The Nobleness of Life is to do Thus

A tribute to Omar Azfar by Azra Raza, M.D.

There’s a special providence in the fall of a sparrow. If it be now, ’t is not to come; if it be not to come, it will be now; if it be not now, yet it will come: the readiness is all.

Shakespeare, HAMLET, Act v. Sc. 2.

At the end, the readiness to face whatever providence had in store was there, both in the case of Omar as well as his mother Naheed. I only saw him two or three times without Naheed in the roughly 16 months of our acquaintance in New York, therefore it is hard for me to think of them separately. She brought her two sons to meet me in September of 2007 shortly after I had moved to New York. Omar, the 38 year old elder son, a graduate of Oxford and Columbia, had been diagnosed with a highly malignant osteogenic sarcoma of the left shoulder. He had received a round of aggressive chemotherapy a few days before and his mouth was a battlefield of raw ulcers, abraded mucosa, bleeding gums. As we sat down to an elaborate meal with family and a few close friends, Omar calmly produced a bottle containing some sort of a bland, soothing drink and sipped away as if it were an equally exclusively prepared gourmet meal, all the while entertaining us with his signature brilliant quips and observations. Such was his class, such his chic. My childhood friend and the current Consul General of Pakistan, Mohsin Razi and his lovely wife Sarwat were present at dinner that evening. Earlier this year, when Mohsin and Sarwat heard about Omar’s death, they rushed to offer their condolences to Kamal and Naheed, both tearing up in the car at the memory of this dinner when Omar had shown such an astonishing and calm acceptance of his condition.

Starting with the first note I received from Omar via cyberspace in the summer of 2007 which was copied to Ama, and ending with my last glimpse of him as he lay dying with his mother curled up next to him in bed, straightening his blanket, holding his hand, I was exquisitely aware of what a unique privilege it was to be witnessing this sublime relationship. Of course love is never quantifiable. In Shakespeare’s Anthony and Cleopatra, Act 1 Scene 1, Cleopatra demands to know how much Anthony loves her.

Cleo.If it be love indeed, tell me how much.

Ant.There’s beggary in the love that can be reckon’d.

Cleo.I’ll set a bourn how far to be belov’d.

Ant.Then must thou needs find out new heaven, new earth.

The friendship alone that existed between Omar and Naheed would require new heavens and new earths to accommodate it.

Arz o samaan kahaan teri wusatt ko paa sakay

Mera hee dil hai wu kay jahan tu samaan sakay

I can divide my association with Omar, which lasted a total of approximately 16 months, into three distinct phases. The first phase starting in the early summer of 2007 was all business; should he be treated at NYU or go to Memorial Sloan Kettering Cancer Center? Who is the best surgeon? Should he come to Boston for a second opinion? Should he receive this combination of chemotherapy or that? Then came Phase 2 when he started the dreaded but inevitable slash-poison-burn (surgery-chemotherapy-radiation therapy) cycles, settling more or less into a routine of sorts, punctuated by periods of pancytopenia, intense susceptibility to infections, excoriated mouth, an occasional hospitalization due to sepsis, and finally, a brief period of recovery only to be followed by more of the same. Once during this time, I asked Naheed in front of Omar why she did not go back to Karachi for a few days to see her ailing mother and to fetch her things as she was now planning to stay for the long haul, at least until his chemotherapy ended. “He will not let me go,” she simply said. I looked at Omar. It was true. He could not bear to let her out of his sight. So Naheed, who had come for a few days to New York to finalize Omar’s engagement to Mursi, ended up staying almost two years, spending practically 90% of her waking time either with Omar or working on something related to him.

Surprisingly, this second phase, perhaps the most exhausting for any normal individual, proved to be the most productive for Omar. He was teaching, he was analyzing current events, he was teeming with original ideas, he was writing profusely. Above all, he was confident and optimistic.

