By Shaili Jain
“Your father’s health has taken a turn for the worse. We’ve stabilized him, but he is approaching the ceiling of care. We’ll allow family to come in, two at a time, but visitors have to self-isolate for ten days afterward.”
My husband, R, and I sat on the couch in the living room of our London rental listening on speakerphone to Dr. P, a senior pulmonary specialist at an east London hospital as she took care of R’s father, ill with COVID-19 pneumonia.
This day, a Friday in January of 2021, marked day 20 of my father-in-law’s hospitalization. He was one of the unfortunate ones for whom a bout of coronavirus meant his own immune system, after killing the virus, went into overdrive from healing to destructive, attacking his own organs. For the past three weeks R and I have been virtually coordinating his medical care and, like millions of families around the globe, were immersed in the language of COVID: cytokine storm, Optiflow, venturi mask, CPAP machine, D-dimers and dexamethasone. We have been consumed in a daily rhythm of making calls to the hospital, waiting for medical updates from the doctors, anxiety, tears, randomly preparing perfunctory meals, and sleepless nights. As the brown children of immigrants raised in England, we have also reprised our childhood roles: advocates and translators for our parents and navigators of the hospital systems that will always remain anathema to them.
This is the call we have been dreading. As Dr. P talked, I moved closer to R on the couch, instinctively grabbing his hand, and while I wait for him to respond, I studied his face, a face I had known for 30 years. The cheekbones were more chiseled, skin tanned from the California sunshine, and sideburns greying, but it remained the face of the man I’ve loved since my freshman year of college.
“Thank you for updating us, doctor. I’ll make my way to the hospital shortly,” R said calmly.
As we hung up, R looked at me, his face stunned.
“This is it. Dad’s not going to make it, is he?”
My mind whirled.
“We just have to take one hour at a time,” I murmured. “Call the rest of the family, they need to be updated.”
***
Not long after the world had celebrated a U.K. grandmother becoming the first to receive the Pfizer COVID-19 vaccination, R’s London-dwelling elderly parents reported feeling under the weather. By the morning of our Heathrow-bound December 19 flight, my mother-in-law was coughing and my father-in-law was nursing a sniffle. Sitting next to R, double-masked, in the quiet departure lounge of San Francisco International Airport, our interlocked hands sanitized to cracked rawness, I shared my gut instinct. “The doctor in me doesn’t have a good feeling about this.”
Two days after arriving at the London rental that would become a temporary home for myself, R, and our two teenagers, I’d watched the news reports with mouth agape: a new U.K. strain of COVID-19 was responsible for a steep rise in cases. The earlier progress made in fighting the virus yielded to a new reality – Christmas was cancelled, and new lockdowns were announced. In the days that followed, my parents-in-law would both receive positive COVID-19 tests, attributable to this mutation that was spreading rampantly in populous London. A panel of government scientists deemed the new strain more contagious and 30 percent more deadly than the original virus. Most chilling was the fact that, in the U.K, COVID-19 death rates were highest among Blacks and South Asians.
Like my own, R’s parents were also part of the post-World War II wave of Indian immigrants to England. As brown kids born and raised in the often-racist Great Britain of the 1970s, both our formative years had been steeped in the traumas of working-class immigrant households. R and I were intimately acquainted with the life circumstances of these communities of color and how this correlated with their high COVID-19 death rates. The east London postal code where R was raised, and where his parents still live, was filled with the invisible workers who kept a metropolis-like London churning: bus drivers, janitors, deliverymen and small business owners – lower-paid workers in the public-facing occupations who didn’t have the luxury of working from home. And in Great Britain, with its deep and far reaching oppressive colonial history, such workers were more likely to hail from Black, Asian and minority ethnic backgrounds.
We also understood the mindset of these families who lived life stuck in survival mode – when trauma, stress and job insecurity are everyday facts of life, there is a limit to how much mindshare gets devoted to a global pandemic. Moreover, a pervasive mistrust of White authority (e.g., politicians, government scientists and doctors) runs deep among the Indian, Pakistani, Bangladeshi and Caribbean communities living in under-resourced pockets of the U.K. The traumatic history of the British Commonwealth means they are skeptical of people in power and more reliant on their own respective clans. This deep-rooted generational mistrust translates to millions being stuck in a surreal time warp — they cling to cultural superstitions, traditional norms and religious ideologies decades after their counterparts back home have evolved and adapted to the realities of a new day. So, if your family mobile chat spreads the fake news that keeping raw ginger in your pocket will protect you from coronavirus, that may influence you more than the BBC public service announcement telling you to wear a mask. Moreover, you’re willing to bend lockdown rules to fulfill duties related to births, deaths, and marriages, because nothing matters more than obligation to your own kith and kin.
