Keep Throw Change

Many years ago I was talking to a physician colleague who is also in solo practice. I asked her how she made it, as she only worked in the office, and didn’t do hospital rounds. Her response has stayed with me and I dredge it up when the going gets tough. She said: my needs are not that many.

I coined the KTD acronym and Marie Kondo became the millionaire. Decades ago yielding to my near-OCD clutter-phobia, I created a method to deal with organizing rooms. It is simple and works well: you start from one corner of the room and for each item ask the question of whether you should keep, throw or donate it. Marie Kondo has the exotic Japanese twist to basically the same premise. And I certainly don’t identify with the rolling up of clothes instead of regularly folding them that she does. 

With the Covid-19 crisis we can extrapolate the KTD practice to what has suddenly become a massive individual, national and global issue. And the KTD can become KTC, keep, throw, change.

Individual

I want to keep the breakfasts with my mother with no background pressure of things to do. Also the drives with my family in which the conversations are deeper and more spiritual as the content has shriveled, being that interaction with friends has gone down, and mundane stuff has exited. 

Health and time

Prophet Muhammad (peace be upon him) said that the two most valuable things we have are health and time. And I want to treasure these. I had a schedule before Ramadan and now that fasting is here, the schedule has to change a bit but productivity, contentment and joy lie in creating another schedule and then dutifully following it. Being near-OCD, multitasking, female and physician have been assets to me. And though time now does not run away from me like it used to, I want to keep valuing it and harnessing it, and keep it front and center, as life slowly returns to normal. 

Rushing around

We’ve got to get rid of the rushing around. A lot of us realize that all we were doing was jogging on the spot. We’ll need to choose how we will fill our day. A conscious, perhaps a written plan, is vital to reintroducing items in our schedule. Life has this bad habit of descending into automatic chaos unless you rein it in, train it. Whether it is office or house work, it is essentially endless and can swallow you whole if you’re not careful. We must be controllers of our time, not let it control us. Which reminds me of another Mahjabeenism: if you don’t lead life, it tends to lead you. 

My needs are not that many

Many years ago I was talking to a physician colleague who is also in solo practice. We were discussing the challenges of practice and not wanting to be bought out by hospitals and dealing with practice finances. I asked her how she made it, as she only worked in the office, and didn’t do hospital rounds. Her response has stayed with me and I dredge it up when the going gets tough. She said: my needs are not that many. Cloistered at home we realize that our needs are really not that many, and as we return to normalcy, not immediately expanding our needs is paramount. 

Life trajectory

All this time has afforded us a unique, albeit forced, opportunity to assess the trajectory of our lives. Professionally and personally we can assess and decide what combination of keep, throw, change we should use. 

Quran immersion

For years I have wanted to reach a point of understanding the Quran when it is recited or read. Even before the Covid-19 crisis, I’ve been working with the Quranic app and it is amazing in the way that it teaches Quranic Arabic. The current cloistering situation lends another unique opportunity for Quran immersion. Previously in Ramadan iftar parties and taraweeh prayer really ate into the already chopped up day. I’ve discovered another great book that takes each Quranic Arabic word and places the English meaning below it The Glorious Quran Word to Word translation. Hopefully when Ramadan ends I will continue to have a daily relationship with the Quran. 

National

Daily condolences

Pre-Covid I would write a condolence message once a month or maximally every two weeks. Muslims write the Quranic text of “to God we belong and to Him is our return”. Last week I had pasted it in Arabic calligraphy to someone. This week I have sent condolences twice each day. It first started with deaths narrated on television, then of relatives of friends, then distant relatives. I dread how it is closing in. This has to stop. 

Social inequity

The tales are harrowing. “I used to earn $250,000 a year and now it is zero” said a radio interviewee. “Thank you for donating to our fitness club” is gratitude from a business owner who needs donations to get through this crisis. Seeing the miles-long car lines in Texas to get donated food is difficult to process in our minds. Is this America? A Mercedes in the line gets its turn. The owner can get his car payment deferred for a month or two but has clearly run out of money for groceries. It seems people have become paupers overnight. The factors that have led to the tremendous inequality in our society need to be redressed. 

Stampede through the eye of a needle

The CARES Act 2020 through the Paycheck Protection Program was intended to help small businesses across America. But appears that no safeguards were put in place and the stampede through the eye of the needle got sharks across America, with slick lawyers and smooth relationships with bankers, to run it dry within a week. 71 publicly traded companies received $300 million of the $346 billion that was allocated to help small businesses leaving many small businesses out in the cold. Even though payroll documentation has to be provided, and the assistance was meant for companies with less than 500 employees, the loophole that Shake Shack used was of having less than 500 employees in one location. Due to public condemnation, Shake Shack has returned  the $10 million assistance it got, but the other billionaires are enjoying the money. This ever-widening gap between rich and poor also needs to be addressed urgently, and quickly become a thing of the past. 

The great equalizer

Covid-19 takes the rich, famous, regular and poor, and its humiliation of America is hard to process. Regression to the status of a developing country, and the dubious distinction of being the world’s Covid hotspot is ignominious. Americans deserve better than the performance of the federal government having essentially no stockpile of ventilators and personal protective equipment and the lack of an integrated federal and state response to tackle the pandemic. Our disaster response needs urgent and intense overhaul. 

Medicare for all

The first domino has fallen. More than 16 million Americans have filed for unemployment which terminates their health insurance. Our health care system was already very flawed, leaving large segments of the population uninsured due to the ridiculously high monthly insurance premiums. That flaw is now going to involve a large swath of the population. Medicare for all is the only way that the sequelae of Covid-19 can be addressed. 

Trump’s tyranny

If a person in any organization had suggested that disinfectant be inhaled, ingested and injected, they would have been fired on the spot. There is a rise in emergency department visits of people that have done exactly what Trump suggested three days ago and the number of calls to Poison Control have skyrocketed. Perhaps there should be a class-action lawsuit against Trump for aggravated assault or attempted murder. Whether we use the T for throw or the C for change, Americans must act in November to remove the embodiment of lies, the spectacle of stupidity and the epitome of incompetence that Trump is. We should try to retain a smidgeon of respect in the world community. Four more years is akin to a death sentence especially after our Covid suffering. 

