There Is No Outside

The emergency room is a smog of coronavirus—and how could it not be? A person on a bed deprived of even the modesty of a curtain can’t be expected to keep a mask on for the eight or twelve hours they may be waiting there, before anyone comes to examine them. Those who end up waiting longer, as so many do, may get upgraded to a spot near the wall, which helps create the illusion of being in a room. One wall, after all, is one more than zero. This is how poor folks experience our health care system.

Health workers can respond to this crisis by taking up working-class struggles as our own

Image via Flickr.

I work at a New York safety-net health system that serves poor folks who are mostly Black and brown. The primary-care clinic where I am a resident closed two weeks ago: like most major hospital systems throughout the US, the hospital has put a stop to all non-acute care, aside from telemedicine. Most of the primary-care doctors and other subspecialists who’d normally see patients for routine checkups have been drafted onto the frontlines, into the emergency rooms and hospital corridors of what professionals call “the inpatient setting.”

Until recently I was at home as a back-up, waiting to fill in when other residents got too sick to work. While I waited, numerous friends checked in on me—some of them even sent me masks in the mail. A number of those masks, like the ones solicited by my brother and gathered from his friends, are real N95 respirators. They’ll do some good for me and my fellow emergency room workers as our system continues to fail us and our patients. My sister made cloth masks, and those I hope never to need.

There is little certainty about how things will look inside the emergency room by mid-April, when mortality is projected to peak—much less in a month’s time. My hospital recently started giving out new N95s every day, but by no means is that the norm: nurses at Harlem Hospital recently protested a policy requiring them to use a single mask for five twelve-hour shifts. Without sweeping federal, state, and local protections, any level of sustained protection is tenuous and subject to the whims of administrators and a corrupt and broken supply chain. Never mind that there is simply much we don’t know, like how the seasonal variation seen in other coronaviruses will play out in this case. This moment of crisis is also a moment of extreme uncertainty.

The stereotype about those of us in internal medicine is that we are overly scrupulous. It’s not unfounded. The time to think about a single patient and reflect on their condition always feels like a luxury for me, but it’s an important luxury all the same. Which is to say that the emergency room is not a place where I’m very comfortable. I’d been assigned to be in the emergency department (the ED) at this time since the beginning of the year and showed up last Monday at 7 AM after taking twenty-four hours to recover from weekend night coverage at a different hospital in the same system. The ER is chaotic on a normal day. The last time I entered, a few months ago, it was near capacity, with all of the “chair beds” full of the less urgently sick people, many of them chatting on the phone while waiting to be seen. Those kinds of patients are now being seen in a tent outside. The folks in the actual ER don’t all need supplemental oxygen, but all of them look miserable. I noted “lethargy” in the documentation for every single patient I saw during my first night shift last week.

The emergency room is a smog of coronavirus—and how could it not be? A person on a bed deprived of even the modesty of a curtain can’t be expected to keep a mask on for the eight or twelve hours they may be waiting there, before anyone comes to examine them. Those who end up waiting longer, as so many do, may get upgraded to a spot near the wall, which helps create the illusion of being in a room. One wall, after all, is one more than zero. This is how poor folks experience our health care system.

On my second day in the ED, I saw a nursing assistant gently scold an older patient for having his mask under his chin. She fixed it for him, but less than an hour later I heard his terrible cough disturbing his half-sleep. His sheets were askew, and his mask was off. Intubation—the process of putting a tube in a person’s airway for attachment to a breathing machine—generates small particles that may stay airborne for a few hours before settling onto surfaces. People get intubated in the ED and in other hospital wards multiple times per day, hence the increased demand for—and shortage of—N95 masks. The mask protects from airborne infection if it’s been fitted perfectly, and if the mask is not contaminated. If you are waiting in line to perform chest compressions on someone being intubated, like I was recently, it’s hard to imagine being clean afterwards. You could take a shower and find yourself an entirely new outfit, or wear some kind of hazmat suit. It is self-evident that none of these is anything close to an option for most health workers right now.

I’m writing this from home, because a few days into my work at the ED I developed upper respiratory symptoms. This wasn’t a surprise. Despite modest improvements in PPE availability over the past couple weeks, it’s likely that I’ve contracted the virus, as have so many other health workers. Though I spent my days in the ED swabbing others for the virus and will soon resume this work, I couldn’t get tested there myself. For that I had to travel forty minutes on the subway to another site, putting myself and other commuters at risk. But even that seems better than the ever-worsening status quo: a shortage of viral media containers is putting a stop to worker testing. In any case, broad testing with epidemiology to guide quarantine is no longer an available public-health intervention at this point, though we still need broad testing and the roll-out of a serology test (blood tests to look for immunity, rather than the nasal test to look for the virus) to guide us in the coming months. The test itself has significantly reduced clinical usefulness right now. It’s obvious to anyone in any hospital in New York that all of us are just walking through the smog. There is no outside.

It would be foolish to claim that I don’t feel dread about what is happening—about what I’ve seen and what I’ll be a part of again in a few days’ time. We all feel that dread. Like everyone else, I have friends and family I’m concerned about. My partner is a health worker like myself. He’s also an immigrant without family nearby. A few weeks ago we introduced each other to our siblings over email, just in case.

