As the pandemic of SARS-CoV2 (the novel coronavirus that causes COVID-19) unfolds it continues to impact contemporary forms of sociality and community, health, care, governance, and global interconnectedness. These changes and the myriad challenges they pose are critical fodder for anthropologists of health and medicine, and we are called upon now to document lived experiences, reflexively use social theory and the other tools at our disposal to elucidate what Geertz (1973) might call the “web of meaning” constructed around COVID-19, and reflect upon existing macro-level social structures and systems. There will undoubtedly be much ink spilled about the ways in which this pandemic has and will continue to alter health and sociality, including systems of power and inequality, and how conditions in the United States have primed the entry of SARS-CoV2 virus for such unprecedented destruction and death.
Here, we offer a glimpse at how policies and practices are being lived in these early weeks. As physician-anthropologists on the frontlines of care in Seattle, where the pandemic first took its domestic foothold in the US, and New York City, where case numbers and fatalities continue to surpass predictions and stagger the biopolitical imagination, our perspective allows us to compare and contrast details of the pandemic that have affected our patients and our communities while thinking across the scales of affected individuals, healthcare practice, and political economy. Our brief contribution to this evolving collection of COVID anthropology bounces from coast to coast; from hospital wards, ICUs, and ERs to living rooms and outpatient clinics. It engages actors from individual patients and family members to state and municipal governments and corporations.
On February 27, 2020 I was working overnight in the hospital covering for the teams that had left for the day and admitting new patients to the ward and ICU teams. It had been a particularly active cold and flu season, and a large part of the ICU care involved an intricate choreography of providing care for patients with infectious respiratory illnesses while avoiding spreading those to their neighboring patients with recent lung transplants and critically low white blood cell counts. It had been a moderately busy night for me; I had been caring for a patient admitted with influenza who had a cardiac arrest overnight while in the hospital and was transferred to the ICU, and I was glad to see the sun creep over the horizon signaling the near-end to my shift. When one of the critical care doctors arrives in the morning, he was encouraged that the weeks of cloudy skies were finally giving way to some sun on his early morning drive, but that did little to distract from the noteworthy new cases of novel coronavirus in the region, which had heretofore been something happening elsewhere in the world – something we had suspected only in those with known contacts or a history of travel to China and South Korea and of which we vastly underestimated the infectivity. By late February we had reports of confirmed cases in the region without any known exposures. “It’s all over,” the critical care doctor said. “Now it’s just out there, circulating, and we can’t track it. I’m thinking of writing an op-ed for The Seattle Times about how we should no longer shake hands…”
What perspective comes in a month’s time. That following weekend uncovered the outbreak in the Kirkland Life Care Center, which was the first domestic spark of a now devastating conflagration, and along with it the fear of spread among our other patients and hospital staff. We have seen avoiding handshakes give way to physical distancing and to mandates to stay at home unless providing essential work or seeking essential services. Our ICUs are still populated with the critically ill and immunocompromised, but are also now pushing the limits of our resources with additional patients with severe pulmonary symptoms from COVID-19. Many of these patients who ultimately progress to requiring intubation and placement on a mechanical ventilator die despite these interventions. That patient who suffered a cardiac arrest with flu, whose family came to visit and was updated at bedside while I explained his infusions of life-sustaining medications, his ventilator, and the uncertainty of the days to come, would now be isolated from his loved ones because of the new hospital policy on limitations on visitors. Especially so because they were also sick at the time with respiratory symptoms.
Such an event is almost unfathomable now. Indeed, many patients with and without COVID-19 are dying in isolation with families at home quarantined themselves or may – if they are lucky – have a virtual visit on a tablet at the end of life. The novel coronavirus has brought about a new age in the practice of medicine where any new symptom is a call to test, healthcare workers are faced with the devastating impact of deaths that are multiple and morally distressing, new and unproven treatments come with federal regulations meant to ensure that patients who have indications for those drugs can access them and that they are not being hoarded or misused, and virtual outpatient office visits have become the new norm. It has signaled a profound change in the way we structure and deliver healthcare, and we are left to find new ways to comfort, care, and heal.
