Driving An Ambulance In One Of The World's Most Dangerous Cities

Who would risk their own safety tending to the injured and recovering the dead in one of the most violent cities on earth? Samira Shackle rides along with a driver from the world's largest voluntary ambulance service.

The impact of the explosion sent Muhammad Safdar flying backwards. He looked up from where he had landed and saw that the glass on his parked ambulance had shattered. 

As he tried to pick himself back up, fellow ambulance drivers from the Edhi Foundation gathered around him; it looked as if Safdar was bleeding. But he had not suffered any external injuries. "Human flesh got stuck to me," he recalls now, as we sit in the ambulance control center in downtown Karachi. "My friends were checking me for injuries, but it was pieces of other people. I was trembling hard and I couldn't hear my own voice when I spoke. It sounded juddering. I could only hear whistles."

It was 5 February 2010 and Safdar had already dealt with the fallout of one explosion that day: an hour before, a motorbike laden with explosives had slammed into a bus carrying Shia Muslims to a religious procession. Safdar had raced to the scene to load the dead and injured into his ambulance and take them to nearby Jinnah Hospital. With more than 30 injured people and 12 dead, the emergency room was chaos, with people crying and screaming as doctors struggled to cope. He was still inside the hospital when the second bomb exploded just outside the entrance.

He did not realize until later that he had suffered head injuries. At the time, he followed his first instinct, which was to get up and continue to help. A further 13 people were dead, with scores more injured. "Everything was a mess, there was blood everywhere, the whole place was like that," Safdar remembers. 

The hospital entrance was badly damaged and there were fears that a third bomb could hit. Ambulance drivers took the worst injured to other nearby hospitals for treatment. Three ambulances were completely destroyed, so they worked with what they had. 

Across the crowds of injured people, Safdar kept his eyes on his boss, Abdul Sattar Edhi, who was sitting inside an ambulance. Despite being the famous founder of a huge charitable empire, Edhi made a point of remaining at the frontline of rescue work. He had been collecting the dead and injured alongside his workers. Safdar ran over to Edhi. "I came to pick him up in case of a third blast, but he said, 'I am not going. Wherever I am, there isn't a blast, so I am not moving.'" Safdar continued to haul bodies to ambulances parked outside. Amid the dirt and blood of the explosion, he spotted something suspicious: a noticeably clean-looking motorbike in the car park with a TV set strapped to the back. Safdar ran back to Edhi to tell him what he had seen. Edhi alerted police and stayed put as they defused what turned out to be a third bomb.

In 13 years as an Edhi ambulance driver, Safdar has lost count of the rescue jobs he has done. He has entered burning buildings, dived into water after shipwrecks, retrieved bodies and survivors after terror attacks and industrial accidents, and navigated running gun battles.

Sporting red T-shirts emblazoned with 'EDHI' in bold white letters, these workers are a familiar sight at Pakistan's all too common disaster scenes. Here in Karachi, a throbbing megalopolis of around 20 million people, there is no state ambulance service, despite overwhelming need.

For decades, Karachi has been troubled by violence. This is the country's economic epicenter, where Pakistan's different ethnic groups come in search of work. Ethnic conflicts have been simmering since the 1950s, ramping up as conflict and natural disasters elsewhere in Pakistan pushed more people into the city. For years, a brutal gang war raged in the slum of Lyari, and as terrorism drastically increased in Pakistan after 2001, Karachi became a key militant operating ground. Since 2014, a bloody crackdown led by the army has brought a semblance of calm, but tensions bubble under the surface. 

Safdar, in his rudimentary ambulance, has been at the frontline of the multifaceted conflicts consuming his city, placing himself at huge personal risk for very little money. What does it mean to be an ambulance driver in an uncertain, violent and shifting context? And why would anyone choose to do it? 

 

It was 2003 when Safdar first stumbled into the Edhi Foundation's main office, shouting that his brother had waited too long for an ambulance. Safdar was around 22 (it is common in Pakistan for people to be unsure of their exact birth date), and his brother Adil was 20. Muhammad Liaqat was on duty. "Our reaction was not to reply in any aggressive way," he says. "He has a very good heart, but he is hot-headed." 

