Social Justice

I read this piece in this week’s NEJM and found it to be very thoughtful. I hope you do too.

n engl j med 382;19 nejm.org May 7, 2020

Fear and the Front Line

Susan L. Murray, M.B., B.A.O.

I have been thinking a lot about fear lately, and how much it behaves like a virus. How it can spread insidiously, person to person, or airborne, through new media and old, faster than we can contain it. How it induces so many of the same symptoms as a virus does: sweating, palpitation, nausea, shivering, and sometimes an almost overwhelming desire to curl up under a blanket in a dark room and stay there. How once fear has infected you, it is hard to get rid of, but extremely easy to pass on to others.

It is 2014, a different virus is splashed across the front pages, but the same sort of unease is in the air. I am a newly minted fellow at a small-town hospital, a long, long way from the epicenter of infection or anywhere that a genuine case of Ebola virus has been confirmed. On the street and on the wards, people are anxious. Having the wrong color skin is enough to earn you the side-eye from your fellow passengers on the bus or train. Cough once, and you will find them shuffling away from you.

The hospital is caught up in uncertain paroxysms of preparation for an epidemic that it hopes will never come. There are meetings and then more meetings. We are taught how to do the personal protective equipment hokey-pokey of gowning and degowning. There is ongoing debate as to whether we have the right gear. A sign appears on the entrance to the pneumatic tube leading from the emergency department to the laboratories: “If patient has Ebola, please do not put blood in chute.” Everyone seems uncertain.

“What will you do if we get a case?” my resident asks me, after yet another querulous staff meeting.

I eyeball the rows of gleaming new anti-Ebola Wellington boots lining the back wall of the ward. “Maybe I’ll just call in sick that day,” I sigh.

And then, one otherwise ordinary day, a young man arrives in the emergency department. He is in pain and shaking, far from home and struggling to overcome a language barrier. His cancer, when I assess him, is one of the most advanced cases I have ever seen. The edge of his liver is craggy with cancerous deposits. His bones are pockmarked with metastases. His skull is swollen with disease and pushing into the substance of his brain. He squirms in pain in the bed. We do what we can for him, but he is almost too sick for treatment. All we can do is try our best to make him comfortable.

Just before midnight on the second day of his hospitalization, he spikes a fever.

The possibility that he is infected with Ebola is remote, hypothetical. The embers of the epidemic in his home country are guttering. In 3 days’ time, the World Health Organization will declare it officially extinguished. But the guidelines for quarantine are clear. I discuss it with my attending, and she agrees that we need to take every precaution.

And just like that, the atmosphere starts to change.

The rumor spreads like ripples from a stone dropped in a still pond. I watch faces turn gray and eyes turn glassy as I try to explain that our suspicions are low, but yes, we are taking every sensible precaution. Work on the ward slows to a crawl. We do not have enough protective gear stocked, and other departments are suddenly guarding theirs jealously. I am told by a senior doctor that he and his entire department are unavailable to consult on the patient until further notice, since their safety cannot be guaranteed.

I am lucky, or maybe I’m just reckless, but the knowledge of the remoteness of the risk, and of the shiny, red patch of phlebitis on the man’s left arm that is almost certainly the source of his fever, inoculates me a little against the fear. In fact, I am almost certain that Ebola virus did not lay quiescent for a month and then travel 600 miles across the country to infect this man before he got on a plane to come here. I am prepared to bet my life, but not to ask others to do the same.

Still, at 5 a.m., wrapped up in a protective gown, trying and failing to get an IV access into his thrombosed vein because no one else will enter the room, I want to scream my frustration. The patient is only semiconscious now. He moans in pain as he sleeps.

At 8 a.m., when the day shift arrives, things only get worse. There are nurses hiding in the ward storeroom and doctors threatening to turn around and go home. The head of nursing arrives to demand that one of the nurses take responsibility for caring for the dying man. Eventually, she takes off her suit jacket, gowns up, and cares for him herself.

Most health care workers I know are brave people who perform demanding jobs in difficult circumstances. But one of the terrifying things about an outbreak of transmissible disease is that it’s not just our own life and health that we are being asked to put at risk in caring for patients. We risk being the vector that brings the illness home to the people we love — to our children and partners and parents — and that can be truly terrifying. It is easier to risk our own safety than to threaten the people we care about. Without support, without proper education, training, and contingency plans in place to help protect health care workers and their families, fear can run riot through a hospital or through a community. If we are not prepared to fight fear and ignorance as actively and as thoughtfully as we fight any other virus, it is possible that fear can do terrible harm to vulnerable people, even in places that never see a single case of infection during an outbreak. And a fear epidemic can have far worse consequences when complicated by issues of race, privilege, and language.

At 5 p.m. that evening, the man’s tests return, giving him the all clear. Around the ward, life begins to relax, heart rates slow, people smile again, the whole thing begins to seem a little like a bad joke, as the effects of the fear virus ebb.

The patient dies at 6 p.m.