Tariq Jameel too

Tariq Jameel is a Pakistani preacher a’la Billy Graham. He is charismatic and has a large following in Pakistan. His lectures have been attempts at humor, with superficial and distorted religious teachings. The fake-crying really gets me. As does the fact that seemingly educated people, including Prime Minister Imran Khan and former Prime Minister Nawaz Sharif,  just love him. His latest edict is that the Covid-19 pandemic occurred because women are shameless and not properly clothed. Religion in Pakistan, as elsewhere, is a multimillion-dollar industry and especially in Ramadan, the money really flows. Revolutionary poet Habib Jalib has a beautiful verse: 

Muflis jo agar tan ki qaba baich raha hai

Waiz bhi to minbar pey dua baich raha hai

Doanoan ko hai darpaish sawaal apney shikam ka

Ik apni khudi, aik khuda baich raha hai

The poverty stricken is selling his clothes

And the preacher sells prayers at the altar

Both are faced with the question of hunger

One is selling his self-respect, the other is selling God. 

There is no priesthood or confession in Islam; it is entirely deeds based. On the Day of Judgement we will be presented with a pictorial representation of our worldly life and our accounting will be individual, with no parents or preachers intervening. The accounting of religious clerics however will be a notch, or many, above the simple individual accounting that we will endure, because they have the ability to guide or misguide large groups of people. Previously the flock was restricted to the mosque and its surroundings; with the advent of technology, it now is millions at a time worldwide. It behooves the likes of Tariq Jameel to remember that frank misguidance of millions of people will be an insurmountable obstacle on the Day of Judgement. Pakistanis would be well served to listen to the calm, logical, scientific and current-day applicable lectures and interpretations of Javed Ahmad Ghamdi

Global

Climate change

The videos and photos of the skyline of cities around the world since the Covid-19 quarantine are quite stunning. The clarity of the air and the chirping of the birds is such a balm in these troubling times. As the pandemic subsides the world must actively decide on what industries it will re-allow and the massive polluters it should not. Passivity in this regard should be avoided. We have damaged the planet enough; it is now a time of introspection and revision. 

Cooperation

Cooperation among world health bodies such as the World Health Organization, the United Nations, The World Bank etc. are vital so that we truly work together as we are all in this together. Trump’s bullying and threats first to the United Nations and then to the World Health Organization should cease. If it is one thing that Covid-19 has demonstrated is that it will attack nations of all stripes and the best response is a concerted and not divided one. 

We are taught that after fasting in the month of Ramadan, or after Hajj the Muslim pilgrimage, one should work toward and notice a change in ourselves. Similarly we should keep the valuable, discard the unnecessary, and change some issues/people as we emerge from our Covid-19 quarantines. And as documented in world history and known individually, if we don’t learn from our mistakes, we are made to repeat them. The price next time might be incalculable. 

COVID-19 Cloistered Syndrome

Even though we are cloistered in luxury, it feels like incarceration. The human mind takes a while to process trauma but knowing this does not seem to reduce its impact. My mind goes through these cycles of dread.

I am terrified of, and at the same time fascinated with, blindness and imprisonment. Only because I know I couldn’t handle either. Thus 48 Hours, Forensic Files and 20/20 are my favorite shows. The point when the murderer is sentenced has a particular impact on me because of the essential impossibility, in my mind, of spending 30 years or life in prison without the possibility of parole. 

The cycles of dread

Even though we are cloistered in luxury, it feels like incarceration. The human mind takes a while to process trauma but knowing this does not seem to reduce its impact. My mind goes through these cycles of dread. Starts with the morning when the bed is a magnet and I am steel. Email’s been checked, Whatsapp’s been checked, articles have been read. And then the mental persuasions begin: “come on get out of bed, it’s gonna be ok” and variations of the same. 

Each day is more onerous than the last, because the case-rate and fatalities are so much higher. On March 1^st 2020 there were 89 Coronavirus cases in the US. By March 7^th there were 446, by March 14^th 2,776, by March 21^st there were 23,432 and by March 31^st 186,258 people were infected! And as of April 2^nd there were 243,134 cases in the US and 5,864 deaths, and on April 8^th 427,824 cases and 14,721 deaths. We used to casually use the word exponential, now we see it every day.

So one option is not to watch or read anything related to the COVID-19 pandemic. But that doesn’t work for me. And this week it is people we know who are in the ICU; statistics are so different from when a disease hits home like that. And as the days go on, those episodes of paralyzing dread become sickeningly familiar. 

Sunlight the savior

Even a twenty-minute walk does wonders. “I can do this” and “this too shall pass” become fulfillable mantras. Just the pre-walk is like a one-hour vacillation of the fight between the “go” and “don’t go” voices in my head. And the sinking realization that it has come to this; an activity and numerous others that were automatic in the past are actual projects now. 

Bankruptcy

A physician colleague just posted something hilarious and horrid: “if this saga continues, I will have something in common with Donald Trump, Chapter 11”. And speaking of Trump there is first the specter of small businesses going out of business and then suffering Trump’s press briefings and manifest incompetence. 

Small businesses are seeing a 70-80% reduction in activity. And this applies to a large swath of businesses from manufacturing to medicine. A bipartisan CARES Act 2020 was passed but has run into all kinds of snafus, and the immediate provision of $10,000 to small businesses and the Payroll Protection Program seem like they may not materialize or will arrive when irretrievable damage has been done. The consequences of this are not just small businesses filing bankruptcy, but millions of people losing their health insurance. Which in turn make a recession a definite, and the Second Great Depression a probability. Scaling back, pre-retirement or retirement plans are so much more palatable when they are done on our time; having them shoved in your face just worsens that cycle of dread. 