Adil had contracted polio as an infant, and the disease – eradicated in much of the world but still endemic in Pakistan – left him disabled. He needed a series of painful leg operations. With no car and limited funds, the family relied on Edhi ambulances' low-cost transportation services.

Despite Safdar's anger, he was impressed. "I saw other people waiting at the hospital for hours for transportation," he recalls. "Edhi Sahib [a term of respect] alone was trying to help." Safdar had dreamed of joining the army, but needed to stay at home because of Adil's illness. So, he got a driver's license and joined the ambulance service. "He saw the work we were doing and he got activated to join," says Liaqat. "Now he creates trouble for us every day."

Karachi's ethnic conflict and violent gang war was in full flow. On his first day, Safdar went with another driver to collect one of the unclaimed bodies frequently found on the streets. He couldn't look. The other driver slapped him in the face. "What do you think this is?" he said. "It's a human being. What are you? A human being. Why are you behaving like this?" Safdar picked up the corpse. 

"It takes time to get used to this work," he says. "A lot of people leave after a week or so as they can't take it. They have fear in them."

Safdar is a thin man with a meticulously stylish haircut, equally quick to laugh as to fly into a rage. His boss, Anwar Kazmi, ironically introduces him to newcomers as "our most polite driver". Safdar is constantly chewing a betel nut derivative, which has an amphetamine effect – a common habit among drivers in Pakistan. He is outspoken and talks a million miles a minute, his rapid hand movements expressing a world of emotion. He wants to punch the boss of the rival Chhipa Ambulance Service in the face, and refuses to enter a government hospital where the proprietor was once rude to him. But he cannot stand to see suffering, sometimes getting in trouble for using his siren for non-emergency call-outs, and stopping to help if he spots anyone injured or lost on the road.

His usual base is at the Edhi Ambulance Service's main control center in Kharadar in Karachi's bustling old town. The office is open to the street, with a kiosk at the front for donations. 

In a city where media groups and hospitals have armed guards, this accessibility is unusual for a high-profile organization. Inside, drivers sit and chat in between shifts, the overhead fan whirring and causing the dim electric light to flicker over their faces. They standardly work shifts of 18, 24 or 36 hours. At night, some nap on their ambulance stretchers. High up on a wall, stuck to peeling paintwork, are photographs of eight drivers killed in service. 

The bosses sit in this room too, behind two large desks. Kazmi, general manager and spokesman, is always stationed at the right-hand desk, two phones and a mobile in front of him. 

The organization was founded by Kazmi's friend, Abdul Sattar Edhi, a poor man from an Indian village who came to Karachi at Partition in 1947. Starting with a small pharmacy tent, his work rapidly expanded, powered by donations from ordinary citizens. With the help of his wife Bilquis, he set up a maternal health clinic and a center for abandoned children. A big donation allowed Edhi to buy his first ambulance, a second-hand truck. 

Pakistan can sometimes be a cruel environment, its residents caught between the dual pressures of poverty and violence. Yet it is also a place of great kindness, with a strong culture of charitable giving. Donations from what Edhi called "the common man" still power the foundation. It refuses state money, and has politely turned away donations from businessmen it deems "unethical". It fills many gaps left by the state, operating a dizzying array of services, from homes for victims of domestic violence to food banks to a shelter for stray animals. 

Kazmi has a persistent cough and frequently quotes Karl Marx. Despite the heat, he wears a woolly hat and a waistcoat over his salwar kameez. "I'm leftist-minded. Edhi Sahib was too," he tells me. "Some 40 years ago, he said to me, 'You can't say when the revolution will come, but this is a way to serve the common man. Come and work with me.' So I joined."