In the early days of our own union, R and I decided education and an indefatigable work ethic were our escape from the powerlessness that defined our childhoods. In 2000, both tired of class-obsessed England, we’d made the ultimate commitment to the new world and left England for America. Together we’d built a modern life taking the only path available – working very hard at mastering difficult things. I was a psychiatrist, PTSD specialist and trauma scientist, while R was a technology start-up executive. Over the decades, we had collected accolades, reached targets, and accomplished goals which served as a healing balm that caressed the scars of our harsh early years.
The pandemic only further highlighted the differences between our Old World origins and New World life. Our adopted California tribe implicitly understood exponential virus growth, incubation periods, and why a facemask must cover your mouth and nose. Most of all, we understood how things you can’t see can still kill you. Our well-paying jobs and access to high-speed internet afforded us the privilege of spending most of the pandemic in a safe bubble, but all that changed in December 2020 when we returned to the country of our birth. In a global pandemic, a postal code, or a ZIP code in America, can determine destiny – simply living in the less affluent pockets of London means a higher risk of infection. Social distancing is near impossible on the narrow pavements of the inner city that, even in lockdown, those pavements were filled with unmasked pedestrians. The thin streets are lined with rows of century old-terraced houses, themselves barely six feet in width. Central London imposes a financial penalty for drivers of personal vehicles, so public transport becomes the default for those who are strapped for cash. Skyrocketing housing prices means multigenerational living is the norm, but this only adds to overcrowding in the grocery stores, hospital waiting rooms and local parks, structures not built to withstand this surge in population.
The forward momentum that was part and parcel of our dynamic Silicon Valley life was screeching to a halt, yanking us back into the helplessness of our past. Mental whiplash ensued along with the realization that, no matter how successful our new world accomplishments, we might not escape the destiny of our origins and our family was hurtling toward becoming a COVID-19 statistic. Our immediate concern was for R’s mother, who had the medical conditions associated with poorer outcomes from COVID-19. In contrast, his father was the healthy parent with the good genes who, with his tall, broad muscular frame and erect posture, easily looked a decade younger than his 80 years. He was the caregiver to his wife, walked five miles a day, had no major illnesses, and had never spent a day of his life in the hospital.
This was not to say his life had been free of strife. He was the only member of his family of origin to leave his small Indian town for a better life in London. Even though he had an Indian master’s degree, he took the demotion required for so many immigrants and worked in the British postal office as a mail sorter. Once, during the 1970s, on his way home after working a double shift, he was viciously attacked by a group of skinheads at a railway station, and his subsequent police report went uninvestigated. He lived through the loss of his youngest daughter who died of childhood leukemia at age seven. Living far away from his beloved parents during a time when air travel was neither affordable nor frequent meant he was unable to make it home in time for either of their funerals. Despite all these cumulative wounds, he maintained a fastidious concrete positivity about life, saying, “Everything is fine, there is
nothing to worry about.”
In the days leading up to Christmas, R called his parents everyday inquiring about their symptoms. Fever? Cough? Shortness of breath? Did you eat? How much water did you drink? In the backdrop, we continued to digest the local news reporting on hospitals running out of oxygen, ambulance shortages, and packed emergency rooms. Determined to avoid either of his parents needing to be hospitalized, R had a pulse oximeter shipped to their home and called 111, the National Health Service helpline, on their behalf, which resulted in a prescription for an antibiotic for his mother but no further recommendations for his father other than to keep rested and hydrated.
As we headed into the new year, R’s mother appeared to be slowly recovering, but the same could not be said for his dad. The frequency of our check-in video calls increased as we registered a dissonance between his self-report, “I’ll be fine…don’t fuss,” and his gaunt face and lethargic appearance. We could not shake the feeling that he was an unreliable narrator, not because he was intentionally deceiving us, but rather his ingrained stoicism was distorting his own perception of reality. Relative to what he’d endured in his immigrant life, how much harm could a little infection really do?
