Life Interrupted: A Journey of Sibling Loss, Legacy, and Oral Cancer Awareness: Parul / Manu

Dr. Dean: 0:12

/Hello and welcome to The Broken Pack™, a podcast focused on giving adult survivors of sibling loss, a platform to share their stories and to be heard. Something that many sibling loss survivors state that they never have had. Sibling Loss is Misunderstood™. The Broken Pack™exists to change that and to support survivors. I'm your host, Dr. Angela Dean. Today's episode features Dr. Parul Dua Makkar talking about losing her brother, Dr. Manu Dua, to oral cancer. Both of them were dentists. This role that they played impacted their grief, his illness, and how she's changed her work and her life to be both a self advocate for her grief and herself in other ways, and as it's played a role in changing her work and how she's making an impact in leaving a legacy. She's an author and her brother was an author as well. Take a listen All right. So welcome to the show. What would you like to tell us about yourself?

Dr. Dua Makkar: 1:25

Hi, thank you for having me. First of all, it's a

Dr. Dean: 1:27

You're welcome.

Dr. Dua Makkar: 1:28

here to share this journey. I'm Parul. I am a dentist based in New York and, I lost my younger and only sibling. It's been three years now, March. to cancer, and the irony of the whole thing is that, he died of oral cancer, and both he and I are dentists, or were dentists.

Dr. Dean: 1:50

Yeah. Thank you for sharing that. I just reread, the book and so I know that'll be part of our conversation as well, but I was wondering how you would describe your brother and what you want us to know about him?

Dr. Dua Makkar: 2:04

Manu was carefree. He was very honest. He didn't have any grays zone. It was black or white. It was right or wrong, He loved life. He really did. He enjoyed, every minute that he lived and he lived it to the fullest. He did things that he wanted to do, not what peer pressure society expected of him. So he really lived life to his own terms and fully. He wanted to live more. He really had so many plans and, arrived to the different term.

Dr. Dean: 2:37

And the age difference was about seven years, you said?

Dr. Dua Makkar: 2:41

Yeah. Seven and a half. Exactly. He was June. I was Jan. That's exactly seven and a half.

Dr. Dean: 2:49

How was your relationship with him?

Dr. Dua Makkar: 2:50

I think I was more of a second mother to him. and we were raised very differently. I grew up, my formative years. I was six when we moved from India to Abu Dhabi and that's where he was born. So he grew up, I grew up in an Indian predominant culture. I went to an Indian school in Abu Dhabi, Manu went to a British school. He didn't know Hindi, which is our, native tongue. He learned it later on in life. And then, I always say we grew up with two different parents. My parents were, earlier on the marriage, they were struggling and he was born almost a decade after them being married, and he was born when my parents were a little bit more financially stable and were able to offer him more, And then I left for college, half across the world in, the late nineties, to the States and he was 10, I was 17. And so there was a big gap. It wasn't like I was coming home every weekend. I was coming home every few months for holiday break and Manu and my parents were still in Abu Dhabi at that time. And then they moved to Canada. Again, it wasn't like Toronto or New York. It was, I was still in Oklahoma and he was in Calgary and it was, a full day flight. So we grew up, pretty much like only children and we would meet. So what really united us was, dentistry. Because when I graduated dental school, he graduated high school. And then we lived together in the same house and he followed my footsteps. He watched me and my career and he decided to follow my footsteps. And then I got married when he got Dental school. So when I would go back home after marriage, he was in dental school and he would come back. so yeah, we were very, we were never together for long. And, And so he always looked up to me. And then I think at some point our roles reversed where I started listening to him and he was very much more read and worldly and he would offer me advice on my career and my practice. He even helped me lay out the plans for my new practice because he had already started his prior to me opening my own from scratch, because I waited for my kids to be older. So somewhere along the lines, the roles reversed And, We taught, we took courses together. We went to DR, we took an implant course together. We would talk about cases and yeah, dentistry united us.

Dr. Dean: 5:08

So that's interesting. I wonder what it was like. I know that you're doing a lot of advocacy for oral cancer awareness for dentists and other professionals. And I'm wondering how that was to learn that he had oral cancer while you were both dentists?

Dr. Dua Makkar: 5:22

Manu had a lesion and he showed me, he's like, this has been bothering me. And I looked at it, He was in Calgary. I'm in New York and this is 2019. And I said, dude, this doesn't look good. you need to get this biopsied. And he's like, no, I've got my oral surgeon friend. I'm on this medication and we haven't done the biopsy yet because it's something not serious. And I go every summer and, this was June. He was just shy of his 33rd birthday and I go in July. So we celebrate his birthday together. He's bought a new house. And, I said, show me your tongue. And this lesion that he showed me a month ago is is really ulcerated and he's having trouble eating, like we went out for sushi. He's no, the wasabi hurts me, trouble talking. And I looked at the lesion and I'm like, are you kidding me right now? Why haven't we biopsied this? And so when the cancer diagnosis, I think there was part denial. like I said, he was 33. He had a startup scratch practice in 2016. You just bought a new house. He, did all the special build. He picked all his, finishings. He bought custom furniture. He was high on life. uhhmm His practice to every little thing he built, he was featured on a Dental Town, which is a dental magazine. And he was on the cover of that magazine in 2019. and he had the cancer diagnosis at the same time. And so I think there was a lot of, denial did not want to get the earlier biopsy because he feared if it would be true what he had. My dad lost his mom, our grandmother to cancer, a different form. For my dad, it was always cancer associated death.