Pakistan is a conservative, religious state. Unusually, the Edhi Foundation ignores caste, creed, religion and sect. This strict stance led to some criticism from the religious lobby while he was alive. Edhi lived in a humble, ascetic way, even as his charity became a multimillion-pound enterprise. He never took a salary, and refused to pander to his growing celebrity, preferring to sit outside the office with a begging bowl. He lived with his wife and four children in a small, two-room apartment, and continued to take a leading role in rescue operations like that at the Jinnah Hospital. He often took his sons with him. 

Faisal Edhi, his eldest son, remembers the first time he saw the aftermath of a terrorist attack. It was 1986 and he was 10. "People were burned. They were in pieces. I took a shroud from somebody and his face and leg was next to each other. I still remember those scenes. It was very strange for me, that his leg is next to his face. Actually, he was ripped apart." 

When Edhi died on 8 July 2016, Pakistan entered a period of national mourning. He was hailed internationally as the "world's greatest humanitarian". Leadership of the organization passed to Faisal. Criticism from religious conservatives about the family's beliefs ramped up. Donations dropped. Pakistan is watching to see if Edhi's legacy can be continued.

Like other Edhi ambulance drivers, Safdar is technically a 'volunteer' and works for a basic salary of 4,300 rupees a month ($43). A household driver would earn 10,000–15,000 rupees. This basic salary covers the high-risk rescue work; the easier 'patient services' jobs – moving people between hospitals and transporting corpses – incur a small fee, so drivers receive a commission of around 100 rupees ($1) per trip. Sometimes patients tip. But clearly, money is not the motivating factor. 

When Safdar talks about his medical knowledge, his face lights up. Edhi drivers receive a few days of basic instruction, and those who display an aptitude later get more specialized training on an ad hoc basis. Safdar can rattle through the procedure in the event of a heart attack, electrocution, broken bones, fire, bombs. He has tricks for picking up heavy people, and uses the grubby cushion in his ambulance to prop up the unconscious to keep their airways open. "Doctors giving me these trainings would ask me how long I have studied for, and I would show them my thumb," he says proudly. This signifies illiteracy: those who cannot sign their name use a thumbprint for official documents. "They'd say, 'You seem like you've studied for a long time, because you know the right questions to ask'."

He and other workers care passionately about continuing Edhi's legacy. Staunchly non-hierarchical, Edhi had a personal relationship with even his most junior staff. Safdar visits his grave regularly, and keeps in his ambulance a dog-eared newspaper obituary, which quotes him saying that Edhi was "like a father". Safdar likes to look at the page, knowing his tribute is recorded.

Between jobs, Safdar can usually be found in one of the small shops near the Kharadar base. The biryani stall dishes up heaps of steaming rice and meat to drivers on their breaks. The 'juice bar', with white walls and bright orange plastic seats, sells fried chicken and canned drinks. Safdar loves to cook and sometimes takes over the kitchen here. The tea shop nearby brews vats of traditional masala chai; milky, sweet, spiced tea which fuels everyone at the Kharadar office through their long shifts. 

Until recently, ambulance drivers were constantly on the go. Now that the security situation has calmed, what drivers term "gunshot incidents" – targeted killings, bomb attacks and gang battles – are less common. 

Sitting in the tea shop, Safdar pours a small amount of his tea into the saucer so it will cool quicker, slurping it up from the plate. "I am always on call even though I'm free right now," he says. A call comes through. In an instant, Safdar is in his ambulance. There has been an explosion in the Defence Housing Authority, an upmarket suburb. 

Safdar drives at alarming speed, weaving between lanes of traffic, careering down alleyways, siren blaring. Edhi ambulances – small Suzuki Bolan minivans equipped with a single stretcher and oxygen canister – are not set up for pre-hospital care. But their small size means they can zip through Karachi's five lanes of frequently gridlocked traffic at high velocity. Safdar shouts through his loudspeaker for people to move. "Hey Muslim! Go quicker!" he calls to a man with a long beard wearing a prayer hat. "Rickshaw driver, get out of the way! Old lady, move it! Son of a bitch, are you drunk?" He screeches to a halt outside the flats where the explosion has taken place. A crowd of journalists has assembled, and blue-clad drivers from the Chhipa Ambulance Service greet Safdar warmly.