R and I had grown up bearing witness to our parents’ suffering, whether it was the misery caused by major traumas or the torment of the daily microaggressions that accompanied life in a country where the color of their skin rendered their voices unheard. The absence of safe spaces in our childhood meant self-reliance within the family became a necessity, and this included us, as children, taking on the role of becoming parents to our own parents. Merging with their suffering led to a role reversal, as we learned from a young age to constantly worry about our parents’ physical and emotional wellbeing. This process of parentification also meant that in the face of our parents’ Old World suffering, any New World hurt we experienced paled in significance. We learned to negate our own feelings, and in merging with part of a more painful whole, we ourselves ran the risk of making our own emotions invisible.
In his late 20s, R had tussled with his father, urging his parents to move from his ever-declining childhood neighborhood, a place R had come to equate with their chronic sufferance. R was contemptuous of the mindset of the average Londoner now living in this postal code and perpetually frustrated by the lack of good healthcare available to his aging parents in an area that had become overpopulated and under-resourced. Yet his father resisted R’s arguments to move to a “better area.” Maybe he’d become too attached to the home he’d lived in since 1973, a house full of memories of his children when they were young, including memories of the daughter that never made it to adulthood? Perhaps my father-in-law had no energy left for another move as he had thrown every ounce he had into that original move from India – a destiny-changing move, which ensured his children and grandchildren a whole world of different opportunities? By his 30s, R and his father reached an uneasy truce on the topic; by the year R turned 40, both father and son had settled into a more peaceful acceptance about the situation. R quit trying to parent his own parents into making a decision he felt was in their own best interests. All this meant that for the 20 years that we made our annual visit to England from America, our first stop was the modest terraced East London home of R’s youth. My father-in-law seemed to possess a sixth sense about when our taxi would arrive, because he was always there, standing outside, to greet us: a kiss on the cheek for R, a fatherly touch of my forehead that conferred me with his blessings, and hugs, laughter and an abundance of grandpa jokes for our growing children.
Now, stuck in the eye of a COVID storm, R was again thrust into the role of parent. Immigrant kids often end up making decisions for their parents that, in an ideal world, no child should have to make, and they are also left to deal with the burden of the excessive responsibility that comes with such choices. On the morning of January 3, after R’s verbal poking and prodding, my father-in-law admitted that he was feeling a bit short of breath first thing in the morning and last thing at night. Within minutes, R made the call for an ambulance and, later that day, his father was admitted to a hospital in the heart of an East London borough with a mild COVID-19 pneumonia.
Whatever hope we might have once held that my father-in-law would make a complete recovery from COVID-19 dwindled on day five of his hospitalization, when his doctor called to inform us that R’s father was struggling to breathe, and they were now giving him hospital-grade oxygen to keep his saturation levels in the normal range. According to the doctor, while there was still a reasonable chance of his recovery, he remained in real danger and the next seven to ten days of progress would be critical in determining his overall prognosis. This sobering statement was followed with an obligatory discussion with the family about end-of-life and do-not-resuscitate decisions.
Along with this heart-breaking turn of events, I witnessed a shift in R who, faced with the possibility that his father might die, aged overnight. With each subsequent FaceTime call he made to his dad, his own hair greyed, the circles under his eyes darkened, and his weight steadily dropped. A tenderness seeped its way into their conversations, and I watched how, during this time of crisis, the considerable differences in their ideologies dissolved, revealing instead only their stark similarities. On one particularly tough day, when hope was evading even my ever-optimistic husband, R choked up during his FaceTime call with his father. “I’m not leaving England till you come home from the hospital, dad.”
In the Old World Indian patriarchy, honoring one’s father is one of the highest virtues, and Lord Rama — an avatar of the god Vishnu, the most virtuous hero in the Hindu religion, and a person revered the world over for his goodness as a son — remains the personification of that ideal. During the distressing days of witnessing his father’s demise, I watched R’s strong sense of filial duty emerge as he took on that ancient avatar for himself. The patriarchal burden that had, until now, rested on his father’s shoulders now shifted directly to R’s, bypassing any surviving parents or other family elders.
***
Dr. P’s unexpected Friday evening call interrupted my evening meal preparations, so as R started calling family, I returned to the kitchen reasoning that he had not eaten properly all day and he needed something in his stomach before he would leave for the hospital. I finished boiling the abandoned half-cooked pasta and doused the rigatoni in a pre-made carton of tomato mascarpone sauce. As the adrenaline-fueled distress of the evening ebbed, my mind started to churn. The doctor in me played out the consequences of R going to the COVID ward to be at his dying father’s bedside. What would come of him exposing himself to this more virulent and deadly strain? None of us have had COVID (so no natural immunity), nor have we been vaccinated, so our best-case scenario was putting R in strict isolation on the top floor of our rental and spending 10-14 days hypervigilant for signs of fever, cough, loss of taste or smell, all the while remaining COVID negative. A daunting scenario, but nonetheless doable. What if his hospital visit resulted in a mild case of COVID-19? That, we could also handle. I had packed some basic medical supplies and PPE in my luggage, he could monitor his symptoms and communicate updates to me via phone, and I could deliver food to his bedroom door until he was COVID-free.
