Chronicity and COVID-19: Kinship,Illness and the State in Pakistan

Abstract

Based on a year-long study involving interviews and surveys among low-income households in Karachi and Lahore, this article describes how participants articulated their experience of the pandemic through ideas of ‘chronicity’ which consisted of poor material conditions, longstanding health problems, and the risks of COVID-19 infections. I consider the bundling of the three elements in relation to the Pakistani state’s imposition of social distancing regulations through its security infrastructure which resulted in reinscribing social differences based on class and religion. Through ethnographic research, I consider how the centrifugal forces at play in the cities at large were negotiated in kinship as members came together during times of illness and emergencies, and conversely, when care to intimate kin was neglected as social distancing practices were taken up selectively in a way that overlapped with deep seated hostilities within families, resulting in further impacting the health of the vulnerable in the absence of adequate health services.

Introduction

‘Paisay atay hein tou log bhee (people come as money comes)’, said Faiza, a maid working in a gated community in Lahore. ¹ Her husband had recently lost his job and found employment in the same house where she worked. The loss of job led to a much more stable arrangement for Faiza and her husband when other participants of our research suffered from the economic downturn in the country. Yet stability entailed newer forms of responsibilities. For instance, Faiza and her husband’s increased income followed the entry of Faiza’s sister as well as her brother-in-law in her household. The sister had escaped the beating of her husband, and Faiza had to take the painful step of asking her to return to the husband’s house when Faiza’s own family, including her three children were being deprived of the fruits of her hard work. The increase in income led to tensions between the husband and wife especially when the husband wanted his brother to stay which Faiza disagreed with. In low-income households where I conducted interviews the need to socially distance involved continuous negotiations with kin and settling existing obligations towards them, which included providing care to the elderly as well as others in need. Faiza’s father-in-law died during the study after suffering from heart enlargement, who was taken to a retired military doctor by one of his employers, also a retired officer of the Army, which sparked jealousies due to preferential access to healthcare among relatives, especially in context where other relatives had been deprived of basic healthcare.

Among affluent families, one extended family of Delhi-wallas were interviewed in Karachi who continued to gather with relatives, until three COVID-19 related deaths took place, after which their patterns of interactions shifted to interaction only within the immediate family, including daughters and sons-in-law. The same was not possible in a low-income neighbourhood, where networks of obligation such as care for the vulnerable and demands for the repayment of loans led to an inflow and outflow of relatives. For many like Faiza this decision was very difficult because she simply could not deny the entry of relatives in her household during times of distress.

What then has been the impact of COVID-19 on social solidarities? More specifically, how does illness result in scepticism within kinship? Historians writing about epidemics in colonial India have commented on their impacts on pitting people against each other resulting in social tensions being heightened not only between but also within classes (Chandravarkar 1992: 232). In Pakistan, scholars usually consider biraderis as the basis of social organisations. Biraderis may refer to one’s caste, may be used for specific religions, but may also be used to refer to extended families. Biraderis or clans play a powerful social role entailing a creative process of becoming members by showing duty to others (Lyon 1999, 2002). Notions of honour in biraderis are thought to entail patience and the repression of traumas and dissent (Qureshi 2013; Wheeler 1998). While there may be dissatisfaction with power centralised in a patriarch, members may still show commitment to a joint family, oscillating between Islamic and customary modes of social organisation (Ahmad 1976). Biraderi affiliation enables members of lower classes to make claims of similar status as that of owners of capital (Khalid 2002; Khan 2010). Yet as much as extended clans are organised around powerful men, men’s outmigration for work may also result in ‘matri-weighted’ households or a shift in decision-making authority, at least within the domestic space, from men to women (Rahat 1990). As the possibility of opting out of a biraderi by forgoing relations of exchange remains open, membership can also be extended to new households (Nasir and Mielke 2015), thus creating new forms of dependencies. In the context of Pakistan, marriage between cross-cousins and the exchange of gifts between the wife’s agnatic kin and affines demonstrate how agnation is supplemented by affination (Alvi 2007; Ballard 1990). Some have questioned the solidarity of biraderis by pointing out conflicts with members who bear conflicting pressures of work, family and conjugal kin (Harris and Shaw 2009). Practices of exchange within biraderis between temporary and permanent kin involve leveraging the other by lavish payment of gifts (Alavi 1972; Eglar 1960; Shaw 2000). The exchanges of gifts have been considered as providing a safety net for households in poverty. Some have considered marriage as enabling intra biraderi political manoeuvring as well as expanding influence in institutions of the state (Lyon and Zeb 2016). Yet conflicts between and within extended kin networks also reveal the disruptive impacts of illness. Gazdar (2007) has astutely pointed out that while kin groups are referred to interchangeably through words like ‘biraderi’ ‘zaat’ and ‘qoum’ in urban and non-urban settings, and while these identifiers provide the basis of inter-marriages, there is still a public silencing about biraderi identification due to the modernist appeal of Islamist and cosmopolitan types (Mohmand and Gazdar 2007: 87). In everyday life though, lower caste identifiers, such as ‘neech zaat’ (low caste) ‘badnasals’ (bad lineage), ‘chuhras’ (Christian menial workers) and ‘mussali’ (Muslim shaikh menial workers) are in common parlance and are used pejoratively to justify discrimination and violence (Mohmand and Gazdar 2007: 87). In fact, for many, qoums, zaats and biraderis can be treated as ‘caste-like’ because they share principles of endogamy, hierarchy and sometimes even pollution. Given the overlapping features of extended clan and caste, it is important to consider why extended kin networks may be useful sites to interrogate the impact of policing, disease and health in contemporary Pakistan (Loureiro 2013, 2015).

