Two years

It is “Happy Doctors Day” though I think many would have mixed feelings about that title. I had a series of conversations recently where people said, “I didn’t actually hear much from doctors these past few years about their experiences” compared to what is filtered through mass media or unverified/often misinformation in social media. I’ve written before [http://www.theurbanresident.com/2021/03/10/epilogue-prologue/] about how awkward, painful, and technically challenging it can be to describe; to summarize:

It is one thing to say, “2020!” with the sort of half-shrug and rolled eyes that we all instinctually and collectively understand to mean… something? Something exceptional, something indescribable, something chaotic, mournful, apocalyptic, boring, filled with a wordlessness that describes both terror and malaise. It is another thing to try to select actual words and stitch them together into something that makes sense out of something that has felt so completely non-sensical.

I was recently shopping in the local grocery store and overheard:

“Look on the bright side, we don’t have to wear masks any more!”

I was wearing one and almost stopped walking to mull over that comment. Two years prior, I stood in the exact same grocery store and overheard a different sort of conversation:

“This virus is all about the hype and a way for the media and drug companies to make money. Remember H1N1, SARS, Zika, bird flu? Ain’t nothing going to come of it.”

Two years. My oh my how grocery store small talk has changed.

Implicitly and explicitly, the US has accelerated towards “accepting” Covid as endemic and normal, and because I track related data closely and see patients in the hospital, am asked for an opinion of this at least once a week. I have increasing ambivalence when I speak, not because I am less certain in an opinion but because, in the most optimistic sense, I am increasingly met with an uncomfortable shuffle in response to my uncomfortable responses. (In the pessimistic sense, I am wary of being met with outright hostility and denialism, but that would be nothing new.)

Where are we now? And what does life (in the US at least) look like moving forward?

Here I become the Debbie Downer because my conclusions draw from other terrifying, heterogeneously fatal, highly politicized conditions with public health consequences such as firearm violence. My take is not something that is inspiring, pacifying, or very hopeful because we should daily be reminded as to how we have come to accept episodic instances of mass shootings in schools killing children as so normative that our most consistent policy response is to have more active shooter drills and armed guards and in some states propose even more guns be available to the public.

There. That felt good to say. Even if it felt uncomfortable to read, it is as bluntly obvious as it gets. How I feel about Covid and the future is similar: premature death for all will be more likely, mostly for those unvaccinated, also for those medically vulnerable, but for everybody everywhere (including vaccinated) because we all live, breathe, age, and die in a society that ties your health to your earning potential & productivity

Ed Yong at The Atlantic, as usual, says it best:

America is accepting not only a threshold of death but also a gradient of death. Elderly people over the age of 75 are 140 times more likely to die than people in their 20s. Among vaccinated people, those who are immunocompromised account for a disproportionate share of severe illness and death. Unvaccinated people are 53 times more likely to die of COVID than vaccinated and boosted people; they’re also more likely to be uninsured, have lower incomes and less education, and face eviction risk and food insecurity. Working-class people were five times more likely to die from COVID than college graduates in 2020, and in California, essential workers continued dying at disproportionately high rates even after vaccines became widely available. Within every social class and educational tier, Black, Hispanic, and Indigenous people died at higher rates than white people. If all adults had died at the same rates as college-educated white people, 71 percent fewer people of color would have perished. People of color also died at younger ages: In its first year, COVID erased 14 years of progress in narrowing the life-expectancy gap between Black and white Americans. Because death fell inequitably, so did grief: Black children were twice as likely to have lost a parent to COVID than white ones, and Indigenous children, five times as likely. Older, sicker, poorer, Blacker or browner, the people killed by COVID were treated as marginally in death as they were in life. Accepting their losses comes easily to “a society that places a hierarchy on the value of human life, which is absolutely what America is built on,” Debra Furr-Holden, an epidemiologist at the Michigan State University, told me.

As a hospitalist, it is literally my job to deal with death, expected or not. Even prior to Covid, in a typical week I might have daily experiences telling people they are dying or watching them do so despite heroic and often extreme efforts to prevent it. Any doctor will tell you, the past two years haven’t made any of this sort of thing easier, even if we all readily recognize the finality and inevitability of death as it’s literal experts.

So it both amuses and infuriates me when people, who usually have never seen a dead body much less been involved with or carried responsibility in preventing a person’s death, casually tells me, “What’s the big deal with Covid? It’s only X%, less than that in children, and comparable-in-some-way to flu, car accidents, cancer, heart attacks, etc., and you only need to worry about it if you’re old or immunocompromised.”

I’ve been struggling to understand why these comments bother me so much. One simple thing I want to say is that Covid is an additive risk of death; it is not as if for every person who dies from Covid, one less death from a car accident or a bullet or a drowning magically occurs.

The more complex thing to describe is a set of emotions: how it feels to sit down to tell a patient, “This is a new diagnosis,” it’s ramifications as an immunocompromising condition, and eventually, “I strongly recommend you consider getting vaccinated for Covid now” and watching their eyes widen with realization and fear. Should I tell them, “That’s how it feels to be in the X%”? Or how it feels when I’ve said “You have Covid” to someone struggling to breathe, and hear “But I’m vaccinated and boosted!” Should I tell them, “That’s how it feels to be in the X%”?

Of course not. It would be preposterous to do that. We do not even do that in casual conversation about the children who are murdered in their schools, the elderly who wither away in nursing facilities, or those with other special needs in group homes.

What does it mean to be a doctor in 2022? I don’t really know. My interpretation is that, by an unknown degree and intensity, it means looking forward to a future in which the world is only more sick than before yet one that is simply less motivated to do something about that than in 2020. That is what I have been quietly mourning and preparing myself for these past few months.

I think I’m almost done with that process, with realizing that it’s never been easy or expected for the public to learn to deal with illness and death and so I shouldn’t expect it to suddenly be so. As a pediatrician I try to cut up grapes and hot dog bites and fuss about car seats and gun safety though with varyingly human degrees of attention and laxity. Sometimes it is literally my job to educate and advocate for others and sometimes it is not. I am slowly (even if inconsistently) coming to an “uneasy peace” (cf Patrick Sharkey) with the brutishness of public life… mostly so that, when I am expected to be there at the bedside for the days of anticipated and unanticipated sorrow and crisis of my patients, I can do so with less of my own.

To my colleagues: thank you for being there. Some days I don’t know how or why we continue to, and so don’t blame or shame at all those who have left. We never learned about any of this in school; evidently we missed the opportunity to assent to participation in the trial for it as well.