What has happened in Seattle over the last month, as ad hoc policies have been implemented and resources mobilized, has laid bare the interconnections between health, the state, and private enterprise. In a perfect storm of neoliberal policies, companies like Facebook, Tesla, and Amazon as well as venture philanthropy firms like the Bill and Melinda Gates and Paul Allen Foundations have been relied upon to provide costly healthcare and health security – not only to fill the gaps of an absent social safety net, but also to provide basic resources and guide public policy in a contemporary crisis. The result is a fractured system regulated by a failing economy put in place to bolster production and sustain investments in biomedical capital first and to protect and support the health of the population second. I think – or am at least hopeful – that positive change to the healthcare system will come as a result of the stresses placed on critical points of weakness in these interconnections. Kim references the nationalization of Spain’s healthcare system below, and others have commented on how COVID-19 may push the United States to develop a single-payer national healthcare option. In the worst case, I fear that once the imminent threat of the virus is somewhat contained, this more intercalated system of enterprise-sustained healthcare will persist as governments and health expert-driven policy recede.
As soon as Vice President Mike Pence was appointed as chairman to the White House Coronavirus Task Force, Facebook hosted the WHO and corporate leaders from Google and Amazon to discuss the pandemic response (in lieu of the CDC and the National Security Counsel (NSC)’s pandemic response team, which Donald Trump and his administration had dismantled to limit government bureaucracy and reduce the NSC’s payroll). On a federal policy level we are seeing corporations become embedded in disaster management, staking claims to response efforts and situating themselves to provide goodwill to communities that are hurt by their operations. While corporate firms shifted to telecommuting, unemployment applications increased in Seattle eight fold immediately following the economic crisis. My young primary care patients, who lack the risk factors to keep them from coming to clinic, suffer from profound anxiety about the state of the world, and I am left with little to offer aside from an understanding ear and a plug for therapy, mindfulness, occasional pharmacotherapy, as well as ways to stay engaged and active. Meanwhile, each time I drive to clinic I see a new homeless encampment. I can’t prescribe paid time off. Amazon, which is notorious in the area for its negative impact on local businesses and for fueling a rise in the cost of living associated with what is now the third largest, and one of the fastest growing, homeless population of any city in the United States, and its recent monetary influence on local elections, donated $5 million (or rather created a fund to which small businesses could apply for a grant) to help businesses that surround its offices which will close without their usual Amazon employee patrons.
Private industries are also relied upon to shift production to ventilators and PPE. Elon Musk, the CEO of Tesla, and original coronavirus denier, has stated he would buy and ship ventilators. Some masks were distributed around healthcare systems in Seattle, but ventilators were eventually sent to New York as the case burden in the city began to overwhelm their healthcare system. The machines he purchased from a medical supply company and packaged with the Tesla logoturned out to be bi-level positive airway pressure machines, not mechanical ventilators. While bilevel machines (also known as non-invasive ventilators) are useful for people in critical respiratory failure to avoid intubation, they are not indicated for respiratory distress/failure caused by COVID-19 or other pulmonary infections and may aerosolize and hence facilitate the spread of SARS-CoV2. Musk has mentioned that Tesla will also be contracted to manufacture ventilators along with General Motors from the federal government. Companies that capture the public imagination around technoscientific advancement, and to whom the public looks for science news are tweeting misinformation and supplying incorrect and inadequate resources.
Lastly, the Gates Foundation and the Paul Allen Foundation provide philanthropic donations to support research biomedical innovation that drives venture capital investments and promotes profits in the healthcare industry. The Gates Foundation has been providing funding for vaccine research and novel therapies – the most effective of which so far in our practice have not been the cheap anti-malarials touted in the news, but rather expensive biologics and immunomodulators along with antivirals. They have also funded research into additional testing modalities including antibody testing, which will be crucial in helping to investigate the question of immunity and anticipating the afterlives of this and other potential novel coronaviruses, but pumps money into biomedical capital during a time of healthcare crisis.