In the context of urban poverty, the experience of the pandemic and the limits it placed on mobility intersected with geographies of policing in post-9/11 Pakistan, exacerbating existing health conditions whose treatment was delayed with potentially fatal consequences, resulting in new socialites around care for the vulnerable. I show that although the participants were aware of the virus and its lethality, their primary concerns were chronic illnesses like high ‘blood pressure’ and ‘sugar’ (diabetes), which they attributed to pressures of maintaining livelihood, growing economic uncertainty and troubled family relations and hostilities in wider kinship networks. I first discuss how low-income minoritised groups experienced excessive forms of surveillance as existing ideas about hygiene, class and religion were coalesced into new anxieties about minority groups being carriers of COVID-19, which can be understood through longer processes of treating the middle-class nuclear family as the object of emulation in disease control programs in Pakistan. I then discuss the challenges in caregiving as fears around COVID-19 became inseparable from existing chronic health conditions, where families provided care to the sick by weighing the immediacy of the providing care to the vulnerable with the risk of infecting the vulnerable or their own families. Finally, I ask how in low-income resource settings, populations avoided testing and feared hospitalisation, but that cases of hospitalisation for symptoms overlapping with COVID-19 and chronic conditions also provided moments for families come together in the care of the sick. While conditions of the pandemic do not necessarily create new tensions in kinship, as poor economic conditions and hostilities have persisted, they do intensify existing conflicts in a way that improving illness concomitantly implies improving tense kin relations. The experience of the pandemic tests these fraught relations, as families come together in events of acute illness and death, but also further isolate the vulnerable, a move that is intensified under conditions of lockdowns and the fear of infection.

In this article, I use ‘chronicity’ as a guiding concept. I define chronicity as the combination of material scarcity and disease in which flows of resources generate violence in kin groups. Here the inequitable distribution and lack of care due to the fear of infection makes the experience of COVID-19 indistinguishable from the existing chronic health needs of the vulnerable (Manderson and Smith-Morris 2010). I ask what care looks like in the retrenching of primary healthcare and out-patient care during COVID-19 (Manderson and Wahlberg 2020), and the medical triaging of patients in times of emergency (Nguyen 2010). Instead of resorting to ‘autonomous patients’ or representations of ‘self-less’ caregivers, I also invoke chronicity to consider a sense of stuckness in navigating complex kinship relations (Hage 2009), where caregivers and the vulnerable are involved in ‘illness work’ or ‘chronic homework’ for the division of responsibilities (Corbin and Strauss 1985; Mattingly et al. 2011), with co-morbidities representing the intermingling of diseases and reluctance of the sick to overburden caregivers (Weaver 2016). However, I also add that illness is shaped by ‘pathological’ relations which are marked by scepticism towards intimate kin, often settled within wider families through violence, threat of legal retribution or formal and informal complaints in institutions of the state like the police and mental asylums (Chua 2012). Chronicity not only throws light on existing health conditions and how the pandemic reactivated anxieties about them within families, but also how illness provides an opportunity to recalibrate social relations once marked by grievances.

Methodology

To understand the kinds of pressures placed on social relations due to COVID-19 among low-income groups, I conducted telephonic surveys in four low-income households in two major cities of Pakistan, Lahore and Karachi. I selected two cities because of their high-population densities and because these cities frequently experienced lockdowns when cases increased, compared to remote cities and villages. Participants in Lahore mainly belonged to Christian families, whereas the ones in Karachi consisted of Muslim ones. In Pakistan, para-military forces were deployed for the implementation of lockdowns in different provinces starting in the March of 2020. Karachi and Lahore are the two biggest cities of Pakistan with populations over 10 million, with weak health infrastructure unable to provide for the health needs of the growing populations living in dire economic conditions.

