During the ongoing COVID-19 pandemic, hospitals have served a dual role in regards to infection control and management. Hospital emergency rooms and intensive care units have been overrun with COVID-19 patients coming from the community. Hospitals have also been sites of infectious disease spread as healthcare workers and patients share space, air, and ultimately, germs. Hospitals exist within context – the anthropological study of hospitals has demonstrated that they cannot be teased apart from their social, political, ecological, and biological surroundings (Long, Hunter, and van der Geest 2008; Singer 2014; Street and Coleman 2012). Furthermore, the hospital absorbs and reflects local history, culture, and politics in such a way that they become both physical and affect-laded representations of their milieu, what Street has called “affective infrastructures” (2012).

Kehr and Chabrol (2018) have reflected on the manifest ways in which by expanding our ethnographic view beyond hospital-based medicine gives perspective on emplacing the hospital, or rather finding the hospital “as such.” In that vein I suggest that additional attention be paid to the physical space and affective endeavor of the hospital: What does it represent? To whom? By utilizing the case of infection control at a public teaching hospital in the Midwestern United States, I argue that the permeated, imagined, feared, and affected hospital operates as a catalyst that takes looming infectious disease threats and folds them into existing racial and economic disparities impacting the infectious disease epidemiology of a geographic region. The particular assumptions and practices already in use in hospital settings pave the way for COVID-19 to deepen existing divides in medical services. The ebb and flow of infection-related practice in the hospital space is such that, to the patients and staff at my particular field site, infection is always present and forever threatening. This murky milieu ultimately lends appreciation to the interrelatedness of the control of infection (i.e., infected bodies), social dynamics (i.e., like structural racism), and the hospital space (i.e., as a physical and affective structure).

The New (Old) Lady: A Hospital with Memory

The city skyline. A lake glistening beyond. The city’s medical institutions are steeped in the history of this Great Lakes city – infrastructure, politics, poverty, and racism. Frontier[1] is a rare public institution, made even more unique when one considers that its nationally-renowned Level 1 Trauma Center, equipped to treat and rehabilitate patients with severe trauma injuries, is kept afloat by underpaid physicians and surgeons working overtime. The hospital took early stands on patient advocacy and now provides a majority of the charity care for the city. Frontier is also famously a creative inspiration for the television series ER (1994-2009). The original building, chronicled as an “old lady” by historians, was vacated in 2002 as staff and patients moved down the street. The two hospitals have existed within sight of one another for almost 20 years, a physical manifestation of improvement alongside decay (see Street 2012). Frontier is a hospital with memory.

Medical practice at Frontier is imbued with the biological, social, and political dynamics of the city. In an interview with a former administrator at Frontier, I became aware of the type of engagement this long-standing institution has with other healthcare entities and medical practitioners in the region. Other administrators and policymakers “treated it [Frontier] like a zoo,” he said. Over the next hour, we talked through the racism, economics, and cultural values that allowed Frontier to exist as a place for dying rather than for living. The former administrator laments the willingness to profit off of Frontier because of its collection of rare and threatening infectious diseases. Notably absent in their engagement was an acknowledgement and appreciation for those rare and threatening infectious diseases being present in individuals from marginalized populations from the surrounding area. Physicians from around the city could rotate at Frontier where they would gain experience and gather data from the “zoo.” The intrigue and fascination mobilized in early studies of patients at Frontier is reminiscent of the extractive and abusive medical experiments like the Tuskegee syphilis study (1932-1972) performed on Black patients across the United States (see Hoberman 2012).

The types of infectious diseases seen among admitted patients at Frontier, even today, run the gamut. An infectious disease consult team dedicated solely to patients with HIV/AIDS is now a rare feature of medical practice in the United States, but Frontier has one. Furthermore, infectious diseases not endemic to the region – Chagas disease and malaria – could be seen at Frontier due to the itinerancy and underlying poverty of their patient populations. These infection control challenges signal the existing racializations of patient populations that filter in from the region, they are reputational overtones and undertones that do not go unnoticed by leaders in the hospital system who work hard to make clinical care their focus. The legacies of the city inflect infection control and the ability to address infectious diseases, both the ones that appear as a mundane part of daily practice and the ones that exist on the horizon as looming threats.

