Memorializing Covid

by Danielle Ofri
The Lancet

The notifications are more than two years old by now, but I still cannot bring myself to delete them from my hospital’s electronic medical record (EMR). There is the “expiration alert” that signaled my very first patient to die of COVID-19—a chipper Ecuadorian who had just spent months struggling to recover from profound depression, only to fall victim to SARS-CoV-2 in the first weeks of the pandemic. There is the desperate note from a daughter whose father with liver disease was decompensating rapidly at home, but was too afraid of COVID-19 to seek medical attention. There is the too-late notification regarding another patient whose cancer effloresced during the pandemic, and who suffered the brutal intensive-care-unit death she never wanted. She was already septic and unresponsive when she arrived at a distant hospital, so they had no way of knowing the end-of-life instructions she had given me.

Memorials are foundational in our society. As human beings, we seem hard-wired to respond to tragedy with memorials. There are the immediate but evanescent memorials—the flowers, ribbons, and teddy bears marking the site of a shooting or a crash. Then there are the spontaneous community memorials—murals and street art—that erupt, urgent and specific, in the wake of convulsing events like the police murders of Breonna Taylor and George Floyd. At some point, the official memorials enter the scene.

The official memorials may take years to materialise and can entail contentious wrangling among stakeholders. But once erected, they assume the role of a defining locus of mourning. As public monuments to grief, these memorials usually reflect intensity of loss with grandness of gesture. The 9/11 Memorial in New York City and the Holocaust Memorial in Berlin resonate with us precisely because they manage to be magnificent even as they are mournful, their sheer vastness a tribute to the scale of suffering.

COVID-19 does not seem amenable to such grandness, at least right now. Perhaps because the millions of deaths from COVID-19 have been diffused so widely, often in isolation—and of course still ongoing—the memorials that are starting to crop up are very human in scale. In the main plaza of Buenos Aires, Argentines have been piling up small stones with names of those who died, an echo of the Jewish ritual of placing stones of remembrance on a gravesite. In London, a wall of hand-painted hearts and names appeared on the Albert Embankment along the river Thames. The residents of Bergamo, one of the Italian regions earliest and hardest hit by COVID-19, are simply planting trees.

The inbox of my EMR has come to feel like a memorial. The messages, however utilitarian in origin, have become tributes to the patients I’ve lost. Deleting them feels like a betrayal. Seeing those messages during my workaday routine keeps the splinter wedged under my skin, ever so slightly. It’s not that I wish the pain to remain, but smoothing it away feels unfair. My patients did not have that option.

The utilitarian sundries of everyday life have always been valued by historians, but they become memorials only in retrospect. On March 28, 1944, Gerrit Bolkestein, a minister in the Dutch government-in-exile, made a radio announcement from London. He appealed to Dutch citizens to hold onto their diaries and letters in order to chronicle life under German occupation. A young Anne Frank, already 2 years in hiding, heard the radio broadcast and immediately began editing her own diary with an eye towards the future. She was aiming to produce a record of her secreted life, not to mention a publication pedigree for an aspiring author. She ended up creating one of the most powerful memorials of the Holocaust.

Life in lockdown inspired many to take pen to paper, either from the urge to memorialize or from sheer boredom. The National Women’s History Museum—an online museum based in the USA—initiated the Coronavirus Journaling Project in the spring of 2020, inviting women and girls to submit journals, letters, and photos of their daily lives. By the time the call for submissions closed in December, 2021, more than 500 entries had arrived. The writings run the gamut of pandemic experiences. A woman in South Carolina, herself of Chinese descent, wrote about her long-time plumber who refused to fix the toilet of her Japanese tenant because the plumber was convinced the tenant was from Wuhan, China. A young woman from Massachusetts found herself in the hospital for weeks with preeclampsia, while the pandemic unfolded around her and the anxiety-laden air skyrocketed her blood pressure. The exhibit offers COVID-19 sonnets, poems about emergency medical technicians and the Dow Jones Industrial average, even an academic treatise on “Creating School Equity in the Midst of the Pandemic.” These are interspersed with photos of art projects, nature scenes, pets doing the darndest things, and humans tethered to their electronic devices, eking out a simulacrum of connection. These visual and written journals paint a picture of how ordinary people coped during the pandemic, chronicling life at a historic moment.

