Karachi, Pakistan - Before I saw my mother in May, I had been dreading the meeting. I had no idea what to expect.
She was angry and resentful the last time I saw her. She had been cloistered inside a rehabilitation facility in Karachi since late 2015 and was fiercely resisting treatment. Soon after she arrived, her team of carers - a psychiatrist, the founders of the rehabilitation centre and her "psychological rehabilitation person" - had wanted to change tack and cut off all contact with the family.
She has to feel that there is no way out of here except through us, they said.
She was furious at the bind she found herself in - admitted to the facility by her family, and unable to voluntarily opt out of the programme. She wanted to leave and couldn't understand why we wouldn't allow it. It isn't her first stint in rehab, but it is the first place where she cannot bully, argue or sweet-talk her way out. There are guards at the gate here.
I am told to wait in a conference room on the ground floor. A woman walks down the stairs. There's a shaft of afternoon sunlight at her back and I can't make out her face. But she has the shuffling, slow gait that I know well - her feet drag with each step, her head droops.
I brace myself. But then the woman moves out of the light and I see that it's not her.
When my mother does appear, the first thing I notice are her high, full cheekbones. Last time, they were anchored by puffiness. I'm surprised by the significant amount of weight she has lost.
"How are you?" she asks, as she reaches out for a hug. It's a simple question, but not one that she has asked in a very long time. Her hair is combed. She wears berry-coloured lipstick. Her clothes are clean and ironed.
She sits beside me at the table and leans forward.
"You're looking very nice," she says. "Your hair has grown so much!"
Has it? I am embarrassed by the attention. You look nice too, I tell her bashfully.
"How is your work at the magazine?" she prompts.
"I stopped working at the magazine in 2011," I remind her. She pauses. The hair, the job - she remembers me as I was five years ago.
|The author with her mother in Karachi around 1987 [Courtesy of Sanam Maher]|
Before and after
My mother is one of the millions of addicts or substance abusers in Pakistan.
My sisters and I brought her to this rehabilitation centre, The Recovery House (TRH), in the last week of December. As 2015 wound down to a close, her driver found her early one morning on the kitchen floor, unconscious from an apparent overdose of prescription medication. We didn't know what she had taken, or how long she had been unconscious.
After a certain number of hours, it is too late to pump someone's stomach. We were told she had been lying on the floor for longer than that.
My mother has never made peace with her childhood. Her resentment at being left behind in Pakistan as a young girl, raised by relatives while her parents travelled the world for work, festered for decades. Her doctors say her depression, and later her substance abuse, find their roots there.
She would get high, she tells me now, because she wanted to be numb. "I thought, 'I'll overcome the pain,'" she explains. "Problems didn't exist when I would get high."
My mother's dependence on painkillers and sleeping pills crept up on her.
I thought, 'I'll overcome the pain' ... Problems didn't exist when I would get high.
As a teenager who suffered from frequent headaches, she grew to like the relief simple painkillers like paracetamol offered, reaching a point where she would sometimes "fake" a headache in order to be given the medicine. She liked the small buzz she got, she once explained.
A little over a decade ago, the headaches became debilitating migraines, and she was prescribed a stronger painkiller - an opioid analgesic - which needed to be injected.
At what point did the migraines ease while the prescription continued to be filled? I cannot remember. I can only recall before and after.
Before: I am seven years old and have a pair of purple and white roller skates, bought on a trip to London in 1992. My mother holds me by the hands and propels me through Hyde Park. In Karachi, we celebrate Christmas every year in honour of my Christian nanny with a small fake fir and snow that comes out of a spray can.
My mother is Pakistan's first female maxillofacial surgeon and when I take a fall into an empty swimming pool and split open my chin, she stitches it up so deftly I barely feel a thing. She gives me a boomerang from her travels to Australia with the World Health Organization because I don't cry.
After: Those hands are unable to operate because they are so swollen from the medication she injects herself with. She misses birthdays because she is "unwell". She begins to eat the same paan slaked with the addictive and euphoric mix of tobacco and areca nut that she researched for years as one of the first to uncover its inevitable link to oral cancer.
I am 17 and living in London, waiting each day for a phone call from Karachi after she tries to kill herself and ends up on a ventilator in the ICU.
