Zoya Gul

RUNNER UP

The Cost of a Few Rupees

Coarse liver echotexture with irregular margins. Multiple lesions are noted, likely multifocal HCC. The largest lesion measures 6.8 x 4.7cm. Portal vein shows tumour thrombus.

“Is it curable?”

My mum frowned, examining my face for signs of concern. Since starting medical school five years ago, I had become my family’s foremost medical authority.

I scanned Nano’s report again. Three letters blinked at me from the page, unmoving: HCC. To most, a quiet, unassuming little abbreviation. To me, something else entirely. 

HCC. Liver cancer.

My throat dried. This was a situation I had encountered so many times during my training— the invitation to a quiet room, the ‘warning shot’, the gentle breaking of the news (“I’m really sorry to tell you this…”), the box of tissues slid routinely across the table. But now, language escaped me, and the entire performance crumbled. I simply shook my head.

*

I was two when I met Nano, my mother’s mother, for the first and last time. I have no memory of my trip to Pakistan to visit her, but the photo evidence remains: little me feeding goats, clambering up the side of a motorcycle, and sitting in my Nano’s lap, an exaggerated grin plastered across my face. Growing up, Nano’s voice was a constant feature of my Yorkshire household, where my mum called her daily. My own interactions with her never extended beyond polite niceties— an inherited love expressed through broken, heavily accented Urdu and awkward smiles delivered over video call. When she fell unwell, I was brought closer to her in a way I never expected.

The doctors had given Nano just six months to live. By the time my mum flew to Pakistan, she was already bedbound. Having just started my final year of medical school, I remained in the UK. Throughout the day, I received a steady stream of medical updates from my family abroad, which I hastily reviewed in between lectures and ward rounds. I was the only person they knew— the only person they trusted— who could translate the alien language of drug lists, radiology reports and blood test results into something comforting, something that made sense.

But to me, nothing about Nano’s care or illness made sense. A mistrust of Pakistani healthcare meant that she was being cared for at home by her children, none of whom were medically trained. Over video call, I watched my aunts and uncles insert cannulas, set up IV infusions, and draw up injections without a sterile field in sight. Whilst her children fumbled over her, Nano’s emaciated figure would lie unmoving on the bed, her head propped up against a pillow to aid her strained breathing. Even through the blocky pixels of my phone screen I could make out her changed body: eyes a highlighter-yellow, abdomen tight and swollen, bones protruding. Needles pricked the back of my eyes. There was my Nano, reduced to a set of clinical signs and symptoms. My Nano, a page of a textbook.

*

Later, I discovered the reason behind my family’s distrust of Pakistani healthcare. A prior hepatitis infection, caught from a reused hospital needle, had led to Nano’s cancer. With horror, I learnt of how the infection became chronic, then cleared once antivirals became affordable almost a decade later. By then, the damage was done. The sequence of biological events that would ultimately lead to her death had, unbeknownst to my family, been set into motion. A single plastic needle— a couple of rupees’ savings— had sealed Nano’s fate.

A flame, red and searing, swelled up in my chest. The situation was unheard of in the UK, where clear guidelines and protocols dictated patient care. ‘Free at the point of delivery’ was the driving principle of the NHS, but in Pakistan, profits took precedence over lives. I thought of the hospital wards I attended each day, with their shiny floors and freshly packed sterile equipment, and a haze clouded my mind. The makeshift hospital room where Nano lay dying was dingy in comparison, slowly filling with sewage water as Pakistan battled heavy floods. I thought of how my British passport was the only thing that protected me from a similar destiny, and felt the bitter guilt pierce my stomach.

As Nano deteriorated further, a number of profit-generating interventions were suggested by doctors, despite no clear clinical reasoning to support their use. I was consulted over each decision, and spent desperate hours scouring the internet for NHS guidelines and medical publications, for any sort of framework of care to cling to. Despairing, I realised that such guidance was pointless in a country where money dictated which care was possible, and for whom. By this point, repeated glucose measurements had left Nano’s fingertips roughened and scabbed (an alternative way of monitoring was, of course, too expensive), and nobody knew if her morphine dose was sufficient enough to allay her pain. The flame in my chest roared larger and larger.

“How much longer do you think she has to live?” my mum whispered to me one day over the phone. It was six weeks after her diagnosis, and Nano had stopped eating, drinking, and urinating. It did not take a medic to understand that she was now hovering between life and death. Her jaw hung loose, her breath rattling against the flimsy oxygen mask my uncle had sourced from a nearby pharmacy. I had taught him how to measure Nano’s oxygen saturations, how to adjust the flow rate of the device. Did it make a difference? I found myself wondering. Had anything I tried?

I remembered my mum’s question. The conditioned, ‘exam’ response surfaced in my mind, but I shooed it away. My eyes and ears and throat were on fire. What use were careful words now? Nothing in my medical training had prepared me for this. No amount of knowledge or clinical language could explain what had happened, or why. No words could hold the weight of my heartbreak.