Psychiatrists, in general, are hardly ever called to make life and death decisions. But where medical science ends, the realm of ethics and philosophy begins. And that’s usually when I get calls from my medical colleagues.

So it was, soon after the Covid-19 surge in Lahore in June that I found myself in the hospital where I teach, being asked about prolonging a patient’s life with heroic medical measures. The person I was talking to is an old and dear friend, a surgeon himself, and he wanted my opinion on his father-in-law, who had recently been diagnosed with Covid-19.

The patient was in his late seventies and very sick. His lungs were filling up with fluids and his heart and breathing were failing. A final effort was made by intubating him and connecting him to a ventilator. Like many elderly people, he had a number of medical problems and would likely not survive for long, and placing him on the ventilator would simply prolong his life (and his agony).

It appeared that if he was not intubated immediately, he would die in a matter of hours. If he was intubated, he would probably die in a few days. So what should be done?

Initially, I was strongly opposed to the idea of prolonging his life artificially, knowing the very poor prognosis. But after a high powered medical meeting in which the senior most medic in our hospital, a highly qualified chest and respiratory specialist informed us that the intubation would likely be temporary, I relented and the patient was placed on the ventilator.

His condition stabilised for a day or two and then took another nosedive from which there was no coming back. He died a few days later. As he was nearing death, I advised his family to withdraw all futile medical interventions, letting him go peacefully.

Beyond heartbreaking

Spring in Lahore is beautiful. The weather is cool and clear, flowers are blooming and all seems well with the world. Even though frightening news had been coming out of China and elsewhere for weeks, Lahore, in its characteristically laidback culture, was celebrating the season. So when the first case of Covid-19 was reported in Pakistan on February 26, no one paid much attention.

The Mayo Hospital, where I work, is the oldest medical institution in Pakistan and one of the oldest in the subcontinent. It was established as Lahore Medical College in 1860, preceded only by the Medical College and Hospital, Kolkata (established in 1835), the Madras Medical College, Chennai (established in 1835), and the Grant Government Medical College, Mumbai (established in 1845).

During times of national or regional disasters or epidemics, Mayo Hospital is usually designated as the main referral centre for those affected. So it was with COVID-19 patients in Lahore. This meant that all of us at Mayo were on the frontlines when the Covid surge hit Lahore in late May. Once it began, it seemed to have no end and we understood firsthand what Italy, Spain and New York City had gone through before us.

My psychiatric team and I were tasked with helping patients of Covid-19 and their families deal with the emotional and psychiatric issues resulting from the illness. The stories we heard were beyond heartbreaking. A man was quarantined in our hospital after testing positive for Covid-19. It happened during the early days of the pandemic in Lahore when the government had mandated that everyone who tested positive would have to be quarantined in a hospital or a specially designated quarantine centre.

Later the government allowed “home quarantine”, provided certain precautions were followed. Our psychiatry service was called in to help a man who had recently received news that his mother had died. Naturally, he wanted to attend her funeral but could not, since the risk of spreading the infection to other mourners was too high. He was not allowed to leave the hospital. Already distraught at being confined, away from his family, he attempted suicide by using a bedsheet to hang himself from the ceiling fan.

Under ordinary circumstances, our consult team would have provided him counselling, psychological support and, if needed, medicines. But during the surge, Personal Protective Equipment (PPE) including masks and body suits were in short supply and limited to those providing direct care to the sickest patients. Fortunately, our university had just set up a tele-psychiatry service at the behest of the government to deal with such an eventuality and we were able to assist the man without exposing our psychiatric team to infection.

Face to face with mortality

Another call we received involved a woman quarantined in the Covid-19 ward of our hospital. In the process of being brought to the hospital, she had become separated from her 12-year-old son and 14-year-old daughter who were also in quarantine. She was frantic and we were called because the medical team could not calm her down. Thankfully, we managed to help her locate her children as well as provide her with the psychological help and support she needed.

In addition to the patients of COVID-19 and their families, the pressure on healthcare workers was unrelenting. In Mayo Hospital, this led to widespread panic among our doctors, nurses and paramedical staff. Rumours and hoaxes were flying around thick and fast: Covid-19 was a conspiracy against our country and all Muslims; those dying of the virus in Mayo Hospital were being killed on purpose by doctors; after killing them with poisoned injections, their bodies were sold to Bill Gates in the USA for thousands of dollars (this last occasioned by the fact that patients who died of Covid-19 required special burial protocols since even a dead body could transmit the illness to those handling it). Our task was to help our medical staff cope with this unending stress and continue treating the sickest COVID-19 patients.

During this harrowing time, I went to the hospital almost every day, even after our hospital was closed off to everyone other than COVID-19 patients. A psychiatrist does not have the luxury of expressing their fears to others and, like most doctors, we are reluctant to ask for help since we have been trained to offer help to others, often at our own expense.

But a life-threatening pandemic is a great way to squarely face one’s own mortality. The mask of everyday trivialities is ripped off and one can see deep into the abyss. As medical professionals during Covid-19, not only were we facing our own mortality every day, we also risked carrying the infection home to our parents, children and families.