She loses track of days, months and then years, not knowing when her five daughters graduate from college or begin working. In 2014, she is "unwell" and misses my wedding.
|The author's mother at a wedding in Sialkot, Punjab, in 1976. She grew up in this city, living with relatives while her parents travelled for work [Courtesy of Sanam Maher]|
Opiate abuse and government neglect
There are 8.9 million substance abusers in Pakistan today, and the number is steadily rising. In less than three years, 2.2 million people became new users.
According to a 2013 survey on drug use in Pakistan by the United Nations Office on Drugs and Crime, or UNODC, an estimated 1.6 million people misused prescription opioids, taking them for non-therapeutic purposes, without doctors' advice or orders.
The UNODC 2014 World Drug Report confirmed that the prevalence of opiate use in Afghanistan, Iran and Pakistan was among the highest globally, and in Pakistan, had risen from 0.7 percent in 2006 to 1 percent in 2013.
In five countries including Pakistan, the non-medical use of pharmaceutical drugs was found to be higher among women , who buy medication such as Xanax or Lexotanil to counter everything from anxiety, stress and insomnia to marital problems and weight gain. The medication is often doled out to friends as well. The Drugs Act of 1976 regulates the sale, manufacture, storage and distribution of such drugs in Pakistan and prohibits the sale of certain drugs without a prescription.
My mother's habit, however, spiralled out of control within a system that made it possible to buy a butterfly needle with bread at the nearest general store - no questions asked.
The 2013 UNODC survey revealed that those wanting to seek treatment for addiction in Pakistan deemed private treatment centres to be more effective; only 20 percent said they would trust a government facility. Yet, a staggering 99.7 percent of those surveyed simply cannot afford the treatment they need.
Even as an estimated 700 Pakistanis die each day from drug-related complications - even more than the number of lives lost to attacks by armed groups, an estimated 39 a day - the government severely neglects the health sector. In the last financial year, it spent only 4 rupees (about 4 cents) on each addict's healthcare or rehabilitation, or 0.42 percent of the 26.8bn rupees (about $256m) allocated to health in the federal budget.
On June 3, the government announced the proposed budget for 2016-2017. In its current form, spending on health has been slashed, with less than 1 percent of the budget, or 24.95bn rupees (about $239m), to go towards healthcare. In comparison, defence spending is up by 11 percent, with 860.1bn rupees ($8.2bn) allocated to this sector.
"There is no proper policy for maintaining rehabilitation centres in the country," the director general of the Anti-Narcotics Force, Major-General Khawar Hanif, told parliamentarians in 2015.
We learned how there is "no proper policy" from one facility in Lahore where patients live in such squalor that my mother emerged without drugs in her system, but with a head full of lice. Another institute in the same city handcuffs patients suffering from withdrawal symptoms to their beds. One facility with branches in Islamabad and Lahore bases its treatment on a regimen of prayers five times a day, spiritual counselling and Quranic education.
My mother's experience taught me that in Pakistan it is not enough to want treatment. Finding it is the first of many hurdles to recovery. According to the UNODC survey , 99 percent of respondents said there were no inpatient treatment options they could access where they lived. For the lucky ones with facilities in their area, 87.1 percent of respondents said there weren't any available slots.
It's a common refrain among those battling addiction, or with family members who are, even if they can afford the best healthcare available in the country. It is the reason a place like TRH exists.
The Recovery House: Treating substance abuse and mental illness
Six years ago, three siblings who were unable to find a suitable rehabilitation facility for two family members suffering from mental illness founded the small 15-bed facility. As a psychiatric rehabilitation centre, TRH works on the premise that substance abuse problems can be symptomatic of untreated or mismanaged psychological or psychiatric issues. TRH is the first place where my mother has received treatment from people who understand how a psychiatric illness and an addiction can tear through the lives of those who love her.
Dr Shahida Mirza, a retired major and now the director of TRH, is one such person. A gynaecologist by training, she first arrived at the institute with an MBA and a desire to work in administration, but with little understanding of addiction and rehabilitation.
"I hadn't really encountered mental illness before I came here, and I used to think it was just an excuse for people to overreact to things," she recalls.
She changed her mind once she witnessed patients having psychotic episodes. The real turning point came when she heard the stories of parents who brought their children to TRH for addiction treatment.
"It all sounded so familiar to me when I looked at my son [who was then about 15] and how he was behaving," she says. "I began to wonder, is my son doing drugs? If this can happen to someone else's child then why not mine?"