What if his symptoms took a turn for the worse? That scenario fueled a sick feeling in the pit of my stomach. What if he became too sick to measure his pulse oximeter reading or too weak to get a tray of food or communicate with me by FaceTime? I’d have to go in with my basic PPE to nurse him, but what if I got sick too? How would I ensure it did not spread to our children? And what about the worst-case scenario – what if his symptoms were severe and we had to call for an ambulance? As a middle-aged man of South Asian origin being treated for this deadlier variant of COVID-19, in an overloaded government healthcare system, what would his prognosis be?
Every fiber of my being knew R’s decision to go to the COVID ward was a mistake. Yet shockingly, despite having an honors degree in microbiology, over 20 years of experience as a practicing physician, and world-class science training, I was frozen and unable to challenge R to rethink his decision. The last few weeks of bearing witness to R’s filial duty toward his sick father had thrown us both back into the Old World values of our youth where patriarchy reigns supreme. As a wife and daughter-in-law, what I had to say under these circumstances paled in significance, even though I understood the risks better than most and I was the one who had to take on the side effects of R’s decision. I stood staring out of the kitchen window into the pitch-black evening darkness and felt myself shrinking. My father-in-law’s fatal illness thrusted us back into the ingrained rhythms of our ancestral DNA where R plays Rama and I, by default, am forced to assume the role of his wife, Sita.
Sita is the cultural ideal of a woman that permeated my childhood. Sita, the wife of Lord Rama and an avatar of the goddess Lakshmi, accompanied her husband into exile and was then abducted and imprisoned by the evil Ravana. Upon her release, she underwent an ordeal of fire to prove her purity, only to be banished by Rama, in deference to his public’s protests that her captivity had tarred her. The world in which I was raised attached a nobility to a woman who was a Suffering Sita – the good wife who says yes to others, even if it means saying no to herself, over and over. To this day, billions of Hindus all around the world celebrate this ancient union as ideal – a symbol of love and devotion, even though the virtuous Rama was guilty of benign neglect toward Sita: ignoring her undesirable circumstances despite the fact he also held responsibility for them.
When R and I came of age in the early 1990s, it was still acceptable for brown British girls to be coerced into arranged marriages with grooms from the Indian subcontinent. With our “love marriage” (our decision to marry was driven by us, not our parents), R and I made an unwavering commitment to modernity: we lived together before we got married; I did not take his last name; R supported my career aspirations, which meant that, on paper, I would become more educated than him, and the two decades we’d lived in America represented us building a life where we took turns prioritizing careers, housework and childcare.
Yet, as the years rolled by with us both reaching for the heights of our careers, all while caring for children at home and aging parents abroad, our marriage had periodically been branded with the deep cultural imprint of Ram and Sita’s inequitable relationship. This ancient traumatic rhythm manifested with my claim that, despite doing the lion’s share of work that kept our demanding 21st-century household running, R did not truly value me. R’s response? He did value me and had no idea what I was fussing about. This bristling had previously stirred deep discontent in our modern relationship, and here it was again, this time triggered by a global pandemic.
I reached over the Miele stove top to switch off the electricity and cast the pasta pot, now holding a hot, red gelatinous bundle of rigatoni to one side. I felt an oppressive patriarchal force burrowing down through the centuries and forcing me into silence – a force so strong it rendered me illogical. I had the professional expertise to understand the gravity of this situation, yet I felt I didn’t have permission to speak. I sensed the Old World pressures that were, once again, straining my marriage. Then, perhaps due to the months of built up COVID-related existential angst, a moment of clarity: These patriarchal forces were so entrenched they will seep into every aspect of my life forever. I had to draw a line in the sand that represented enough and rid myself of every trace of the Suffering Sita within me. It dawned on me that the only thing that mattered in this moment was that no one else in this family got sick with COVID-19, and I had to do everything in my power to ensure that outcome – even if it meant that R and I would have the biggest fight of our marriage, a conflict powerful enough to sow the seeds of its eventual destruction.
