Jac Saorsa, Discarded mask. Oil on paper, 2020
First posted in Synapsis, 15 May 2020
In early January, scientists identified SARS-CoV2 as the causative agent for a cluster of pneumonia cases in Wuhan City, Hubei Province, China. The first official death from Covid-19 (the infection caused by the novel coronavirus) was reported by China on January 11. The United States reported its first confirmed case on January 21st. The first death outside of China was reported on February 2nd. As of May 11th, there are 4,171,859 cases worldwide with 285,690 dead. In New York City, where I work as an emergency medicine physician, there are 178,766 cases with 14,753 lab-confirmed and 5,178 probable deaths. In our hospital system, we reached a high of 2,554 patients as of April 12th, of whom 766 were requiring mechanical ventilation. The numbers have subsequently been dropping throughout New York City and state.
The slower pace and volume in the emergency room feels like a pause, the eye of a hurricane or a calm before a storm. It’s a moment to take stock, the end of the first phase.
The persistent and continued lack of proper testing and source tracing has cost lives. More than ninety percent of early deaths in the United States could have been prevented. The rapidity with which a PCR test was developed only makes its continued limited availability that much more appalling. New York state tested a total of nine patients in the month of February. Recently, virologists sampled discarded blood from emergency room visits on a random day in February and found that more than 5% of patients already possessed antibodies to the novel coronavirus further cementing the reality that the virus was circulating widely. The NYC DOH was dangerously unprepared and understaffed. On March 8th, I attempted to test a patient with a significant confirmed exposure and symptoms consistent with Covid-19, but after 5 days of waiting for a result, the DOH informed us that they could not run the test. It was not until mid-March that our lab was doing its own PCR testing, and even that was highly limited. Throughout March and April we sent home hundreds of patients with the presumptive diagnosis of Covid-19, even when they were short of breath and had markedly low levels of oxygen in their blood. They were all sent home without being tested.
The situation we are now facing in the United States is the result of years of profit-driven reductions in hospital patient capacity, austerity budget cuts to emergency preparedness, and the defunding of local health departments. Hospital mergers have resulted in a decrease in available beds across the United States from almost 1.5 million in 1975 to less than half of that in 2018 (728 thousand). Private equity, with its demand for steady profit margins, has been investing heavily in the health sector. EmCare and TeamHealth, the two largest United States emergency medicine staffing companies, were acquired by the private equity firms Onex and Blackstone Group, respectively. Together they manage almost 600 billion dollars in assets. Private equity typically extracts short term value out of a business, maximizing profit margins while increasing debt and finally selling at a gain. Emergency capacity and preparedness, by contrast, is seen as waste. As profits are prized over need, private equity organizations are gutting the public service of healthcare. The commodification of health has left us with an inadequate infrastructure. Most gallingly, private-equity backed urgent care facilities and physician groups have been on the vanguard of calls to reopen the economy.
The experience of treating patients with Covid-19 has been harrowing. The diagnostic challenges typically associated with emergency medicine were replaced with prognostic challenges. EVERYONE was infected with the novel coronavirus–over 80% of our admissions for weeks tested positive–but we could not always be sure who would recover and who would get sicker. It felt like someone opened a spigot one day in March, and we were suddenly flooded with very sick, hypoxic patients. Guidance changed hourly, and we threw away decades of clinical experience and expectations. Patients with Covid-19 exhibited wildly protean manifestations ranging from myocarditis, renal failure, blood clots and strokes. But its most severe respiratory form was surprisingly consistent and almost pathognomonic: Bilateral patchy ground glass opacities on chest x-ray with extreme, “silent” hypoxia. On any given day during late March and early April, there were more than fifteen to twenty mechanically ventilated patients in the emergency department when there are usually only one or two. Our hospital converted all of its operating rooms into Intensive Care Units each with room for six ventilated patients. And more importantly, recent data suggests that up to 80% of those patients were dying. Whether because they are the sickest patients or whether our high tech treatments were actually hastening their death is not yet clear. But they were dying. I had six patients die on one shift. Typically, 80% of ICU patients survive their stay. In the era of Covid-19, it has been less than 40%.