Surveys and follow-up interviews were conducted through telephone calls to prevent the risk of infection. The limitation posed by telephone calls was that they did not allow me to capture ethnographically the changing household dimensions, but this problem was overcome with the help of interviews with multiple household members. Based on initial contact established with the four households, additional members were also interviewed which yielded a total of 20 people through snowballing. The interview population also consisted of families other than the kin groups whose members participated in the surveys. The three-month surveys were conducted during the first wave (April–September) and follow-up interviews were in the second wave (November–January 2020) when daily increase in cases reached 750 and the third wave (March–June 2021) when active new cases increased to 4,500 (A. Ali 2020; Gul 2021). Households were paid 5000 Pakistani Rupees (30 USD) each month for their participation in the surveys. The three-month long surveys helped track when acute symptoms other than those from infections were experienced during government lockdowns due to unemployment. Some 3.78 million migrant workers faced direct threats of layoff during the first wave (The News, 2020). As I noticed, the symptoms of chronic illness and acute episodes such as fainting or high blood pressure improved over time as the economy reopened and the Pakistan government began to employ ‘smart lockdowns’ in localities where COVID-19 cases increased. By drawing from interviews which went beyond the three-month long household surveys conducted with relatives of key informants, I will also refer to the overall health of other members within the household and the wider kin without which one cannot fully understand the experience of illness. In addition to drawing upon data from interviews, I have also used participant observation and fieldnotes from my visits to government hospitals in Lahore and Karachi.

The ‘Unhygienic’ Minority

Pakistan is a setting where poor religious minorities have been notably stigmatised during COVID-19. The origin of the virus in the country was attributed to Shia pilgrims returning from Iran. Christian population who are highly dependent on domestic service and sanitary work, have also been highlighted as exceptionally vulnerable to stigmatisation and scapegoating (K. Ali 2020; Ayub 2020; Shami and Majid 2014). The Pakistan government deployed an infrastructure once used to fight militants to track COVID-19 cases (Hashim 2020). During the third wave, the Pakistan Army was asked to come in the aid of civil powers to implement social distancing, a move criticised as the country also experienced a surge in militancy (Dagi 2021). Spatially, this infrastructure was erected in the form of check posts where temperature and face coverings were checked for those travelling through public transport, with frequent cases of police brutality (Nihad and Shah 2020). Perceptions towards public health measures were influenced by the state’s aggressive intervention in everyday life. While public sites were set up to administer vaccines, there was also an emergence of fake vaccination certificates, which were acquired by two of the participants of the study (Dagia 2021b).

In the case of Christian domestic workers I interviewed, I observed that their experience of wearing masks was impacted by their perceptions about being treated and stereotyped as ‘unhygienic’. Due to the pressure of being continuously under surveillance, people often wore masks performatively such as while entering shops and crossing check posts. In fact, in both post-colonial India and Pakistan, there have been various cases where people have been forced to carry physical traces if they were infected, such as bearing indelible marks of ink as in Maharashtra (Lovett 2020), which is perhaps also reminiscent of the colonial era plague control efforts where trains prohibited entries of lower classes and humiliated travellers by publicly sanitising them in wooden bathtubs after their arrival in colonial Karachi in 1897 (Wellcome Collection 1897). In fact, the Epidemics Diseases Act of 1897, which instituted the use of coercion against those disobeying state injunctions is still in place in India and Pakistan. What then are some of implications of such laws for the poor during COVID-19?

When I interviewed Faiza’s husband to assess how he was following social distancing guidelines, he told me, ‘I am wearing the mask because if baji (a female employer) sees me without the mask, she might report me to the gate, and I might be disallowed from entering for work’. In Pakistan, workers from the massihi (Christian) backgrounds, who had once been low-caste Hindus, have especially been sought by municipalities for sewage works (ur-Rehman and Abi-Habib 2020) are doubly discriminated on the basis of caste and religion (Streefland 1973) which overlaps with longer colonial and Christian histories of institutionalised racism towards the Pakistani catholic minority. These communities have also responded to marginalisation by finding spiritual connections with Hindu, Sufi and Shi’i practices (Fuchs and Fuchs 2020; Walbridge 2003). The use of colonial-era blasphemy laws and Islamic revivalism since 9/11 has led to increasing mob violence against Christian groups and increasing indifference by the state to defend them (Gregory 2012; Jaffrelot 2020). During colonial times, traditional sweepers had been considered as fetters on modern city planning and sanitation (Prashad 1995). Drawing upon Mary Douglas idea about how the threat of ritual pollution legitimises social hierarchies, Beall (2006) has shown how the state has appealed to Christian groups by creating an impression about intense competition for scarce job entitlements associated with hereditary and status-based identification. When Christian workers get employments as domestic labourers, boundaries between ‘clean’ and ‘unclean’ are often put into pressure, creating anxieties around their social status, as they intermingle with families of their employers, and often also draw upon these relations in times of distress.

During the early days of COVID-19, employers had denied entry to domestic labourers but due to the demands of household chores, had to ask them to return to work mostly at specific times and in specific rooms when residents were away. Most workers were given unpaid leaves, while others continued to work under the pressure of providing for their families, often feeling guilty about the possibility of infecting their loved ones and putting them at risk (Habib, 2020). The Christian worker’s so-called lack of hygiene became entangled with the fear that they might infect their employers’ families. This perception was fomented by their family-based occupation as ‘sweepers’. One Christian maid who had converted to Islam, Zahida, shared that both her ex-husband as well as son had worked in Aitchison College as ‘sweepers’ (a boy’s school created during colonial times).