Omar Azfar [[email protected]]

Wed 2/6/2008 5:24 PM

Hi Azra Apa

Here's a link to my article”Power to the People” which you'll find entertaining
http://www.dawn.com/2008/01/26/op.htm

Otherwise, still in chemo – cisplatin this week – and have a left lung surgery coming up on the 25th (they cleaned out the right lungon 2ndJanuary). Ifosfamide will follow, hopefully with Muramyl Tripeptides if the IRB approves.

Cheers

Omar

Azra Raza wrote:

Dear Omar,

Just a note to let you know how much I enjoyed your Power to the People article. I think it is a brilliant idea! Among your many excellent suggestions, I thought the idea of using Television to provide interactive transparency to the process was one of the best things I have read. Good work. Keep it up!

How do we get it across to the people?

All the best,

Azra Apa.

And then again on 2-22-08:

Dear Azra Apa

Here's the word version. It would be great if you circulate it. What I really want is to get it translated to urdu (sadly my own is not quite up to snuff). Dawn had said they would but I havent received a translation yet. Also I was shocked to learn that Dawn doesnt have an urdu outlet, not even a website site. I havent sent it to 3quarks but was thinking about asking Dawn if that would be OK. Dawn's own website doesnt make it easy to find (Google searches bring up the wrong date etc.)

More generally I was thinking that there should be a web site that offers translations of interesting articles in the international press in Urdu.I even suggested it to Ama as somethingshe should run.Essentially it needs some one who has the judgment to pick interesting articles and can organize some translators. I have no idea how much interest there would be, but it bothers me that right now people in Pakistan dont even have access to interesting ideas.

I was thinking of writing a piece next on the importance of elections within political parties, using the American primaries for Dawn next but dont have the energy right now.

I've started Shantaram which I am enjoying, and looking forward to the plot heating up. In fact a few weeks agomy department chairJoan Hoffman was visiting and has also started reading it and I think has read a substantial portion of it and wants to talk about it!

Cheers

Omar

And then a month later on 3-11-08:

Hi Azra Apa

We're having a little impromptu dinner party tomorrow evening. Marina aunty, her son Asimand Sara (Sara Suleri prefers to be neither aunty nor apa)are coming, asis Shehzi Khaloopossibly my good friend Steve Leslie. (Tasso khala has a cold so she'se skipping out).

It will be a fun small evening. I really hope you can make, and sorry for the short notice. If you'd like to bring your sister or daughter they are of course most welcome.

This time Mursi is in town so you'll get to meet her too. I'm also trying to keep Ama out of the kitchen! The price is an untested Bengali cook, but I think its worth it.

If tomorrow doesnt work we should try to meet some other time. I'd like to talk about several things – my article on Power to the People has apparently been translated into Urdu but I havent seen it yet. Next week will be really bad (Ifosfamide) so the week after would be the best time.

Cheers

Omar

He came to dinner at my house in May 2008 when Richard Dawkins was visiting, and had a long chat with Richard who later commented to me about what an interesting conversation he had with Omar. Then in early June, he called me one day to say that as opposed to someone who has come up with a list of the hundred books one must read before dying, he had compiled a list of approximately a hundred books that one must read in order to live and would I be interested in going over the list with him. My dearest friend Sara Suleri Goodyear was staying with me at the time, and we were both delighted at this idea and arranged for Omar to come over for dinner with his list. This was one of the 2 or 3 times that I saw Omar without Naheed.

Thu 6/19/2008 4:48 PM

Hi Azra Apa,

Here's the list – its a bit longer or shorter than 100 books depending on what you call a book.

See you soon

Cheers

Omar

(Please scroll down to see the complete list from Omar at the end of this tribute)

That evening turned out to be one of the most intellectually stimulating ones as each of us offered our remarks on the titles that Omar rolled out with a twinkle in his eyes and that lovely way he had of looking askance at one. I will always treasure this time with him. (My serious complaint about this list was the conspicuous absence of some of my own top favorites. Where was Deevan e Ghalib? Where were Mir, Iqbal, Faiz, Qurratulain Hyder, Mushtaq Yusufi, Ismat Chughtai, Manto?). After he left, Sara and I talked late into the night about Omar. We marveled that someone so captivated by life, so engaged, could demonstrate such remarkable equanimity in the face of almost certain death.