Proximity to so much death and the uncertainty over the efficacy of our treatments has led to stress, anxiety and situational depression for frontline healthcare providers. These effects have been further augmented by moral distress and moral injury. Modern hospitals often place healthcare workers in situations of moral distress, where their individual and personal values and ethics of care come into conflict with institutional norms, restraints and motives. In the Emergency Room, with a focus on throughput and flow, human dignity is often sacrificed to expediency: Patients do not get single rooms, they experience long avoidable delays, and they suffer through significant periods of information silence. During the coronavirus pandemic, the moral distress of every day medical practice has been amplified by a mortal hazard. The lack of proper personal equipment and the poor guidance on infection risk has imperiled the lives of healthcare workers. Accurate counts in the United States remain unavailable; as of this writing, 27 doctors and nurses have been reported dead from the coronavirus in the US. At least sixty-one doctors have died in Italy. Dr. Li Wenliang, the young Chinese ophthalmologist who sounded the early alarms on the coronavirus died on February 7th after being pilloried by the Chinese government.
Every single frontline healthcare worker has been put in a condition of danger because of the politics of austerity and the “do more with less” ethos of neoliberal management philosophy. The scarcity of PPE was a result of ineffective planning, exacerbated through misleading guidelines, and then used as a leverage for political gain. For a time, the hospital’s internal class system determined who was issued coveted n95 masks. Medical techs, transport staff and other lower wage earning healthcare workers were asked to muddle through with simpler surgical masks. Hospital corporations at first suggested that only the most basic protections were required, adjusting guidance upward only when confronted by illness or death among the staff. The everyday boardroom calculus that has begun to transact in patients’ lives, profits and productivity over the last few decades, has very quickly become accustomed to making similar decisions about its employees. The pandemic has permitted our profit-driven, patchwork healthcare system to gut the basic rights and protections healthcare workers must expect to do their jobs. It has done so by relying on their tattered commitments to ideals of care, turning these into militaristic platitudes (‘we do our job because it’s the right thing to do’).
The mismanaged response to the virus should put to rest the role of the healthcare system in paean’s to American exceptionalism. The well-documented testing debacle is underscored by recent budget cuts to the CDC and the shuttering of the White House office responsible for pandemics. We are afflicted with unimaginable high and low tech shortages—our hospital almost ran out of plastic swabs to collect nasopharyngeal samples. We spend almost twice as much money on healthcare as a share of our economy than any other OECD country, and yet we have a lower life expectancy than 11 member nations. We have far and away the most pandemic deaths in the world.
Jac Saorsa, COVID-19 Cell. Ink and wash drawing, 2020
The situation in our nursing homes, prisons, day facilities and other institutional settings will be one of the greatest modern failures of infection control. After years of privatization’s strategic neglect, these sites are understaffed, and the basic essential workers are underpaid. As has been documented in Seattle, not only were the resources and protections for care workers in nursing homes inadequate, because of casual labor contracts, those very same careworkers worked in multiple nursing homes, transmitting SARS-CoV-2 across care sites to vulnerable populations. The death toll in these facilities is a catastrophic moral failure to protect our most vulnerable members of society.
Like nursing home workers, our essential workers are racialized and gendered. Home health aides, medical assistants, grocery checkout clerks are the essential workers of the first wave. But are they really expendable workers? As the unemployment numbers are released over weeks, like a car accident in slow motion, the fact that the hourly average wage has increased only underscores that most of the jobs lost are the same kinds of positions with low income salaries that are considered “essential” in some sectors. And often these same marginalized workers who have lost their jobs are the people most at risk from Covid-19. The essential worker of the future may be a different kind of worker if all of our current essential workers become expendable.