Tyrannical Trump

Never fails that when I am trapped in the kitchen cooking dinner, Trump’s press briefings are on and all channels carry them. Piled on top of the cloistered blues is the tyranny of Trump. It is hard to comprehend that the President of the United States would bully reporters, call the World Health Organization names, peddle hydroxychloroquine repeatedly, lie blatantly, fight with all things Democrat, alter facts whimsically and be altogether rude, grandiose and delusional. With the reverberant theme of “it is this way because I say it is”. And the citizenry has no recourse. “The  CDC recommends face masks but I won’t be wearing them” is Trump’s typical of “do as I say and not as I do”. The cycles of dread are fueled with the sickening realization that a petulant teenager has the lives of millions on his narcissistic little hands. 

All this time

Time was that vacations and staycations were just so awesome. Now time hangs heavy and the voices that propel to action feel shrill. I used to dream of a sabbatical when I would write my book. That the day is filled with telemedicine, cleaning, napping, cooking, the news and bed makes my self-worth tank. And I re-read those self-affirming memes that soothingly forgive you for essentially becoming a lump of lard. 

Fat on the other side

I’m very fat-phobic and my children accuse me of wanting to commit fat-icide. My mother and aunts were fabulous cooks; and round and rolly to prove it. And it was so plain that most, if not all, famous chefs are obese. So I figured I would dislike cooking and that would take care of any roundness that might threaten me. One of the memorable things of this cloistering will be that I discovered the joys of cooking. The family appreciating the meal every evening, is truly one of the greatest joys I have ever felt. Fortunately for me, I don’t have a sweet tooth and am not a stress eater; quite the South Beach lo-carb diet queen. That I have never been skin-and-bones is all my mesomorphic build, genes and metabolism-as rationalized by all overweight folks. Used to weigh myself once a week, now it is every day. The cycles of dread, my molasses like inertia, the specter of a financial fall, the disgust of governmental corruption and incompetence, the sadness of the national and global death toll and the fury of how this pandemic could have been handled differently will all be there. But at least I won’t be fat on the other side. 

The World on Reboot

On one fine day in Wuhan China the novel Corona virus traveled from bat to human and then between humans. And in that sentinel event, God conveyed, again, that He was in control. 

Like in a bad chapter of a sci-fi novel, the Corona virus pandemic will kill many and leave many in sudden poverty. It is indeed surreal to comprehend that in our lifetimes we will have seen a pandemic and likely The Second Great Depression. 

“These pandemics are on a one hundred-year cycle, almost like clockwork” said Dr. Nasir Husain, an infectious disease consultant. This piqued my curiosity, so I looked it up, and he is right. The Great Plague or The Black Death in 1347 killed an estimated 75-200 million. The world got a bit of a respite until the Italian Plague of 1629 which killed 280,000. Then the plague of Marseille in 1720 killed 100,000. The Spanish Flu, or the influenza pandemic in 1918, is estimated to have killed 17-50 million people. And in 2020 the Coronavirus.

At the time of this writing there were 307,725 Covid-19 cases and 13,054 deaths worldwide. Sadly by the time you read this, you will note that that the cases are exponentially higher. 

The slow unfold

The WHO vacillated a bit before it called the Coronavirus outbreak a pandemic. And after it did, instead of our government going on overdrive and doing a national clampdown, the country got split between people calling it overblown (Trump fans) and others demanding immediate action (labeled the liberals). At the time of this writing, only three states, California, Illinois and New York have gone into lockdown and it feels like this is a developing country, with the government’s focus on censoring the news and not wanting to face the rising numbers. There is a shortage of ventilators, ICUs, personal protective equipment and even masks. We have a defense budget to invade and destroy other countries, but we cannot protect our own. Trump was informed of the Covid-19 threat in January 2020 but did nothing about it. Instead our corrupt Congresspersons sold and bought shares on the stock market, feared the Coronavirus threat in private and denigrated it in public and boasted of our preparedness to tackle it. 

Every day my strategy of medical practice changed. On Friday, March 13, we worked on advising people observation when they called in with respiratory symptoms, and examined some that came for unrelated visits but had respiratory issues. By Monday March 16, we converted to telemedicine, except for having to physically see some patients who I cannot prescribe medication to without a urine drug screen.  

The Second Great Depression?

America has slowly closed down. The Stock Market is reminiscent of the Great Depression. Unemployment claims are surging and it is predicted that they might reach an unprecedented territory of 2.25 million. How does a country recover from that? My private practice has been scaled down to the point that survival beyond 30-45 days at this pace is difficult to envision. I’m trying to hold on to my employees because starting from scratch when all this is over, is not a good move. Other small businesses in America cannot do this. To come to terms with the sudden change in our fortune-with little work and the stock market crash-just adds to this one word that my mind keeps churning up. WHAT?! Seems we will spend the next couple decades getting out of this medical and money mess. Which looks like the Second Great Depression to me. 

Stages of Grief

To think that the entire world is going through Elizabeth Kubler-Ross’ Five Stages of Grief is also weird. For a few seconds in the morning while the brain is still half asleep there is respite. And then it suddenly hits; and for me it is mainly denial/disbelief at what just got unleashed, and anger at our government for its incompetence and the deaths of thousands. Hopefully, not millions. 

Individual and national arrogance

All those aphorisms of “we’re in this together” and “it’ll never be the same again” suddenly stop being corny. When we go away on vacation, almost invariably, we reboot, we reflect. From existential questions to simpler ones like where am I headed or should I consider a career change. With this Covid-19 induced forced vacation, the world is on reboot; our questions multiply and the answers seem to hide. We took so much for granted: parties, concerts, travel, shopping. If I dare plan a quick grocery stop now, the yelling chorus from my daughters is enough for me to want to jump off the cliff instead. Groceries must be delivered. 