More directly honoring those who died of COVID-19 is the Covid Memorial Online. Next-of-kin could post a photo and short note about their loved ones through social media and the submissions were gathered into a single website. The notes are poignant: “Rest my dear dad, rest.” Some are trenchant: “She managed to kick cancer’s butt but lost her battle to COVID after 26 days of fighting it.” Others lay out the cruel ironies of timing: “Sadly, the vaccine came a little too late.”

Scrolling through these slices of lives brought back memories of the shattering weeks after the 9/11 terrorist attacks in the USA. To honor the victims but also to help elucidate the exact death toll during that confusing aftermath, The New York Times published photos and short biographies of those who died under the title “Portraits of Grief.” A new batch appeared every day for 3 straight months. The daily reading of them became a ritual for so many, the grief somehow hitting even harder when the series drew to a close.

For those of us in health care, it has been especially painful to recognize the staggering number of our co-workers who have perished in the COVID-19 pandemic. An article from April 1, 2020 on the medical news website attempted to list the health-care workers worldwide who had died in the first few weeks of the pandemic. Anguished readers kept submitting names and 1800 colleagues were documented by the time they stopped updating this record a year later. Kaiser Health News and The Guardian undertook a comprehensive effort to track down every US health-care worker who died during the first year of the pandemic, many of whom lacked sufficient personal protective equipment in the early days. The resulting database of 3607 deaths is a work of investigative journalism, but it feels like memorial, especially as I scrolled through and found familiar faces.

Some of the most poignant COVID-19 memorials have been transient. For a month in the autumn of 2021, almost 700 000 tiny white flags were planted on the National Mall in Washington, DC, each representing a person who had died of COVID-19. The acres of precise unassuming flags evoked the dignified grief of military cemeteries in Normandy and Arlington. Anything displayed on the National Mall is, of course, political. The exhibit of COVID-19 flags can be regarded as a direct descendent of the AIDS Memorial Quilt, whose defiant 1987 display on that location forced Americans to confront the human dimensions of an epidemic they preferred to ignore. (A 13-year-old in California has taken up the baton of sewing-circle activism and initiated a Covid Memorial Quilt.)

The grand memorials of the COVID-19 pandemic are still to come, if they come at all. An ambitious World Memorial to the Pandemic is planned for Uruguay. Architectural firm Gómez Platero has already won a prize for this unbuilt monument that envisions a sleek metallic disk perched on the rocky, windswept coast of Montevideo. Someday this memorial might become a destination for those who have lost friends and loved ones, although given how far-flung the mourners are spread, the overwhelming majority will never be able to visit.

However, even with the grandest of monuments and the most poignant of designs, the most resonant memorials will always be the ones that are individual to the deceased.

In the autumn of 2017, one of my dearest patients died. A diminutive nonagenarian from the Philippines who had been under my care for years, she was the matriarch of a prodigiously successful and loving family. I had the opportunity to visit their home only shortly before her death, and that is when I learned of my patient’s equally prodigious green thumb. After she died, her daughters gifted me one of her plants. For eleven months of the year, this Clivia miniata lazes on my windowsill, a flop of unassuming topiary. Once a year, though, it bursts into riotous orange flowers. This sudden eruption always catches me by surprise. My humble houseplant elbowing from background to foreground feels almost like an unexpected visit from my patient. I remember her self-deprecating laugh every time she tried to hoist her 4-foot frame onto my examination table. I remember the packets of dried mangos she slipped into the pocket of my white coat whenever she returned from a trip back home. I remember her cosy cardigans and her sensible shoes. I remember her progressive weakness and the struggle to breathe as her infirmities got the better of her. I remember my last visit to her, and how I walked home in the unforgiving rain.

The exuberant blooms are ephemeral—they hardly last beyond two weeks—but that does not diminish their beauty. It is a beauty tinged with sorrow, as any self-respecting memorial should be.