African Americans, Latinx and other people of color are dying disproportionately. Almost every single patient that I took care of with severe Covid-19 was black or Latinx. They are more likely to take public transportation, to not have second homes to escape the cities, to work in “essential” jobs that cannot be performed at home, to live in multigenerational families, to suffer the effects of pollution and overcrowding, to have pre-existing health conditions like diabetes and hypertension. The differential course in these populations may have something to do with viral burden which is increased with repeated exposure in crowded, cramped spaces with poor ventilation. Not only does the virus augment pre-existing inequalities, but those pre-existing inequalities are, in fact, containing the virus. Either indirectly or directly, federal, state and local governments are containing the virus by allowing it to multiply and thrive in low resource settings amongst the most marginalized and vulnerable populations. Cordon sanitaire prevents the virus from getting out, but it also prevents the people from getting out – or the healthcare workers from getting in.
All of our pre-existing social inequalities and vulnerabilities have been exacerbated by this crisis. Patients with disabilities are doubly affected. They have baseline higher burdens of disease and rates of poverty than those who are not disabled. And they may be particularly affected by forms of social isolation, as they may depend on caregivers for mobility and other basic needs. Even seemingly benign “solutions” like facemasks can pose a significant impediment to deaf people who rely on lip-reading for communication. Disabled peoples swell the ranks of the dead in this pandemic. In the last week of March, I treated a woman with cerebral palsy and difficulty phonating, who could not be heard over the hissing of oxygen tanks, obscuring her wishes about life support. The following day, a group home sent an entire ward of autistic men to be evaluated for fever and cough, and all were diagnosed with severe coronavirus related pneumonia. And on yet another recent shift, a man with muscular dystrophy and mobility impairment arrived in severe respiratory distress, but days too late, because his own aide had been sick and unavailable. In times of resource allocation, manufactured crises and critical shortages, we should reaffirm disabled persons right to fair treatment.
Telehealth is being touted as a form of “forward triage” that protects patients and healthcare workers through virtual visits. But this innovation only further exacerbates disparities across a digital divide. White middle and upper class patients access healthcare from the security and comfort of their increasingly “smart” homes, while poor people must access care in physical spaces that pose danger.
Medical interventionism and technoidealism has significant limits: remdesevir, hydrochloquine, azithromycin, toclizumab…the list of failed or minimally successful interventions for Covid-19 will continue to grow. But this should not push us towards pessimism; the only medicine we have is behavior, politics and a working federal response. Prevention, global public health, the development of improved hygiene, the augmentation and coordination of services and assistance for the disabled, the ameliorations of state racism, an increase in the living wage and better housing will all mitigate against the effect of this pandemic and future pandemics.
Despite facing both political and economic adversity, my colleagues come to work with a heady resolve. They go through their intensified rituals and ablutions to show up for every shift with compassion and determination. While there are no known curative treatments and the only likely successful intervention—an effective and safe vaccine—is years away, there are many forms of care in this pandemic. Families were prohibited from most healthcare settings and patients have been dying alone. But my colleagues and I would FaceTime relatives before intubations or other dangerous interventions. There are countless stories of nurses and physicians attempting to humanize these experiences, either by affixing their photographs to their gowns, playing music over the beeps and whirrs of the machines, of simply holding a gloved hand during a patient’s final moments. Even as we attempt to engage in social cultural critique at a structural level, we still practice care at the level of the individual.
Finally, the failure of our inadequate response is simply the latest example of science denialism and an assault on expertise. There is a systematic global rejection of scientific consensus that is used by authoritarian governments to suppress dissent among increasingly immiserated populations. From climate change denialism to anti-vaccine groups and creationists, the assault on scientific literary is a deliberate campaign to achieve nefarious forms of political control. While we can and should continue to challenge the mergers of science with big business and denounce ideology masquerading as “science” that promotes inequality, racism or sexism, we also need to emphasize a pragmatic, rational and empirical method based on data, hypothesis, and consensus.
Rishi Goyal, MD, PhD, is an Assistant Professor in the Department of Emergency Medicine and the Institute of Comparative Literature at Columbia University where he is the Director of the Medicine, Literature and Society Major. He is also an Adjunct Associate Professor of Humanities at the University of Southern Denmark. His writing has appeared in The Living Handbook of Narratology, Aktuel Forskning. Litteratur, Kultur og Medier, and The Los Angeles Review of Books, among other places. He is a co-founding editor of the online journal, Synapsis: A Health Humanities Journal, and is the recipient of numerous grants and awards.