In late March, my mother and I were having our routine Covid-19–era argument about my upcoming clinical duties. She said I was acting like a teenager. I said she was treating me like one. “What if you end up on a ventilator?” she asked. “I live or I die,” I said. She was silent. It was not my kindest moment.
I have lupus and am on immunosuppressive therapy. When it became clear that Covid-19 would hit the United States hard — including Boston’s Brigham and Women’s Hospital, where I practice — I decided to proceed with my scheduled 2 weeks of attending on our inpatient cardiology service in April. I thought about the decision, but I didn’t find it difficult. Despite limited data, it seemed reasonable to assume that my risk — of both getting infected and becoming critically ill — was higher than average. But I was weighing these unknown risks against one that was entirely predictable: the agony of sitting out the biggest public health crisis of our time.
The moment when I grasped Covid-19’s potential to destroy the world, and our lack of preparedness to stop it, was in early March. I was at the TEDMED meeting, and between talks I read a story by a Seattle physical therapist with Covid symptoms who couldn’t get tested. “This is incredibly frustrating,” she wrote, “because I am trying to do everything right in a system that punishes moments of ‘weakness’ like taking days off.” Wow, I thought. If we can’t even test infected health care workers and keep them from infecting vulnerable patients, this is going to get really bad.
I also knew I wanted to help. Sitting on my left was Kerri Palamara McGrath, a Massachusetts General primary care physician whose 2-year-old son was struck by a van and killed 2 years ago. On my right was Lucy Kalanithi, a Stanford internist and the widow of neurosurgeon Paul Kalanithi, who wrote his 2016 book When Breath Becomes Air as he was dying, at age 37, of cancer. Both my friends had faced unfathomable tragedy. Each had a young child at home whose life had already been undone by loss. And yet as they went off to the front lines, they described eagerness and relief at being able to tend to affected patients. Obviously, there is nothing weak about a health care worker staying home when she’s actively infected. But if our system punishes weakness more generally, maybe it’s because, as the pandemic reminds us, we need health care workers to be strong.
In the ensuing weeks, I see courage everywhere. When I interview doctors about Covid-19 in Italy, a young physician tells me about his older colleagues stepping up to the plate. “You can see the fear in their eyes,” he says “but they want to help.” Over 100 physicians have now died.
I see heroism among people who don’t work in health care. “I can’t work from home and my job is an essential city service that must get done,” a sanitation worker writes in a Twitter thread that goes viral. “Us garbagemen are gonna keep collecting the garbage, doctors and nurses are gonna keep doctoring and nurse-ering. It’s gonna be ok, we’re gonna make it be ok.” And yet it’s not OK. For complex reasons, Covid-19 has taken a disproportionate toll on minority communities,1 and since minorities account for a greater proportion of “essential workers” who don’t have the luxury to socially distance or work from home, there’s no less heroism in these workers’ commitment to their jobs than in physicians’ dedication to theirs.
I see bravery among other immunosuppressed people. My father, a rheumatologist, tells me about an 83-year-old patient with severe rheumatoid arthritis, hypogammaglobulinemia, and COPD. Each winter she is hospitalized for pneumonia. The day before her virtual visit with him, she fell and emergency medical services had to come help her back to bed. Yet she’s seeking my father’s advice about something other than her own health: she’s worried about loneliness and isolation during the pandemic; can he help her to hold the hands of dying ICU patients? She is not afraid of death, she says, and believes no one should die alone.
My mother became a cardiologist at a time when very few women did. She survived with a “take no prisoners” approach; she thrived by maintaining her profound capacity to care. In my childhood memories, I see her standing at the stove trying to cook us dinner, only to leave in the middle to tend to a cardiac emergency. Many nights, I awoke to the sound of her answering service calling. If she was summoned to the hospital, she tiptoed out, putting on her shoes just before opening the door, so I had to listen carefully for her last few steps. Then I’d assume my vigil, staying awake until the sound of the garage door signaled her return. I never told her this; it would have pained her to think that my well-being was compromised in any way by her work. But it wasn’t: I understood she was saving lives, which required sacrifice. Though the point at which sacrifice becomes self-sabotage differs for everyone, I wonder why I shouldn’t do the same.
