Mid-June 2020 in Karachi, Pakistan

"Doctor Sahib, aap ke Abu ki breathing treatment ka time ho gaya hai (Doctor, its time for a breathing treatment for your father)", the male nurse attending to my dad called out, jolting me awake from my slumber.

I muttered in return, "Theek hai, sahi se betha ke dijiay ga (Ok, make sure to have him sit up properly before giving it)", and turned on my side to go back to sleep on the daybed that had been set up in the living room right outside the study, which had since been converted to a COVID isolation room for my dad.

Despite the closed door, the persistent beeping of the my dad's 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, stayed alone in the hospitals that were already beyond their capacity, as overworked and underpaid doctors scrambled in dire circumstances. This in itself was not any different than the US, or really any other country in the midst of a COVID surge. But the difference in quality of healthcare was mind-boggling.

When I got here last weekend, 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?"

I was seriously 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'

And, so I tried to keep an open mind when my mom 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 (Son, life and death are in Allah's hand. They had called us so lovingly, we could not say no)", she had replied to me, which made my blood boil further.

So, let's see...they are ready to risk their lives to attend some random rich friend's son's wedding, but when I ask to get married to a woman who is perfect for me in every way they cut me off?

But that was all 5 days ago, and with my dad's progressive worsening, there was a sense of foreboding at home and I had to let go of my own issues with my parents. My dad had gone from disdain to reluctant acceptance of my presence. My mom was obviously relieved to have me there, even if our conversation had been tense and strictly related to Abu's condition. On my first day here, she had tried to ask me about my life and even brought up Madi, but I had to cut her off. The wounds they had inflicted were too raw, and I had no interest in making them worse.

After all, as I had told my mom, when I got back to Chicago Madi and I would wed regardless of what my parents thought, and then no one could come between us. We still didn't have a date though, much to my dismay. Moin, had some exams he had to take in the first week of July, then one of Madi's aunt who lived in Florida wanted to attend, but she couldn't take time off till mid-July. After that I was scheduled to be in the ER and ICU back-to-back.

So even though Madi's dad had said we could get married on the first available weekend, sadly, that weekend seemed to be a good 2 months away.

Thinking about my last 5 days in Karachi, had pretty much killed any chance of me falling asleep again so I gave up and got out of bed. At least my back was healing well, and I hadn't needed to take any pain killer for the last couple of days.

'Focus on the good, you'll get through this' - Madi had texted back one time when I was complaining about everything going on in my family, including the fact that although my mom had called me because I was a doctor, she seemed to double check everything with my dad's 'real' doctors, who came to visit every other day or so.

I need to focus on the good in my life!

It is 11 pm in Chicago, maybe Madi is still awake...

"Hello...", she picked up almost immediately.

"Are you awake because you were thinking of me?", I asked her, trying to talk in what she referred to as my 'flirty' voice that always made her blush.

"Haha...very funny!", she laughed, and I imagined her scrunching her nose and sticking her tongue out at the phone, "I was thinking of you, but only because I found this article on the overuse of antibiotics during this pandemic and potential for worsening antibiotic resistance. That's the last thing a country like Pakistan needs where antibiotic resistance is already so common"

"Yeah...saw that too. You won't believe this, but when I got here he was on 5 different antibacterials...for a what is a viral infection! I've been trying to get his doctor to stop them, there is no evidence that Abu has anything besides COVID. But everyone second guesses me here!"

The overuse of antibiotics was criminal as far as I was concerned. There was already talk of there being a post-antibiotic world, a world where antibiotics no longer worked because the bacteria had developed such a lot of resistance. Many feared, that this pandemic would hasten the approach of those times.

"Isn't there a saying in Urdu, about a house and chickens and lentils that explains your situation. My dad would always say it to my mom..."

House, chickens and lentils...that made me laugh loudly. I loved how my wife-to-be remembered Urdu sayings in English, but only parts of them, which when she said out loud made no sense at all.

"You mean...ghar ki murghi daal baraabar? (A chicken dish from home is equal to a lentil dish?)"

