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“This will define your life,” my attending physician said. it was the middle of an April night in the intensive care unit. Covid-19 was surging through New York City, overwhelming hospitals. Earlier that evening, another of our patients died. Our team had worked desperately to save his life. When I called his wife to give the news, she wailed into the phone in horror and disbelief.
During a rare lull in our work, my attending, a pulmonary and critical care physician, asked how I was holding up. I’m a resident physician in internal medicine, still training to practice medicine independently. I rely on my attendings to guide me through uncertainty. “I’m OK,”
I told him, hoping that saying it would make it true.
Before Covid came, I had accepted a three-year fellowship position, which begins this July, to specialize in pulmonary and critical care medicine. PCCM physicians are meant to be experts in lung diseases, procedures like intubation, and ventilator management. The field’s foreseeable future—and therefore mine—is largely devoted to the sickest Covid patients.
My experience in this crisis has been shaped not only by my field and the fact that I am in New York City but also by the hospital where I work. Bellevue in Manhattan is the nation’s oldest public hospital, known for its response to prior scourges like yellow fever, tuberculosis, and AIDS. Today it is one of 11 public hospitals that make up NYC Health + Hospitals, including Elmhurst Hospital in Queens, Lincoln in the Bronx, and Woodhull in Brooklyn. Like the rest of H+H, Bellevue provides care to anyone who comes through its doors. Among its patients are some of the most marginalized New Yorkers: the homeless, incarcerated, impoverished, and undocumented.
It was Bellevue’s history that drew me to train here. That it has been at the forefront of epidemics and in the care of the marginalized is no accident. Infectious diseases have a long history of preying on the neglected and oppressed. When the Covid pandemic began, there was talk of it being a great equalizer. But as history would have predicted, that turned out not to be the case. Black and Hispanic New Yorkers 45 to 64 have died from Covid at about three times the rate of their white counterparts. Among the younger population, the disparity is even more stark: Black and Hispanic New Yorkers 18 to 44 have died at nearly five times the rate of their white counterparts. While wealthy New Yorkers have sought safe haven in home offices and vacation homes, the virus has spread rapidly through the city’s essential workplaces, jails, and homeless shelters.
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As I tend to my patients in the Covid ICU, I struggle to process reality. The attending physicians who are my teachers have few answers; this disease is new to all of us. Faced with so much uncertainty and devastation, history is the closest thing I have to a guide.
I grew up about a three-hour car ride north of Bellevue—but a world apart. Saratoga Springs was comfortable and homogenous. We had a backyard pool, a wood-paneled station wagon, and a golden retriever. The youngest of six siblings in a big Irish Catholic family, I was under the impression that my great-aunt’s marriage to an Italian Catholic made our family multicultural. My grandfather, a signals officer on a Navy ship in World War II, referred to New York City as “the zoo,” conjuring in my mind a wild and dangerous place.
As a teenager, I knew I wanted to become a doctor. I spent the summer after my freshman year in college in a lab injecting messenger RNA into zebra fish embryos. I was terribly bored and not very good at it. Realizing that if I wanted to someday care for patients, I needed to learn about health care at the human level, the next summer I persuaded the staff at a small HIV/AIDS advocacy organization in San Francisco, Project Inform, to take me on as an intern.
Project Inform was founded in 1985 by AIDS activist Martin Delaney to expedite the development and distribution of potential AIDS treatments. He said the 1980s in the Castro neighborhood, the hub of San Francisco’s gay community, was like “walking in the graveyard.” As he and his friends faced the devastation of this new disease, they were met with government silence. President Ronald Reagan didn’t give a major public address on the crisis until 1987, after nearly 21,000 Americans had died of AIDS. Looking back on the crisis, Delaney estimated that he’d lost 80 percent of his friends to the disease.
He died of liver cancer in 2009. Over his years of AIDS treatment advocacy, he had found an ally in Dr. Anthony Fauci, who was appointed head of the National Institute of Allergy and Infectious Diseases in 1984 and remains in that position. Fauci said of Delaney, “Without his tireless work and vision, many more people would have perished from HIV/AIDS…. He was a formidable activist and a dear friend.”