So I did what I have always done to deal with my emotions: I read and wrote whenever I had time. My own grandfather, Faiz Ahmed Faiz, who lived his last years in Lahore and died in Mayo Hospital in 1984, wrote a haunting poem while hospitalised with a heart condition. He called it “Ek bekhwaab raat ki wardaat” (“The Experience of a Sleepless Night”):

It seems at this moment there is nothing, anywhere
Not the moon, the sun, darkness or light
A shroud of beauty on the windows of the eyes
Or the repose of pain within the havens of the heart

— Translated by the author

He had once laughingly said that one poet was enough for one family, so it was not without some apprehension that I started experimenting with poetry during Covid-19.

“Pandemic” was one of the first ones that I wrote in the early morning hours of May 8 before the Covid-19 surge in Lahore:

A sickly moon rises
Over treetops
In the dawn hours
Birds awaken, chirping, cooing, singing
Heralding a new day
Nothing else stirs
The city is asleep, mostly
But the monster is here
Inside each of us
Eating us from within
Leaping from one to another
We fear it and yet
Pretend it’s not there
Why is it devouring us?
No one seems to know
Except the holy man in his mosque
Who calls out and gathers his worshippers
For the monster to feast on;
Love is distance
Faces are masks
Hiding what lives in our hearts
Even from ourselves
And when the sun rises
And the day begins
We wonder if it will be our last
The last day of a long journey
That has tired us out
And yet
So much remains to be done

Dealing with grief

In the course of writing my grandfather’s biography, I had got to know him well, much better than when he was alive and any fear of being compared to the great man himself didn’t seem to matter in the days of Covid-19, since we might not live to see the next week or the next month anyway.

The pandemic peaked in Lahore in late June. It was a terrible, frightening summer with hospitals filled to the brim, news coming in every day about people we knew getting sick and dying while the rest of us held our breaths, waiting to see if we would make it.

Gradually, almost imperceptibly, new cases started declining and by the end of July, when Lahore was bathing in the monsoon rains, there appeared to be a hint of light in the horizon. I continued doing what I know best: talking and listening to people and trying to offer hope and comfort. When I found the time and energy, I wrote a few more poems.

Today, as the mornings and nights of Lahore begin to cool imperceptibly, new cases of Covid-19 are also ticking up gradually – a reminder that the virus is still very much with us and is here to stay. The pandemic has also brought with it an explosion of new cases of stress, anxiety, depression and more serious mental illnesses, putting a strain on an already overburdened mental health system, not just in Pakistan but all over the world.

Just a few days ago, I visited another surgeon friend in the hospital. His elderly father, stricken with Covid-19, is fighting for his life. My friend too came down with it though he has recovered now. Thankfully, Covid-19 is no longer the terrifying prospect that it was back in March. None of the members of my family got sick with Covid-19 and neither did I. But that could change tomorrow or the next day. The pain and sorrow of those who lost family and loved ones is also very much on our minds.

Psychiatrists are expected to help people who are grieving, but how do you console someone who has lost someone they loved dearly? How do you offer words of comfort to someone whose sole desire is to be reunited with the person who has passed away? I do not have the answer to these questions but came upon some clues while writing about my grandfather.

On a sweltering day in July 1952, Faiz was particularly happy, even though he was in jail on charges of sedition and conspiracy against the government of the day. He was happy because his beloved older brother, Tufail, who he had been close to since childhood, was coming to visit him. When their father had died unexpectedly, Faiz had wanted to quit his studies and go to work to support his mother and the rest of their family but Tufail had forbidden it, insisting that he complete his studies. He had assumed the entire burden of supporting the large family.

During the infamous Rawalpindi Conspiracy Case, he had even helped Faiz’s wife, Alys, find a lawyer willing to take on his case. This time, however, Tufail brought good news. The dispute with the extended family members over their father’s ancestral lands had finally been settled in their favour. Tufail believed that if they managed the lands judiciously, their family, including Alys and her two young daughters, could be financially comfortable.

But their meeting was not to be. In the early morning hours of 17 July 1952, Tufail suffered a fatal heart attack and passed away. Faiz wrote about his grief in his next letter to Alys: “This morning, instead of my brother, Death came to greet me. Everyone was very kind. They took me to see my life’s most prized possession which was now dust. And then they took it with them.”

Even while saying eternal farewell to his older brother, Faiz did not lose hope. He regained his composure soon and wrote to his wife:

“…please do not worry. This wound is sudden and unwarranted but I am strong enough to bear it and not bow my head. I only wish I was outside and could offer the strength of my arms to those weaker than I whose sorrow is more burdensome than my grief.”

Those who are grieving after losing a loved one to Covid-19 can take solace from Faiz’s words (written in another letter to Alys from prison):

“When, in one’s heart, there is a storm of grief and pain, one must keep one’s head high enough to be able to see a ray of hope in the future, to maintain one’s faith in life and preserve one’s ability to appreciate beauty and goodness. One’s struggle to persist must continue after all, not just for one’s own life but also for the sake of all those things one holds dear and precious. So do not suppress your tears, just hold your head high. The storm will pass, the clouds will part and the sun will come out again. Maybe not tomorrow or the day after, perhaps many days hence, but it has to happen eventually.”

Ali Madeeh Hashmi is a psychiatrist, writer and translator. He is the author of Love and Revolution: Faiz Ahmed Faiz, the authorized biography. He lives in Lahore.

This series of articles on the impact of the coronavirus pandemic on publishing is curated by Kanishka Gupta.