"Yes...yes...that one...and stop laughing at me!", she exclaimed over the phone, even as it sounded like she herself was doubling over with laughter.

A few seconds later when we were able to finally catch our breath, she asked me how I was really doing. I hated putting a damper on the few minutes of joy I had felt over the last few days, but I knew she was worried about me and would see right through my excuses if I didn't tell her the truth.

I let out an involuntary sigh, "I miss you, Madi...I wish you were here with me"

But that made my mood even more pensive, because I knew that she could never be with me, while I was in this house. She was not welcome here, and I would never ever put her in a situation where she could be disrespected. If I ever had to come here again, it would be on my own.

Which was a shame, because not everything in this house and the memories it stored for me 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 my friends or Sehr's friends, as well as relatives, of all kinds.

But that was before my dad became the overly successful businessman he was now. I had already planned to leave home for college then, but every time I would come back I felt that our family's world had become all that much smaller and more 'exclusive'. To the extent that even I sometimes felt excluded.

"I miss you too, Omar...but you're there for a very honourable reason. Besides, we will have the rest of lives together InshaAllah. Right now, your family needs you, and I am so proud of you for deciding to go to them"

I didn't know whether it was the lack of sleep, or her beautiful soul that shone like the sun and warmed me even from halfway across the world, but I could feel my eyes get wet just thinking of how lucky I was to have her in my life.

Wetness that I know my mom noticed when she walked into the room just then. So, I said goodbye to Madi and hung up.

"Assaalam Alaikum Ami"

"Walaikum Assalaam", she said quietly.

"Abu was just getting his breathing treatment. I think we need to stop his antibiotics. There is no need for them. You're just putting him at risk of getting infected with a highly resistant bacteria that we won't have treatment for"

For once, she actually agreed with me, "Ok, just tell Dr Hussain that you are stopping them. I don't have a problem, you are obviously the expert"

I nodded and was about to leave the room when she asked, "Who were you talking to?"

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...", my voice was admittedly a bit curt.

"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, "Because 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"

I walked out of the room then, because had I stayed in there I would not have been able to keep the promise I made to Madi, to stay civil even if my parents riled me up.

Besides, I had told my friend and classmate from med school that I was going to call him. I wanted to catch up on life in general, but he was also a UK trained ICU physician who had returned to Pakistan and was now one of the city's few properly trained Critical Care Medicine doctors at our alma mater medical school's affiliated hospital. And I wanted to get some inside information on what the ICU bed situation was like in the city. Given my dad's on-going decline, I felt that he may need to be put on a ventilator soon, something we could not do at home.

I took a deep breath and called my friend. We weren't super close back in med school, and had only done a couple of rotations together. But we had plenty of mutual friends and I had always respected him.

It was obvious that we had a lot to catch up on when right at the beginning of our conversation he asked me, "How is Noor doing? You guys have kids yet?"

"Actually...Noor and I did not end up getting married. But she is well and she has a little daughter"

I could only imagine his embarrassment as he stuttered, "Uh oh...I uh...I am so sorry. Last I knew you two were getting married"

Funny how the world works...

"Oh that's ok, don't be sorry. Noor's husband is actually a really nice guy and InshaAllah I am getting married to one of Noor's very good friends instead. So it worked out well for both of us", I couldn't help but smile at how wonderfully easy it was say to all of that now.

"Not sure if I want to know the details, but sounds like a plot straight out of a Bollywood movie"

We both laughed at that and reminisced about our med school days a bit more before moving on to more serious conversation.

"I am sorry to hear about uncle. I am glad that you've been able to keep him at home. You may want to consider putting him on steroids if his blood markers of inflammation are going up. There is an on-going study to look at that and I hear that the preliminary reports show it has some benefits in severe illness"

We had been avoiding the use of steroids till now in the US, and had mostly relied on more targeted anti-inflammatory drugs, but steroids were a whole lot cheaper and more widely available. And if the study results continued to hold up, we could have at least one drug to use for severe COVID.

