June 2020 in Karachi, Pakistan
Omar
June 14: Pakistan Says Its COVID-19 Cases Could Rise to 1.2 Million by End of July (Voice of America)
Asad Umar, the head of the National Command and Operation Center (NCOC) directing Pakistan's battle against the virus, said Sunday the escalation in COVID-19 infections was a cause of grave concern for the government.
"Unless the current trend is reversed, our experts are telling us the number of cases could double by the end of June and could even reach one million to 1.2 million by the end July," Umar warned while addressing a news conference in Islamabad.
"Doctor Sahib, aap ke Abu ki breathing treatment ka time ho gaya hai," the male nurse attending to my father called out, making me look up from my laptop. (Doctor, its time for a breathing treatment for your father)
"Theek hai, sahi se betha ke dijiay ga," I replied and told him I'd be there in 5 mins. (Ok, make sure to have him sit up properly before giving it)
The living room just across Abu's room was where I had spent most of my time since landing in Karachi. Despite the closed door the persistent beeping of the monitors and the constant attention he needed, on top of me being jet lagged, meant that I hadn't gotten much sleep in the last 5 days that I had been here. He was about 10 days into his illness and his symptoms of breathlessness and his oxygen requirement were progressively getting worse.
If he was in the US, he would be in the hospital. But here in Pakistan, there seemed to have been a sudden proliferation of concierge medicine capitalizing on the shortage of beds in actual hospitals. These were services that were provided by reasonably qualified doctors at home along with the required nursing support and lab testing support.
On the upside, it helped keep patients out of the already overcrowded hospitals. On the downside, this was yet another example of the stark difference between the 'haves' and the 'have-nots'.
Those who could afford it, enjoyed the luxury of home, reduced risk of acquiring non-COVID infections, and had access to loved ones without the usual hospital restrictions. Not to mention that they were able to access vital supplies like oxygen tanks by paying triple or quadruple the usual price by buying them on the black market.
Those who could not afford it, stayed alone in the hospitals that were already beyond their capacity, as overworked and underpaid doctors scrambled in dire circumstances.
When I had landed, things had been extremely tense in the city of Karachi, which at the time seemed to be the epicenter of COVID in Pakistan. In fact, the entire province of Sindh was leading the country in COVID cases. The Government of Pakistan had only opened up 25% of their airspace, and had implemented a number of measures to screen incoming passengers for COVID.
Things at home had not been any less tense. Ami had not bothered mentioning anything about my arrival to Abu. And so when I walked into his room after a 20+ hour flight, and another 2 hours in immigration, customs and then the COVID entry protocol, he took one look at me and growled, "Why is he here?"
Clearly, he wasn't on death's door as was described to me and I was ready to turn around and get on the next flight back to Chicago, except that I remembered Madi's last text messages to me just before my flight took off.
It may not be easy, but remember the reward you will get from Allah by taking care of your parents.
So try to keep an open mind.
No matter what happens, I will always love you.
Those were the words I leaned on heavily, trying to keep an open mind when my mother explained that he had been under a lot of stress lately which is why she thought he had gotten COVID in the first place. She didn't want to agitate him further by mentioning me.
I had to bite my tongue instead of explaining to her that, 1) stress doesn't cause a viral infection, only a virus can cause a viral infection, and 2) perhaps he shouldn't have gone to his friend's son's wedding that they had held illegally by paying off some event space owner, despite the fact that these places were supposed to be shut down by the local government's decree.
That wedding had now been linked to at least a dozen COVID cases, with a handful of the elderly in the ICU now.
"Beta, zindagi or maut tou Allah ke haat mein hoti hai. Unhoun ne itne pyaar se bolayaa tha, hum mana nahi kar sakte the," she had replied to me, which made my blood boil further. (Son, life and death are in Allah's hand. They had called us so lovingly, we could not say no)
But that was all 5 days ago, and with my father's progressive worsening, there was a sense of foreboding at home and I had to let go of my own issues with my parents. Abu had gone from disdain to reluctant acceptance of my presence. Ami was obviously relieved to have me there, even if our conversation had been tense and strictly related to Abu's condition. Shadab bhai had shown his face once, very briefly to get some signature from Abu, and then disappeared.
