7. Heart clinic, Larkano

The Doctor is in.

My brother Fawad drove us that particular afternoon to Papa Saeed’s clinic--a short drive across town through the now-familiar streets of Larkana. Because he is protective of my safety, Fawad wanted me to sit in the backseat of the car, where I would be less visible. In general I had grown quite used to wearing covering my head with my dupatta whenever I rode in a car, but when riding with Papa alone I always rode happily in the front and didn’t mind the inquisitive stares of Larkanians who so rarely see pale-faced visitors to their city. But it is not unusual for women to ride in the back, completely covered, as a matter of routine. Dark window shades a common feature of many cars in Pakistan, serving to protect the women inside both from the harsh rays of the sun and the roaming gaze of men on the street. We didn’t have those screens up in the windows, but I kept myself well veiled as I sat in the backseat with Papa, while our guard, Hajji Mehmoud, sat in the front.

Papa’s clinic is situated near the mouth of a long alleyway that was already quite familiar to me from his photographs. I love alleyway views like this one, with their different surfaces and angles, with light bouncing in unusual directions as it ricochets down the narrow passage. And there were extra reflective surfaces for that light on this particular afternoon, mirrors of leftover rainfall from the previous day--a rare occurrence in arid Larkana.

The office was already open and alive with patients when we arrived. Papa’s assistant had already triaged several patients, early arrivals, who were now hovering about the small waiting room. We squeezed through this room and turned right to enter Papa’s inner office, which is not much bigger than the waiting room. 

“Not many patients today, SWEET EM!” said Papa as he rounded the corner of his desk and sat down. “Maybe because it is Saturday. You want some tea? And cookies?” And he motioned for the assistant to go and fulfill that order. As usual I have no idea where the tea came from, but after a while it did materialize as always, along with a plate stacked high with crumbly butter cookies.

Doctors' alley.

Waiting room.

But within moments the “not many patients” started streaming into the room. They do not set up appointments in advance--they simply know what hours Papa usually comes in, and they come, and they wait their turn. Sort of. While Papa tends one patient, the next patient or two is already in the room. And most patients are accompanied by a small swarm of relatives, so the room fills quickly, but the mood is kept buoyant by Papa’s joyful banter and impish giggles. 

This busy scene, a doctor’s inner office brimming with simultaneous visitors, came as a genuine surprise to me. In America, a doctor’s office is a quiet sanctum of privacy and confidentiality--not just by choice, but by law. The Western legal system protects medical information with iron-clad injunctions, and a person’s medical condition is considered extremely personal information, to be divulged only with the most trusted friends and associates. The Western attitude is so extreme, in fact, that one can easily find oneself in an awkward situation around the simple question “how are you”--because if the answer is anything other than “fine,” then careful tiptoeing must often ensue if the inquirer wants to ascertain the source of the other person’s ailments, even if he merely wants to be compassionate. And there are further complications to medical etiquette in the Western setting. Health matters are not only considered private and sensitive to the person in question, but a potential burden to the hearer. Someone who is genuinely suffering from some illness, through no fault of his own, will feel uncomfortable telling others about it, in fear that it will burden or discomfort them. And even more frequently, Westerners will keep their ailments secret for fear of being judged, for being considered ‘weak’ or ‘unfit’ for whatever essential work they are supposed to be doing with their lives. 

Coming from this context, it has often amazed me -- but in a refreshing way -- when my Pakistani friends announce their illnesses in public statuses, share images of their surgical wounds, and even upload images of themselves in hospital beds, connected to IV drip fluids. I myself have had to spend what felt like interminable stretches of time lying wretched in a hospital bed attached to such a drip, and feeling so ashamed of my potentially perceived ‘weakness’ that I didn’t even want visitors--and I would have been mortified if anyone had shared a picture of me in that situation. But for many of my Pakistani friends, this is not something to be ashamed of at all. It is a normal thing, to go through health woes, to ask for prayers, and to recover. On the whole, that strikes me as a much healthier attitude. Westerners, on the whole, try to conceal illness and forget about it. I think that we in the West actually tends to give the impression that we are never ill and never suffer -- which is both egregiously untrue and unhelpful for our own psyches and our appearance to the world. From what I have observed in the East, illness is far less stigmatized, more present, more normalized.