A urine test confirmed the presence of opioids in her son's system, and he admitted to using heroin and smoking hashish. As TRH only accepts patients diagnosed with an underlying psychiatric or psychological disorder, Dr Mirza’s son did not qualify for treatment there.
My son soon became one of the zombies there.
"My son was desperate to stop using, but he was scared of the withdrawal symptoms," she says. "He was admitted to a rehab in Lahore, but they didn't believe in weaning him off the heroin with replacement drugs, saying it is equivalent to killing the patient slowly with poison."
When patients couldn't control the side effects of going cold turkey, body builders hired by the rehab would pin them down while a staff member administered a sedative.
"My son soon became one of the zombies there," Mirza recalls.
|The author's mother with her first child in East Ham, London, 1977, a few months after moving to the UK for work [Courtesy of Sanam Maher]|
No evolution in how addiction is treated
Dr Uzma Ambareen, the medical director at TRH, has been practising psychiatry in Pakistan since 1998. In her opinion, the approach to treating addiction in the country hasn't evolved in those 18 years, with most medical practitioners or rehabilitation institutes focusing only on curbing the substance abuse or detoxing in this way rather than understanding what feeds the addiction.
The method all but ensures a high rate of relapse, she says.
"Most people in Pakistan, and this includes doctors, believe that using or abusing a substance is a choice and it is within your control," Dr Ambareen explains. "If you're an addict, they think you're being indulgent. You're being bad and you can stop, but you're choosing not to."
After his third relapse, Mirza's son refused to return to rehab. She combed the country for a facility that could help him. She found that while many followed the practices of his former rehab, some did not allow her to enter the facility to see what it was like. Ultimately, she decided to help her son herself. Under the supervision of a psychiatrist, she detoxed her son at home.
Most people in Pakistan, and this includes doctors, believe that using or abusing a substance is a choice and it is within your control.
"I don't even want to recall how difficult it was," she says. For the first 24 hours, she held her son's convulsing body and prayed for the replacement drugs to work. When he attempted to leave the house to buy heroin, she decided to drive him to his dealer and administer his drugs herself.
After a few months of sobriety, he relapsed once again.
"I just couldn't go through the process once more, and I took him to an institute in Thailand where he could get the treatment he needed," she says.
After eight months and $40,000 in loans to pay for the rehabilitation, her 25-year-old son has been clean for the longest period since he was 16 years old.
The key, she feels, was the intensive therapy process that helped him understand the roots of his addiction.
TRH takes its cues from this form of rehabilitation, focusing on psychological and social interventions rather than chemical or pharmacological ones. Thus, patients, or "clients" as they are referred to, spend their days not just in group and solo therapy sessions, but in gardening, music, and computer classes. There are trips to the beach and a bowling alley.
"The idea is to work with patients with long-term chronic disorders, beyond medications," Ambareen explains. "We want to get them as close to where they were before the onset of their illness, and to restore their functionality to as close to 100 percent as possible."
The process, she says, can take months, and even then TRH cannot guarantee that the patient will not relapse. TRH insists that patients are "for life" - they must touch base with the facility after they leave to stay on track. Ambareen is hesitant to quantify the facility's "success rate", explaining, "There are successes and I guess what you would call 'failures', but you have to remember that the illness itself is characterised by relapses. And the risk of relapse in patients with substance abuse is very, very high."
|The author's mother in Piccadilly Circus, London, pregnant with her oldest daughter. This photograph was taken shortly after she arrived in the city from Karachi [Courtesy of Sanam Maher]|
Families stop expecting much
Unfortunately, many patients are pulled out of the facility by family members who believe there isn't much to be gained from long-term treatment.
"Most people here do not understand the concept of psychiatric rehabilitation," Ambareen feels. "We're living in a country where most psychiatrists don't even get it, let alone other doctors or families."
"Most of the time the family just wants the person's symptoms to be controlled," she says. "Once the patient is not being violent and eating three meals a day, the family says that is adequate. They stop expecting much."
With little understanding of the concept of rehabilitation, families accuse doctors of ulterior motives for wanting to keep treating a patient - the monthly fee of 125,000 rupees (about $1,200) for inpatient treatment.
"They think we're out to make money," Ambareen says. "We may feel the patient is just at the beginning of their rehabilitation, and can go on to become productive, get a job, or be in a relationship, but the family has given up on that a lot of the time."
While TRH tries to educate families about the nature of psychiatric disorders or addiction, many parents refuse to attend sessions.