Dr. Dean: 7:03

mmhmm

Dr. Dua Makkar: 7:04

And then, I remember my dad asking me that question, is Manu going to die? And I said, No, Papa, he's not going to die. He's young. He's healthy. He's active. He plays all the sports and he's got no other core morbidities. This is not your mother who is 60 some years old. This is a young 33 year old. three year old, they're just going to take out the lesion and they're just going to remove all the bad stuff and radiation. He's going to be fine because we know cases of people who have had cancer and have survived and have lived full lives or had more time on their hands. So there was no doubt in any of our minds that he would do it. I'm like, no, I know this. I know people who've had cancer in their mouths and it's fine. It'll be okay. And that's what we really believed to be. Unfortunately, it was very aggressive and it returned after his first surgery where half his tongue was removed and graft from his arms. All of that was an eight hour surgery,

Dr. Dean: 8:02

hmm.

Dr. Dua Makkar: 8:03

and he went back to practice. He actually came to New York to see me and then went back to practice. Within two months of his surgery, the cancer returned

Dr. Dean: 8:12

mm

Dr. Dua Makkar: 8:13

and that's just when COVID hit. COVID hit, we got shut down in March, as dentists and Manu's cancer returned on April 1st, that same year, 2020.

Dr. Dean: 8:24

mm hmm. I was trying to think back. So if you were shut down, was his treatment delayed?

Dr. Dua Makkar: 9:47

So his initial treatment wasn't delayed in 2019 where half his tongue was removed in the surgery and all that. But after his second diagnosis, he got his surgery immediately, He was diagnosed, April 1st and April 17th. Two weeks later, he had a second surgery where he had lymph nodes removed more, went back in for the neck dissection. And they saw a lesion on his chest. And hindsight's always 20 20.

Dr. Dean: 10:16

Mm hmm.

Dr. Dua Makkar: 10:16

And, they ignored it. It was too small to do a biopsy. And it was on the same side as his initial tongue lesion.

Dr. Dean: 10:23

Mm

Dr. Dua Makkar: 10:24

They wrote it off and they gave him chemo radiation anyway.

Dr. Dean: 10:27

hmm.

Dr. Dua Makkar: 10:28

he finished that in the summer and that's when he quit dentistry. He sold his practice.

Dr. Dean: 10:33

mm hmm

Dr. Dua Makkar: 10:34

I guess between COVID uncertainty, I couldn't travel, borders were shut down. He decided he's just going to quit dentistry and focus on his health. And he started writing the book, the blogs.

Dr. Dean: 10:45

mm hmm

Dr. Dua Makkar: 10:46

That was his outlet because there was no contact with friends, with family. He was single, it was just his parents, so he needed something to share the grief with. Writing was his outlet. He found his calling in it, I think. And I think after the radiation and chemo, there wasn't enough follow up because of COVID. It did play a role. He was supposed to have a six month follow up. It got delayed. The chest lesion had grown. They were to do a biopsy. That got pushed another month. Before he could even get that biopsy, he was in the hospital with failure to breathe because the cancer was in his lungs. which was shown on the CT scans, which they didn't biopsy, but he had fluid in his lungs and that's why he couldn't breathe. And that fluid was drained and it was positive for squamous cell carcinoma. and then it was just a downward spiral from then on. That was December of 2020. And, at that time, even then we were still hopeful that he would pull through. but yeah, definitely, I think a lot. With what COVID played a role was Manu was in isolation during all the treatments

Dr. Dean: 12:04

Mm hmm.

Dr. Dua Makkar: 12:05

radiation. My parents would drop him, pick him up. There was nobody holding his hand during the

Dr. Dean: 12:10

Yeah.

Dr. Dua Makkar: 12:11

There was nobody with him when the consults were done with the doctor. So when you're in your thirties and you're getting this,"Oh, we're going to do experimental. We're going to do immunotherapy. We're going to do chemo. These are your after effects. This is what you need to do. We're doing wills. We're doing end of life plans. We're processing all this information and it's a treatment protocol, all of that, side effects, loss of hair, the burns from radiation, disfigurement, and he did it alone.

Dr. Dean: 12:43

Mm hmm.

Dr. Dua Makkar: 12:43

and I think that's how COVID plays a role in

Dr. Dean: 12:46

Yeah.

Dr. Dua Makkar: 12:47

his mental status, and maybe not processing the treatment protocol and we weren't there. We didn't have a choice.

Dr. Dean: 12:56

Yea that sounds so very isolating and awful. I worked in a cancer center at the time. And I do recall just how alone and isolated the patients reported feeling. So I wonder if that's also added to your grief.

Dr. Dua Makkar: 13:11

like, when my dad lost his mom to cancer. It was in India, and we were in the Middle East, and they would take turns, my parents. That was 30 years ago. Here we are in the western side of the world, there's so many advances made, and here we are at the same outcome.

Dr. Dean: 13:31

Mm-Hmm.