All of us have had varying levels of arrogance and have doled out injustice. As we are cloistered in our homes a personal inventory is very much in order. This is the time to repair relationships and ask for forgiveness. And most of all, put down the smartphone and just sit and talk to your family. Indulge them. Especially if you are a parent, realize the anxiety, however camouflaged, that your children are going through and alleviate it. Reassure your parents and friends and keep the conversation positive. Arrogance in Islam is akin to shirk or the sin of association, for arrogance can only belong to God. 

National arrogance, especially the arrogance of American leadership, appears to have not even been lightly dented by the massive catastrophe that the Coronavirus pandemic is.

In the war and devastation in her country, the very young Syrian child, just before her death said "I will tell Allah every thing". It seems that Allah listened.

No one speaks of the American killing of one million Iraqi civilians on the basis of the lie of Iraq having weapons of mass destruction. The incarceration and torture of millions of Uighur Muslims in Xinjiang China is not spoken of, even by Muslim countries, for fear of Chinese trade reprisal. Israeli apartheid and the daily brutalization of Palestinians is presented to the world with a switch of victim and aggressor. The world, even Saudi Arabia and the United Arab Emirates, both hungry for Indian trade and money, looks away as India continues the ethnic cleansing of Muslims and has kept Kashmiris in lockdown for nine months now. Iran has suffered a significant Covid-19 toll but America refuses to lift sanctions, and innocent Iranians suffer the lack of basic medical care. Even the desperation of our own citizens doesn’t return us our humanity and compassion. 

Who’s in control?

On one fine day in Wuhan China the novel Corona virus traveled from bat to human and then between humans. And in that sentinel event, God conveyed, again, that He was in control. 

Jawad Ahmad, a Pakistani singer, introduces one of his songs with a poetic representation of the Quran and Hadith in the form of a conversation between God and us, in which God says:

Oh son of Adam
There’s something you want and something that I want

But what will happen is what I want

So submit yourself totally to what I want 

And perhaps I will give you what you want

But if you are disobedient and rebellious with what I want

I will tire you out in your pursuit of what you want

And in the end it will always be what I want

Submission

The only sanity is in submission. Entirely to God’s will. Stay at home, be kind to your family, strengthen your spirituality, learn new skills, wash your hands, take every precaution and stop panicking. God’s got this. Wa uffawidu amri ilallah inallaha baseerun bil ibad: I entrust all my affairs to God; indeed God is aware of His servants. (Quran 40:44)

China's pre-genocide of Uyghur Muslims

It was a wonderful start to Imran Khan’s ascent to premiership that the Dutch cartoon contest was cancelled. Appears Foreign Minister Qureshi was convincing in his dialogue with the Dutch and a crisis and killings were averted. This foreign policy winning streak is continuing, at least in some sensitive issues.  

“China is treating Islam like a mental illness” is the title of an article in a recent issue of TheAtlantic. And the deeply nationalistic, hardline rule of President Xi Jinping looks at Islam like the diseases of depression or addiction. He has interned one million Uyghurs in internment camps, called “re-education camps” to “cleanse” the mind of Islam which is likened to an ideological illness, akin to a virus in their brain. Here they are brainwashed to praise the Communist Party, sing nationalistic songs all day, study President Xi’s vision of China, confess to and apologize for praying. They are also forced to eat pork and drink alcohol. For resistant subjects there is torture, solitary confinement and death. 

The Qing Dynasty reasserted control of Xinjiang in the 19^thcentury. Xinjiang, population ten million, is in northwest China and borders Pakistan’s Gilgit Baltistan to the south. The Uyghurs are Turkic people, linguistically, culturally and ethnically close to Central Asia, despite a long history of Chinese rule. In 1933 and again in 1944, ETIM or East Turkestan Islamic Movement, tried to secede and China responded ruthlessly. Chinese officials deny the existence of the internment camps, and have hinted at terrorist activity in Xinjiang, but there is no evidence of this. 

Many of the Han, the predominant Chinese group, have migrated to Xinjiang in another effort toward Sinification of Xinjiang. This Sinification was proceeding at a languid pace until a couple of years ago when Chen Quanguo arrived. Quanguo had created an intense surveillance system in Tibet from 2011-2016 and was so successful in crushing dissent there, that his system has been implemented in Xinjiang. 

It is this century’s new Gulag. And is considered pre-genocidal. Reminiscent of the Rohingya genocide by Myanmar. 

Teachers ask children to spy on parents and report their praying or reading the Quran, neighbors spy on neighbors, the entire population is monitored through GPS technology and DNA-sampled. Men are sent to internment camps, and satellite images show expansion of the internment camps, and in some villages men cannot be seen, only women and children. There are ghost towns where no one talks to others. Women are sent to internment camps also.   

Ramadan is banned, no beards or veils can be publicly visible, passports have to be surrendered and saying salam-alaikum can send you to an internment camp. Qurans have been burned and mosques have been closed down. Factories and hospitals are converted into re-education camps. When they come a black hood is placed over the head, and in the internment camps prison uniforms, shaved heads and political indoctrination begin. Baths are rare and washing of hands and feet is not allowed, as it resembles ablution. If the prisoners comply they are released, if they do not, insanity or death await. Those who have left the internment camps and then China itself have told the same story of conditions in Xinjiang. 

Assimilation into the Chinese mold takes the form of internment camps and orphanages, both of which are overflowing. Communistically called “child welfare guidance centers” these massive orphanages house Uyghur children separated from their parents, where they are locked up like farm animals in a shed. Sinification of these children, needless to say, is easy. 

Rebiya Kadeer, President of the World Uyghur Council said: “the real intent is to eliminate Uyghurs as a distinct ethnic group”. Turkey and Malaysia have protested but the most vocal protest has been from the most unlikely places: US Vice-President Mike Pence called on the Chinese government to release the one million prisoners that it is holding in re-education camps for political indoctrination and denunciation of religious beliefs. US Senator Marco Rubio and American UN representative Nikki Haley have been similarly excoriating.  