“It’s not your hill to die on,” my sister-in-law texts me. I wonder: Whose hill is it, then? I have many colleagues whose age puts them at risk, some of whom are world-renowned for their scientific and clinical expertise. Should they be on the front lines? What about women who are pregnant or trying to conceive? What about physicians who haven’t cared for critically ill patients in decades, or who have a spouse or child at risk, or who are simply scared and don’t want to do it? What about other essential health care workers — those who clean rooms, transport patients, hand out masks — for whom the financial consequences of not working may be more stark? And what about trainees, many of whom, unlike me, don’t have a choice? We pay them the least, work them the hardest, and rely on them for the majority of direct patient interactions. The odds of survival are better if you’re young, but with so many people infected, some young ones will die. Given all the impossible conversations the pandemic has forced about how much we value any given life, why have there been so few about how much health care workers value our own?
Though my father suggests I spend this time writing, I’ve long found writing inadequate in the face of profound loss. In 2001, I moved to New York City to begin a graduate program in creative writing. Two weeks later, 9/11 happened. Attempting to process the tragedy, I wrote a story about it. It was terrible, as my professor made clear; it was too soon to write about the loss, she said, and it was not mine to grieve. I stopped writing and spent the rest of the year wandering around lower Manhattan, staring at posters of the thousands of people who were gone. Thinking about what their lives might have been, I knew I didn’t want to tell stories whose tragic conclusions could not be undone; I wanted to be inside them, with a chance to help write better endings. I left the program and went to medical school.
Making yourself the hero of the story is a narrative cliché, yet many of us tell an “I want to help people” tale when seeking entry into the profession. For some clinicians, the pandemic offers an opportunity to take on that role as never before. But for those who can’t, the stories of heroism may be as silencing as they are intoxicating. Clinicians on the sidelines must confront not only shame and guilt, but also the loss of their primordial story. Who are you, if you can’t be the hero you imagined yourself to be?
In a press conference during New York’s Covid surge, Governor Andrew Cuomo talks about the selflessness of the citizenry willing to give up their own agendas for the common good, and how sometimes leaders learn best from the people they’re tasked with leading. Emphasizing the need to transcend partisanship, he reflects on what it means to be tough. “Within that word ‘tough,’” he says, “is smart and united and disciplined and loving. They are not inconsistent, to be tough and to be loving.”
My mother and I have our biggest argument on the first anniversary of the death of my cousin — her brother’s youngest son. We don’t speak for 2 days — unusual for us under normal circumstances — and about 2 months in quarantine time. During those days, the number of employees infected at my hospital climbs, and the Boston Globe publishes a story about the high rate of infection among Massachusetts’ health care workers.2 To me, the numbers reinforce the need to step up, given the likelihood that my hospital will be short-staffed; to my family, they are terrifying. Even my sister, an endocrinologist and my most reliable ally, isn’t on my side. My father sends me an email labeled “A family plea,” and when I don’t respond, he texts me an emoji. The situation is clearly dire; he’s texted me an emoji only once before, and I’m certain the first time was by accident.
My parents are isolating at home in Portland, Oregon, and I call my dad the next afternoon on FaceTime. “I’ve never seen your mother like this,” he says. “She’s been crying for 2 days.” He hands her the phone, and when I see her face, I am overcome by the feeling I often have when meeting a sick patient for the first time after having only reviewed their chart. The data tell you the gravity of illness, but I never feel it until I see the person’s face. I have learned to brace myself for this piercing moment when I see patients. But I did not brace myself for my mother. She is wearing gloves and her hair, usually down, is up; I ask her why, and she says it’s so she doesn’t touch her face. I can’t recall ever having seen her afraid. Talk to me, I say. Had she flown off the handle, I would have known what to do. Instead she says, “I can’t bear the thought of never seeing you again.” “OK,” I say, “I’m out.” And that was that.
My clinical chair tells me not to give it a second thought and, within minutes, has found someone willing to take my place. One day I hope to thank that person, but right now I can’t make myself check to see who it is. The dates I would have been on service coincide with Boston’s Covid surge. Those caring for these patients, as well as all the other essential workers around the world risking their lives, will always be heroes.
But the pandemic has also revealed a quiet kind of heroism: that of the billions of people whom we’ve asked to stay home, abandon their livelihoods, and set aside their own identities for the sake of preventing deaths they cannot see. There will be no parades for these people. Most will not be able to connect their sacrifices to any one life saved. Yet there is heroism in their stories, too. Writing the postpandemic script will be tough. But if we remember that everyone has a role to play, the empty pages will, once again, be filled with stories.