Two million dollars from the Paul Allen Foundation was allocated to fund testing among patients experiencing homelessness. It is unclear whether this was made as a donation in response to the pandemic and the particular crisis it poses to those without stable housing or if these were un-earmarked funds that were put to this use. Regardless, testing alone does not offer a solution to the pandemic’s impact on this population or the community at large. As I rotate off of nights, I message our homeless outreach clinics to see how I can help. I’m told that tests have not rolled out to this population yet. Patients who are aware of the pandemic and exhibiting concerning symptoms are being tested in the emergency room. In the first few weeks, they were discharged from the emergency room without test results if they were not sick enough to warrant admission to the hospital. Without being able to confirm that they did not have COVID-19, they were barred from acceptance into a shelter, and healthcare providers were instructed to call their shelters and tell them not to let the patients in. Furthermore, patients without cell phones, webcams, or smart phones had no way of following up with a provider as telemedicine was rolled out to limit healthcare-associated exposures. Since then, a “lounge” has been constructed that is not staffed by healthcare providers where patients can await their results – a process that at best takes about 8 hours. In the beginning of the pandemic we were told that the city was purchasing rooms in a motel where folks could quarantine. I have yet to hear of patients being sent there, though some first responders have quarantined there, and as of this writing we are still waiting for shelter spaces to open up for COVID-19 patients.
It seems as though we are witnessing a reversal of the development paradigm James Ferguson described in Lesotho as an “anti-politics machine” (1990), where supposedly neutral technical interventions obscured geo-political and financial interests. Instead we have the overt biopolitical control of population health and safety by corporate interest. The federal government has left states to fend for themselves and contracted with corporations for resources. States plead for those resources and compete against corporations and venture investments for the means of scientific knowledge production. Meanwhile, patients and healthcare providers face crises not only to manage COVID-19, but also the challenging chronic conditions that predispose folks to worse outcomes with COVID-19. Patients suffering from all sorts of maladies are staying home – both under quarantine and for fear that if they go to the hospital they will die, alone. They have lost trust in healthcare, and in many ways it feels like all roads were leading here, yet it’s in the small acts of care like practicing mindfulness with a patient in clinic or using a tablet to provide a virtual end-of-life visit that we are reminded of the intimacies of inhabiting a field of uncertainty, and how binding our human ties are.
New York City (Sue)
I am treating patients for opioid use disorder over FaceTime from my house in my sweatpants. I never thought of seeing patients before over FaceTime technology from the comfort of their and my respective homes. If you can call self-isolation, shelter in place, or quarantine “comfort.” I just watched the patient, who does about 2 bundles or 20 bags of heroin a day, vomit from withdrawal into the sink while on FaceTime with me. He had experienced an overdose earlier in the week, and was hospitalized in the intensive care unit and then discharged without a prescription for life-saving medication (methadone or buprenorphine). Through a post-overdose program, he found his way to me. I diagnosed him with opioid use disorder, over FaceTime, and prescribed him two weeks of buprenorphine. “Thanks,” he said, “I’m so grateful. I was just looking around for things to sell [hustle] in my apartment” in order to get money for heroin to alleviate the symptoms of his dopesickness. What does it mean for me to “care” for him now when I cannot touch him, examine him or sit with him?
As a physician-anthropologist, I have been working to address structural violence and structural vulnerability for people who use drugs and people who are incarcerated or leaving prison/jail for several years here in New York City and in Boston. I have dedicated my clinical practice as well as my research efforts to thinking about people who have fallen through the cracks or even worse, have been systematically abandoned or harmed by a precarious social safety net. These are patients who have always been at a very high risk of harm and death, from homelessness, systematic racism and incarceration, de-institutionalization, red-lining, retrenchment of social services, and bad health policy. And now I fear that they are at even greater risk of death from these harms with the addition of COVID-19.