The Edhi Foundation has around 500 ambulances in Karachi, out of a fleet of more than 1,500 across Pakistan. This makes it the world's largest voluntary ambulance service. The Chhipa Ambulance Service is also philanthropic, running on a similar model to Edhi. Founded in 2007, it is Karachi's second-largest ambulance fleet. 

"I don't consider them ambulances," mutters Safdar. "As far as ambulances go, we are the dons and these guys are just kids." Once, he got into a physical fight with some Chhipa drivers. Edhi was still alive then and made sure Safdar was arrested. "He wanted to teach me a lesson," Safdar says.

The Defence explosion was caused by a domestic gas cylinder, and four people were badly injured. The rate of injury and death from poor health and safety standards is particularly noticeable now violent crime has reduced. 

The security crackdown began in earnest in 2014, triggered by two major incidents. One was a Taliban attack on a school in Peshawar, one of the country's northern cities, on 16 December, in which 150 people, mostly children, were slaughtered. The other, on 8 June, was a brazen assault on Karachi's airport. Around 11pm, ten heavily armed militants entered the airport and launched an assault. Heavy fighting with the Airports Security Force ensued. 

A group of Edhi workers arrived at the scene soon after the first blast and provided medical back-up to the security forces. Clad in bulletproof vests, Safdar and his colleagues were inside the airport for 16 hours as the gun battle raged. "During the active fighting, our job was to keep in a corner and watch for injuries and see if someone was shot," says Safdar. Workers darted out with their stretchers to pick up the wounded. Of the 28 who died, 14 were security officials. 

In Karachi, the security operation that ensued involved a substantial number of alleged extrajudicial killings by police. Sometimes, ambulances are called to clear up the mess. On this subject, Safdar is uncharacteristically reticent. "Whether it is a big raid or a small one, back-up is needed. Sometimes we arrive and find police in masks. It is our job to check if anyone is alive, not to ask any questions." 

Edhi workers have not always had an easy relationship with the police. In April 2012, Lyari was consumed by a new iteration of an old gang war. The police staged a crackdown, shutting down electricity and water supplies. Whole streets resembled a warzone as police and gangsters battled. With thousands of people trapped inside without basic supplies, Edhi announced that his ambulances would deliver water, rice and powdered milk door-to-door. This allegedly angered police, and led to widespread conspiracy theories and (unsubstantiated) allegations that ambulance drivers distributed arms. 

"My job was to take groceries to homes," says Safdar. "We couldn't do much for the injured as the government was involved. But lots of families had other emergencies – heart attacks, going into labour. We catered for that despite the operation."

One day, Safdar claims that he and a colleague were apprehended by Chaudhry Aslam, the then police superintendent. He cut open the sacks of rice, looking for weapons, and took them into custody. The incident demonstrates the dangers of operating an ideologically independent organization in a corrupt and unpredictable state. Safdar is sanguine. "My only regret is that I was not able to slap Chaudhry Aslam in the face as he arrested us." 

 

The call comes in the early afternoon. A dead body has been spotted in the sea, near the port. Siren blaring, Safdar weaves between cars. "It is not common for us to have accidents, and when we do, it is usually the public's fault," he says. A large truck fails to give way. "I don't think you can even hear the horn!" he shouts, glaring at the driver.

At the port, Safdar picks up the sheet from his stretcher. Bodies are harder to lift when they are waterlogged: limbs are fragile and parts can come away. When the wooden rescue boat comes in, he and a colleague climb nimbly down the rocks and onto the boat. They roll the corpse onto the sheet, wrap it around, and carry it up to the waiting stretcher. It is a fresh corpse, a few hours old, and has not started to smell. The man was in his 60s. 