China has arrested 50 Uyghur women married to Pakistani men in Gilgit-Baltistan. And Pakistan has done nothing in response. 

Pakistan’s Federal Minister for Religious Affairs, Pir Noorul Haq Qadri, recently said that strict regulations and laws fuel rather than counter extremism. To promote religious harmony, China should exercise patience, the minister told China’s ambassador to Pakistan, Yao Jing. He also suggested that a delegation of Pakistani scholars should visit Xinjiang to help. 

Canceling the Dutch cartoon contest was important, and kudos to Religious Affairs Minister Qadri for protesting to China.  Seems Pakistan is trying to be the voice of the Muslim world. These efforts are a good start but have not continued with the war in Yemen. More on that travesty another day. 

Mindsets, Mercy and the Qatra effect

We might be witnessing a tectonic shift in Pakistan’s socio-politics. Prime Minister Imran Khan’s address to the nation was so ambitious that some think he has promised the nation the moon. 

In individual lives and those of nations, idealism is a good thing, particularly when it is backed up with a solid action plan. In goal setting you shoot for the stars, and settle for an average or slightly above average result. Cynicism and supercilious criticism only perpetuate the status quo. And if there is one nation on earth that cannot survive the status quo it is Pakistan. 

Imran Khan had an exhaustive list and dealt with education to agriculture, corruption to climate change. His reading glasses are testimony to the fact that he had a thought out plan of action for each item. As an aside, I must say, that his reading glasses have to go. During his oath taking, it was hugely awkward to see him flip out his sherwani and dig out his glasses. He needs a quick visit to an ophthalmologist who will fix him up with trifocals so when he talks and then reads, he doesn’t have to go from handsome to grandma; he would just keep the trifocals on and rest his arm from the back and forth, and sport a scholarly look all at the same time.  

The changes that Imran Khan lists are only possible with a change of mindset. Seventy-one years of explosive population growth, an imploding economy topped with baffling corruption has served to fashion the Pakistani psyche. Time was that the middle class, the classic perpetuators of morality, maintained integrity and faced adversity with the rules they grew up with.  But who can live on love and fresh air? Especially over the last thirty years or so, you see survival of the fittest on full display. 

My first brush with corruption was in 1982 when the clerk in Dow Medical College’s office demanded money for release of my mark sheet. But 2016 will go down in my family’s history as giving all of us PTSD, post-traumatic stress disorder. My mother, my daughter and I had traveled to Karachi so that Ammi could collect my late father’s pension. In current day Pakistan, your two options to get anything done are doling out money or applying influence. Those government servants know how to break you. I chose influence application to greasing palms. And my distress was worsened at the plight of the many desperate faces roaming those halls that didn’t have the connections I did. 

The trend isset at the top. Everything, small or substantial, matters. To his credit Imran Khan knows this. His ill-fitting sherwani caused a buzz on social media and it seems a regular tailor stitched it. Brave to wear a Peshawari chappal at his inauguration. Wearing that chappal, Imran Khan gives many messages; he is thumbing his nose at Western culture, showing pride in our own and underscoring simplicity. When there is no fear of retribution and the Whistleblower Law comes into effect, there will be a nationwide movement to self-correct. Or else get turned in. 

That Islam insists on honesty and principles becomes an empty lecture when leaders drive away in bullet and bombproof Mercedes and BMWs, not one but fifteen at a time, into mansions with 500 servants and food to feed a squadron. A three-bedroom home with two cars is a great start! Changing that mindset that has been groomed and nurtured for decades is the challenge. Except for the elite one senses a national enough-is-enough frustration. How and why is life so difficult at every step from the time one gets up till the day is done? 

There is in fact a danger of the pendulum swinging the other way and the elite and corrupt getting street justice. Imran Khan assiduously avoided vengeance. And it is important to maintain this. A mindset change has to happen but it must be modulated to achieve results and not revenge. 

I was very touched by his repeat explanation of creating rahm or mercy in our hearts. One really notices its absence in Pakistan. How do people live with themselves spending millions of rupees on a wedding outfit and the many wedding functions, when all around them are starving children begging on the streets? Mercy has been squashed out of our hearts and we’re blind to the misery around us. I was looking through clothes at a boutique on M. M. Alam Road in Lahore in July 2013; most of the outfits were Rs. 25,000 and above. The power went out and the generator quickly hummed in. Under his breath the salesman said that the power outage didn’t matter to him for his six children sweated in the day and studied by candlelight at night. I asked him how much he made and he said Rs. 25,000 a month. I left the store and cursed our nation’s inequity.

Qatra qatra darya ban jaata hai-drops coalesce to form a river. The cost of the Bhasha Dam is estimated to be Rs. 1450 billion. The small Rs. 10 SMS donation created by the Supreme Court, and then larger donations from Pakistanis and Overseas Pakistanis, can be the drops that can easily coalesce to give us the dam. 

All of us, within and outside Pakistan should do at least one thing to change things. Plant a tree, clean your street, educate a child; the opportunities are limitless. Imran Khan has great minds in his cabinet and advisers. In five years if we achieve even half of his “lofty” goals, we will easily see Naya Pakistan. 

Pakistanis bailing out Pakistan

Any ray of hope for Pakistan seems quickly clouded by its dire financial straits. Not handled wisely the State Bank of Pakistan’s minuscule reserve of $9billion can pose an existential threat for Pakistan. 

In May of 2018 the State Bank of Pakistan’s external debt was $91.8 billion, a whopping 50% increase over the last four years. Servicing this debt keeps us in the rewind and repeat cycle. An urgent and multipronged approach will be needed to yank Pakistan out of this quagmire. 

In his somber and statesmanlike speech after the July 25 election, Imran Khan called overseas Pakistanis “our biggest asset”. Harnessing the financial power of overseas Pakistanis might be a very effective part of the urgently needed multipronged strategy to heal Pakistan’s financial crisis. 