Just then R burst into the kitchen and rushed toward me, sweeping me into a tight hug. Pressed against his chest, I heard him breathing hard. Fighting back tears, he said, “I can’t go into the hospital. Who will perform Dad’s last rights if I get COVID?”
In traditional Hindu culture, the last burial rites of a parent are the responsibility of a son – an assignment grounded in an ancient belief that only a male heir has the power to pave the way for his parent’s soul to reach “moksha,” or heaven. As his father’s only son, R assumed this duty as it lay squarely on his shoulders. On a better day, a day before COVID-19 had wreaked havoc in our lives and world, R and I would have debated such antiquated beliefs and their relevance to our modern lives, but this was not the time for such a discussion. It was my father-in-law’s belief that R should perform his last rites, and in the face of his impending death, nothing else mattered. As I held R tight, I felt relief that he had organically come to the same decision (albeit for different reasons) that moments earlier I was ready to go to battle for. I also felt deep sadness that he had to choose filial duty over his wish to be at his dying father’s bedside.
That night, we were lying in bed, sleep evading both of us. I wrestled with R’s decision. I feared the downstream mental health consequences of such a traumatic choice – would he suffer guilt, depression or a complicated bereavement? I started to second-guess myself. Had I blown the risks of getting infected out of proportion? My insomniac churning sparked a possible solution. My father-in-law at the time was COVID-negative and received only palliative care, so perhaps he could have been transferred to a non-COVID ward? A ward where the risk of exposure to a visitor was slim? This was a more justified risk that R could take, so duty would not rob him of a chance to hold his dying father’s hand.
Early next morning, we called the hospital and asked to speak to the doctor on call. I explained the situation, asking if an accommodation could be made. The doctor listened patiently, and then in a calm voice, laced with the heaviness of fatigue, reminded me of the gravity of the situation.
“There is no non-COVID ward in this hospital, every ward is now a COVID ward. It’s not a good idea to come to the hospital…you can catch COVID walking down the hallway.”
***
The weekend marked the start of a virtual vigil at my father-in-law’s hospital bedside. Over these hours we slowly accepted our family’s defeat against COVID-19 and let go of any hope for his recovery. We shifted our energies, instead, toward ensuring he has a peaceful death. A Hindu priest delivered a last prayer, via telephone, and religious music played softly in the background as he took a few sips of the Indian holy water (ganga-jal) that my mother-in-law delivered to the ward.
As he was lying in the hospital bed, a reduced version of his former self, struggling to draw each breath, he somehow summoned the strength to listen to our final messages for him. Then, with determination, he shared his last words of advice for his children and grandchildren. When it comes to R’s turn, I mentally predicted what he might say.
“Take care of your mum,” or “You are the man of the house now” – loving reminders of what is expected of R in the years ahead: a formal passing on of the responsibility baton from immigrant father to son.
I imagined R’s response in return, seeing him bravely conjuring up the boldness required to give his dying father the reassurance he needed.
“Don’t worry, Dad, I’ve got this. I’ll take care of everything.”
But then my father-in-law took us by surprise. For a man not known for his mastery of the spoken word, he spoke with poetic lucidity, voicing a single intimate sentence he never explicitly stated to R before.
“You are my good boy, my special boy, I see your face every time I close my eyes and you’ll forever live in my heart.”
R broke down in tears and, because our lives have been intertwined since we were teenagers, I knew what he was feeling. A burden lifted from his shoulders as his father’s deathbed message did not consist of a wish, request or instruction. It was a sentence, without conditions, signaling to R that he was known by his father, that he was seen by him and that, more than the Old World values of duty, respect and honor, pure love was what ultimately defined their bond.
The next day, as the sun shone uncharacteristically bright for a January afternoon in London, my father-in-law peacefully slipped away. COVID-19 may have caused his death, but in his last words to R, he ensured the virus will not leave indelible scars on his son’s psyche. Instead, his dying message provided R with the sustenance he will need to eventually heal from the sudden loss of his father, beautiful words that will, in time, form a bridge transporting us safely from our Old World traumas back to our New World lives.
Shaili Jain, M.D., is an Adjunct Clinical Professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. She is an internationally recognized leader in communicating to the public about trauma and PTSD. Dr. Jain’s acclaimed debut non-fiction trade book, The Unspeakable Mind: Stories of Trauma and Healing from the Frontlines of PTSD Science (Harper, 2019), was nominated for a National Book Award. Her essays and commentaries on trauma and PTSD have been presented by the BBC, CNN, The New York Times, STAT, Newsweek, The Los Angeles Times, TEDx, public radio, and others.