The third phase of my acquaintance with Omar began around September 2008. He was now on a slippery slope and knew it. After multiple surgeries to remove metastatic lesions including parts of both lungs, he continued to experience recurrences at distant sites. He was diagnosed practically on the day we were collecting to celebrate his 40^th birthday with a large mass on the affected arm even as he was getting chemotherapy. This was not good news. Naheed, his best friend Noor, and his entirely devoted and inspiringly lovely wife Mursi brought him to see the well known bone and soft tissue sarcoma expert Dr. Gerald Rosen at St. Vincent’s Comprehensive Cancer Center. Gerry advised radical surgery to remove practically half his shoulder, arm and chest to excise a wide margin around the primary tumor since the principle site from where the malignant cells were continuing to seed needed to be cleared out. The Memorial team was not in favor of this and Omar was torn. Gerry offered to arrange with surgeons he knew to undertake the risky and extensive surgery insisting that this was absolutely essential. As Naheed, Mursi, Noor and Omar sat in my office that afternoon after their visit with Gerry, and Omar pointedly asked my opinion, I was blunt with him. “Look, granted that the radical surgery Gerry is recommending is an enormous risk, but it is the only life saving measure. You are young and the odds are high that you will get through it fine. Give yourself a chance and go for the surgery. The alternative is an experimental trial which under the best of circumstances will prolong your survival by a few months. In short, your choice is between curative versus palliative measures. The former is fraught with potential catastrophes, but it is your only chance of cure. Having said that, it is your decision, and if you wish to go on an experimental trial, then I promise to get you any drug you want.” He heard me calmly, and finally said he will think about what I had said. He called me a couple of days later to ask my help in getting him enrolled on an experimental trial.

Thu 9/4/2008 6:33 PM

Dear Azra Apa

Thanks so much for the offer to getme onto a trial. Here are a couple of links to the trial. The drug is R1507 made by Rauch, and is in phase II of trials. Its had significant success against some cancers and some success against osteosarcoma. Everyone seems quite excited about it.

There are also other trials listed on the NIH trial etc. but they use other drugs to attack the IGF pathway and are sometimes used in conjunction with other drugs. I have no way of guaging whether these drugs are effective. I will email you those links too, but I think its best to concentrate on the links in this email.

Thank you so much

Omar

If the best testimonial to a man’s success is the friends he makes, then Omar was the Bill Gates of friendship; he was also the happiest miser since he saved every friend he ever made. Among those closest to him, I only got to meet the bright, quietly efficient and deeply affectionate Noor who made many trips across the Atlantic to be by Omar’s side. His unreserved devotion to Omar was nothing short of inspiring. Omar’s two siblings had been working valiantly throughout to save their brother’s life. They searched the net incessantly for news of any novel approaches to therapy or announcements of clinical trials. Sara, the sister Omar doted on, came to see him with her adorable little boy and Omar was immensely cheered up by their visit. One of the loveliest things about Omar was that while he was interested in big things, he knew how to be genuinely happy in small ways. He personally called me to say he would so like me to meet Sara and brought her over for dinner one evening. I was astounded by the detailed questions Sara asked me that evening about Omar’s situation, the choices available to him, his immediate and long term prognosis. Obviously, distance did not matter in their case as she was acutely aware of every detail about Omar’s condition. Farid, who happened to be at the crucial period of completing his doctoral dissertation at Brown, nonetheless spent every moment he could spare with his brother, rushing to New York every chance he got. Farid also accompanied Omar to his medical appointments whenever he was in town and stayed with him at the hospital when Omar was an in-patient. He was extraordinarily involved in even the minutest details of his brother’s medical situation. One evening as they were leaving my home, I was greatly touched to see Farid quietly adjust the sling on Omar’s arm and help him into his coat without a word from Omar who continued talking to me the entire time. Despite being deeply involved, the family as well as friends, entirely respected Omar’s independence and supported him unconditionally whether they agreed with his decisions or not. They stood resolutely by him and faced the tragic choices with a fortitude that reminded me on more than one occasion of the famous line from Faiz sahib:

Jo aye aye ke hum dil kushada rakhtay hain

Thu 9/4/2008 6:42 PM

Hi Azra Apa

Farid sent these in.