There is something mysterious and magical about love for Pakistan. My American born children don’t understand it. You’ve got to feel it to know that there is a lot you would do for Pakistan. Many expatriate Pakistanis, like me, are deeply grateful to Pakistan for making us all that we are today. I can never completely repay Pakistan, Civil Hospital Karachi and Dow Medical College for making me a physician, essentially for free. In its time of desperate need, Pakistan should capitalize on this love-guilt-debt emotion that numerous expatriate Pakistanis feel.

I came to the United States for residency training with plans to return on its completion. When the time came to return, there was a spate of killing of Shia doctors in Pakistan. My former husband is Shia and we thought it wise to not endanger the family. Till today I remember how I wilted inside.  And, outside, dropped roots that ensured that returning would not happen. 

According to the Ministry of Overseas Pakistanis and Human Resource Development, there are 7.6 million Pakistanis who live abroad. In 2017 they sent remittances to Pakistan totaling $20 billion. 

Political commentators Rauf Klasra and Amir Mateen have come up with a brilliant idea that can Band-Aid Pakistan, at least for the present. Each overseas Pakistani is urged to transfer $1000 to their families’ or their own accounts in Pakistan, with instructions to not draw it for at least one month. Considering 7.6 million overseas Pakistanis are members of families, if we were to take one third of the 7.6 million and persuade them to send $1000, it amounts to over $2 billion. This could go toward debt servicing, so the chasing-our-tail phenomenon with regard to the external debt stops. 

In addition to the average expatriate Pakistani, there are the billionaires. Like Pakistani-American Shahid Khan who owns the Jacksonville Jaguars an American professional football team, as well as the Fulham Club a British football team and an automotive company. His net worth is $8.5 billion. British-Pakistani Anwer Pervez is owner of Bestway and United Bank and has a net worth of $3.8billion. Pakistani-American Ashar Aziz is owner of FireEye, a cyber security company, and has a net worth of $1billion among many other very wealthy overseas Pakistanis. 

Omar Aziz, the future finance minister of Pakistan, has not ruled out any measures to deal with Pakistan’s debt, including reaching out to the IMF. Perhaps reaching out to overseas Pakistani billionaires and multimillionaires to donate to reduce Pakistan’s debt, or lend money at no interest, is doable. 

The Ministry of Overseas Pakistanis ought to create two departments; one called “Donation for Debt Reduction” and another called “Loans for Business Development”. Legal framework should be created quickly to protect the overseas donor and lender. If overseas Pakistanis are assured that their donations or their loans will be assiduously protected and channeled appropriately, we just might have an ongoing stream of money that will bolster Pakistan quickly and effectively. The loans for business development should be based on the micro-financing concept of Nobel Prize winner Muhammad Yunus. Low interest or interest-free loans to families to start businesses will reduce unemployment and raise people out of the poverty that Imran Khan spoke of repeatedly. 

“There’s a tide in the affairs of men, which when taken at its flood leads onto fortune” said Shakespeare. There is a Naya Pakistan fervor in Pakistan and among expatriate Pakistanis; we should pivot quickly to capitalize on this. That magical love for Pakistan is at its peak, full of hope and yearning. 

It is little that we overseas Pakistanis want in return. The right to vote in Pakistan’s election-not traveling to Pakistan-but where we live and in a Pakistan embassy or consulate. Eliminating red tape, politics and competitiveness when we try to bring our talent to Pakistan. We don’t want to usurp jobs, we just want to help, for instance in creating addiction centers, with the latest technology, to combat Pakistan’s drug epidemic. 

Finger pointing is now pretty pointless. We can all take the responsibility to redress the havoc wreaked by past misgovernance. Instead of international banks or the Chinese always bailing out Pakistan, the average, wealthy or super-wealthy overseas Pakistani could really help. Our guilt will be assuaged and our hopes realized.  

Treatment choices in opioid addiction

TREATMENT CHOICES IN OPIOID ADDICTION

Mahjabeen Islam MD FAAFP FASAM

More than 50,000 people die of opioid overdoses every year and now more people are killed by opioids than traffic accidents or guns.

All of us know someone with the disease of opioid addiction and everyday we either personally deal with the devastation that opioids cause, or read or hear about it. Opioids are taking lives the way that the AIDS epidemic did when it was at its peak in the 1980s and early 1990s. We were able to control the AIDS epidemic and if the government, the health care system, law enforcement and actually each and every one of us decides that we are going to defeat this epidemic, we will.

First things first: it’s a chronic disease

 A lot of people think that opioid addiction is a weakness, a personal failure or a character flaw. Society and people like to feel stronger by making others feel weak. But we know from medical research that opioid use disorder is a chronic disease, much like diabetes, high blood pressure and asthma. And like these diseases it has no cure, the same relapse rates, and, if you want to follow it, excellent and successful treatment. 

If you take diabetes as an example you know that some people have a “touch of sugar” and others are insulin dependent diabetics. In mild diabetes, some patients only need to watch their diet and exercise regularly, others take pills to lower their blood sugar, and some have to inject high doses of insulin every day.

So everyone who is prescribed or tries an opioid doesn’t get addicted. We have receptors in our brains called mu receptors, which opioids latch onto and we experience an opioid high. Everyone’s brain is different and many factors like our genes, the age at which drugs are tried, the dose used, the potency of the drug, whether it is eaten or injected, our social and family condition, our psychiatric issues all control the mu receptor and whether we don’t get a high, get a bit of a high or a very intense one.

Before determining the right treatment for opioid use disorder it is vital to understand that this is a chronic disease. If you don’t understand and accept this, treatment is probably not going to work for you.

There ain’t no motivation pill

For any treatment to be successful the patient has to be motivated. Families, courts, jobs or a society pushing a person to get sober doesn’t work. The motivation has to come from within the person. I like to tell patients that I don’t have the motivation pill, and if I did, my face would be on the cover of Time magazine!