"Ok, I'll think about that. But over the last day now, Abu has barely been maintaining his oxygen levels in the high 80s. In the US we would be putting him on a BiPAP machine or a ventilator. If we can't get an ICU bed, what are our options?"

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 it can get tricky to manage that at home as well.

"You can probably get a BiPAP machine if you're willing to pay a lot of extra cash...and manage him at home, if you have the experience. But I am afraid the availability of ICU beds and ventilators is very unreliable. Right now, in the last 3 days, we have not had a single ventilator available in the province of Sindh"

I did have plenty of experience managing the BiPAP machines, thanks to all those extra shifts I had done in Chicago's field hospital. And my friend promised to be available by phone if I needed extra help. Plus, I could always reach out to Madi and others back in Chicago.

"Ok. Thanks yaar, you've been extremely helpful", I told my friend before hanging up and dialling the number of the home medical supplies company.

Unfortunately, that company said they were completely out of BiPAP machines too but promised to let me know as soon as one was available. I wasn't going to offer to bribe him, but others must have, because the man on the phone immediately said, "Aur bhai sahab, paison ki baat nahi, machine available hi nahi hai. Aap jitnay marzi mujhe paisay dein, mein aap ko machine guarantee nahi kar sakta houn (And brother, it's not a matter of money, those machines are just not available. No matter how much money you give me I can't guarantee that machine to you)"

And that reply was similar to all the other companies I called right after that.

Money can't buy health...that has never been truer

I was standing in our kitchen trying to look up the studies on the use of steroids in COVID, that my friend had just mentioned, when I heard Ami calling out for me in a loud, panicked voice.

"Omar, Abu se saans nahi liya ja raha (Abu can't breathe)"

My father had looked frail to me when I first saw him 5 days ago, but now as he tried to sit up and breathe I actually felt sorry for him. Madi was right. I would never have forgiven myself if I hadn't come here. So many of my other patients had gone through the same cycle of symptoms, but now that it was my own father that feeling of helplessness was somehow a lot worse.

His nurse and I helped him cough a bit more to clear out his airways and then had him lie on his belly, which seemed to have helped my patients in the US. We increased his oxygen as well, and with all of that his oxygen level slowly rose to 90%. I asked the nurse to check which pharmacy had steroids and then to go get it. Data, or no data, it seemed like that was the only treatment available to us at the moment.

"This is very uncomfortable", my dad complained about lying on his stomach.

"Abu, this is the only option you have. It will help open up your lungs a bit. Please just put up with it", I replied to him, trying to sound convincing enough.

In the furthest corner of the room, as far away as possible from my dad, my mom sat with her mask on. Praying for Abu with tears in her eyes. I was going to reassure her too, but instead she looked at me and in an accusatory tone said, "Tum itne bare doctor bante ho (you pretend to be this big doctor), how is this his only option"

I really did not want to get into an argument with her, so I kept quiet. I also didn't need to prove anything to her. I could honestly say that I had been trying to take care of my father to the best of my medical knowledge and skills.

But she clearly did not see it that way. Apparently, I had not yet put in all the 'effort' I should have.

She glared at me and 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? 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"

(Use your contacts and get an ICU bed for your dad. We have collected so much money, when will that be of use? Omar, 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. Is she seriously kidding me?

I tried so hard to stay civil in that moment. I even actively tried to picture my Madi's beautiful face, hoping that would calm me down and I wouldn't regurgitate everything that was coming to my mind right then. But the arrogance of my mother was just too much.

I tried to keep my voice even and emotionless, but the bitterness and anger at what they had done to me and Madi and seeing her attitude now, made that impossible, "Ami, are you serious? Are you seriously saying that just because this family has money that Abu's life is worth more than someone else in the same situation. Kuch Khuda ka khouf karein aap (You need to fear God)"

Hearing her own words repeated back to her must have made her realize how ridiculous she sounded, because her facial expression immediately changed, and she tried to say, "That is not what I meant..."