Love

Omar

— On Thu, 9/4/08, Azfar, Farid wrote:

From: Azfar, Farid
Subject: summary of trials
To: [email protected], [email protected]
Date: Thursday, September 4, 2008, 5:13 PM

Called and they are still recruiting for osteosarcoma. The IGF-R1 is

being attacked with something different, however. 

Schering-Plough:

http://clinicaltrials.gov/ct2/

show/NCT00617890?term=IGF-1+osteosarcoma&rank=2

Called and left a message, but website says they're still recruiting

for ostesarcoma (and this is the one that we think Meyers is trying to

get on and Harvard says is closed)Hoffman LaRoche:

http://clinicaltrials.gov/ct2/show/NCT00642941?term=IGF-1+sarcoma&rank=5

The following two are recruiting, but not for osteosarcoma. Although

maybe this is when the "compassionate use" might apply? 

http://clinicaltrials.gov/ct2/show/NCT00563680?

term=IGF-1+sarcoma&rank=2

http://clinicaltrials.gov/ct2/show/NCT00720174?term=IGF-1+sarcoma&rank=1

Omar started a clinical trial at Montefiore hospital and seemed in an unusually good mood when he and Mursi came for lunch at my place in November with my friends Mushahid and Dushka and their son Mustafa. He gallantly rose to his Shazi Khaloo’s defense when I attacked Shaheryar mercilessly for making a statement to the effect that people find it easier to handle failure than success. By early January, the trial had failed, and he was exploring other possibilities with his usual vigor and velocity.

Thu 1/8/2009 9:24 PM

Hi Azra Apa

Here is the link for the reolysin monotherapy trial

http://clinicaltrials.gov/ct2/show/NCT00503295

Here is a trial for reolysin and carboplatin and paclitaxel in San Antonio

http://clinicaltrials.gov/ct2/show/NCT00753038

Thereis a similar trialin the UK, for which they are not as categorical in saying I can't join but it seems difficult

http://www.cancerhelp.org.uk/trials/trials/trial.asp?

freetextsearch=reolysin&searchtype=freetext&trial=17024&trialno=16644&spage

=1&objective=0&cancer=0&stage=0&phase=0&treatment=0&location=0

I have also found some mention of a joint reolysin cyclophosphamide trial in the UK but I cant find it on their web-site

Thanks so much for al your help

Omar

Wed, 1/14/09

Hi Azra Apa

Thanks so much for contacting BMS about me. My reluctance to join a dasatinib trial is based on the fact that there will be delays before joining and once I join there will be restrictions on trying anything else. By comparison if I just take the drug I have greater flexibility.

Much love

Omar

The drug Dasatinib which Omar so badly wanted was approved for him on a compassionate basis in record time. Before I could actually deliver the drug to him, I received the fateful call from Naheed on Tuesday night, January 20, 2009 as I was having dinner at home with my dear friend Mona Khalidi. “Omar is having difficulty breathing, so I thought I will let you know.” I could not swallow another bite after that call. Mona was very disturbed to see my state. “Is something wrong?” Yes indeed; something is terribly wrong when a parent is watching her child die. “The response to a greeting from a younger person in Arabic is often, may you live to bury me” Mona said. Alas, for my Naheed, this was not to be. I arrived at Omar’s place to find him propped up in bed, severely short of breath. Kamal, his beloved father, sat ashen faced in the living room; Naheed and Noor were fussing around Omar while dearest Mursi, ever the most loving wife and efficient caregiver, was taking detailed instructions from the home health care nurse at the dining table for the administration of sublingual morphine.