Dr. Dua Makkar: 13:32

I remember when my grandmother passed, my parents used to take turns. And I want to share this because how compounded grief was at this time. My dad's the only child. He lost his dad early on in life. So he never knew his dad. He knew his only parent living was his mom. And I was 14, Manu was seven. My mom was visiting with my brother in India, and she called my dad and said, you need to come home now. And I was left with friends cause of middle school and it was April. I still remember that. My dad flew for the final rites with Manu. Now, fast forward almost 30 years later In a different part of the world same parents. My dad watched his only parent die of this horrible disease Now he's watching only son mm hmm die in front of his eyes. My mother lost her mother April 4th. April 1st Manu was rediagnosed

Dr. Dean: 14:37

mmm

Dr. Dua Makkar: 14:37

So now she's lost a parent for who she can't grieve because she was in India. And then in February of 21, my dad asked me that same question. He asked me, is Manu going to die in February of 21? And this time I told him, yes,

Dr. Dean: 14:56

mmm

Dr. Dua Makkar: 14:57

you have to be prepared and you have to let him do what he wants, let him eat the foods that he wants, whatever his heart desires. You have to be ready.

Dr. Dean: 15:07

Mm-Hmm.

Dr. Dua Makkar: 15:08

I knew the diagnosis. I had been reading the reports. I knew the outcome. They knew the outcome. Manu knew the outcome, but we never talked about it. And in March, it was a Friday where Manu was taken to the hospital for failure to breathe and he had some edema. And it was a normal occurrence at this point, him going back and forth to hospitals. And my dad's like, Manu's going in. Don't call him. He's going to be admitted. Call him tomorrow, and I happen to be working that Saturday. So in between my patients, I called and my dad's like, we're meeting with the palliative team. Call us later in the night. We have to deal with stuff. So I knew it was coming and that evening, my mom, I finally got a hold of her and she told me the same thing that she told my dad. 30 years ago, I was scheduled to fly. at this point you needed compassion, release papers and all of that, because borders were shut down and there's a whole protocol to make it across the border. And I had my paperwork. I was coming anyways, a week later. So she says,"Come as soon as you can. He's not going to make it." That same phone call she made 30 years ago. I remember as a 14 year old and my child is now 14

Dr. Dean: 16:33

Mm

Dr. Dua Makkar: 16:34

And I'm like, okay, I will do anything in my power to come and I'm expediting PCR results on a Sunday and then the following day. And, I booked my flight. I get the result within 3 hours. I say goodbye to Manu like this and I told him you need to let go. It's okay. I'll make it as fast as I can, but you have my permission. Don't wait for me. He was sedated, and he's got morphine drip on, and his organs are shutting down. And then, I think that allowed him to let go, because that evening, he passed and my parents called me and showed me his deceased body and they're kissing him and they're loving him and they're like, he was just here. I was sitting right next to him. When did he leave? We didn't even know. And then three months later, my mother loses her dad.

Dr. Dean: 17:29

mm

Dr. Dua Makkar: 17:30

So my mom lost both her parents and her son within a year. And my dad lost both his parents, watched his only surviving parent die of cancer, watched his youngest son die of cancer. So the grief has ever compounded.

Dr. Dean: 17:46

Yeah. And that's a lot of loss for you as well.

Dr. Dua Makkar: 17:50

With no one.

Dr. Dean: 17:51

Yeah.

Dr. Dua Makkar: 17:52

Because I'm in the States without, I grew up in different parts of the world, so I didn't have the village that I grew up with. It's all disappeared.

Dr. Dean: 17:58

Mm-Hmm.

Dr. Dua Makkar: 17:59

with people who didn't know my brother very well, and who, nobody else's lives get affected. just yours.

Dr. Dean: 18:08

Yeah Did you end up making it there the next day?

Dr. Dua Makkar: 18:12

I did.

Dr. Dean: 18:13

What was that like for you?

Dr. Dua Makkar: 18:16

I knew I was planning a funeral, and I, I think my mind didn't know what I was doing. I was an autopilot. I wrote the eulogy on the plane. I was wearing a mask and I'm crying. I'm alone. And then I go, and my dad's like, you have to go to the funeral home. I can't pick the casket. You have to do it. My mom's like, I can't pick out his clothes, you go into his closet because it smells of him. Now his house was, this is where the book's title comes from, because when I entered his house, there was a magazine where he, the same magazine that he had first talked about his cancer journey, he had written an article about leaving dentistry. And that got published the same month, at the time of his death. So it hit hard and everything is, his clothes are on the floor, unmade bed, medication, food in the sink. It's his life interrupted. And it was just so unreal because I had never faced death of a loved one. All my grandparents passed in a different country. I knew they're gone. it's like, They're supposed to leave and they've gone and it's done, that's just the circle of life, but this brother of mine whose diapers I've changed. I remember him taking his first steps. I remember him as a baby, He'd color my books and I would get so mad at him and, he'd crayon all my notebooks and, and I have my own kids. I'm like, as a mother having to know, go through this and as a sibling having to go through this and who do I share this with? I had no one. My parents are doing their own grief. They have each other. The sibling loss is so unique,

Dr. Dean: 20:02

mm hmm

Dr. Dua Makkar: 20:03

and when I sat on that table with the funeral director across from him, and I had all this paperwork and things that need to be signed off, and do you need a casket, do you want his fingerprint, do you want to see his body, do you want this, do you want that, the makeup, and what idol do you want, and what prayers do you want said, and all these things that you need to go through, you're like, it's just, it's You're just deciding, pictures and I'm like, crap I have to do this two more times for my parents. Who's going to sit with me? No one. And

Dr. Dean: 20:41

and he was supposed to be there for you,

Dr. Dua Makkar: 20:43

I'm like, this is, I don't understand what's going on because I'm supposed to be picking out stuff for his wedding or write, his wedding speech to emcee his. dance, my kids didn't get to dance at their uncle's wedding. They performed songs at his celebration of life, right? It's just unrealistic. Sometimes I want to wake up and be like, this is all just a bad dream. And I feel like, yeah, my parents have each other and they've had their shared grief and they both understand what they're going through, but there's a sense of loneliness. that I feel that, my parents will age and they're aging faster because of, what they've gone through. I'm going to lose everybody of my blood. I've lost all my grandparents and now my parents, my cousins live far apart. I don't have that kind of a relationship with them that I'm close to them because of circumstances. And, it's just me.

