There’s a Sickness Outside

A doctor reflects on how dread and anxiety can become their own pandemic

Nitin Ahuja
Image of COVID-19 virus. Graphic by Bianca Ibarlucea.
Graphic by Bianca Ibarlucea

Soon I’ll start another weeklong rotation as the rounding gastroenterologist at my hospital, where, as expected, cases of COVID-19 are on the rise. Lately my non-medical friends have been offering up their spontaneous thanks for the work that I do, which flatters me, and makes me a little sad, and heightens my sense that I’m walking into a different world—a field of risk. This week, with my usual office hours on hold, I’ve mostly been at home, texting colleagues, reading headlines, and taking account of what gives me comfort and what gives me pause. I derive comfort, for instance, from the idea of ventilators as closed circuits, the infected lungs of a mechanically supported patient sealed off by plastic tubes from the rest of the world. I’m given pause when I remember that the coronavirus is shed in other ways, including the feces that I regularly encounter in procedural settings. Comfort: thermal checks at hospital entrances, and a policy that no employee with a fever will be allowed in. Pause: rapidly depleting stores of respiratory masks, normally discarded and replaced with every encounter, now limited to one per provider every few days.

Sometimes I imagine throwing that mask aside and striding youthfully, heroically, into the fray—entering patients’ rooms like always in my starchy white coat, sorting out the story of their bowel habits, placing my stethoscope ceremonially upon their rumbling abdomens and crackling chests. Against their labored breathing I’d keep mine measured, resigned to illness, the odds decent enough for my eventual recovery. But there’s no real claim to martyrdom in a pandemic, when every victim becomes a vector. So my attention returns to these symbols of leakiness and enclosure, these energized borders at various scales—the sliding glass doors of the intensive care unit, the rooftop helipad and ambulance bay, the bare skin intermittently exposed between my gown and gloves.

Professional dialogue surrounding COVID-19 follows the basic precepts of germ theory, the late–nineteenth-century discovery that a specific pathogen will trigger a specific cascade of physiologic dysfunction. Predictably, microbiology research efforts have focused on reliable testing and treatment for those germs, efforts that rely upon and reinforce a particular understanding of our physical selves: that we are each a closed system facing discrete and measurable external threats, which enter our bodies in defined ways—in the case of respiratory infections, for example, most often via the mouth and nose. Confronted with the challenge of this new pandemic, however, such confidence easily falls away. Instead we fall into older patterns of thinking about illness, in which threat seems to come at us from all sides, in which our physical selves feel dangerously porous to the strange, potent world we inhabit.

This thinking dates back to antiquity and is built on a sense of the body’s inherent and continuous vulnerability to infiltration. In Inescapable Ecologies, the historian Linda Nash refers to these two models as the “modern body” and the “ecological body.” The modern body is the body of the early twentieth century, ascending in parallel with the medical laboratory, where fluid analyses and imaging techniques promote the ideal of complete internal legibility. It is a mechanical body, divided rationally into systems that can be subdivided into component parts, each of which might be studied for isolated pathology. The ecological body, by contrast, is unpredictable and irreducible. It reflects properties of humoral balance, the ancient concept of vital fluids dictating one’s personal temperament, and of environmental balance, health supported or disrupted by subtle changes in weather and landscape. The key distinction between these models is the question of permeability, which is insignificant to the modern body, but foundational to the ecological one. Prior pandemics, from malaria to the Black Death, were explained by the concept of miasma—noxious vapors emanating from some hidden source, sickening whoever had the bad luck of passing through them.

Our early response to the coronavirus pandemic borrows from both ideas of the body. The ubiquitous images in popular media of the SARS-CoV-2 particle—a gray sphere studded with thorny red projections—aim to identify the threat and make it visible, inviting us to remember its basic materiality. And yet we grapple constantly with the pathogen’s elusiveness. These days, to walk into an emergency department, or through a drugstore, or along a narrow city street is to reckon with a sense of dread at the prospect of those barbed particles suspended in the air, or coating the countertops and shelves. It is an old-fashioned dread, miasmatic—the sort we might presume germ theory to have cleanly displaced.

If laboratory methods gave us our modern bodies, the protracted lack of those methods during the COVID-19 crisis has made space again for turning back toward pre-modern sensibilities. Were hospitals and communities suddenly flooded with an infinite supply of rapid viral swabs, or a reliable antibody screen developed, or a vaccine approved for use tomorrow, we would watch the apprehension receding in real-time. Clear lines could be drawn around sick individuals, in turn legitimizing an approach to this sickness as a single disease entity; we could begin to separate the susceptible from the immune. But for now we are forced to scrutinize whatever data we can find to organize this affliction and its various potential courses, from pulmonary to hematologic to gastrointestinal, from mild to moderate to severe.