Still, despite the ever-growing number of nurses, residents, and other young health workers succumbing to this virus, I am not inclined to lean into dread. I’m trying to focus on the meaning of this terrible moment, and the chain of dysfunctions that has already caused so many so much harm. The shortages, the inefficiencies, the discomforts—all of these aren’t mere inconveniences to be dealt with, or temporary problems to be overcome. Our health system is broken. It has been broken for a long time and has been deteriorating steadily, somehow under the radar, even as it put increasing strain and burdens on the many lives it didn’t simply ruin outright. You don’t have to spend any time inside an emergency room to understand the single most consequential fact about our health system: it is built on a foundation of denying care. This is how the poor have experienced our health care system, and now that experience is—rightly but belatedly—attracting international attention. The pandemic is a moment for health workers to reflect on our own work and our own position in that same system. We must think about our sick and dying patients and appreciate how the nature of our work ties our struggles to those of the poor and the dispossessed.

We are losing colleagues just as we continue to lose the uninsured and the homeless. Health workers were already stretched thin, yet we shoulder most of the burden of the relief effort. Before the pandemic began, the New York nurses’ union and a coalition of community organizations were fighting a hospital closure in the Bronx, and some of the other residents and I had just started trying to think about ways to support their campaign. But the onset of the crisis has shifted everyone’s priorities. Where we saw the acceleration of hospital closures as a central front of the war on poor people, under the new dispensation no threat is greater than the pandemic itself. Joel Freedman, the owner of the empty building that used to be Philadelphia’s Hahnemann University Hospital, refused to reopen it in response to this crisis. Freedman is evil, but the pandemic shows us that even this extreme form of depravity is just a step or two removed from how things work. It is just one way that the ruling class expropriates the rest of society.

My understanding of my place in this oppressive system has been shaped by my work with Put People First! PA, a human-rights organization made up of working-class people building power to win universal health care. I began working with PPF-PA before starting medical school in Pennsylvania, and since I moved to New York my comrades and I have tried to bring the spirit and the strategy of the Poor People’s Campaign to health workers. I’m just one of many health workers who have been a part of the organization for many years, and the clarity of this moment has brought us all closer together. Working-class leaders throughout Pennsylvania connected by PPF-PA and other PPC organizations in the state share bonds of deep trust and commitment across lines of division. We regularly do collective work on teams including neighbors and people throughout the state, something often neglected by advocacy organizations with more paid staff, and this why we thrive even when limited to digital tactics. Soon after the crisis began to take shape, the members of PPF-PA wrote a list of demands.1 We want the reopening of closed hospitals, delivery of food to people in quarantine, handwashing stations for homeless residents, and much more. All this organizing work—over the past few years and especially over the past few weeks—has prepared my comrades and me for this situation. We understand this moment because it is the awful but logical consequence of an unsustainable and inequitable system.

In moments of crisis, we find each other and catch others who are falling. The pandemic has strengthened those of us who already believed the status quo was untenable and that our basic needs must be enshrined as human rights. Advocacy organizations who were fighting for crumbs may have a harder time responding to this moment, but organizations of those who could barely survive under “normal” circumstances are growing and flourishing. Groups like the National Union of the Homeless are a model and an inspiration in these times. If the current moratoriums on eviction in New York City and elsewhere are not prolonged and the number of people who are homeless increases further, as Rev. Dr. Liz Theoharis predicts, homeless mothers will be teaching more and more people about the reclamation of abandoned homes and other righteous survival tactics.2

In my very particular context, it hasn’t always been easy to channel the spirit of the Poor People’s Campaign to organizing health workers—partly because good organizing takes more time and experience than I have had, and partly—crucially—because medicine usually ignores, reassures, and manages the language of the oppressed into silence. Gliding past people’s individual needs and their desperation is the mandate of a profit-driven health system. The direness of this situation will bring patients and health workers together almost by default, but the other thing that can unite working-class people is clarity about our shared conditions.

Health workers aren’t just working even longer hours and putting ourselves in danger. We are also at the heart of enormous grassroots campaigns to gather the PPE that our system failed to provide. All this, and hundreds of thousands of people may still die as result of our poor preparation. The fight for fair working conditions, safe staffing, and dignity for health workers has never been more clearly tied to the fight for all of our basic needs and, by extension, the fight for a more just and habitable planet. Now is a time for health workers to recommit to the real heroes—the people and the organizations leading these movements—not to cling even more tightly to a narrow conception of what we think is winnable.

If cloth masks like the kind my sister made me get any use, I hope it’s as an emblem for a mass movement in which the nurses, doctors, and environmental workers finally align on the side of the poor. There have been medical students and others saying things like “this is what I went into medicine for,” clamoring and war-ready like the invincible students in A Separate Peace. If war imagery is to be unavoidable in this moment, let’s instead glorify the working class, cloth-masked and garbage-bagged health workers, too. Let’s exalt all of the poor and dispossessed warriors organizing for freedom on the frontlines of this man-made disaster.

  1. https://www.putpeoplefirstpa.org/coronavirus/ 

  2. The National Union of the Homeless and PPF-PA unite with many other organizations under the banner of the the Poor People’s Campaign: A National Call for Moral Revival. It is the rebirth of the original Poor People’s Campaign called for by Martin Luther King, Jr. when he began to speak out against the war in Vietnam and economic injustice, transitioning from a framework of civil rights to human rights. This is the vision that can unite many different parts of the working class. It brings health workers together with homeless folks as movement siblings, rather than as victim and savior. 

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