Dr. Dean: 21:47

mm hmm yeah I think that's such a unique part of this too because you have a partner and you have your kids, but it's that family of origin,

Dr. Dua Makkar: 21:56

Exactly.

Dr. Dean: 21:56

that whole shared history,

Dr. Dua Makkar: 21:59

history.

Dr. Dean: 21:59

a secondary loss. Yeah.

Dr. Dua Makkar: 22:01

yeah. and it's reminded Every single occasion, every single celebration, every single holiday, the what ifs, the what could have beens, the what should have beens. And there's nobody to blame. It is what it is. And you have to come to terms with it. When you grew up alone as an only child. That's all, you know. When you have siblings, you're like, yeah, remember when dad did this or mom did this or, silly history. Remember when you had guests over and you locked the oven and we, all the food got burnt, like all these little stories. And I don't have them. And so there's a lot of anger sometimes. Like I get so mad at him some days. I'm like, damn it. You let me do everything. I have to take care of the parents. You left all your writing. I have to put the book together and I have to take care of my kids and you're not there to take that responsibility to take them, You left everything on me. I'm like, you had a great time and you left.

Dr. Dean: 23:10

I have that same conversation with my brother all the time.

Dr. Dua Makkar: 23:15

Yeah,

Dr. Dean: 23:16

So that was 2021

Dr. Dua Makkar: 23:18

correct.

Dr. Dean: 23:18

when you passed. Okay. And I believe the Canadian border was still closed for some time.

Dr. Dua Makkar: 23:26

Oh, yeah, it was still closed then. The day of his funeral, because you have to have limited release, which places you have to go to. So I was there for two weeks. My husband flew for my husband to fly. he needed to prove he's coming for a Canadian citizenship. So he had all the paperwork. There's a, there's an eight page cleared by the government. Then he had to prove with our marriage license, he came separate. So he had to prove the marriage license, my Canadian passport copy that he's coming that yes, I'm married to this woman. Yes. She's a Canadian citizen. And, this is why we're coming in the funeral paper director and signed off on the funeral stuff. So it was a nightmare. The Canadian, have an app you had to check in every single day, that we would get calls. How are you isolating? Where are you isolating? You're only allowed to stay in places where you've written on the limited release, which is my parents and my parents have to sign that off that. Yes, we take responsibility of her isolation. I would get calls. Where are you getting your food from? Where are you staying? Which part of the house are you staying? How are you getting fresh air? I'm like, okay, I have a walkout basement and my food is brought downstairs. All of these. So for me to go to the funeral home, the day of the funeral home, only 20 people were allowed. That was another thing we couldn't share grief with others. We only 20 people allowed. And we had 300 people on zoom across the world.

Dr. Dean: 24:50

Mm hmm.

Dr. Dua Makkar: 24:51

That's why we did a celebration of life. at the end of the year after the covid restrictions were lifted, but it was just this constant. So the day of the funeral, I am actually on the phone with the Canadian consulate because the funeral director had to sign off a limited release to allow me to be at the funeral home for my husband and I. So I'm calling there, I'm like, I need this paperwork faxed and sent over. The government had to know that I'm going to be at this place on limited release for this purpose. Like it, it's just the whole process was just a nightmare. I don't even know how I processed everything. So instead of grieving for my brother and planning that, I'm doing this dumb paperwork.

Dr. Dean: 25:36

Yeah. I almost wonder if that felt like a distraction in any, positive way, but also delaying your grief.

Dr. Dua Makkar: 25:45

I've never thought of it that way. That's a very interesting way to put it. Was it a distraction? Yeah. Now that I think about it, I don't think the grief hit me until months later and that's when I had my first panic attack

Dr. Dean: 26:01

Oh.

Dr. Dua Makkar: 26:02

This was in June and I was at an event and what had happened was I was on the phone some stuff from my parents who were dealing with their own depression and stuff. I was at work and I couldn't take so much time off work. I'm a private practice owner. I took three weeks off. Um, but then I was back to working and that's when I heard the music that he loves to dance to. And I'm like, Oh, how much he would have loved this. That broke me. And since then I've gone to a lot more funerals and I've I've broken down. Because it's déjà vu, or I've attended a few young deaths, in the 30s, 40s, and I watch the parents, and I think of my parents, and this reliving this whole thing. So it's a constant reminder. But my grief, I don't think I initially processed it until three months later, when I broke.

Dr. Dean: 26:59

So that's an interesting aspect too of you being the private practice owner. And I fully get that as a private practice owner myself, that you don't work, you don't get paid kind of approach.

Dr. Dua Makkar: 27:11

But you

Dr. Dean: 27:11

also you can take more time off than if you had worked for a corporation, right? So it's both a blessing and a curse, I guess. But what was it like to go back to work, especially because you shared the same profession?