Despite the dyspnoea, Omar was his usual self, wearing a pink Lacoste shirt. He never lost his sense of style. As soon as he saw me, he asked about the Dasatinib. I told him we got it and he gave the brightest smile which lit up the room. He proceeded to recount the great time he had had watching the swearing-in ceremony of Mr. Obama. Now, he said to me, please tell me a good joke. I promptly recounted the apocryphal story going around. Mrs. Clinton, piqued by a snide remark about her husband’s administration turned on the reporter and said through a steely grin, “So. Please remind me exactly what you did not like about my husband’s eight years in office? The peace or the prosperity?” Omar let out a hearty laugh at that and then wanted Mursi to come and change him into pajamas. He insisted on getting up to go to the bathroom even as Mursi tried to get him to stay in bed. That was the last time he would get out of bed. He was given more oral medications after that and sublingual morphine and slowly he slipped into a sleep of sorts. His breathing was more and more labored.

I thought he should be admitted for intravenous morphine, but Mursi said his wish was to meet the end at home. In that case, I wanted them to bring a morphine pump for him; the nurse said it could not be done till the next day as such elaborate arrangements take time. This is the only time in the space of 16 months that I saw my darling Naheed lose her cool. “What kind of a system is this Azra? We have paid for everything all along and we are prepared to pay cash for whatever they want now. Why aren’t pharmacies which are supposedly open 24 hours a day able to provide him with morphine now? Its money they always worry about in this country, isn’t it? Tell them I will give them all the cash they want. Azra, tell them! Get them to bring morphine for him now!” Let us go for a little walk I suggested. I forced her to come down and we stood outside the building on Riverside drive in the freezing January night and she smoked, her face impassive. Eventually she turned and looked me in the eyes and asked me how long it would be now. I could not meet her gaze for long. Do you want me to be brutally honest? Yes, she said, staring blankly at the sidewalk. It could take several days, but I don’t think he will last this night. She looked away and kept smoking. We came upstairs silently. Half an hour later, she asked me to sit on the sofa with her in the living room and said okay, now describe to me in detail what to expect when the end comes. I did. Slowly and deliberately. After a while, she went and lay down next to him. Thus I found them several hours later as I went in to say goodbye. A few hours later, around 5:30 a.m., I got her call. She simply said Omar had stopped breathing.

And again, from Anthony and Cleopatra, Act 1 Scene 1:

Ant.Let Rome in Tiber melt, and the wide arch

Of the rang’d empire fall! Here is my space.

Kingdoms are clay; our dungy earth alike

Feeds beast as man;

The nobleness of life is to do thus.

Indeed, the nobleness of life is to do exactly what both Omar and Naheed did during the scoundrel times they faced together. I salute them both and feel the richer for knowing them:

Maqam e shauq teray qudsiun kay bass ka naheen

Unhee ka kaam hay yay jin kay hauslay hain ziyad

Note from The Daily Star:

(http://www.thedailystar.net/magazine/2009/04/04/remembrance.htm)

Omar Azfar was the, eldest son of Kamaluddin Azfar and Naheed Jafri Azfar from Karachi, Pakistan. He was the beloved husband of Mursaleena Islam and son-in-law of Anwarul and Zeenat Islam. Omar was a Professor of Economics at John Jay College of Criminal Justice, City University of New York. He held B.A. Honors from Balliol College, Oxford University in Philosophy, Politics and Economics (PPE) and a Ph.D. in Economics from Columbia University. He was the author of numerous research publications in Development Economics and the Economics of Corruption – he was working on a research paper, on police corruption and its impact on the lives of the poor, an issue he felt strongly about.

Omar passed away peacefully in Manhattan, New York, on January 21, 2009 at 5:30 a.m. Omar was diagnosed with bone cancer in May 2007 which later metastasised to the lungs. He endured months of tests, treatments and six surgeries with strength, courage, and good humour. Omar happily watched the Obama inauguration the day before he passed away. He was in good spirits, surrounded by friends and family, until the end. He is survived by his wife, grandmother, parents, brother, sister, nephew, and countless friends.