Patients who have been through treatment multiple times know that that the times it worked, they had been motivated themselves. The times it didn’t they were either half-hearted or had been pushed by other people or factors.

As physicians we try to give the best treatment we can for the patient, but we are not always able to judge the strength of a patients motivation and dedication toward recovery.  It is very easy to see through the patient who is half hearted and trying to dupe the system. Because of the large number of people that need treatment, we have no patience, or room, for people that are either not ready for recovery, or are trying to use the system, or both. We want to save the life of someone who really wants sobriety, not play games with patients.

Counseling is essential/Customizing treatment to each patient

With every kind of treatment, patients are more successful with sobriety when they go through group and individual counseling. These sessions help the patient understand what started their addiction, what their relapse triggers are, what to do in case of a crisis, the importance of sober support and getting back to school or work.

How often a patient should get counseling has not been scientifically established; all we know is that counseling helps a lot with recovery. We assess each patient and try to determine how severe their addiction is, as well as their family and social situation, and come up with an individualized service plan to best help the patient.

Some patients do well with once a week group therapy, while others have to start with three to five times a week counseling sessions. Yet others need to be in an inpatient facility or in residential treatment. It is important to customize or tailor the treatment to each patient instead of adopting a one-size-fits-all approach.

Treatment choices

1.     Abstinence-based treatment

2.     Methadone maintenance

3.     Buprenorphine-naloxone: Suboxone, Zubsolv, Bunavail

4.     Naltrexone pill

5.     Naltrexone injection: Vivitrol

Abstinence-based treatment: you’re kinda on your own

The phrase “cold-turkey” comes from opioid withdrawal because when opioids are stopped suddenly the person feels cold, has goose bumps, sweating, nausea, vomiting, diarrhea, insomnia, anxiety, irritability and muscle and bone pain. While the patient may feel that they are going to die; opioid withdrawal does not kill and usually after two to five days, the severe withdrawal symptoms go away and the patient may just be left with some cravings.

In the old days, all we could do was help patients through the withdrawal with medications like Zofran for nausea/vomiting, Imodium for diarrhea, Motrin for pain, Flexeril for muscle pain and clonidine for cravings. And we counseled patients and hoped for the best. This form of treatment doesn’t work well for all patients, in fact only a minority maintains sobriety with this and relapse rates are high.

It remains a choice for those patients who don’t want any medication-assisted treatment and there are patients that maintain long-term sobriety with this and counseling.

Methadone maintenance: the original treatment

Methadone is a long-acting opioid and in the 1970s methadone clinics started in cities across the United States. The government tightly regulates methadone clinics because methadone is a very powerful, long acting and dangerous opioid and can kill easily. In a methadone clinic a physician evaluates the patient, and calculates their methadone dose, mainly based on their opioid use.  The patient drinks liquid methadone in the presence of a nurse and has to come every day to take the liquid methadone.

Advantages of methadone maintenance:

1.     Potent opioid; takes away all opioid withdrawal symptoms and cravings.

2.     Proven to reduce opioid overdose death rates.

3.     Very close monitoring of patient, so is good for complicated patients who have used high dose opioids for a long time with little sobriety.

Disadvantages of methadone maintenance:

1.     Daily visits to clinic.

2.     Difficult to hold down a job or go to school.

3.     Unfortunately very high methadone doses are typically used. Some patients are therefore high on methadone.

4.     Difficult to wean off as withdrawal from methadone is particularly severe.

Buprenorphine-naloxone: Suboxone, Zubsolv, Bunavail

(For ease of understanding I will be using Suboxone to represent buprenorphine-naloxone)

Active ingredient is buprenorphine and not naloxone:

A lot of people think that Suboxone works because it has the opioid blocker, naloxone, in it. This is not true. Suboxone, Zubsolv and Bunavail’s active ingredient is buprenorphine, which is an opioid. Buprenorphine is not a powerful opioid and has just enough of an effect on the mu receptor to treat withdrawal symptoms and take the craving for opioids away.

When Suboxone is used under the tongue, the buprenorphine is absorbed and becomes active. The naloxone does not work when it is taken under the tongue. Naloxone only becomes active when it is injected and if Suboxone is liquefied and injected the naloxone in the Suboxone places a patient in immediate and severe withdrawal. So the reason that naloxone is placed in Suboxone is to prevent patients from liquefying Suboxone and injecting it.

A great medication:

Buprenorphine-naloxone is a great medication and has been successful in turning millions of lives around. Eight to sixteen milligrams per day is a common dose. The lowest dose should be used which keeps the patient’s withdrawal symptoms away, especially the cravings. At sixteen milligrams the mu receptors are saturated and when a higher dose is given it is only the bad side effects that the patient notices, not necessarily an improvement in cravings or withdrawal symptoms.

Stages of treatment:

1.     Induction

2.     Stabilization

3.     Maintenance

4.     Weaning

Induction: This is the first stage. The patient is requested to present in opioid withdrawal so the Suboxone can be started immediately. The lowest possible dose of Suboxone that will take care of withdrawal is given to the patient and they are rechecked in two to three days. If the urine drug screen in the next visit is negative, and a dose increase is requested, we do raise the dose.

Stabilization: in the next few visits we focus on stabilizing the Suboxone dose. Sometimes the dose is too much and the patient feels that they are nodding during the day, and thus the dose is reduced. Others feel that the dose is insufficient. If the urine drug screen is negative and the patient is compliant with counseling, the Suboxone dose is increased.  

Maintenance:

This is the phase when the patient is comfortable with their dose and typically is the longest of all the phases of buprenorphine treatment.

Weaning:

Depending on the dose of Suboxone that the patient is on, it can take one to four months for a patient to be weaned off Suboxone completely. The dose of Suboxone is lowered very gradually and the patient advised that they will feel opioid withdrawal symptoms for two to five days, and after that, they are pretty much fine. Essentially all patients realize that they had been unnecessarily nervous about dose reduction, and indeed they felt a little achy and have a bit of insomnia for a couple days, but that after that they were fine.