Dr. Dua Makkar: 27:26

It was good because I, it gave me something to do. and then what I missed was I would share cases with him, or I would be doing a procedure that he loved and I would want to show him my x rays and I can't. But because it was oral cancer and because he was a dentist, I was a dentist and because his doctor, his, oral surgeon didn't biopsy and prescribed him medication, a prednisone, which is an immunosuppressant, and maybe that, we don't know. I'm just, guessing. Did that contribute to his cancer being more aggressive and spreading faster? I don't know. But my point is that, of self advocation. you see something, it doesn't seem right. Get a biopsied. His friends told me like, Manu wasn't quite, we met him at a conference and he wasn't, didn't have the energy, he wasn't feeling like himself. And that was in March and June was when he showed me the lesion. So the lesions been there for a while. This is when it'd be

Dr. Dean: 28:33

Mm hmm.

Dr. Dua Makkar: 28:35

why he didn't, and this is what I push for and for doctors not to prescribe unless you know what you're prescribing for in the first place. I have seen it. How hard is it? He had his wisdom. So they thought it was either lichen pinus, which is an autoimmune thing, or it was, he had his wisdom teeth taken out. They're like, Oh, it's from rubbing against the wisdom tooth. This is why you have an ulcer in your mouth. you took out your wisdom teeth. How hard is it to just take a small part of your tongue and get a sample?

Dr. Dean: 29:03

Yeah.

Dr. Dua Makkar: 29:03

Right?

Dr. Dean: 29:03

a little bit of the anger coming out as you're talking about that.

Dr. Dua Makkar: 29:06

Yeah. I'm like, and I don't want these repeated mistakes.

Dr. Dean: 29:10

Mm hmm.

Dr. Dua Makkar: 29:11

I couldn't save him. Maybe I can save someone else.

Dr. Dean: 29:15

Is that how you shifted into the advocacy work? Do you want to say more about that for our listeners? Sure.

Dr. Dua Makkar: 29:21

So this is what I advocate on, talk on oral cancer, what it is. And in my path of when Manu was going through treatment and doing the CT scans, what treatment protocols are, like, I didn't know, I'm not a surgeon, that's not my field, right? I just know how to diagnose it. And my realm of diagnosis, because I'm a general dentist, is, okay, I see a lesion, yeah, that looks suspicious. Off you go to the oral surgeon and hats off, right? that's my.

Dr. Dean: 29:50

Mm hmm.

Dr. Dua Makkar: 29:51

And I'm like, you know what? I learned after Manu, I learned to do my own biopsies. if I can do surgical extractions and place implants, I can do it. I learned my own biopsies. Why delay the time? Why wait for the patient to go somewhere else and then they don't do the follow up, or they don't go to the, they delay it on their own. They're like, you're in my chair, I'm just gonna take it off and send it on. I changed the way I practice. and I'm more vocal about sharing my journey with my patients, and other people because it really opens up. Patients feel that empathy and I have a very different relationship with my patients now. What happens after you're diagnosed, the psychological impact, the treatment, the fluoride trays, the radiation trays, the, dry mouth syndrome, the, you know, your mucus is thickened, what do you do? And these patients are going to be in your chair. And how do you help them? I didn't know these things because I just. I didn't deal with it and now I'm sharing that and this is why I created the Dua Good Job. It's a pun off my maiden Manu's last name..

Dr. Dean: 31:00

Yeah.

Dr. Dua Makkar: 31:01

I'll give Manu the credit he came up with it. He used to call his website used to be Dua Good Job where he used to share his blogs. And and the whole symposium is on this to that cancer is not just an isolating thing that it's a multi dimensional approach. There is an oral systemic link that it can metastasize to people who have other forms of cancer like breast and stuff. They can have oral lesions present. You need to be knowledgeable. and that's my motive is bringing this awareness throughout and have an open conversations between medical professionals and dental professionals and truly understand how you can practice empathy as a doctor,

Dr. Dean: 31:44

Mm hmm.

Dr. Dua Makkar: 31:44

empathy to the family, because your patient is so overwhelmed with how much information they're being given. And the person who's watching on the sidelines is so overwhelmed with having to take care of this sick person that you need to. their support also in the process.

Dr. Dean: 32:04

absolutely. My background as a psychologist in, oncology settings, I actually worked in the head and neck survivorship clinic here at UPMC before I left. And, that's a very multidisciplinary, clinic there. And the reason I, as a psychologist, was there was to support both the patients. and the caregivers because it's such an adjustment and that coordination of care between a dentist and the oncology team is difficult at best, given our health system here. So I'm glad that you're doing that.

Dr. Dua Makkar: 32:36

yeah, and I have I have cancer surgeons in there, I have oral surgeons, who are talking about oral systemic links. I have a psychologist talking about anger in the dental chair. And I'm sure you've experienced that, right? Your anger, sometimes you're angry at the doctor who's diagnosing you, because you don't know where to shift your anger to.

Dr. Dean: 32:54

Mm

Dr. Dua Makkar: 32:55

but yeah, so I have such a diverse group of speakers. we're talking about this and and this is open to all health care professionals. whether you're a resident, you're a student, or you are, any field of medicine, practicing or any field of dentistry.

Dr. Dean: 33:11

Do you plan to do it annually?

Dr. Dua Makkar: 33:13

This is my 1st year, so I can see what kind of response I get, but I think it's been pretty good.

Dr. Dean: 33:17

I'll put the link in the show notes. Okay.

Dr. Dua Makkar: 33:20

Yeah, this is virtually, but it's aired on the, on Manu's birthday, he would have been 38, but you can watch the recordings throughout because it's on a Thursday and a lot of work and everybody's time is important. we have it set up so that people can watch it later on, and it'll be available for the next six months

Dr. Dean: 33:39

What would you like to say about the book? And I'm also curious as to how that has played a role in your grief process.