As a 19-year-old intern at Project Inform in 2008, more than a decade after the peak of the AIDS crisis in the United States, I didn’t see young gay men dying from AIDS with little hope of treatment. By then, effective treatments had been developed; the critical issues were lack of access to treatment and prevention. (HIV/AIDS still disproportionately affects people of color and the poor—the same groups disproportionately affected by Covid.) Nonetheless, the legacy of those desperate early years was palpable there. The middle-aged gay men I worked with, whether they had been infected by the virus or not, were all survivors of a plague.
That summer I met with a seasoned HIV/AIDS physician so I could learn about her career in medicine. In a conference room in her clinic, the gray-haired doctor told me that she had lost over a thousand patients to AIDS. I recall sensing that her soul was tired. Talking with her, I realized how little I knew of the devastation and destruction of disease. I wondered if I could ever do such heartbreaking work but also longed to have such a sense of purpose.
When I started my biology and chemistry premedical courses, I thought becoming a good doctor involved a straightforward formula of studying science and wanting to help. What I learned about AIDS, beginning with my time at Project Inform, added vital complexity to that formula. I learned that like a virus, neglect and oppression can kill and that like medication, activism can save lives. I realized all the medical training in the world can still leave doctors powerless in the face of disease. I came to believe that sometimes the most important work a doctor can do is to be present with her patients in their fear and sorrow.
On July 1, 2017, a month after graduating from medical school, I started my three-year internal medicine residency at Bellevue. These years have been an education in the bodily manifestations of inequality. Though my colleagues and I strive to provide excellent medical care, our tools are inadequate to mend the harm done by racism, mass incarceration, inadequate housing, poverty, and cruel immigration policies.
In my primary care clinic, I struggled for months trying to help an undocumented immigrant manage his diabetes. Through a phone interpreter, I suggested he inject insulin multiple times a day because once a day didn’t seem to be working. He told me that wasn’t possible at his workplace—a low-wage job with few protections. So I proposed plan B, and when that wasn’t possible, plan C. We worked together within the constraints of his life to try to prevent the complications of diabetes, like blindness, amputations, and kidney failure. In the back of my mind, I feared we were delaying the inevitable.
With just four months remaining in my residency, the Covid pandemic was declared. As my friends with office jobs began working from home, I worried about people like my primary care patient, who wouldn’t have that option. Would information on the new virus be available in his language? If he lost his job, what source of income would he have as an undocumented immigrant? If he got infected, how could he maintain social distance in overcrowded housing to keep his family and neighbors safe? If he became ill, would he face a higher chance of death because of his poorly controlled diabetes, itself largely the product of his difficult circumstances?
By the end of March, I was caring for patients with Covid in the ICU. Nearly all of them were intubated and on ventilators because their lungs were so severely damaged from the virus. A necessary but unfortunate consequence of this was that I couldn’t talk to my patients and get to know them. Which may be why the memory of one patient with whom I did speak stands out in my mind.
Mr. Perez (I have changed his name to protect his privacy) was a middle-aged man with diabetes who came to the hospital with a fever and cough. His oxygen levels were normal when he tested positive for Covid. However, his blood work came back with severe electrolyte derangements, likely triggered by the disease.
Perez diligently covered his mouth with a face mask, only briefly revealing a gentle smile when the nurse checked his temperature. When I told him that he had Covid and needed to be in the ICU, I wondered if he realized he was on a precipice. I hoped that my mask and face shield concealed my fears and that my voice conveyed optimistic competence. “Gracias, doctora,” he said, steadying his gaze straight ahead.
Our 54-bed ICU was overflowing with Covid patients, so we wheeled Perez to a satellite unit, a part of the hospital that had been temporarily converted into an ICU to manage the surge. The satellite ICU had several beds in an open arrangement. No walls or curtains separated the patients. Aside from Perez, all the other patients had breathing tubes in their mouths and their eyes closed. I worried what he would think of his own fate, seeing the others.
I assured him that while all the other patients had Covid, his case was different, as he needed just medications, not a ventilator. “Va a estar bien,” I told him. It’s going to be OK.
Not long after we arrived in the ICU, Perez’s heart rate skyrocketed, and his blood pressure plummeted. Alongside an attending physician volunteer from the West Coast and an agency nurse from the South, I pushed fluids and medications into his veins to control his heart rate. He shook with chills as I wrapped him in blankets and rubbed his back. Sweat dripped down my back under my plastic gown as I whispered to my attending, “I don’t have a good feeling about him.”
