Mrs. Gomes, my umpteenth patient of the day, is an older woman — only slightly older than myself — who came to the emergency department with a cough, an upset stomach, and diarrhea.
Compared to the constant train of patients with known and suspected Covid-19 I’ve already seen this shift, at least for now she belongs in the camp of the tired but otherwise well-appearing. There are no worrisome findings on her physical exam: a borderline fever, a solid oxygen saturation level, and a chest X-ray without the worrisome white puffs and fingerlike haziness common in the lower lungs of patients with Covid-19 pneumonia.
After she has been given a few liters of intravenous fluid, Mrs. Gomes (the patient’s name and identifying details have been changed) is eager to go home. I move my N95 mask off the raw bump growing on the bridge of my nose, a pressure sore from wearing the mask, and tell her that she’ll learn the results of her Covid-19 test in a day or two. In the meantime, she should keep her face covered and self-quarantine.
She scrunches her brows, then plays with her face mask. “But I’m supposed to visit my daughter,” she tells me.
Her daughter, I learn, lives a plane flight away.
Though we are waiting on the test results, I suspect from her symptoms, and the accompanying fatigue, that she’ll test positive for Covid-19.
“You shouldn’t be traveling for the holidays,” I say, raising my voice. “You likely have Covid-19.”
“What?” she yelps.
Over the N95 mask I wear a surgical mask, and a face shield in front of them. These necessary layers of protection echo my normal speaking voice back to me. What’s loud to my ears is heard as incomprehensible mumbling to patients. Turning up the volume has become part of everyday communication, which doesn’t feel right in situations like this one when I actually feel like screaming.
How could she travel for the holidays during a pandemic in which the daily national death toll makes each day feel like 9/11? The constant influx of very sick patients stress hospital capacity across the United States and impose unbearable burdens on health care workers.
Gripped by this ominous reality, I feel my tone leaking with judgment. Mrs. Gomes seems to be a kind person. I regret the edge to my voice and brace for a well-deserved sharp retort from her.
During this second surge in Rhode Island, where I live and work, I no longer feel as noble and inspired as I did last spring. I’m tired, a less-admirable version of myself. There’s a tendency to be critical of patients such as Mrs. Gomes, whose actions feed this unprecedented crisis. Admitting this leaves me embarrassed, especially when I notice the severity and purity of her disappointment, like that of a child whose ice cream has fallen to the sidewalk.
“I’ll wear a facemask when I’m there,” she says. “Promise.”
Behind layers of protection, my interactions with patients feel dampened of nuance. Despite all that’s covered, there’s a wealth of texture revealed in the window above the cheeks. From behind Mrs. Gomes’s window, I read an expression of sadness and longing.
There’s a heat in my eyes, and it carries the force of a silent scream.
I can’t believe I’m back in our reopened Covid-19 unit sweating in full protective gear—including a gown and a surgical cap in addition to the many facial coverings. Not long ago, my state had one of the highest rates of Covid-19 infections per capita in the world. We don’t need more lives disrupted, futures irrevocably altered, breaths snuffed out. We hang all our hopes on a vaccine because not enough people are doing the simple things — wearing face coverings and appropriately social distancing.
I explain to Mrs. Gomes how, if she has Covid-19, she could infect people in the airport, on the plane, and in her daughter’s house. She doesn’t argue with me. I’m impressed by the precautions she’s taken to date. She lives alone and goes out in public only to shop for food and take the occasional walk. She clearly recognizes the risk of infecting others, and the dangers of virus transmission in indoor spaces with proximity to others. But she recently attended a birthday party with relatives, some of whom weren’t wearing masks. Somehow, family is different from the public. Her contact with family counted as a different type of engagement, as if shared DNA or familial connections provided a containment against the virus.
“I won’t be leaving my daughter’s house,” she says. “I’ll be spending a few days at home with my daughter and grandchildren.”
I rub my nose through my masks. A low-level headache taps between my eyes. I can barely take the weight of the thin wire-rimmed eyeglasses perched on my face.
“But if you have Covid, you’re the one they should be distanced from. You’re putting your daughter and her family at risk.”
There’s so much attention on the extremes of responses in this pandemic. Defiant people refuse to wear facial coverings or social distance based on political affiliations, conspiracy theories, personal beliefs, and misinformation. Less often do we talk about what seems to be irresponsible behavior that doesn’t fit into neat categories.
In my many conversations with patients in the emergency department, it is this other group, which defies familiar classification, that is more common.
Social distancing is a problem in this pandemic. But so is the distance between knowledge and our lives, our assessment of risk and our needs. Mrs. Gomes is worried about becoming infected with Covid-19, yet the odds of her transmitting it to others didn’t match her need to see her family.
Like many of my patients, Mrs. Gomes isn’t being unreasonable or irrational. They’re realists, struggling to balance the reality in which they’re living. I’ve cared for several patients with Covid-19 or who have signs and symptoms of the disease and awaiting test results more terrified of the consequences of missed paychecks than SARS-CoV-2. They had mouths to feed, rent to pay, and hope for something extra for holiday gifts. I argue with them the way I make my case with Mrs. Gomes.
I’m learning that it’s laziness to judge their behavior, to assume they’re selfish or unwilling to sacrifice personal comforts for the greater good. Part of me wants to tell Mrs. Gomes that it’s ridiculously dangerous for her to get on that plane. But she already knows that. Educating her about Covid-19 requires more than knowledge about the virus and protective measures against it. Scientific evidence isn’t enough.
Even behind multiple layers of facial coverings, communication requires the willingness and fortitude to put scientific evidence about Covid-19 in the context of a life and the body. The coronavirus, for all its lethality and social destruction, isn’t the only big problem in many of my patient’s lives. It’s one of many. Patients make decisions for reasons that aren’t immediately clear to outsiders.
Because it takes extra effort and time — both often in short supply — it’s easier for health care providers like me to lump the perceived resisters into a large category of misbehavior rather than putting the risks of getting or spreading Covid-19 on balance with the many other risks.
Because of the pandemic, Mrs. Gomes hadn’t seen her daughter and her family in many months. Her desire to spend time with them is so intense, it’s worth dying for. It was love — not selfishness — that blinded her ability to recognize that she could become a threat to their health and the health of others.
This is not to say there aren’t those who congregate irresponsibly in large groups at parties, clubs, beaches, and seats of government power. They have a heavy hand in the record numbers of cases and the rising death toll.
But I’m trying to withhold judgment, as hard as it may be, and understand what motivates these actions. Because when Covid-19 is finally behind us — and pray that time comes soon — parsing out the questions of “why” with a little more sensitivity and clarity will be necessary for building a healthier society.
Jay Baruch is an emergency physician, professor of emergency medicine, and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University.