Spatially the pinds (villages) from where the labourers were drawn were close to gated-communities and affluent neighbourhoods of Lahore. Waqas a gardener, also from a Christian family, had shared in a frustrating manner, ‘There is no COVID-19 in our communities, it seems like only the rich people have it’. According to Waqas, COVID-19 was also a ‘disease of the rich’ which showed that other health and social concerns among the poor were much more pressing than the possibility of getting infected by COVID-19. I interpreted this comment as signalling how he experienced COVID-19 not as a disease, but affectively in the form of restrictions and biases he encounters during his work in gated-communities. In fact, one resident of a gated-community said, ‘COVID-19 is only happening in the cantonment. I do not get why police check posts have been set up. If you leave the cantonment, there is no such thing as COVID-19’. Meanwhile the screening of people on motorbikes was much stricter compared to people in cars. Workers like Waqas perceived the middle-class population’s following of standard operating procedures (SOPs) as selectively targeting or excluding them. Even though the perceptions about strategies to follow SOPs varied, they magnified longstanding religious and class-based antagonisms.

These tensions were also activated within broader kinship structures in low-income families. One woman from a Christian family, Parveen told, ‘Upon getting diagnosed with TB, the news spread in the biraderi like wildfire, and they all tried to tell my employer that I had a cough because of TB’. Parveen missed a day or two of work. Her relatives interpreted her cough as a symptom of tuberculosis. Faiza who was Parveen’s sister-in-law (bhabi) told her employer about Parveen’s TB supposedly under the pretext of safeguarding her employer’s family’s health. Although initially dismissive, Parveen later confided in me about her diagnosis of tuberculosis and how it could be used by her extended family, with whom she was in competition for jobs, to marginalise her. She said

My pulmonary problems (phepro ka masla) were accompanied by hallucinations about a young boy who would not let me pray and would strangle me when I was lying in bed. I recovered when I shared this episode with a priest in a nearby church. Now the boy doesn’t disturb me anymore.

In addition to accusing relatives, in low-income neighbourhoods responsibility for outbreaks were also levelled onto other ethnicities. For instance, on Band Road in Lahore where Afghan refugees live next to the Christian communities, one Christian male said, ‘These Afghans have been crossing the borders and have been bringing COVID-19 with them, their virus is much more contagious’. Thus, the fear of infection existing both within extended families but could also be directed towards an ethnic other, in this case, the Afghan refugees who lacked Pakistani citizenship. Thus, biological caricatures drawn on the bases of susceptibility, shaped suspicions towards an ethnic other resulting in the latter’s targeting as ‘infectious’.

Perceptions about illness among Christian groups were also accompanied by perceptions about their social behaviours. Employers suggested that domestic abuse in the families of the maids was rampant. This did in fact correspond to reality but ignored the structural conditions that resulted in increasing violence and different norms and behaviours in these groups (Canguilhem 2008; Han and Das 2015). In everyday experience, participants shared a sense of stuckness. Zahida’s (formerly Christian) son-in-law had been paralysed (faalig) and suffered from a loss of memory due to the consumption of low-quality liquor, which has been the cause of mass poisonings among Christian communities in the past. The son-in-law had also physically abused her daughter; however, the daughter could not leave him because of her children. It was common for employers to listen and intervene in the domestic affairs of maids in cases of abusive relations. While there was care, this was also laced with judgements about low-income Christian families, which resulted in their norms and behaviours, shaped by structural conditions, to be understood stereotypically. One employer once said

yay nichli zaat kay log hein, inn kay lyay jitna bhee kar do yay apni aukat dikha daitay hein (these people are from the lower zaat (used to refer to their class, status as well as kin belonging) and whatever you do for them, they will always show what they are worthy of.

During COVID-19 attitudes towards Christian workers were inseparable from biases about their kinship relations and hygiene. One example to illustrate this was of Gurya, a Christian domestic worker who began to miss work, due to her sickness. Her employer found out that she had been missing work because her brother was COVID-positive. When I asked the employer to describe why Gurya was laid off, she said

Gurya had gained a lot of weight and would find it difficult to work. Also, she smelled really bad. She came from a pind (village) and lived in very unsanitary conditions in a small room with her husband and children. They did not have a bathroom in their house and had to use the fields to defecate.

Imagining the Disease-free Family

At the same time in national public health messages, the middle-class nuclear family was being used as a model to be imitated by the wider population. The low-income family remained the locus of intervention often enacted in violent forms. Glover (2007) has shown how in colonial Lahore, the cantonment was created as a space of constant surveillance, which was impossible in the way people lived and organised in the inner city, perceived as a space of chaos. Previous dictators have also failed to adopt pro-poor policies as was evident in when the poor were resettled in the outskirts to make Karachi a modern city, resembling colonial city planning in the form of cantonments (Gayer 2014). Thus, even during pandemic, I understood sites for policing populations as existing specifically at the junctions between cantonments or gated communities where the affluent families resided and slums or small villages (pind) from where the domestic labour came.