Dr. Dua Makkar: 33:46

Yes.

Dr. Dean: 33:47

Yes. Life interrupted.

Dr. Dua Makkar: 33:49

This is the most tangible thing I have of him. I don't have his kids. There's no other legacy. I don't have him and to share him with the world. This is it. Manu had expressed that he wanted to be published. I flew down in December of 2020 when he had fluid in his lungs and he got a chessboard placed in. And that's when I knew this was, my, I had other medical friends who were like, you need to get on a flight. And I was not vaccinated at that time. The world was a very scary and New York was the epicenter and my parents are like, no, you can't fly. We're all losing one child. We cannot have you. What if you get COVID? You've got young kids. What? My dad was not listening to me. So I wrote my dad an email and I said, Manu is my only brother. And at that time, I didn't tell him he was going to die, but I just said you need to let me come see him. I have not seen him, since his diagnosis, he had flown in September, but I'm like, I have not seen him since his second surgery, all the chemo, everything. I've not been there for anything. Let me just come. And I put on a mask and I flew. My husband was scared. Everybody was scared. But that's when he told me, he's I've been writing, I really want to be published. And then I said, okay. I found a publisher and I told him in February,"I found a publisher, let's get you, I need your manuscripts" he's like, no, I've got time, I really want to write more. And then I said, okay, you've got nothing else going on. Go ahead. there was, he was barely walking, he had lost so much weight struggling to breathe, drink twice a day sometimes. And, so when I found all his writings, the unfinished pieces, I put it in the same chronological order as he had put in them, and it was my way of doing something for him because I felt a failure as a dentist, as a sister, as a daughter in so many aspects. I couldn't be there. I couldn't save him. I couldn't push him. there's always, there's a guilt. There's a survivor's guilt. I have the same gene pool as him, why him, not me. I've been reading this book called Worthy and in that, I read there's a special reason why you've been picked and, your purpose is different than, and you have to live to your purpose. And there's a lot of healing and this book was part of that healing. yeah, I couldn't be there, but I did something else for him that he wanted. I still got to do something for him. And. I helped finish it. I wrote the epilogue, The Aftermath of Cancer, that it's a joint project and it's tangible. And when I read it, it's in first person. So if I ever feel like talking to him, I read him.

Dr. Dean: 36:42

hmm.

Dr. Dua Makkar: 36:43

You're still talking to me in first person.

Dr. Dean: 36:46

It struck me because I reread it and it felt like what a gift to be able to have his words on paper. And so many of the entries felt very much about how he perceived the world and engaged in the world. And so it, it felt like in reading it I was like, Oh, I have a little bit of a sense of who he was. And as his sister, that must be, like you said, the thing that you can hold on to, because you don't have a lot of other things.

Dr. Dua Makkar: 37:09

I don't. His house is sold and his cars are gone and there's nothing tangible.

Dr. Dean: 37:15

Mm Hmm.

Dr. Dua Makkar: 37:17

And and I knew when he had given up, He never gave up. I don't think he ever stopped fighting.

Dr. Dean: 37:25

Mm

Dr. Dua Makkar: 37:26

But in Jan of 2021, he was admitted for two weeks in isolation. Complete isolation because it was still COVID. He had a lot of fluid buildup. He had a demand. They were draining him and he had high white blood cell counts. And so silly, he would shy away from telling us the full details of what he was going through, he was protecting us, He was admitted one time for high calcium levels. I'm like, Manu, why do you have high calcium levels? And he's like, no, don't worry about it, Didi, it's because I had too much calcium pills. Not because your cancer is down to your pelvic bone and you're slowly degrading. Manu, why do you have a high white blood cell count? Not because you have a cell necrosis. he's no, it's just some infection. They're just going to fight it off. I'm in two weeks at the hospital. And when he was in that hospital, he had written, the chapter, the last blog, New Beginnings. last chapter, that last paragraph, and he always shared his writings with me, right? He's okay, Dee, this is what I wrote. and when I read it, even then I knew. It was any day now,

Dr. Dean: 38:40

Mm Hmm. Mm

Dr. Dua Makkar: 38:41

and then he stopped writing after that because he just got really sick. And then February, and he was getting immunotherapy. And it's again, I don't know if he knew and was eminent because in Feb, I told him, I'm like, kids are off. I'm going to come. He's don't come now. I'm getting more radiation. I have another lesion and that's positive for cancer. Also, the chest port was moved and the initial chest port side had fluid retention, and that was cancer. And he's I'm going to get more radiation on my abdomen. I'm going to be done by March something. And so why don't you come that weekend, March 21st? So I was to fly. But I already had my tickets. I had, and that's why I got the compassion release because it's only valid for a month. So I had it applied in December and then I applied it for March. And I said, okay, so February is going to take me time. I'm vaccinated now. Okay. And my husband's going to come to, we planned this all, unfortunately passed before all of it, but had he not told me I

Dr. Dean: 39:40

You would have been there.

Dr. Dua Makkar: 39:41

I would have not been able to make it. I would not have my paperwork. I would not have, been ready to fly. and the day I was supposed to fly was his actual cremation. So in some ways he knew and. He just told us as much as he felt he needed to tell us. and and that was his sense of control, He couldn't control the other aspects of life. So this is what it was, he did things his own way. He never came to anything, He fought to the end as much as he could, and he did it on his terms.