In any event, the patients who poured into Papa’s office on this Saturday afternoon did not seem at all bothered by my presence during their visits, even though I was not only an outsider, but an outsider with a camera. All were pleased to greet me and have their picture taken, even as they were being examined. Of course, they were all introduced to me as Papa’s daughter from America--so not really an outsider. But still, their unabashed openness, not only with me but also in view of a handful of other strangers who were waiting to be seen by the doctor, was remarkable to me.

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The first patient was a woman with a gentle smile, who was accompanied by a man, probably her husband, but perhaps even her father or some other relation. The woman sat up on the examining table, and Papa's standard cardiological dialogue ensued.

“Dey khabar. Dil men soor aathey?” asked Papa. (“Tell me what’s new. Any pain in your heart?”)
She shook her head. 
Papa raised his stethoscope to her back. 
“Saah khann,” he instructed. (“Take a breath.") 
She breathed. “Drigho saah khann,” he said. (“Take a deep breath.”) 

This particular patient didn’t speak much, letting her companion do most of the talking. He had a businesslike manner and a stately appearance, with a bright white beard and a weathered underneath the coils of an ajrak turban, and he wore a blazer over his shalwar kameez. He brought with him a bag full of the woman’s medicines, which he presented to Papa Saeed and discussed them with him in some detail. And this was also a striking contrast to what I am used to: not only medical information but medicines themselves are strictly regulated in the West, especially in America. For any drug more powerful than a simple Tylenol (paracetamol), a patient must get a prescription from the doctor to present to the pharmacist, who then passes it through elaborate insurance bureaucracy before eventually printing up a specially labeled bottle with dosage instructions as well as the patient’s and doctor’s contact information, and often an additional small file of papers that include every possible side effect that has ever been experienced with the drug in question. (I am not kidding.) In Pakistan, there are no such regulations in place. Drugs are bought without prescription and without insurance (and prices for drugs, fortunately, are only a tiny fraction of what they are in America). A doctor is needed to give the crucial advice about what to take and in what dose, but after that it is up to the patient to buy the right medicine and remember his dose. Conscientious patients and their caretakers, like this gentlemen in the ajrak turban, are wise to bring the medicines themselves to the doctor and make sure that they are being used properly.

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EKG unscrolled.

Around this time, Papa’s assistant, who had been busy in the anteroom, reached back in through the doorway to lay a small wad of paper slips into a slot on Papa’s desk. Papa unfolded one of these narrow strips to its full length of perhaps a yard; it was printed with a fine red grid overlaid with a jagged black line--the printout of an EKG. [Note: yes, admittedly, the acronym “ECG” makes more sense as an abbreviation of Electrocardiogram. But EKG is also an accepted version of this, and it’s what we usually say in America. In any case, it’s the same thing.] As I would soon learn, every patient receives an EKG during triage, before his or her visit with Papa, and the results reliably appeared upon his desk in time for him to peruse them. Like other doctors’ offices that I have seen in Sindh, nothing here was computerized. There was no computer on Papa’s desk, and no clicking of a mouse to check into medical records. This medical system is analogue, physical, unmediated.

Payment is treated likewise in a simple and unmediated way. Before leaving, each patient pays the same fee, in cash -- 500 rupees, which translates to roughly $5. This amount can buy much more in Pakistan than it can in America, as food and most other products are much cheaper. To poorer Sindhi patients, 500 rupees is a significant amount, but still it is not overwhelming. For Papa, it is essential income and spending money for his family.

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More than just a mustache.

Many more patients came through the door in these few hours I spent at the clinic. Some came from nearby villages, others from within the city, and some had even traveled dozens of miles to come to Papa specifically. One such patient was a formidable-looking Baloch gentleman wearing a Sindhi topi over his immense and impressively coifed beard and mustache. That aspect of severity fled quickly from his face when asked by Papa Saeed to smile for the camera--an irresistible entreaty, as anyone who is familiar with Papa will already know.