In all four households, members got diagnostic tests for blood pressure, respiratory problems, chronic heart problems and diabetes from nearby pharmacies and clinics. The frequency of acute symptoms such as fainting was highest during the half of the research. Free COVID-19 testing was very limited and private labs charged almost PKR 5,000 for each test. Due to low per capita tests, Pakistan was referred to as a ‘data fog’ along with India and Bangladesh. ² In some cases, I observed that families did get tested when there was suspicion because of infection, especially after a death in the family. As I show in another article, one woman in Nazimabad (Karachi) had gotten herself tested when her husband died of typhoid and was being treated with suspicion by her neighbours (Khan 2020). Recent literature has made contributions about the reliability of knowledge about COVID-19 symptoms and prevention in low-income settings (Austrian et al. 2020; Lau et al. 2020). During interviews, I observed that knowledge about COVID-19, except for wearing masks and maintaining social distance was very scattered and tenuous. Although the knowledge was received predominantly through TV channels and social media, there was little knowledge about how the infection was transmitted.

There was an increasing pressure to demonstrate that there was no infection in the family after death in households. Out of the 10 relatively affluent families in which interviews were conducted (income more than PKR 100,000), on average, individuals who had been infected with COVID-19 tested twice or more in private clinics. Underlying sensations, fears and anxieties, not having any value diagnostically per se, were taken as signs of illness (Offersen et al. 2016). The relationship between testing and social class has also been considered among working and middle-class people who complained about AIDS-like symptoms and tested several times while being low-risk (Biehl et al. 2001). What I found similar to such studies was that testing rates were disproportionately higher for affluent families compared to families from low-income backgrounds.

The Pakistani state has historically invoked the imaginary of the middle-class nuclear family, with assumptions about authority firmly rooted in parents, in their campaigns about family planning and polio eradication in the past. COVID-19 response used existing healthcare infrastructure previously mobilised for COVID-19. The polio campaign had previously employed visuals depicting parents happily getting their children vaccinated. Modernisation of the country was posited as indistinguishable from family planning (Korson 1979). ³ COVID-19 campaigns also assumed that it was possible for all citizens to avoid unnecessary social contact with kin and non-kin. ⁴ Public service messages continued to insist on populations to remain at home for their safety, as if boundaries of what constituted as home could easily be defined.

In Pakistan, global health organisations have dedicated a lot of effort and resources in ‘eradicating’ epidemics like polio (Closser 2010). The efforts of many global health organisations working in Pakistan like other developing countries has been on ‘disease eradication’ (Packard 2016), even when individuals are much more likely to suffer from increasing rates of non-communicable diseases, due to changing patterns of dietary consumption, pollution and poverty. Many global disease control programmes and interventions also remain class-specific as in the case of polio eradication and sterilisation efforts in South Asia (Closser 2010; Tarlo 2003). Poor communities and those marginalised and living under precarious situations experience displacement and dispossession due to renewal or relocation projects which further intensify their suffering (Holston 2007; Zeiderman 2016; Hull 2008).

Given the restrictions on mobility, how did low-income families navigate care-giving responsibilities, especially under conditions of chronic illness?

Disputes and Chronic Health

The impact on the health of the elderly can be seen from the subjective experience of illness. In the case of Farha who died during the study, old-age, lack of care and conflicts in her household involving the settlement of debts between her brother and son-in-law, were considered as main reasons by relatives for her death. Farha handed over her property documents to her brothers instead of her daughters, which led to an awkward position for her being struck between accusations and counteraccusations about betrayal from daughters, out of which Farha emerged struggling for her life. Her brother threatened to commit suicide in front of her elderly sister and nieces to get Farha’s son-in-law to repay their debts. The daughter whose husband owed the money, was the primary caregiver, but she was estranged from providing care to her mother in her final days. Yet there were other daughters who filled the gap, by assessing trade-offs such as providing care to their mother or infecting her.

When Farha was close to her death, the relative who visited her to check her vitals advised the family to get a PCR test. When hospitals limited access for relatives, families like Farha’s and another one I interviewed (of a different socioeconomic background) in Karachi were reluctant to take members to hospitals just so that they could grieve properly in case of a death. One of Farha’s daughter was relieved to have provided care to her mother in her last days and said, ‘Allah ka shukar mein apni ma ki khidmat kar payi (Thank god I was able to provide care to my mother’. Khidmat (care) has an element of respect and care and is seen to be central to fulfilling one’s responsibility to the dead in Pakistan. Farha’s family did not get the PCR test, neither was there any mention about COVID-19 being the possible cause of her death. A positive test would have meant that her chances of having a dignified death surrounded by the beloved would have been compromised, which led to her intimate kin avoiding the PCR test altogether, despite her poor condition.