Dr. Dean: 40:18

How are you doing now?

Dr. Dua Makkar: 40:20

MMM. I've come a long way. I've definitely become more empathetic. when somebody passes, it's so robotic to say, I'm so sorry for your loss,

Dr. Dean: 40:32

Mm hmm.

Dr. Dua Makkar: 40:33

I

Dr. Dean: 40:33

Mm hmm. Mm

Dr. Dua Makkar: 40:35

can't imagine what you're feeling unless you have gone through that process, unless you have watched a loved one die and been there through the aftermath, you don't, I, and like I said, I lost my grandparents and I was like, okay,

Dr. Dean: 40:53

mm hmm

Dr. Dua Makkar: 40:53

That's life, but to watch somebody die in front of you, Is very, it's a different road and few travel it. so now when people pass, people don't need support as much when somebody has gone, has experienced loss. the few days after people come, they call, they do the phone calls. And you don't need that anymore. You need it when the next holiday comes or you need it a few months later. And you feel alone and nobody's calling and ringing and checking up on you. And it's made me realize how important that is. And I do it. Those death anniversaries, the birthdays, that's when it matters. I've become stronger, and I've realized how much strength I possess. That what I have had to go through endure. In my loneliness in ways. Yes, my husband's there for support, but that's not his brother. His life didn't alter. My kids are too young to remember. They didn't make an impact. and so you learn to stand up for yourself because no one else will. so, when you ask me, like, is there any question off topic? There isn't because I want this to be candid and I've shared this even with my family, like my in laws and everybody that like we celebrated my father in law's 80th birthday and my husband saw my face. It's not that I'm not happy. Yes, I'm happy we're celebrating, my father in law's there with his grandkids and the whole family and all his friends. I'm like, I'll never have that. My dad will never have that. We planned to go away in March of 21 as a family to Hawaii. To celebrate my dad's 70th, and that trip never happened because of COVID. And then a month later, Manu was diagnosed for the second time. We were going to celebrate Manu beat cancer. We're going to celebrate his family. My dad's turning 70. Mom's turning 65. to do this whole thing as a family trip. That trip never happened. My parents don't want to celebrate birthdays anymore. And it was that realization that. And that's when grief hits you. And I took a walk and my husband's do you want to come? I'm like, no, you need to be with your family and enjoy your dad's birthday. I'll be fine. I just need to take time out for myself to process what I'm going through. I'll be back. And it's realizing when to step away and be present when you're ready. And it's okay to say no to things that I just genuinely was like, I can't be there. especially right after the death. even if time has passed, it doesn't just affect you that few months, a year later, the grief hits you at any time and you just have to be ready for it and learn how to cope. And that's what this process has taught me that, and I need to take care of myself. No one else is going to. I need to step away and come back.

Dr. Dean: 44:15

I think that's a nice parallel to your self advocacy statement from before about self advocacy for health, but I think also in grief we have to advocate for ourselves There's different people in your family grieving, your parents are obviously grieving differently, so I wonder if your boundaries and your needing to take breaks feels different than theirs and how you've navigated that.

Dr. Dua Makkar: 44:39

Yeah, I think they're more isolated because they don't have me around. and they are invited to events. And they say no to a lot of things. You're like, we're not ready. We're not in the happy zone and life doesn't stop

Dr. Dean: 44:53

Right.

Dr. Dua Makkar: 44:54

and they have their own healing to do and they are going to have to do it on their own time. And I cannot force it on them. life does go on, I can't forget Manu, but I can keep him as long as I can with me. But do something good and positive in a way, try to let go of the anger and shift it to something else because

Dr. Dean: 45:14

hmm.

Dr. Dua Makkar: 45:16

otherwise it's going to eat me away.

Dr. Dean: 45:18

It sounds like through this work that you're doing, the speaking engagements and the symposium, And the book, that you're carrying him with you.

Dr. Dua Makkar: 45:27

Yeah. And that's what I wrote in the book, my last

Dr. Dean: 45:33

page. I probably read that, I read it before bed, maybe.

Dr. Dua Makkar: 45:38

It's the last page, it was my note to him.

Dr. Dean: 45:42

Oh. That'right Have you been en able to share with your kids about him?

Dr. Dua Makkar: 45:46

They weren't there for the funeral. but when we did the dispersion of the ashes, they were with us, we did it together. And it was so overwhelming. I'm like, okay, this is your uncle in a jar. And because they didn't see the funeral. So they didn't see the actual process. I had to explain it to them, this is circle of life, it's just, you had to learn the lesson a little early. Usually it's your parents or grandparents that you experience this with, not your uncle. Not so early on. And, and we still talk about him. And, my older, who's 14 now, he asks me questions. He's like, if they called him mamu, which mama in our language means mother's brother. So in Deerling, they called him mamu and they said, would we hang out? Would we do stuff together?

Dr. Dean: 46:41

hmm. I

Dr. Dua Makkar: 46:42

would he like me? you know, stuff like that. And I said, yeah, you guys would play Legos together. he loved cars. You would do this. and my son wears his old clothes. Is there about the same height now? Manu shopped, When Manu's cancer had stopped. He came to New York and he went shopping. He came with an empty suitcase and he goes to the outlets and he shopped so much. And he never got to wear those clothes because he got sick right after. And so my son has all these brand new clothes and, shoes and everything. So he feels so much closer to him. It's cool. Mamu left me this and Mamu, he gets all excited. So yeah, Manu is still a part of their lives in a way we talk about him. We celebrate his birthday. We'll take a cake. We'll put a balloon out. We do Rakhi, which is a celebration of a brother, sister bond. And.