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Ladies of Sindh.

The most loving smiles that I received on this day, though, were from a pair of women who arrived together, one wearing a full burqa and the other also elaborately covered, both of whom soon lifted their veils to reveal their gentle faces. Papa Saeed explained to them that I was his American daughter, but he might as well have said that I was their own daughter, from the warmth of the hugs and greetings that they both gave me. And there was something especially poignant to me about this warmth coming from women who wear burqas. Burqas are not uncommon in Pakistan, but I have had very few interactions with their wearers--most Pakistani women I have spent time with wear a simple dupatta as a hijab, or else none at all. But the few times I have spoken with burqa-clad women, after they have lifted that front panel and revealed their smiling faces, I have been particularly struck by their kind spirits. Now, probably they were no more kind than the other women I met in many other situations, who on the whole can also be characterized by beautiful smiles and welcoming spirits. More likely it is simply a remnant of a Western fear of the burqa, which is an understandable if unjustified fear, simply because it is a marker of mystery -- we feel uncomfortable if a face is concealed from us; we feel that this person must be unapproachable. And when the face beneath is revealed as being full of love and grace--it is a memorable thing. I will always remember the grace of these two women, who kindly allowed me to take their portrait.

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When another bundle of EKG-slips materialized on Papa’s desk, I asked if I could go see their source. 
“OF COURSE SWEETIE,” said Papa, who then summoned the assistant, who, in turn, motioned for me to follow him. There connected to the waiting room was another, even smaller and sparer room, where a young girl in green embroidery was lying on a table. Standing beside her was a man who was clearly a relation. “Tawhanjee ddee aahey?” I asked him in my very halting Sindhi. (“Is she your daughter?”) He shook his head and told me in his own hesitant English that the girl was his niece.

Tasveera preparing for her EKG test.

As the assistant started positioning nodes for the EKG reading, I asked the uncle in some combination of Sindhi and English  if it would be okay for me to take pictures. The girl seemed a bit timid, but also curious, and they both indicated that they didn’t mind.

Back in the inner office, I learned that this girl is named Tasveera, age 10, and she has been a patient of Papa’s for most of her life. She suffers from a congenital condition that causes an enlarged heart, and as her heart continues to grow in size, it shrinks in function. She seems a typically healthy girl from the outside--normal in build, bubbly and energetic. “With careful treatment, we have been able to keep her symptom-free, for now,” said Papa.

Tasveera sat on the table and was instructed to “Saah khann.” Then Papa asked her to lie back and rest her head on the pillow.

A patient of the heart.

“You see, SWEET EM!” he said, beckoning for me to come closer. “This is how large her heart is.” With a pointed finger hovering an inch above Tasveera’s chest, he traced an outline of a shape that was at least the size of a typical lung.

“If you promise not to cry,” said Papa Saeed, in a soft tone that I have rarely otherwise heard from his voice, “if you promise just to smile, then I’ll tell you what her heart function is.”

I nodded.

“Her heart is currently functioning at 20 percent,” he told me. 

I nodded again, hiding any reaction while Tasveera sat up and then bounced off of the examining table and sat down in the chair in front of the desk. Watching this lovely, smiling girl, it was impossible not to be bruised by the irony of her suffering, caused by too big a heart.

The next patient was even younger -- a baby in fact, a cute little fellow with a hat on his round head, sitting on his mother’s lap. I asked with trepidation, “Is he all right?”

Papa was already engaged in jubilant interaction with this little fellow and didn’t hear me at first. So I said again, “Will he be okay?”

“OH YES EM!” he replied. “This one is in good shape. See here? Doesn’t he look happy? See, I can make any baby smile. See?” And Papa proceeded to make a number of whimsical sounds in the baby’s general direction, and then offered the little guy a cookie from the plate.

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Cookie time.

Soon after this, I was once again ferried away in a car and delivered safely back home. Papa Saeed carried on for some hours longer, as he does each day, with smiles and laughter, treating the ailing hearts of Larkana.

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heart clinic: photo gallery. 
The same images as above (which you can see here at higher resolution), plus some extras.