To say that he seemed like a vulture circling his next prey was an understatement. Made even obvious with his absolute disdain at my surprise visit.
I donned my N95 and eye goggles, and entered Abu's room. Even I had to admit, that while he looked in reasonable shape 5 days ago requiring oxygen but not a BiPap yet, and the nebulized steroids that I had started seemed to have helped initially, his condition was not improving. In fact, his oxygen levels had been trending lower.
"Sir maximum oxygen per hain, but koi effect nahi ho raha," the nurse told me. (Sir is on maximum oxygen but there is no effect)
That was a new downhill development. Previously we could raise his oxygen saturation to low 90s at least with nebulizers and good chest physical therapy. Now, they were consistently in mid 80s, and my father was obviously struggling to breathe.
"Abu, I think we'll have to put you on the BiPap machine now. You can't keep breathing so fast. You'll tire out and your body will start to shut down."
He shook his head. "No. There is...no machine...available," he said between labored breaths.
"Let me handle it," I told him and came out of the room to make a couple of calls.
*******
"Omar! What a pleasant surprise. Kidhar gum ho yaar?" (Where have you been lost?)
That was Wamiq, my friend and classmate from med school. He had trained in UK as an ICU physician and had just recently returned to Pakistan. A mere two months before COVID hit. And now he was one of the city's very few properly trained Critical Care Medicine doctors at our alma mater's affiliated hospital.
We caught up briefly but the conversation quickly turned serious.
"If I was in the US, we'd be admitting Abu to an ICU right now."
"Sorry man, that's an on-going issue we are all having. ICU beds are completely filled in the hospital, and the ER is full of people waiting to come up. Its the same situation in every hospital across the city right now. There hasn't been a ventilator available in all of Sindh for the last 3 days. Your best bet is to try to get a BiPap machine," Wamiq replied.
A BiPAP machine, unlike a ventilator, does not need a tube to be put down a patient's throat, and actively pushes air into the lungs. But many patients can't tolerate it, and there was a severe shortage of them in the city too.
"Okay, I guess I'll try and manage him at home for now."
I might have said that in an even voice, but deep inside fear was starting to take root. I had managed many patients on BiPap before, but I was after all and intern, not even a fully licensed physician. And while Abu did have a personal physician who came by every day, the man was managing patients at home all across the city. So, at the end of the day it was me taking care of him, all by myself.
Actually, that wasn't entirely true. I had help.
My next call was to a resident, who was days away from being a fully licensed physician. A resident who hadn't slept much over the last 5 days, just like me. Because every few hours she was on the phone, guiding me when my own medical knowledge felt inadequate, supporting me when confidence was all I lacked.
It was nearly midnight in Chicago, but she picked up the phone immediately.
"Everything ok, Omar?"
"Don't you ever sleep, Madi?"
I heard her chuckle, "Don't worry about me. How's Uncle?"
"Not good," I admitted, and updated her, including about my conversation with Wamiq.
"Let me call Naeem Taya. He'll know where to get a BiPap machine from. At least that will buy you some time."
"Thank you so much Madi, I would call myself but after everything he probably doesn't want to hear from me or anyone in my family."
The irony of the situation wasn't lost on either of us. Abu's life may very well now depend on the same man whose livelihood he had snatched away so ruthlessly. Not just that, I had learnt only after coming to Pakistan, he had also been picked up by the police after Shadab bhai reported him, beaten up by them and released only after a hefty bail had been posted by Naeem sahab's family.
"Are you doing ok?" she asked quietly.
