarg, MD; Chong H. Park, MD; Todd C. Kerwin, MD

Downloaded from http://ahajournals.org by on January 21, 2021

Hakimian et al Bradycardia After Consuming Coconut Water 181

Our patient did not have any significant predisposing factors for

rhabdomyolysis on presentation. His body mass index is 23 kg/

m2

, which is in the normal range. He had no history of alcohol or

drug abuse (including cocaine and amphetamines). His phosphorus level was 2.2 mmol/L at presentation, likely not low enough

to precipitate rhabdomyolysis on its own. He had no evidence of

infection during the admission, such as fever or leukocytosis.

Our case demonstrates the potential dangers associated with

excessive consumption of potassium-rich coconut water. To our

knowledge, this is the first reported case of a life-threatening

bradyarrhythmia associated with the use of coconut water.

Patients who consume such beverages, especially those with

renal impairment, should be advised of the potential dangers

associated with drinking unrestricted volumes.

Disclosures

None.

References

1. Campbell-Falck D, Thomas T, Falck TM, Tutuo N, Clem K. The intravenous use of coconut water. Am J Emerg Med. 2000;18:108–111.

2. Littmann L, Monroe MH, Taylor L 3rd, Brearley WD Jr. The hyperkalemic Brugada sign. J Electrocardiol. 2007;40:53–59.

3. Rees R, Barnett J, Marks D, George M. Coconut water-induced hyperkalaemia. Br J Hosp Med (Lond). 2012;73:534.

4. USDA National Nutrient Database for Standard Reference. Daily

Reference Intakes - Food and Nutrition Board. http://fnic.nal.usda.gov/

dietary-guidance/dietary-reference-intakes. Accessed July 12, 2013.

Key Words: bradycardia ◼ potassium ◼ syncope

Figure. A, ECG showing

junctional rhythm with tall,

deformed T-waves. B, ECG

after treatment showing sinus

bradycardia and memory

T-wave inversions secondary to

recent pacing.

Downloaded from http://ahajournals.org by on January 21, 2021