From 2017-2018, I conducted ethnographic research[2] on the management of infectious diseases and the use of antimicrobial therapies at this institution. The physicians at Frontier were well-trained in the intricacies of their field. I learned about infection control and epidemiology, including the proper way to wear an N95 mask, plastic gown, and gloves so that no liquids or air particles put you at risk. However, inadequate nursing coverage meant that testing to confirm suspected infection could be delayed or botched (e.g., not taken on-time and in the requested amount). Frontier is a teaching hospital – overworked physician residents received training from infectious disease physicians in the form of “education breaks” in between seeing patients and, given the time, advice on such topics as notetaking for antibiotic durations (i.e., writing the start and anticipated end date for an antibiotic in the patient chart). The residents were hard pressed to take every lesson to heart as they rushed from patient to patient. I observed the mundane aspects of practice intersecting in and around suspected cases of infection in a patient. This daily saga demonstrates the ways in which politically-charged bureaucracy left Frontier with a diminished budget and resources, ultimately creating a catalyst for an uncontrolled hospital-based infection control program.

Looming Threats and Anticipation

Infectious disease staff at Frontier worked in microbiology, infection control and prevention, hospital epidemiology, consulting work, and patient care. Part of their work involved preparing for the spread of infectious diseases regionally, including the assessment of how that infectious disease outbreak might permeate the walls of the hospital. The aura surrounding highly-resistant bacteria attracted funding and motivated physicians to do research and prevention work. As Katherine Mason’s (2016) study of infectious disease researchers in China has demonstrated, novel infectious disease outbreaks can catapult careers and grow departments. As such, while staffs at Frontier attempt to control ongoing infectious disease spread, when a threat looms it has the potential to coalesce and cause reformulations.

Infectious diseases are both a mundane, everyday aspect of hospital-based medical care and the executioner waiting to turn a threat into a “situation” (Massumi 2005). When a threat becomes a situation, the path that hospital-based physicians take becomes clear. When an infection is confirmed on record, treatment recommendations are consulted and action is taken. However, such as in the case above, an outbreak has not yet occurred. The individual patient is infected, but there is a threat that the disease will spread to physicians, hospital staff, and other patients. In this way, the control of infectious diseases at Frontier was often about dreadful anticipation, a looming. Of course, sometimes threats become situations in a big way, such as we all are experiencing with the global COVID-19 pandemic. As SARS-CoV-2, the virus responsible for the condition known as COVID-19, spread through the United States, Frontier received an influx of cases. The COVID-19 pandemic is testing the hospital’s ability to manage breaches of their city and physical institution. They have a situation on their hands, but not one that challenges Frontier’s identity. Rather, the challenges of COVID-19 reinforce what Frontier represents in the city and larger region: a diseased place serving as host to diseased populations.

Alice Street (2012) describes “affective infrastructure” as the ways colonial legacies are reflected in a populace’s engagement with a medical facility. The hospital represents the past, present, and future of a community. In the United States, the history of institutionalized racism has meant that Black and Latinx lives are not only made vulnerable outside, but also inside hospitals, by the nature and texture of the medical care that such marginalized populations have access to. Frontier is an  “affective infrastructure” that intricately and deliberately form part of the patchwork of the city in distinct ways such as in their care of underinsured Black and Latinx populations. Indeed, as I learned from physician fellows who took care of infectious disease patients at both hospitals, stop-gap measures and workarounds like reusing disposable plastic gloves were part of the fabric of Frontier in ways that private hospitals largely avoided with better access to and provision of resources. Furthermore, working in outdated and sometimes dysfunctional negative pressure rooms (i.e., a room for patients suspected of having tuberculosis or other air-borne infections) makes clear the struggles of preventing infection in a resource-constrained setting. The staff at Frontier navigate their circumstances well, but when dealing with the looming presence of infectious disease threats, there is a distinct feeling that the new is just more of the old.