Of course, I wasn't. I was tired, and jet-lagged, and angry at my situation. I missed her so terribly. I didn't want to be in this God forsaken house that had never felt like home anyway. Or have anything to do with its occupants who refused to even acknowledge how unfair they had been to a woman who had put aside all grudges in a heartbeat and been so willing to help me, help them.
Yet, in all that Madi's soothing voice, were the balm to my gaping wounds. Her gestures, however small were a reminder of all that was good in this world.
"I am ok, now that I am hearing your sweet voice," I told her in all honesty.
She laughed, and I imagined her ruby cheeks and those brilliant dark brown eyes framed by a curtain of thick lashes, "Are you flirting with me Dr Khan?"
"Maybe," I smiled at myself.
"How about you come back and then flirt with me?"
"I am going to come back and make you my wife, Madi. Flirting tou bohat door ki baat reh jaye gi." (Flirting will be a far away thing)
In the brief silence that followed, I could bet she was thinking of the same thing I was: the promise we had made to each other, now endorsed by her parents, that seemed so close to becoming a reality. A reality in which nothing separated us.
"I should go and make that call to Naeem Taya," Madi spoke first.
"Yes, thanks again for doing that."
She was about to hang up when she called out to me again, "By the way, I was looking into IV steroid use for COVID patients. There is some data coming out now that supports its use. I would think about starting Uncle on that if his blood markers of inflammation are high."
"IV steroids? That's not what we use in the US though."
We had mostly stuck with anti-inflammatory medications that worked in a more targeted way than steroids did. But as Madi pointed out, those medications were not widely available especially in Pakistan, whereas steroids were readily and cheaply found everywhere.
"I am going to send you some articles. They have the recommended doses listed as well."
"What would I do without you?" I couldn't help saying.
"Let's hope you never have to find out," she replied.
That call ended with me feeling infinitely better than when I had started it. But just as my phone pinged with emails from Madi, with the articles she had promised, I heard a shuffling of footsteps nearby.
"Assalama Alaikum, Ami."
"Walaikum Assalaam," she replied, her voice a lot more subdued that what I was used to. I didn't question it.
"Kissi se baat kar rahe the?" (Were you talking to someone?)
"Ji," I simply replied, in no mood to divulge any more information. But she refused to let up. (Yes)
"Kiss se?" (With whom?)
Her tone wasn't one of anger or accusation, but rather one of muted curiosity. Not that I would ever give in to her. I was not here to give her more fodder for gossip, or for her to tell me why I was wrong in choosing the woman I was in love with.
"No one," I replied, not caring how curt the response came out.
"Omar, you can take her name in this house..."
"Oh, can I?" I snapped. There was that pent up bitterness and anger, that I had subdued for the last 5 days. "The last time I took her name, you and Abu used all sorts of ugly terms and ridiculed her and her family. I have already told you that I am getting married to her, whether you approve or not."
Ami stayed silent. I walked out of the room then. Had I stayed, I surely would not have been able to keep the promise I made to Madi, to stay civil even if my parents riled me up.
*******
Early Evening
It was a shame that I felt like such a stranger in this house, because not everything here and the memories it stored was bad. There had been plenty of enjoyable times that we had spent as a family, especially when we were younger and our house seemed to be brimming with Sehr or my friends, as well as relatives of all backgrounds.
But that was before my father became the overly successful businessman he was now. I had already planned to leave home for college then, but every time I came back it felt that our family's world had become all that much smaller and more 'exclusive'. To the extent that sometimes even I felt excluded.
Those were the thoughts going through my mind as I sat in Abu's room, keeping an eye on him, while reading the articles Madi had sent. I had reached out to Abu's physician too and while he agreed that starting the steroids was a good idea, he had no leads on where to obtain a BiPap machine from or any available ICU beds.
Meanwhile, Abu's blood tests had come back. His inflammatory markers had significantly worsened, convincing me that steroids were the only immediate option we had. That medicine was infusing through his veins when my phone rang. It was Madi.
"I was on my way to work, just wanted to check in. How is Uncle?"