Eventually, we stabilized him. His heart rate and blood pressure came back to normal. He was warm and comfortable. “Va a estar bien,” I said again, hoping he might get some rest.
I was about to leave the satellite ICU when I saw my attending on the other side of the room with another patient. He was standing over a bed alongside two nurses, his head bent down in thought. I approached to ask if they needed help. But before I could open my mouth, I saw that the nurses were zipping shut a white bag that held the patient’s body.
After my first shifts caring for people with Covid, I braced myself for a deluge of patient deaths unlike anything I had ever experienced. By the time I met Perez, hundreds of New Yorkers were dying each day. Through our efforts, we saved many lives. But so many of my patients died, including Perez. Though we corrected his electrolyte issues and stabilized him for the night, Covid blossomed in his lungs. Despite medicine’s best tools, he did not survive.
People cope with this crisis in different ways. I understand the need to focus on the silver linings. Bellevue began playing Journey’s “Don’t Stop Believin’” on the overhead speakers whenever patients were discharged. Colleagues post on Instagram the chalk messages on sidewalks that tell us we are heroes. These gestures bring some people real joy, and I don’t want to take that from them. But for me, they are like cupcakes on an empty stomach—though temptingly sweet, they ultimately leave me feeling starved for real sustenance.
I find myself instead longing for the horror and devastation of this crisis to be seen and acknowledged for what it really is. I don’t want to be soothed so much as believed. During the surge, when I had a few days off, I started to question myself and what I had seen with my own eyes. Was it really that bad? Are you sure you’re not exaggerating this? And then a text from a friend working in the hospital, grieving the death of another patient, brought the visceral memories rushing back.
During the surge, when every patient in our ICU had Covid, I would sometimes walk a long lap around the unit. I wanted to see all the patients through their glass doors not to check on their vital signs or assess their breathing but to acknowledge them as human beings. That private ritual allowed me to hold in my mind both the individual tragedy of this disease and the massive scale of the crisis.
Since Covid came to New York City, I have been thinking of my time working in HIV/AIDS that so deeply shaped my outlook on medicine more than 10 years ago. Dr. Abigail Zuger was, like me, a resident physician in internal medicine at Bellevue. From 1981 to 1984, she cared for scores of people with AIDS. “We grew accustomed to watching our AIDS patients die amid all the glitter of medical technology,” she wrote in 1987. “We could offer them only comfort, sympathy, and palliation.” Reflecting on his experience, Fauci said, “With AIDS in those days, I saved no one. It was the darkest time of my life.” For me, it is a balm in this crisis to remember an earlier generation of doctors who witnessed so many patients die of a new disease while they themselves felt powerless. Their example gives me strength to face our new reality.
Some of my colleagues describe what we have seen as war. Others call it a mass casualty event. I am still struggling to find the words to name it. But whatever we call it, I do not want to rush to heal from it. I need time to sit in the darkness and tend to the sorrow. When my patients are on the precipice, I want the strength to look down into the abyss with them. I know how tempting it is to reach for comforting platitudes: I told Perez he would be OK. But we can’t address this crisis, individually or societally, unless we see things as they really are, not as we wish they were.
Our country alone has lost more than 120,000 lives to this pandemic. That number grows daily. Even as we work to treat the sick and prevent Covid’s further spread, we must also remember the dead. From the AIDS Memorial Quilt to ACT UP die-ins, AIDS activists showed us that mourning and memorial are necessary, life-sustaining work. Without it, the dead suffer a second death of erasure. They become data points devoid of individuality and meaning. When we neglect to honor those we have lost, our commitments to protect the living ring hollow.
As I walked the halls of our ICU during the April surge, I remembered the words of Prior Walter, the protagonist of Tony Kushner’s two-part play about the AIDS crisis, Angels in America. Prior knows the precipice between life and death. He has stared into the abyss and come back to tell us, “This disease will be the end of many of us, but not nearly all, and the dead will be commemorated and will struggle on with the living…. We won’t die secret deaths anymore. The world only spins forward.”