We will and already are thinking about life and times before-COVID19 and during/after-COVID19. There will be no “normal.” In the course of a month, the practice of clinical medicine has changed drastically. I think often about how it would have been just and fair, pre-COVID19, if government regulatory agencies, lawmakers, hospitals and clinics cared about giving the flexibility and autonomy for my patients who use drugs to access what they need in such creative ways instead of having them jump through high threshold hoops to see doctors (long waiting lists, urine toxicology, intakes, counseling requirements, and come back next week). Pre-COVID19, we physicians did not trust our patients, especially people who use drugs. We did not trust poor patients, black patients, patients with erratic healthcare-seeking behavior or those with chronic pain. Yet now, we are freed up to literally meet patients where they’re at, in our homes and their homes, as long as we use two-way communication and do not publicly broadcast our visits on TikTok or Facebook Live. Over the course of the last month, the DEA and SAMHSA have made regulatory changes with such speed that it’s been impossible for addiction experts and practitioners to keep up. Why were my patients with substance-use related conditions ignored, left for dead, or at best, left to contend with high threshold barriers to the care and medications they need?
I am also answering a NYC medical hotline fielding concerned calls from about COVID-19 calls from people around the entire city. As of this writing there are 68, 776 known cases of COVID-19 in New York City. All medical specialties have become COVID-19 doctors in a matter of a month. I am preparing to enter into one of the makeshift hospitals springing up in the city.
On this hotline, I have been fielding questions from the most educated to the least educated, offering phone suggestions and through interpreters telling people what to do and how to best implement what they can to self-treat the symptoms of COVID-19 and how to prevent giving it to others. In many cases, this kind of self-care and prevention is simply an impossibility. There is no one else to go to the store. There are no concerned neighbors checking in. They live in the housing projects. Family is not in this state. There are eight people living in this space, half are sick. Everywhere there is desperation, death, fear, misinformation and panic.
New Yorkers are usually an angry, belligerent and unruffled sort. They are dying en masse and afraid. I tell people to have conversations early on about if they want to receive CPR, or be intubated and placed on a ventilator in case they can’t breathe on their own. They recoil in horror, but they see refrigerated trucks for bodies outside every hospital on the television. Having access to a ventilator—a talisman, a now fetishized object imbued with almost magical, mystical healing properties—has become as much an American right as being able to pursue “life, liberty, and the pursuit of happiness.” This, of course, is a misinterpretation and misunderstanding of what a ventilator does and can do, but that is the nature of the fetishized object, taking on mythical proportions. Estimates from China have suggested that greater than 80% of mechanically ventilated patients with COVID-19 died despite the most aggressive interventions (Ñamendys-Silva 2020).
I sit with patients and discuss what it means to go to the store but have symptoms of COVID-19. There is no one to bring food or medicine. Social isolation is literally killing them or possibly their neighbors. Arthur Kleinman has written about the moral mode of experience and how we can use the notion of exploring “what is at stake” for all actors to grapple with the realities and decisions ordinary people face. He wrote, “And, to be sure, what is at stake in a local world may involve a moral economy of systematic injustice, bad faith, and even horror” (Kleinman 1999: 365). And despite and facing all this, people are forced to make everyday decisions about themselves, their families, and their community. These are seemingly impossible choices that people must make. Should I go to the store, despite having a cough and a fever, possibly giving it to two neighbors? There is no one else. We have no food. Should I go to the emergency room, to possibly die alone, or stay here, suffocating, with my family at the bedside?
There is very little access to testing in New York City currently, especially within the public healthcare system, and even though New York State has tested widely, the estimates are still likely that they are vastly undercounted. Where there is testing, one large, well-resourced private hospital might be able to test in-house, getting a result in under 24 hours, while a small community hospital might be sending out tests and getting results back in four to seven days. I am speaking to people who have classic COVID-19 symptoms and we tell them, assume it’s COVID-19. You cannot get a test, unless you’re hospitalized inpatient with presumed COVID.