Dr. Dean: 47:37

was going to ask you about that. Yeah.

Dr. Dua Makkar: 47:39

Yeah. so I still carry that tradition. I have a tree in front of my house that was gifted and we have a plaque that was also gifted. And, that tree represents Manu to me. It's living, it's alive. And so I tie it to that and my kids watch it. So yeah, Manu is still a part and we talk about it. We, and if you feel sad, it's okay to feel sad and, they've seen me break down and I said, I'll, I just need a few minutes and mommy still loves you. I'll be right back.

Dr. Dean: 48:10

So even being able to take those breaks with your kids is a healthy process. Yeah.

Dr. Dua Makkar: 48:15

And I want them to know that life is not always all about ups. It's downs and you need to learn. To pick yourself after if you have a down,

Dr. Dean: 48:24

Which it sounds like you've really learned to do. Are there other things about grief or sibling loss that you wish you had known then?

Dr. Dua Makkar: 48:38

I wish I'd never known.

Dr. Dean: 48:41

Yes, of course. Same.

Dr. Dua Makkar: 48:42

I don't think I ever in my wildest dreams wish I'd known any of this. I don't wish it upon anyone. In fact, I think I thought about having a third child. I'm like, God forbid, something has to happen. At least they'll have another sibling, cause it's so isolating. So lonely.

Dr. Dean: 49:00

That's funny. My aunt always said that because my dad had three siblings and she always said she was having more than two kids in case they lost one another because they knew that experience.

Dr. Dua Makkar: 49:12

no. And I think, it's you always think things for granted. I always took, I took a lot of stuff for granted. Like I'm a far away from my parents. and I, because I thought Manu would always be there. It was almost a decade younger than me. I'm like, I'm gonna always take care of them. He'll be around. He had lived always closer. He went to college, in Calgary where my parents lived. He went to school in Vancouver. It's only a flight away. He worked in the same city as them. so it was always this predisposed condition that they'll always be there. I left my house at 17. I was only with my parents for 17 years of my life. And then I went to college. I went to dental school and I lived with them for a few years. Then I got married. So I joke around. I'm like, okay, I have them for the first 17 years of my life and I will have them for the last 17 years that they've got left, they're aging now. but it's cherish those moments, be there for your family. I, it's just, take more pictures and videos. I wish I had more of that.

Dr. Dean: 50:09

Yeah,

Dr. Dua Makkar: 50:10

Even though you may think you're promised things, it's not necessarily that they will actually happen.

Dr. Dean: 50:15

exactly. Do you have any favorite memories that you want to share?

Dr. Dua Makkar: 50:26

I think the most fun I've had with him was when we lived in the same house as adults, when he had finished high school, he started college. And then now he wasn't this little annoying brother who would like to try to eavesdrop and I'm talking with my girlfriends and now he was like. he became a peer and somewhere, he became the older sibling. I don't know. but those are like, those three years of sharing the same house, fighting over the bathroom. And he's like, all your contacts are all over the place. I'm like, your toothbrush and your shaving stuff, like we would fight over. We never had that opportunity as we were growing up. So it's these little things that. we could actually go hang out together and those three years are great

Dr. Dean: 51:26

Oh wow, so three years as adults you were living in the same

Dr. Dua Makkar: 51:29

until I got married and then I moved, you

Dr. Dean: 51:32

and you're now in the states.

Dr. Dua Makkar: 51:35

know, New York back into the States, you know,

Dr. Dean: 51:40

thank you for all of that. Is there anything else that you wanted to share or say?

Dr. Dua Makkar: 51:44

no, that's been great. Finding your own people when like you said, you've got this Broken Pack, it's finding your path

Dr. Dean: 51:52

Yeah.

Dr. Dua Makkar: 51:53

because we're all broken in all sorts of ways. And you can never be whole, you can try to find those pieces and maybe make it whole.

Dr. Dean: 52:00

Yeah, I like that interpretation. In fact, That's not why it's named the Broken Pack, but I actually had a couple people reach out when I first named it and the people that I knew and they're like, I'm not broken. I'm grieving. And I was like, I get that. it's actually called the Broken Pack because the wolves grieve and their pack is broken as the family structure. And so that's what the broken refers to, but it's obviously open to interpretation. um, yeah,

Dr. Dua Makkar: 52:28

I know the wolf reference, but I perceive it as finding your pack.

Dr. Dean: 52:33

yeah. I like that too, because part of what I'm doing here is building community. And I know that you and I have messaged about this, but also other things. And it's been nice to connect with people. And so I do plan to build that part of The Broken Pack up slowly because we're small organization right now. But, yeah. Thank you. And thank you for chatting with me today and sharing a little bit about Manu.

Dr. Dua Makkar: 52:55

Thank you. Thank you for having me.

Dr. Dean: 52:59

you're welcome./Thank you so much for listening. Our theme song was written by Joe Mylward and Brian Dean and was performed by Fuji Sounds(feat. MYLWD.). If you would like more information on The Broken Pack™, go to our website, thebrokenpack. com. Be sure to sign up for our newsletter, Wild Grief™, and to learn about opportunities and receive exclusive information and content, as well as grieving tips for subscribers. Information on that, our social media and on our guest can be found in the show notes wherever you get your podcasts. Please like, follow, rate, subscribe, and share. Thanks again.