In Sikar, Rajasthan, tea seller Jagdish Panwar, 62, had saved up all his life to spend on the marriage of his two daughters, Sunita and Kiran. The marriage was scheduled for 3 December this year. The plans suddenly felt disrupted on 8 November when prime minister Narendra Modi announced notes of Rs 500 and 1,000 would no longer be legal tender.
For the next seven days, Panwar had to leave his tea shop and go and arrange cash. The banks were unable to exchange his old currency notes worth Rs 45,000, or even let him withdraw the money he had in his savings account. The bank simply didn't have new currency notes of Rs 500 and 2,000 the Reserve Bank of India has issued in lieu of demonetized currency.
On the morning of Wednesday, 16 November, Panwar made yet another trip to the bank and came home disappointed. After having lunch, he fell ill. He was rushed to a hospital, where he was declared brought dead. Cause of death: heart attack. He was 62.
It is well known that stress can precipitate heart attack. But the incidence of such heart attacks is very low.Dr. KK Agarwal, Cardiologist.
Would it be fair to say that Panwar died because of demonetisation?
Dying of heart attack is far from unusual. According to an estimate, one Indian dies of it every 33 seconds.
Panwar's is not the only such death. More people have died of heart attacks in bank queues than of suicide because of demonetisation. Most such heart attack deaths are of men in their forties and above, well-known to be a high-risk group for heart attacks.
"It is well known that stress can precipitate heart attack. But the incidence of such heart attacks is very low. The stress should have been very acute and the person should have been suffering from heart disease in the first place," says Dr KK Aggarwal, a Padma Shri-winning cardiologist who heads the Heart Care Foundation of India.
Did the stress of not having money for the forthcoming wedding of both his daughters precipitate a heart attack in Jagdish Panwar? His family certainly thinks this was the reason. His son told the Indian Express: "Father was concerned ever since the announcement (of demonetisation). He was worried about paying for the halwai, tent, etc. We found cash and a cheque book on my father when he passed away. He was worried shadi ka kaam bigad raha hai (wedding arrangements were not going as planned). Mother did not sleep all night."
News reports don't say whether Panwar had been a patient of heart disease. "People may have blockages in the heart that they may themselves not be aware of. Often they write off the symptoms as acidity," says Dr Aggarwal.
It is unlikely that Jagdish Panwar, a tea seller in a village in Sikar, had access to preventive check-ups.
Sudden shock
Dr Aggarwal says that moments of sudden shock can trigger cardiac arrest. "There have been those who have died just by hearing that India lost a match. But once again, there has to be pre-existing heart disease," he says.
A few such deaths out of the sudden shock of demonetization have also been reported. A businessman in Faizabad, Uttar Pradesh, felt chest pain soon after watching prime minister Modi's television announcement on the evening of 8 November. He died before the doctor could arrive.
"It's a bit like how stock market crashes precipitate heart attacks," says Dr Aggarwal. "People have invested in a company called Gandhi (whose image is on currency notes) and now suddenly that company's stock has crashed. Its share value is zero. So it can similarly precipitate a heart attack."
Someone with heart disease can have a heart attack anywhere. We get patients who got a heart attack in a train or a flight. These are events and there may be stress.Dr Naresh Trehan
In Kushinagar, Uttar Pradesh, a woman died of shock the moment she heard her precious savings, two notes of Rs1,000 each, were not legal tender.
In Bokaro, Jharkhand, a 70-year-old grandmother died of shock when she heard her 20 year old grandson had died because of demonetisation.
Do queues kill?
But most such heart attack deaths have taken place in bank queues. Is it fair to blame long bank queues for heart attacks?
"Someone with heart disease can have a heart attack anywhere. We get patients who got a heart attack in a train or a flight. These are events and there may be stress. But it is not a straight arrow between demonetization queues and heart attacks. Queues are common in India. The person has to have pre-existing heart condition. From a social point of view, it would have been better for such patients had there not been long queues and it was better managed," says Dr Naresh Trehan, eminent cardiovascular surgeon who heads Medanta hospital.
In an acknowledgement of the problem, the government had ordered banks to serve only senior citizens on Saturday, 21 November.
"It is difficult to say what could have caused these deaths unless one looked at the medical history and post-mortem report of each death. It could be heart attack induced by stress, but that is usually acute stress, which may not be simply explained by standing in a queue. And such a person should necessarily have been a patient of heart disease, although he may not be aware of it," says Dr Aggarwal.
In many news reports on such deaths, acute stress is indeed mentioned. Victims had been going to the bank repeatedly trying to get currency, didn't have enough money to get by or urgently needed money to spend on marriage or unavoidable travel. In many news reports, no such reasons are mentioned.
Some deaths have been of bank managers and cashiers, again reportedly heart attacks because of the stress of having to suddenly handle large crowds and work round the clock. Once again, it may be a matter of debate whether stress precipitated these heart attacks. In Agra, a police constable shouted at a bank clerk for not giving him 100 rupee notes. The 55 year old immediately went into a cardiac arrest, though fortunately survived at the hospital.
Dr Aggarwal says that there could be a reason other than stress for heart attacks in long bank queues. Senior citizens who are heart disease patients (whether or not they know it) often stay at home and are not used to strenuous physical activity. Standing in a queue for hours, with all the pushing and jostling that it entails, could therefore precipitate a heart attack even if there was no acute stress.
That is why, Dr Aggarwal says, the Indian Medical Association has issued an advisory asking patients who are not meant to walk to not queue up at the bank.
May not be heart attacks
Another possibility is that some of these deaths were something other than heart attack.
"For example, being in long queues without water may cause dehydration, which in extreme cases may cause fatal clots in the lung," says Dr Aggarwal.
One such death in a bank queue, that of 70-year-old Siya Ram in Hathras, western Uttar Pradesh, was caused by a brain hemorrhage. Siya Ram had been standing in queues for three days, unable to get his old currency exchanged. After his deaths, locals have faxed the prime minister's office demanding Rs20 lakh in compensation for him. His son has moved the Supreme Court demanding Rs50 lakhs.
Was this a death caused by demonetisation? Well, studies of brain stroke victims do show a strong link with stress.
Heart disease? Don't go to the bank.
What precautions can heart disease patients and senior citizens take while queuing up at the bank?
Dr Peeyush Jain, Director and Head of Preventive Cardiology at Fortis Healthcare, Delhi, has these suggestions:
1. At least half of those who get heart attacks are not aware that they had been at risk. That is why preventive check-ups are very important. Once you know you are at risk, you can take measures to prevent it and it is possible to prevent at least 50% of heart attacks.
2. If you are known to have serious and symptomatic heart disease, then you should ideally not go to the bank and stand in long queues.
3. Don't forget to take your prescribed medicine, as people may forget to do so when their minds are preoccupied.
4. If you have diabetes, make sure you eat adequate breakfast before you go to the bank. Take some food with you in case you have low blood sugar while waiting for your turn at the bank.
5. It is important to be well hydrated, even though it is not summer.
6. Senior citizens have separate queues. If not, you should demand this privilege and everyone is bound to respect this demand.
7. If you are a little unwell, but choose to go to the bank yourself, make sure someone goes along with you.