Hospitals and healthcare systems in New York City and across the country are being forced to compete with each other, and we cannot shift necessary critical infrastructure–whether it’s ICU doctors or respiratory therapists– across regions or the country to meet the inadequate supply and demand. My friend, a pulmonary critical care doctor in California, tried to come to New York and was told he was needed for California. There is not enough PPE, in New York City or anywhere in the country. In our praise of neoliberal government and capitalism, there are and will be so many preventable deaths; Spain nationalized its healthcare system for this reason.
From the frontlines of one of the pandemics, we are just beginning to see how our inequality kills, how the longstanding retrenchment of the social and healthcare systems in the United States, have allowed COVID-19 to change the nature of care and how we live and die. This is a completely new clinical entity for us. Julie Livingston has written that practicing ethnography within the oncology ward in Botswana and “examining processes of making do, tinkering, and ad-libbing help us to better understand the nature of biomedicine in Africa and the work of African healthcare workers, for whom improvisation is inevitably the modus operandi” (2012:21). Improvisation is now the modus operandi of highly interdependent health ecosystems around the world.
Social science and theory have so much to offer at this time: clarity, analysis, a vision of a better and more just world. Audre Lorde, writing about racism and homophobia and the class struggle, now gives me some solace as I reflect on our inherent interdependence: “Within each one of us there is some piece of humanness that knows we are not being served by the machine which orchestrates crisis after crisis and is grinding our future into dust… Survival is not a theory. In what way do I contribute to the subjugation of any part of those who I define as my people?” (1984: 139).
For Nick and I, as physician-anthropologists on the frontlines, we must toggle back and forth between our various hats and dwell in the unfolding and improvisatory spaces, the moments in-between where our social system strain and crack. Our goals might change by the hour or even by the second, but we are here to witness, to act with intention, to help people navigate seemingly impossible choices for themselves, and to strive to take into account what really matters for our patients and our collective futures.
Ferguson, J. 1990. The Anti-Politics Machine: Development, Depoliticization, and Bureaucratic power in Lesotho. Cambridge: Cambridge University Press.
Geertz, Clifford. 1973.The Interpretation of Cultures.New York: Basic Books.
Kleinman, Arthur. 1999. Experience and Its Moral Modes: Culture, Human Conditions, and Disorder. The Tanner Lectures on Human Values. Stanford University: April 13-16, 1998.
Livingston, Julie. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic.Durham: Duke University Press.
Lorde, Audre. “Learning from the 1960s.” In Sister Outsider. 1984. Freedom, CA: The Crossing Press.
Ñamendys-Silva, S. A. 2020. “Respiratory support for patients with COVID-19 infection.” The Lancet Respiratory Medicine.
Kimberly Sue, MD, PhD, is the Medical Director of the Harm Reduction Coalition where she provides national training and technical assistance to improve the health and well-being of people who use drugs. She is a graduate of the Harvard Medical School’s Social Science MD-PhD Track and completed her medical training at Massachusetts General Hospital in Boston, Massachusetts, in Internal Medicine-Primary Care. Her PhD work in medical anthropology examines the intersection of US prison systems, addiction policy, mental health and treatment with women in Massachusetts. She is the author of Getting Wrecked: Women, Incarceration, and the American Opioid Crisis(UC Press, 2019). She currently sees patients in syringe service programs providing low-barrier buprenorphine treatment and serves as an attending physician at Rikers Island Jail system in NYC practicing primary care, chronic disease management, HIV, STIs, substance use disorders and transgender care. Twitter: @DrKimSue
Nick Iacobelli, MD, PhD is an Internal Medicine resident at the University of Washington. He completed his MD PhD in the Medical Scientist Training Program at the Perelman School of Medicine at the University if Pennsylvania. His dissertation, Wards of the State: Care and Custody in a Pennsylvania Prison, is based on fieldwork in a men’s maximum security prison and examines how the legal right to healthcare in prison operates in the context of privatization and legacies of structural racism and oppression.