The participants from the low-income households also used vernacularised symptoms which often overlapped with symptoms of COVID-19, but also revealed longer histories of chronic conditions. One of the participants of the survey attributed COVID-19 to the ‘cold weather’. Another participant, Zahida’s used the symptom jism tootna which literally translates to ‘breaking body’ or ‘body aches’, but she still did not refer to her condition as caused by COVID-19. Symptoms were much more commonly attributed to tiredness, stress and exhaustion. One study conducted by researchers in Agha Khan University about perceptions towards COVID-19 District East, Karachi, showed that even when people considered COVID-19 to be dangerous, a sizable chunk lacked adequate information about its symptoms and social distancing measures (Mansoor et al. 2021). All four primary respondents of household surveys had existing conditions with which they needed help. All four consulted either a medical professional or a traditional healer informally but avoided hospitals altogether.

Acute episodes even when they resembled COVID-19 symptoms were understood in relation to chronic conditions exacerbated by the economic situation of the households, mostly in the first month of the study, that is, September of 2020 when three of the participants had episodes of acute illness. Afzal said that during the first month of the lockdown, he became unconscious after feeling dizzy 4 to 5 times. He reported in an interview that he had ‘Dil mein dard (pain in heart)’, and ‘ankho mein andhera (darkness in eyes)’. He visited the doctor who recommended that he got some diagnostic tests done which would have costed him PKR 4000 to 5000 (25–30 USD). Since his household budget was already tight, he only visited the doctor once but never started his treatment, to which his doctor had said, ‘This is why patients die. They know they are sick but do not take their medicines’, Afzal did not start his treatment and said that the symptoms would go away with time. He told me, ‘I take my medicines only when I am unwell’.

Afzal was having a dispute with his brother over the allocation of property. He claimed that his brother had occupied the lower floor as well as the roof and under the informal mediation of an acquaintance in the police, the latter had agreed to sell the property so that all four of his siblings could get their shares. Afzal tried to register a First Information Report (FIR) against his brother but later found out that the person from the police had been bribed by his brother so that an FIR against Afzal’s brother could be prevented. ⁵ The brother changed his mind and continued to harass Afzal so that he could leave. Under conditions of the lockdown, the tensions between the brothers worsened to a point where Afzal was once even physically beaten up by his brother and nephews. Afzal shared with me a video in which he was bleeding from his head and his nose. Afzal eventually left the household and rented a residence after his nephews began to bully his daughters. After moving out, his expenditure also decreased because the utility bills were no longer divided. Now he could monitor and regulate the electricity usage in his household, without having to pay for his brother’s extra consumption. He mentioned that his symptoms also subsided after moving out.

Another participant, Nazia, was angered by the generosity of her immediate family towards her dire situation. Accepting help from family can lead to a loss of respectability in the wider kin (Das 2013; Han 2012). Eventually due to the loss of her husband’s employment, she accepted her family’s support. Her husband had a heart attack during the first month of the lockdown and experienced visual hallucinations. During this period, her own acute symptoms included fainting due to high blood pressure..

The increase in household income also reflected unique pressures on health. For instance, Zahida’s husband could no longer work as a cab (rikshaw) driver due to his permanent exhaustion, pain in legs, difficulty in urinating and decrease in customers due to the lockdown. He shifted to setting up a vegetable stall so that he would not have to sit in one position in his cab during the hot weather. He contributed PKR 2,000 (12 USD) to the household per month compared to PKR 7,000 (40 USD) contributed by Zahida, which was altogether an increase in household income. However, the husband’s loss of income led to greater pressure on Zahida to pay for the committee through which she was able to cover expenses of her stepdaughter’s wedding. During the first month, Zahida felt like her ‘heart was upset (dil kharab)’ and was very depressed. She also had diarrhoea and aches in her body (jism toot raha hai). The second month when interviewed she described, ‘There was darkness in my eyes and I did not know where I was. It was because of stress about how we will survive since Alam was not earning and I was not getting my pay’. Her chronic symptoms included uterine tumour (gudood mein rasoli) which did not let her walk to work.

When we map net income, in the case of the older participants like Farha and Zahida who were 83 and 65 years old, respectively, the effects of lockdown on the health of individuals from this age group continued even after the first two months, compared to the other two, Nazia and Afzal who experienced severe symptoms and had little extra money, but their health began to improve as the lockdown regulations were made less stringent.

For both Farha and Zahida therefore, the deteriorating health conditions can be attributed to age, tensions in kinship, and being relatively immobile due to age, and particularly in the case of Farha, the weakening authority within the household and ensuing conflicts in the kin group. Zahida had remarried after she had converted to Islam from Christianity. Her husband was already married once before but now he lived with her. Her husband had the responsibility to his kids from the first wife who now resided in Sargodha. Zahida treated her stepchildren as her own. Due to her husband’s chronic health issues, she had the responsibility to provide for her stepchildren in whatever way possible. Upon her conversion to Islam, Zahida’s former family had broken ties with her, except her daughter, with whom she was in touch. Therefore, she described that the pain of being abandoned by her own family also animated her present condition. Zahida continued to receive information about her former family through her daughter, which included the news about the death of her sister-in-law from her ex-husband due to ‘sugar’ (diabetes) which had gone undiagnosed during COVID-19.

