War and Peace is making a comeback this spring, along with other great fat books, book clubbing in general, twelve-bean soups, and other projects meant to reacquaint us with a more glacial, less contemporary sense of time. When I think of War and Peace now, though, my mind strays from the Rostovs and Bezhukovs to Charles Joseph Minard’s graphs of Napoleon’s invasion of Russia. Minard was a nineteenth-century French civil engineer esteemed for his data-rich but immediately apprehensible diagrams of everything from commuter traffic to wine imports. His most famous and damning image, however, maps the progress of the Napoleonic army as it staggered west from Russia back to central Europe. Soldiers’ lives are initially a thick red band, a gash of enormous and emphatic force. Each millimeter of red width stands for ten thousand men. As the march continues, the red band dwindles, etiolates. By the end of the campaign only a small stream trickles back to safely held territory.
As a child, I went to a somewhat old-fashioned Catholic school where history was largely understood as the study of military battles and their outcomes. This kind of education leaves much out, but helps me recognize a Minardian or Napoleonic situation when I see one. It’s becoming rapidly apparent that I, an internal medicine doctor based at two academic hospitals in Manhattan, am part of the thick red band that’s about to be wrung threadbare.
In the Trump administration’s United States, COVID-19 has always been about commodities—that is, their scarcity. First there weren’t nearly enough tests, and the available tests were sporadically employed and sluggish to yield results. Then there were too many probable cases for it to be practicable to test widely, and besides, we somehow ran out of the swabs compatible with the test assays (just as there were finally almost enough of the latter). I’m speaking in the national “we,” and in particular the New York “we.” Here in New York City we’ve mostly stopped testing all but the severely ill sick enough to need a hospital bed—it would be a waste of precious swabs. While we worried about tests and swabs, we ran out of personal protective equipment (PPE) for health care workers.
Over the last two weeks my hospital’s stock of gowns, gloves, masks, and face shields visibly dwindled in every cabinet. Eventually you had to know who to ask about secret cabinets, small locked stashes. It helped to whisper; it helped to have friends. My head was full of combination codes for various locked drawers and closets around the hospital. Then even the locked chambers started to empty. Every day we are told that a modest quantity of new supplies are almost here, but every day they’re not quite here. Ditto for ventilators. There is now a growing array of formal and informal protocols for cleaning, reusing, stretching, and sharing everything from masks to rooms and ventilators, all of them ingenious but admittedly not quite as good as the gold standards for worker safety or patient care. This is ubiquitous in all hospitals in our region, with mine in fact faring better than most. In addition to finding or reusing scarce equipment, new aspects of my job include lengthy and heartbreaking conversations about prognosis and “code status” (a patient’s wish for resuscitation and/or a ventilator), determining which patients’ deaths are imminent enough that they can be allotted their single hour-long visit from the loved one of their choice (otherwise, no visitors allowed), and studying textbooks and videos so that I might serve as an ICU critical-care doctor should the need arise (which normally would require an extra two years of intensive training beyond the medical education I’ve had). Each day a portion of my list of patients is critically ill, and a portion are recovering. I quiz those who are recovering more extensively about their living conditions than I ever would have before. A single male taxi driver living with six other men in a studio in Queens, where they sleep in shifts on a row of cots? Not safe for him to go home, even though his personal prognosis is good and we desperately need his hospital bed for new arrivals.
What feels distinctly different this week is that as more volunteers begin reporting for training and deployment—early-graduated medical students, retired or part-time or private-practice clinicians, some to do direct clinical work, others to offload phone calls and other aspects of social work and public health—the governmental and corporate-sector response seems palpably less worried about the situation on the ground. If you have enough infantry, you can countenance a good deal of loss. Operations can continue even if many are out sick.
It seems to me that much of this scarcity could have been mitigated if the inventory of all public and private sector PPE and ventilators had immediately been requisitioned by a federal public health force, to be deployed as needed to areas of crisis around the country. Instead, individual hospitals, cities, and states all remain in protracted and mutually destructive bidding wars that delay even basic protections for hospitals approaching or experiencing crisis. This week, for example, the proposed collaboration between GM and Ventec to make ventilators appears to be stalling because the involved parties cannot agree on a price. Today, somehow, our hospital’s uptown campus got a hundred more ventilators. This is fantastic (though belated, and not nearly as many as we need); at the same time, I know that this same day, downtown and across the river, there are people for whom ventilators are indicated who are going without, and will die. Almost certainly, people I glimpsed at work today were exposed to the virus, and will sicken next week.
If I haven’t already, I will almost certainly either contract COVID-19 or become an asymptomatic carrier of disease to others. Despite my best efforts, I touch and approach too many people and things—carefully and hygienically, but not infallibly. The odds are overwhelmingly in my favor to have a mild case at most. But aggregated across the city and the region, large numbers of health care workers will be severely ill next week because of shortages and shortcuts this past week, and so on and so forth perhaps into summer.
Despite all this, somehow morale is high where I work. I feel overtaken by giddy surges of love and commitment and awe as I gaze around our offices and wards at the nurses, physician assistants, doctors, respiratory therapists, custodians, techs, and transport workers—my fellow infantry. I’m learning names, ashamed that it took me this long. Other colleagues confess to feeling the same, despite years of building sturdy dams separating work from emotion. Of course, the paradox of my growing scope of love and concern—the rising number of people whom I now care about deeply and individually—is that it raises my odds of experiencing a direct blow of grief and mourning.
In the meantime, some of us look forward to reusing the oddball array of helpful and unhelpful-but-striking garments and headgear, sent to us by generous and well-intentioned tailors and construction workers and others, whenever it next becomes feasible to protest the political situation in the streets. Let our weird apparel remain a symbol of “making do” when we should never have had to. For now we are very much at work.