In the United States, COVID-19 has struck Black and Latinx communities the hardest due to the preponderance of multi-generational households, overrepresentation in the prison system, lack of job security, and residential segregation that becomes visible in the proliferation of food deserts and diminished access to medical care (CDC 2020, Pew Research Center 2020, Vox 2020).

The urban decay that surrounds Frontier is no exception to this larger national trend, the hospital continues to embody the physical space that was once poor house, now medical center. New infectious disease threats get folded in with longstanding challenges: another day, another disaster. Frontier represents temporal continuations – a troubling picture of the relationship between infectious diseases, medical care, and racism that is highlighted during this pandemic but has been present for decades (see, for example, Hoberman 2012, Sangaramoorthy 2020, Singer 2014) and is intensified and grounded in significant ways by the physical and affective presence of a hospital such as this.

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Katharina Rynkiewich is a cultural anthropologist who studies the structures of care surrounding infectious diseases in North American medical institutions including the social dynamics of antibiotic prescribing among healthcare practitioners. Katharina’s research has been funded by the Centers for Disease Control and Prevention, the Wenner Gren Foundation for Anthropological Research, and Washington University in St. Louis. She is currently a postdoctoral scholar in the Department of Anthropology at Case Western Reserve University. katharina.rynkiewich@case.edu

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Notes

[1] Note that Frontier is a pseudonym selected as a nod to the legacy of the institution and its role within the larger geographic region. Certain information about the region has been changed or omitted. Due to particularities and specificities that were difficult to eliminate, the keen reader may be able to glean the true name of the hospital. However, by withholding those details I intend to keep their true names out of print and make sure none of the persons I worked with can be identified.

[2] This essay is based on 18-months of ethnographic research that took place between 2017-2018. It was funded by the Wenner Gren Foundation for Anthropological Research (Grant #9557).

Works Cited

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Hoberman, John. 2012. Black and Blue: The Origins and Consequences of Medical Racism. Berkeley, CA: University of California Press.

Kehr, Janina, and Fanny Chabrol. 2018. “L’hôpital: Pour Une Nouvelle Anthropologie Des Espaces Cliniques.” Anthropologie & Santé 16: 1–13.

Long, Debbi, Cynthia Hunter, and Sjaak van der Geest. 2008. “When the Field Is a Ward or Clinic: Hospital Ethnography.” Anthropology and Medicine 15(2): 71–78.

Mason, Katherine. 2016. Infectious Change: Reinventing Chinese Public Health After an Epidemic. Stanford, CA: Stanford University Press.

Massumi, Brian. 2005. “Fear (The Spectrum Said).” Positions 13(1): 31-48.

Pew Research Center. 2020. “Financial and Health Impacts of COVID-19 Vary Widely by Race and Ethnicity.” 5 May. Available at: https://www.pewresearch.org/fact-tank/2020/05/05/financial-and-health-impacts-of-covid-19-vary-widely-by-race-and-ethnicity/. Last accessed 14 June 2020.

Sangaramoorthy, Thurka. 2020. “From HIV to COVID19: Anthropology, urgency, and the politics of engagement.” Somatosphere. 1 May. Available at: http://somatosphere.net/2020/from-hiv-to-covid19-anthropology-urgency-and-the-politics-of-engagement.html/. Last accessed 14 June 2020.

Singer, Merrill. 2014. Anthropology of Infectious Disease. Walnut Creek, CA: Left Coast Press.

Street, Alice. 2012. “Affective Infrastructure: Hospital Landscapes of Hope and Failure.” Space and Culture 15(1): 44–56.

Street, Alice, and Simon Coleman. 2012. “Introduction: Real and Imagined Spaces.” Space and Culture 15(1): 4-17.

Vox. 2020. “Covid-19’s Devastating Toll on Black and Latino Americans, in One Chart.” 17 April. Available at: https://www.vox.com/2020/4/17/21225610/us-coronavirus-death-rates-blacks-latinos-whites. Last accessed 14 June 2020.