by Danielle Ofri
New York Times Op-Ed
It’s only when both you and your patient are wearing a mask that you realize how much of medical care depends on facial expression and nonverbal communication. As I swabbed my first patients for the coronavirus here at Bellevue Hospital last week, it became apparent that assuaging their anxiety was just as critical as probing their nasopharynxes.
A library hush now reigns in our normally busting-at-the-seams outpatient clinic because all regular medical care is being conducted by phone. But our new “Covid Clinic” — in a snazzy white party tent in the hospital courtyard — is one of the hottest tickets in town. Like the tent of Abraham, all of its sides are open, allowing the crisp March breezes to minimize the risk of infection. Despite the seriousness of the operation, there’s no denying the invigorating uplift of sweet spring air and a resplendent magnolia tree flowering within grasping distance. The only downside of al fresco medicine is that my fingers are numb from the chill, because you can’t wear gloves under your gloves.
The patients offer friendly small talk while I juggle the swabs and vials and specimen bags, garbed in my groovy space-age outfit, with its battery-powered helmet fan blowing filtered air through my head casing. But anxiety seems to emanate from behind their surgical masks, like the billowing waves you might see on an infrared map. The fear is particularly acute for those who also have to bring their children along for testing.
It would be a lie to say that we’re not nervous, too. The news from Italy suggests that 20 percent of health care workers have been infected, and several have died. Thousands of Chinese health care workers became sick with the coronavirus. Our job is not without risk, one we debate every day as we balance our family obligations with professional duties. The memories of medical workers who contracted H.I.V., Ebola, hepatitis C and tuberculosis over the years are never far from our minds. As a co-worker said ruefully to me, “Our colleagues could soon be our patients.”
Hospitals aren’t known for fleet-footed bureaucracy — don’t even ask how long it took to get a water cooler for the staff lunch area — but they do know how to mobilize in a crunch.
When Hurricane Sandy flooded Bellevue in 2012, the staff formed a bucket brigade to haul 500 gallons of fuel — hand to hand in small containers — up to the 13th floor to keep the generators running. Later, those same hands helped carry the patients down those same stairs when we eventually had to evacuate. The vast Northeast blackout of 2003 left hundreds of hospitals without power. A doctor or nurse was planted at the bedside of every patient on a ventilator, ready to start pumping oxygen manually should the generators fail. And of course there was Sept. 11. Within an hour of the attacks, staffing in the emergency departments of New York City’s hospitals were overrun with medical volunteers. Most, sadly, ending up spending that day idle.
History offers balm and jitters in equal doses. Most of those orchestrating the coronavirus response today cut their teeth on the AIDS epidemic in the 1980s and ’90s. Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, played a comparable steadying role during the AIDS crisis, delivering sober statistics, enumerating medical priorities and maintaining much-needed intellectual humility.
In some ways, AIDS was scarier than the coronavirus because we operated in the dark for so many years. We remember the (mostly) all-hands-on-deck attitude, especially in the public hospitals and local health departments. We remember the critical role of public activism in moving the needle when medical progress faltered. When I was a resident training at Bellevue in the 1990s, the hospital created a dedicated AIDS ward, a specialized H.I.V. team, an outpatient virology clinic and — in the darkest of those days — “the dying ward” on 12-East, where patients could have private rooms for their final days.
In our hospital now, the entire I.C.U. wing of the emergency department has been converted to a respiratory unit for patients with suspected coronavirus infections who are too ill to remain at home. All elective surgeries have been canceled, freeing up surgical staff, operating rooms and post-op units. Expedited discharges have opened up scores of inpatient beds. Every available corner of the hospital is being repurposed for patient care, to prepare for the onslaught that is already beginning. And every other hospital is doing the same.
These colossal rejiggerings have created a breathless feel to our work. Every day things are different, but there’s comfort in the concreteness and agility of the process. No doubt there will be miscalculations along the way — even when you hew to solid science, logistics always require improvisation — but the ground troops are moving purposefully.
And thank goodness for that, because on the personal side of the coronavirus crisis, we doctors and nurses feel just as baffled as everyone else. Could rubbing alcohol and aloe gel really substitute for hand sanitizer? Will tissues be flushable if toilet paper runs out? Is it safe to go to the bagel store? What do we do about our older parents? Is it even possible to keep our kids from touching their faces?
We watch the news with just as much anxiety as the general public. We’re relieved that one of our trusted own is up there, though we wish Dr. Fauci had the authority to quarantine the less evidence-based politicians. The way in which this public health crisis is continuously being refracted through a political lens — playing down risks for the sake of ratings, worrying more about the stock market than about lives — leaves medical professionals steaming with anger. We want rational policy, not meaningless fluff. We don’t have time for this.
We remember the precious years — and the tens of thousands of lives — lost while President Ronald Reagan pointedly ignored the AIDS epidemic. We remember how the administration attempted to muzzle Surgeon General C. Everett Koop when he tried to tell the truth about the nature and extent of the disease.
There’s a point at which those without relevant knowledge simply need to stand down. From the perspective of the medical community today, we’ve long since passed it.
History infuses our daily interaction with patients in other ways. Every single day for the past six months, I have recommended the flu shot for my patients, and every day a good chunk decline. When I ask why, most can’t articulate an answer. They offer only an inchoate distaste for vaccines, fomented by the oddly contagious anti-vaccine movement. I remind them that their grandparents would have given their eyeteeth for the vaccines they blithely shrug off. I point out the entirely unnecessary resurgence of measles resulting from a falloff in vaccination rates.
Next month is the 65th anniversary of Jonas Salk’s announcement that his polio vaccine trial was successful, news that was greeted with almost the same depth of emotion as the end of World War II. Albert Sabin’s oral polio vaccine followed in 1961. I wonder how cavalier my vaccine-resistant patients will be if and when a coronavirus vaccine becomes available.
If nothing else, the outbreak gives us a taste of the bone-deep fears our grandparents wrestled with, as well as an appreciation of their profound reverence for science and facts. It shouldn’t escape our recollection that Dr. Sabin was an immigrant and Dr. Salk the son of an immigrant, and that both were effectively barred from many medical schools because they were Jews. If New York University had employed a quota system in the 1930s like Cornell, Yale, Columbia and Harvard, the story of polio might have played out quite differently.
The story of the coronavirus is still being written. South Korea, Italy and China offer possibilities of how Chapter 1 might play out. But make no mistake, there will certainly be Chapters 2, 3, 4 and more. (Here in the United States we’re only belatedly stumbling out from a meandering prologue.)
The epilogues of polio, Ebola, H.I.V. and measles — all, alas, still in progress — remind us that public health is an ongoing, never-let-’em-up-from-the-mat effort. Narrow vision, data ignorance, image-conscious decision-making and truncated memory are the very elements of contagion. No amount of Purell can sanitize that.