Waqas’ mother (Christian household) had also been diagnosed with tuberculosis as the family went through in-fighting over ancestral land. His father and his paternal uncle, who claimed greater share of the property, had stopped talking to each other, with each other’s nephews bringing the two together. Waqas’ mother’s experience of tuberculosis during the pandemic clearly highlighted that the experience of the disease was shaped by disputes in family. Chronic problems intersected with mental health problems. In one household in Lahore, a woman complained that her bhabi (sister-in-law) had done jadoo (magic) on her mother, who remained quiet for days, with her brother beating her mother. Now the family was worried that the son could kill his mother and physically harm his brother to occupy his ancestral properly. A lot of these social conflicts were generative of chronic conditions, which became much more pronounced under lockdowns and with growing poverty. Hospitalisation was feared especially during COVID-19 as I will show below, as many caregivers perceived hospitals as forcefully separating families from their loved ones. Among low-income households, family members, who did have to admit loved ones to hospitals for acute conditions, expressed major anxieties about hospitals simply ‘letting people die’ due to the poor quality of care, especially if families did not resist decisions taken by doctors, as I will show below. Yet these negotiations also had a role in providing momentary relief to otherwise tense relations within wider family networks.

Hospitalisation, Fear and the Resumption of Care

Patients seeking in-patient treatment faced extreme problems, as observed in Punjab Institute of Mental Health, where admission was often only possible with the help of bribes. Private hospitals charged extravagant amounts, which dissuaded many from seeking treatment there. One patient seeking treatment in a public hospital in Lahore shared, ‘The rate for a doctor here is PKR 15,000. You pay the money and can have your relative admitted’. By this he referred to the role of bribery and corruption in accessing healthcare in which medical staff too was implicated. During admission in hospitals, families were required to get a negative test, for which were required to show a proof of a COVID-19 negative test, which took 2–3 days at the least. This delayed treatment in the context of acute symptoms, up to a week or more, as I observed in a state-run psychiatric hospital in Lahore. Yet, people from higher socio-economic status could avoid such obstacles. During a visit to a government hospital in Lahore in 2021, the vaccinator had offered to vaccinate me separately, saying that the rest ‘would not get vaccinated for another couple of hours’, a visible sign of the differential treatment based on one’s class.

Hospitals were not only sites of abandonment, but also reconfigured relationships. Fatima, a 55-year-old resident of Karachi, experienced an episode of pulmonary hypertension during the study. A resident of Gulshan-i-Iqbal, Karachi, she was a teacher in a madrassah. She did not have children and lived in a one-bedroom apartment with her husband who previously worked in his brother-in-law’s company, but now relied on his wife’s income. Fatima experienced obesity and had been told by her relatives to control her diet which was treated as an example of overindulgence amidst scarcity (Solomon 2016). As a form of protest, she no longer kept a measure of what she ate and ignored the impact of specific foods on health (Ecks 2014; Solomon 2016). She denied her sisters’ request to show them her test reports and had also rejected their advice that she should work towards losing her weight. Given her lack of self-care, one of the siblings had angrily said in frustration, ‘you should die (mar jao tum)’. Shortly afterwards both her sisters stopped visiting her. Her increased diet and lack of mobility during COVID-19 exacerbated her cough and difficulty while breathing. The staff from the madrassah had complained to her husband that she felt dizzy and would become unconscious during her classes.

Medical treatment was sought only after she could no longer walk and became restricted to her bed. The delay had also been caused by Fatima’s lack of faith in biomedicine as she had said to one of her relative, which was relayed to me, ‘The cure for this problem is only in homeopathy’. The question of what was the right treatment was hotly debated. In one family interviewed during the research, a father told that he was concerned about his son’s chronic high blood pressure because the son had refused to take his father’s advice, and instead insisted on using homeopathic medicines, while admitting that he was on the verge of getting a brain haemorrhage due to stress. According to Fatima, biomedicine could only provide short-term relief. Treatment too would only occur with a host of side-effects creating further complications later in life. Previously the doctor had suggested that Fatima would have to start oxygen therapy, which she refused, until she had to be taken to the hospital emergency, where she stayed in intensive care unit for three days. The delay in treatment could have had fatal consequences because no one could know for sure when she began to experience symptoms of pulmonary hypertension. Even after she had been admitted in the hospital, rarely did any person in the family discuss the fundamental problems of her health in strictly biomedical terms. Mostly chronic conditions are vernacularised using identifiers such as ‘BP’ or ‘sugar’. However, in more complex cases, there was a reliance on moral ideas about illness, which resisted a single disease category. As in the case of Fatima, her condition continued to be treated as a result of supernatural causes or weakness of faith. There has been a long tradition of considering patient-hood through notions of piety in Islamic societies (Ragab 2018). One of her nephews had commented on her health,

Fate will determine the consequence of her illness; everyone should clear their hearts of any grievance for phupho (aunt). I talked to Hassan (Fatima’s nephew) and he was saying that along with cure (shifa), please also pray for her self-restraint (nafs).