When a body is found, a strict procedure follows. The ambulance takes it to a government hospital, where the death is logged and if possible, relatives contacted. If the person was not carrying ID, the body goes to a police station. From there, it is taken to the Edhi mortuary, where further efforts are made to track its identity. If this proves impossible, the body ends up in the Edhi graveyard.

The Edhi mortuary is in Sohrab Goth, an impoverished area that until recently was an urban hotbed of militancy. The mortuary is set back from the road, with a large open waiting area lined with benches where relatives can wait. To the left are rooms where bodies are washed. To the right is the cold storage facility. A strong smell of disinfectant pervades the building. This is the only functional morgue in Karachi. 

Although state hospitals are equipped with cold storage facilities, most are not operational, with funds earmarked for their maintenance frequently diverted elsewhere. The mortuary deals with unidentified bodies and the aftermath of disasters, but families can also pay for deceased relatives to be stored while they await burial, or for the bodies to be washed in the traditional Islamic way.

Ghulam Hussain, the senior clerk, has worked at the mortuary for 12 years. After his first day, he walked out. "There were so many bodies, in all conditions, fully mutilated, so there were just parts of them. When I saw that, it was like the ground was pulled from under me. It is impossible to forget. It stays with me, it never fades," he says. Two months later, he returned, and stayed. "Slowly, I got used to it. Human beings tend to manage things." He says that on average, between four and six unidentified bodies come in each day, rising to between 10 and 12 in the summer. Up to 30 also arrive from families.  

 

This is difficult work, and Hussain takes refuge in systems. He describes the details of procedures for treating and identifying the bodies. Until a few years ago, bodies were buried within three days, in keeping with the Islamic tradition of swift burial. Now that Pakistan's ID card system is biometric, fingerprints are taken from corpses and sent to the ID authority to check for a database match. This can take anything from 24 hours to several weeks. 

Two men arrive, looking for a relative who went missing eight years previously. Hussain gives them the catalogue, a macabre photo album. When an unclaimed body arrives, staff take three photographs of the face: one from the front and one from each side. These are filed along with a serial number that marks the shroud and then the grave, so that even after burial relatives can find their loved ones. 

The cold storage facility is a metal room with its own diesel generator to ensure the temperature remains at zero degrees despite Karachi's frequent power cuts. The bodies are laid out on metal grills, with three levels. There are two halls. Both smell overpoweringly of disinfectant, but this does not entirely cover the cloying smell of the corpses. In the first room are bodies brought by families for temporary storage, entirely covered by white shrouds, with labels stating their name, age and religion. In the second are the unidentified bodies. Their faces are showing – a practical measure to ease identification. A stray hand or foot sticks out in places. Some bear signs of violence, their shrouds bloodied. One man's face is caved in. He was killed by a bullet to the head. "It is not shocking at all to me to see bodies in such a state of disarray," says Hussain.

When there is a big disaster – a terror attack, a fire, a flood or heatwave – the bodies usually pass through the mortuary. Hussain is troubled not by things he's seen, but times when due process could not be followed. On 11 September 2012, there was a huge fire at a textile factory in the district of Baldia Town. The fire broke out near the compound's locked gates: there was no escape. Over 600 people were injured and more than 200 died. 

Safdar worked solidly for four days to retrieve dead bodies and survivors. "The bodies were so badly burnt that if you tried to hold them, they would crumble. It was so jelly-like that there was no way to hold on to them or carry them out," he says. "You'll hate me for saying this, but we had to use hooks from the butcher's shop to drag the bodies out, wrapped in plastic sheets. You don't think about it at the time. You just have to do what the situation dictates."

Most of the bodies went to the hospital and then, too charred to be readily identified, to the mortuary. For Hussain, it stands out not because of the overwhelming volume of bodies to process, wash and identify, but because of the pressure to do so quickly. Karachi is highly politicised, and occasionally after a big disaster, pressure is exerted by one criminal or political element or another to release bodies quickly. That's what happened in this case. "We couldn't follow our procedures," says Hussain. "We couldn't test the bodies." He is sure that some went to the wrong families. That still distresses him.