Duration of treatment:

This is different for different people and we try to customize the treatment to each patient. Some patients are on Suboxone for a few months, some for a few years and others indefinitely. Just like they had with their choice of opioid, patients get very attached to Suboxone and some become very resistant to dose reduction. Patients want to reduce their doses by one-quarter films and I reassure them that, just the way they had gotten attached to their drug, they have now latched on to Suboxone and we reduce the dose by half a film, or four milligrams, every two to four weeks (when the patient is on eight to sixteen milligrams of Suboxone).

Side effects:

Suboxone can cause drowsiness, constipation, weight gain and leg swelling. And of course dependence as it is an opioid.

How long Suboxone?

Research does not guide us regarding the duration of treatment with Suboxone. To best treat patients I have divided patients into three categories with regard to duration of Suboxone use:

1.     Short term treatment

2.     Medium term treatment

3.     Long-term or indefinite treatment

Short-term treatment:

The patient is on Suboxone for a few weeks and is rapidly weaned to zero and placed on naltrexone.

Medium-term treatment:

This treatment is for one to two years and ideally I prefer the dose of Suboxone to be eight milligrams or below.

Long-term or indefinite treatment:

I reserve this for patients who have concurrent psychiatric illnesses, such as not well- controlled bipolar disease or schizophrenia. If treatment is going to be indefinite, I prefer the dose to be eight milligrams or less.

We try to use the lowest Suboxone dose possible, as patients themselves realize they do not need more than eight milligrams and some then decide to sell or share it. 

“Switched one addiction with another”

People unfamiliar with current research, those stuck in the abstinence-based model and fans of the 12-step program, claim that treatment with Suboxone is switching heroin for Suboxone, an illegal drug with a legal one. This is entirely untrue. And a typical attempt to make oneself look good and the opioid addicted patient feel bad. We have research that shows that Suboxone has a healing effect on the brain and is an excellent bridge from opioid addiction to a life of sobriety.  

Naltrexone pill and injection (Vivitrol)

Naltrexone is a long-acting opioid antagonist and it was initially FDA approved in 2006 for the treatment of alcohol use disorder. In 2010 it was approved for opioid use disorder. Unlike Suboxone, naltrexone does not have an opioid in it and can be prescribed by any physician. To prescribe Suboxone a physician has to be specially trained in prescribing it.

Suboxone and methadone have a lot of research data proving their great outcomes in maintaining sobriety, and reduction in opioid overdoses. Studies show that naltrexone works well in patients who are very committed toward their sobriety. In maintaining sobriety and preventing opioid overdoses, Suboxone and methadone are far superior to naltrexone.

Some patients don’t want to be on an opioid like Suboxone and this is understandable. But it is important to remember that comparing Suboxone to the naltrexone pill or the shot, Vivitrol, is like comparing apples to oranges.

Certain professions like pilots or truck driving do not allow Suboxone and in that situation naltrexone is a good choice.

Naltrexone cannot be given when an opioid is present in the system, as it will immediately put the patient in severe withdrawal. Naltrexone is started either at the start of addiction treatment or after Suboxone has been weaned down to zero.

Naltreone pill:

The naltrexone pill is prescribed at 50mg daily and is inexpensive and approved by essentially all insurance companies.

Naltrexone injection/Vivitrol:

Vivitrol is a monthly injection and lately has been heavily promoted by its manufacturer Alkermes and its use is skyrocketing across the United States. It costs about $1200 per injection and 380 milligrams is injected once a month intramuscularly. Several court systems across the country are also concentrating on Vivitrol. It is important to understand that both the naltrexone pill and the Vivitrol injection work, the only difference being that the pill can be stopped by the patient but once the Vivitrol is injected it obviously cannot be removed, and its effects last one month. And even though use of an opioid while on Vivitrol will place the patient in withdrawal, patients have been known to relapse while on Vivtrol.

The intense marketing of Vivitrol has led to its indiscriminate prescribing by physicians and its recommendation by the justice system and this is placing a terrible burden on our health care system. Vivitrol is not a cure-all and the naltrexone pill is just as good as the injection.

Side effects of naltrexone:

The main side effects of naltrexone, both oral and injection, are fatigue, headache and nausea.

So what should you do?

I’ll list out some options of what you can do when you enter a program:

Option 1:

·      If the patient has not used opioids for at least three days and the urine drug screen is negative the naltrexone pill can be started.

·      If opioids are present in the urine, a return appointment can be made after three days and naltrexone can be started then.

·      Naltrexone pill can be continued indefinitely.

·      If taking the pill everyday is a problem and the insurance company covers Vivitrol, it can be tried.

Option 2:

·      Start on Suboxone.

·      In return visits try to stay on the lowest dose of Suboxone that takes care of opioid withdrawal and cravings.

·      After four to six months of treatment, start weaning process to zero.

·      After Suboxone has not been taken for one week and the urine drug screen is negative for it, naltrexone can be started.

Option 3:

·      Start on Suboxone

·      Have regular discussions with your doctor about the duration of treatment and if it is mutually decided that you need to stay on Suboxone indefinitely, make sure you are on the lowest dose that would control opioid cravings.

Option 4:

·      Go through opioid withdrawal and go with abstinence-based therapy. Meaning no Suboxone and no naltrexone.

·      I am not in favor of this option as the patient is unprotected in dealing with a disease and because oral naltrexone is cheap and effective in the motivated patient.

The lives of millions of opioid addicted patients have been transformed after their entry into programs that treat opioid use disorder. And being the instrument of such a massive change in people’s lives has been, by far, the most humbling and gratifying experience in my life.

Dr. Islam is medical director of UMADAOP of Lucas County and is board-certified in Addiction and Family Medicine. She has over twenty-five years experience in Addiction Medicine and has worked in all phases of treatment, from inpatient to intensive outpatient, residential and ambulatory treatment.

This article was originally published in the UMADAOP magazine in October 2017