I relayed to her the latest levels of his inflammatory markers, "He's getting his first dose of steroids now."
"And his Oxygen status?"
"Still breathing fast, but he seems to be slightly more comfortable."
"Its day 10 of his illness today, right?" she asked.
"Yes."
The pause that followed, spoke volumes more than words ever could. Around day 10 was when our COVID patients in the hospital split into two categories, those that started to improve, and those that got worse very quickly thereafter. By all indications, Abu was falling in the latter category.
"I am worried about Uncle," she finally said.
"Me too," I admitted.
"Naeem Taya said they didn't have any BiPap machines available right now, but he said he would try his best to get one for Uncle as soon as possible. Hopefully, by tomorrow."
She texted me his number, asking me to give him a call as well. I stared at my phone wondering how a man humiliated by my father could be so willing to help him out.
I suppose not everyone was like my father.
*******
Later that Evening
"Omar, Abu se saans nahi liya ja raha," Ami's panicked voice called out to me from his room. (Abu can't breathe)
Though the initial dose of steroids had been administered, I knew their effects wouldn't be immediate. When I entered his room, flooded only by the disappearing evening sun that peaked through the windows and a lone lamp in the corner, he appeared even more fragile to me than he had just a few hours earlier. Sympathy yielded to any feelings of hostility from that morning, and I couldn't help but acknowledge that Madi had been correct. Regret would have lingered if I hadn't been present.
Despite having witnessed many patients undergo similar symptom, facing this with my own father intensified that feeling of powerlessness exponentially more than ever before.
His nurse and I helped him cough a bit more to clear out his airways and then had him lie on his stomach, which seemed to have helped my patients in the US. We increased his oxygen back to the maximum, and after a few minutes the oxygen level slowly rose to 90%.
"This is very uncomfortable," Abu complained about lying on his stomach.
"I know Abu, but this is the only option you have. It will help open up your lungs a bit. Please just put up with it", I replied, trying to sound convincing enough, though shadows of doubt seemed to be making a permanent home within me.
In the furthest corner of the room, as far away as possible from my father, my mother sat with her mask on, praying for Abu with tears in her eyes. I was going to reassure her too, but instead she glared at me, "Tum itne bare doctor bante ho, how is this his only option." (You pretend to be this big doctor)
I had no desire or energy to engage in an argument with her, so I chose to remain silent. There was no need for me to prove anything either; I could genuinely say that I had been diligently tending to my father to the best of my medical expertise and abilities.
However, her perspective differed significantly. According to her, I hadn't invested the full extent of the 'effort' she believed I should have.
She told me exactly why I was failing my family, "You went to the best medical school here. Apne contacts lagao or Abu key liye ICU bed ka intizaam karo. Itna paisa jo katha kiya huwa hai, woh kab kaam ayega?" (Use your contacts and get an ICU bed for your father. We have collected so much money, when will that be of use?)
"There are no ICU beds in the whole of Karachi," I reminded her, politely.
"I don't care, Omar. Agar kisi to rishwat deni hai, tou do. Kisi aur se bistar leina hai, tou lou. Leikan, yeh ho hi nahi sakta ke tumhare baap jaisey mashhoor aadmi ke liyae iss puray shehr mein koi ICU bed na ho."
(If you have to bribe someone, then do it. If you have to take a bed from someone else, take it. It just can't be, that there is no ICU bed in this entire city for a famous man like your father)
Use my contacts? Bribe people, take a bed from someone else - so a famous, rich man gets a bed in the ICU. I couldn't believe what I was hearing, though perhaps I shouldn't have been surprised at all.
I had tried so hard to stay civil in that moment. I even actively pictured Madi's beautiful face, hoping that would calm me down and I wouldn't regurgitate everything that was coming to mind right then. But the arrogance of my mother was just too much.