Once the patient is not being violent and eating three meals a day, the family says that is adequate. They stop expecting much.
"They are scared of people finding out that they come here or that their son or daughter has a problem," Mirza says. "They worry that their other children will be judged or will not receive marriage proposals if word gets out."
All patients who leave the facility are strongly urged to follow up, but Ambareen has found that those who have been prematurely pulled out of the programme, and especially those with chronic relapses, rarely do.
Instead, they are often committed to long-term mental hospitals, as many people believe mental illness or addiction cannot be treated or managed.
TRH donors currently sponsor some patients. The goal is to expand the facility to a 50-bed space, with 30 percent of the beds free of cost. In five years, Mirza hopes that the foundation is able to create a "recovery village", with small apartments for patients who cannot return to their families, or who wish to live independently.
"One of our greatest problems is where do clients go once their treatment is complete?" Mirza explains.
"Sometimes, the family will not want a recovered addict - especially those with underlying psychiatric problems - to return to their home," Ambareen says. "They believe the illness or disorder is contagious."
|This photograph was taken in the author's parents' home in East Ham, London, in 1977, one year after they moved to the United Kingdom [Courtesy of Sanam Maher]|
I hope we meet again soon
I don't know the pain of a parent's death. But I do know what it is like to lose someone every day. The loss is renewed with each relapse. Every schoolteacher or family friend who tried to mother my sisters and me only underscored the absence.
This is not to suggest that my mother is perfect. She can be vain, foolish with money, quick-tempered, dramatic and selfish. She can be impossible to care for. It is difficult to remember her most endearing qualities. She was a woman with beautiful style; she paired hand-painted silk scarves with simple cotton shalwar kameezes and saved her Ferragamo and Ungaro purses for her daughters.
That is what I remembered when we found her walking around her house without a stitch of clothing on early one morning. She was a wonderful cook, and loved to throw dinner parties, listening to ghazals as she dressed for the evening. We never hear from those dinner guests any more. My mother has no friends today.
I cannot blame them. I did not talk to her for a year at one point. Those who know about her problem distanced themselves from our family; many disapproved and blamed my mother's problems on an unhappy marriage or on her children. They told my sisters and me that we would be "punished" with children who treated us just as we treated our mother.
I don't know the pain of a parent's death. But I do know what it is like to lose someone every day. The loss is renewed with each relapse.
My mother's psychiatrist has warned us that a fatal overdose was likely. "I am very surprised that your mother is still around," Ambareen tells me. "People run out of luck a lot sooner than this."
I believed my mother's addiction would end only in death, and on the worst days, I hoped that time would come soon. The pain of losing her, I thought, could not be as bad as the suffering of watching her disappear.
After five months at TRH, however, my mother is a stranger to me. I learn that she loves to play Scrabble. She meticulously records details about her day in a diary. She is reading again.
Every evening, a cook at TRH brings her a cup of tea and sits with her as she teaches him the English names for everything he cooks and sees in his kitchen. She uses an Urdu-to-English translation book bought on one of her trips to a bookstore.
One weekend, he visited an island near Karachi. When he returned, he asked her to teach him the English words for what he saw. She taught him how to talk about the boats and fish, the sea and sky.
She makes detailed plans for what she will do once she leaves TRH. Her daughters are married or live abroad, and she is separated from my father. She wonders how she will occupy her time or live alone.
"We had a group session this week that I liked," she told me when I last saw her. "How to make new friends."
"Tell me how," I say.
"Well, it depends," she replies. "Am I at a party? What kind of gathering is it? Do I see someone I am interested in? Do they give off happy vibes or do they look nice? How do they talk? If I want to make a friend, I would approach that person, say hello and try to get to know them." She pauses. "I would tell them about myself, but not personal details. I'll wait for the time to do that."
"Pretend I am a new person," I tell her. "Shall we pretend we are at a dinner party?"
"No," she says. "Not a dinner party."
"Hi," I say. "I'm Sanam."
"Hi, Sanam," she says with a smile. "What are you doing here at the conference? Are you a speaker or a listener?" She starts laughing.
"I'm a writer, actually," I say.
"Oh really? Would I have read any books you've written?"
"I don't write books, Mum," I say.
"Give me your card," she urges, still in character. "I'll look you up. They're calling us into the session now, but can I get in touch with you later? It was really nice to meet you. I hope we meet again soon."
Follow Sanam Maher on Twitter: @SanamMKhi