So far, these data have left ample space for ambiguity. We note differences from one country’s data to the next; certain families appear inordinately devastated while others are spared. What looks like an interplay between virus and personal constitution unravels one disease into many. Each harrowing story of a young, otherwise healthy adult who dies from complicated pneumonia raises the question of what went wrong. Was there an inborn vulnerability that might otherwise have stayed hidden, some deep-seated loophole for the virus to exploit? Against the grain of age-related mortality curves, there runs the still scarier notion that when faced with exposure, some of us might be preconfigured for doom.

The anxiety induced by the pandemic’s hazy boundaries corresponds with an urgency to shore up life’s more recognizable borders. We retreat into our homes, the rooms and corners we know best, and encourage our loved ones to do the same. We take a head count, stock the pantry, and lock the door. Social distancing makes sense on a public health basis—but also on a visceral one. Leaving for work from my apartment building in Philadelphia, I feel a rush of relief upon finding the maintenance man in the elevator spraying disinfectant on all the buttons. To explain to my Hindi-speaking grandmother why her nursing home no longer welcomes visitors, my father keeps it simple: bimari hai bahr—there’s a sickness outside. For a few of my friends, the headache of canceled international travel has rapidly given way to the mere nuisance of shipping delays on their hand soap orders.

Several of the bodies we worry over are concentric, and it is hard to hold them all in mind at once. Nested within the country are states, municipalities, and families, with risk pushing some at every level into a defensive posture. On the internet I, like many, have seen the video of two women fighting over six rolls of toilet paper, scrolled past pictures of a California gun shop with a line stretching around the block. A few days ago our hospital leadership began asking employees via email to give back any protective equipment they might have stowed away in their private possession. As the crisis lingers and sickness closes in, many people are drawing progressively tighter perimeters.

I have fears about how the situation could deteriorate, the worst of which impel me toward the superstitious belief that it is somehow safer to leave them unspoken. What I can say is that I’m afraid this sickness will remain indistinct and pervasive for months, leading to consequences I’d taken for granted were out of bounds, like life support for the oldest or sickest patients being prescriptively withdrawn, or stones being thrown through neighborhood store windows. Presumably either of these eventualities—the foundering of social or ethical norms—could further erode the motivation of healthcare workers to keep working. I’m likewise afraid of the collapse of my own hospital’s departmental divisions, leading to a makeshift critical care unit being staffed by whoever is available to serve. As has happened in Italy, I might no longer be a gastroenterologist, nor perhaps even much of a doctor really, as much as a set of hopefully useful hands.

With these forecasts in mind, I’ve been recalling what I once knew about acute respiratory distress syndrome (ARDS), the life-threatening condition associated with the most severe cases of COVID-19. In it, the virus triggers a robust inflammatory reaction that weakens the lungs’ capillary walls, causing fluid to leak into the millions of microscopic sacs called alveoli where oxygen and carbon dioxide are normally exchanged. Patients with ARDS are usually placed on ventilators—in short supply—that force oxygen past the fluid filling the lungs and into the circulating blood. In patients infected with coronavirus, the need for a ventilator might last for weeks, each mechanical breath trying to keep all those tiny compartments functional and intact, pushing back against the inflammatory tide.

Healthcare providers, as distinct from public health professionals, train to focus on individual patients, looking after one at a time. It’s rare that we have to consider the simultaneous dissolution of other systems—whether supply chains, the social fabric, or our own bodies. Deficiencies in diagnostic certainty and infrastructural support have fostered another kind of leakiness at the bedside, an intensification of medicine’s empathetic foundations—the hunch that soon enough we too will be lying flat on our backs with tubes down our throats. As the air all around us goes foul, which borders matter most? Like many in my field, I’m fortifying barriers between myself and everyone I love, knowing that those barriers might stay up forever, imposing a vast emotional toll, including the horror of dying alone. Unconstrained, this virus keeps flickering into fog; everyday more people get lost in it. How best to hold the line? Is there a line at all?

Nitin Ahuja is an Assistant Professor of Clinical Medicine in the Division of Gastroenterology and Hepatology at the University of Pennsylvania.
Originally published:
March 27, 2020


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