My voice stayed emotionless, but the bitterness and anger at what they had done to me and Madi and seeing her attitude now, made it nearly impossible, "Are you seriously saying that just because our family has money, Abu's life is worth more than someone else in the same situation. Kuch Khuda ka khouf karein aap." (You need to fear God)
With her own words repeated back to her, she must have grasped the absurdity of her statements. She attempted to backtrack, stammering, "That's not what I meant..."
Yet, I hadn't even started, "Ami everything you said to me, when I asked you to let me marry Madiha, your name, your status, your money, your education - everything that you are so proud of, that made you look down on her honest and hardworking family - none of that will help you today. There are no ICU beds in the whole province, there are no BiPAP machines which we could have used at home, soon we may not even have these oxygen tanks."
She stilled, gaping at me. I continued, "Aap ko samajhe aarahi hai? Aap ka paisa or aap ka status iss pandemic mein bilkul bekaar hain." (Do you understand this? Your money, your status, is completely useless in this pandemic)
Pin drop silence enveloped the room; even the monitors had ceased their rhythmic beeping. Ami sank back into her chair, avoiding eye contact with me. Her focus lingered on the prayer beads clutched in her hands, tears streaming down her face, which she hastily wiped away with the edge of her dupatta.
Had her words not echoed in my mind, I might have sought to console her. Yet, an internal barrier prevented me from approaching her.
A few minutes later, while I listened to my father's chest, he surprised me by reaching out to grasp my hand. Still lying on his stomach, he turned his face toward me, revealing the tears glistening in his eyes.
"Beta, tumhari Ami bohat stress mein hain, un ko muaaf kar do," he told me, taking slow deliberate breaths. (Son, your mother is in a lot of stress, forgive her)
"Abu, it's ok. Don't try to speak. You'll make your breathing worse," I replied to him.
Uncertain whether Ami would ever change, I hesitated to press my point at that moment. Yet, to my surprise it seemed that Abu had been quietly contemplating my words. Perhaps, the struggle to breathe put into perspective the injustices of life.
"No Omar, let me speak. I may not get a chance again," he held my hand when I started to move away. "Tum theek keh rahai ho. Aa jaa ke insaan ke sirf achay values or doosron ki duaein hi kaam aati hein. Insaan apne saath paisa aur social status kabr mein nahi laike jaa sakta,"
Filled with regret, he sighed, "Leikan pachtawa zaroor leike jaa sak ta hai.
(You are correct. At the end of the day, a person's values and the prayers of others are the only thing that help. A person cannot take their money or social status to their grave...but they sure can take their regrets)
Abu closed his eyes. Even those few sentences left him breathless. I chose not to respond, hoping to spare him further exertion, though I couldn't help but regard him with a blend of skepticism, astonishment, and a hint of respect.
Had he truly recognized his mistakes, as I had prayed he would? Was his remorse genuine, or was this merely a performance? Or perhaps, did he experience that sense some of my patients often harbored—a feeling that their end was approaching?
Covering him with a blanket, I turned to leave, only for him to speak again in a hushed tone.
"Mujhe uss bachi ke baare mein aur batao...jis se tum itni ziyada mohabat karte ho." (Tell me more about this girl...who you love so much)"
He wants to know more about Madi? I couldn't believe it for a moment.
Ami too gazed up at me, her expression softened, a complete change from minutes before. But could my parents truly understand me now? A part of me vehemently said 'no'. My happiness wasn't owed to them.
Yet, a gentle, soothing voice urged me to keep an open mind. It assured me that regardless of what transpired with my parents, she would always love me.
I still paused for a few seconds, picturing the way she would bite her lower lip and play with her hair when she was trying to make a difficult decision. I knew exactly what she would have decided to do if she was in my place.
So, I pulled up a chair, and started talking.
*******
I feel like this (slightly morbid) chapter was a long overdue one. I wish people realized the error in their ways before their end is near. But maybe this pandemic holds a lesson for all of us.
May we all get the chance to correct our wrongs before it is too late - Amen
Until next time....Thanks for reading! You all are very quiet, but that's ok 🙂
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