I realised from the conversation in the kin group that Fatima’s illness was considered as inherently social and moral in nature. Fatima had gained the anger of her extended kin group for meddling in other people’s domestic affairs, particularly by picking up fights with her sisters-in-laws. The extended kin began to avoid her. COVID-19 had further intensified her isolation. One of the members of the kin group said that it could be possible that she experienced the illness as a consequence of the deep-seated anger that the extended kin continued to have towards her. This meant that she could only heal if her relatives, particularly her bhabis (sisters-in-law) forgave her. Fatima’s illness was also viewed by some as a form of rebellion. Others viewed it as a substitute for an apology as her condition invoked the sympathy of the extended kin as a means to make otherwise tense relations amicable.

Fatima’s husband had to change two hospitals before she could receive the required care. Fatima’s brother told me about going against the advise of a physician to put his sister on the ventilator. Her brother said, ‘they were going to kill her had I not intervened’. When her brother was interviewed in the third wave, he said,

I lost a friend in a public hospital in Lahore. He was fine when he went, but became weaker when he was in the hospital. The oxygen pressures provided to patients were unregulated. They are killing off patients.

This perception of hospitals as regulating death has been considered in the case of migrant populations and racial minorities in the US (Langford 2013; Rouse 2004), as well as in the context of palliative care (Kaufman 2005). In Pakistan, this suspicion towards biomedicine shaped by its neglect of social experiences of illness was intensified when families viewed hospitals as sites controlling death. This belief was partly a product of delays in receiving treatment among the poor.

During the pandemic, emergency services had been prioritising COVID-19 patients. Since private hospitals were the only choice for the family, Fatima’s husband found the cheapest clinic so that it could not be a burden on the family. She was first taken to a clinic where she was kept for 2 days. The doctors referred her to another private hospital. One of the members of the extended family shared about her condition, ‘Her lungs have spots, and her body has water (Jism mein paani). Lungs have become stuck to each other. She also had high blood pressure and her brain is not able to receive enough oxygen’. I learned in this and related examples that although symptoms were laced with biomedical terminologies, physicians as well as patients rarely communicated the exact diagnosis.

In low-income settings in Pakistan, ‘water in lungs’ or in any part of the body represented pleural effusion which is possible in some forms of cancer, pneumonia as well as tuberculosis. Descriptions about lungs have been used to conceal tuberculosis because of the stigmas around the illness. One example for this is the use of ‘weak lungs’ in Philippines among patients with tuberculosis (Nichter 1994). In Lahore, I observed in a public hospital that physicians used the diagnosis of water in lungs (phepro mein pani) which can be used to refer to medical problems ranging from pneumonia and cancer to tuberculosis. What results from the patient–doctor interaction is a lack of clarity about diagnosis and possible treatment. The anxiety of the relatives grew, until Fatima was taken to a private hospital with proper facilities including a ventilator. She had to be transferred from two hospitals until she was provided with a proper diagnosis and received the right treatment. Her recovery allowed for the mending of broken ties and the site of healing enabled her re-entry into extended kin network as an important member who would agree to be taken care of, something she had denied before her acute episode. Thus, life-threatening emergencies like Fatima’s also provide an opportunity to families that were earlier divided by hostilities to come together and experience kin relations anew.

Conclusion

The experience of COVID-19 in Pakistan has been influenced by one’s social identity which includes one’s class and religious background. One can place the Pakistani state’s relations with its poor in a longer history of urban politics and health intervention programs in which the middle-class educated family has been taken as the standard. Health inequalities can be better understood when we focus on broader spatial geographies which generate social difference in South Asia. The article has provided an approach to consider the centrifugal processes operational in the city at large and how these are absorbed in concrete kinship relations to provide or limit care to one’s relatives in the absence of adequate health care facilities. Once considered from the perspective of longstanding relations, chronicity provides a lens through which we can analyse how the experience of the pandemic reconfigures social relations. The reality of the virus for many of the participants was not simply related to the risk of infection, but also concretely, to daily calculations like whether to help the distressed and if help could lead to intensifying hostilities in kin relations. This means that in the context of emergencies like lockdowns during pandemic, it is important to think about care as an ambivalent category representing responsibility to intimate kin, but also its finiteness. The article has shown how social relations are indeterminate and evolve alongside the changing realities of illness. Chronicity provides a lens to consider not only the existing health conditions and how the pandemic reactivated anxieties about them within families, but also how illness provides an opportunity to recalibrate social relations marked by grievances. By considering the lived realities of the pandemic in relation to class and kinship, I hope that this article will prompt scholars to think seriously about importance of ethnographic evidence in making better public health decisions.