The diversity of New York is on full display in its hospital rooms. Some days, I organize my rounds not by where patients are located but by what language they speak: Spanish, Chinese, English, Creole. That way, I can keep the same interpreter on the phone as I make my way from room to room. One in five Americans speaks a language other than English at home; half of New Yorkers do.
One morning, I gown up and step inside a patient’s room, the interpreter on speakerphone in my scrubs pocket. The patient is a deliveryman I admitted earlier that week; his breathing has worsened each day, requiring escalating doses of oxygen via nasal cannula, and now a face mask. I must tell him that, should his breathing worsen further, the next step will be intubation.
I speak carefully, in short paragraphs, pausing to allow the interpreter to translate. The man stares at me from behind his mask, waiting to learn what his future holds. Thirty seconds after I stop talking, as the interpreter completes her translation, his dark eyes widen, and slow recognition spreads across his face.
He asks what intubation entails, and I explain. Again a delay; again the unwelcome news starts to register. He asks how long he’ll remain on the ventilator. We can’t know for sure, I say, but I hope it’s not long. Tears escape his eyes and his breathing quickens. I worry that the conversation itself will tip him into extremis. During the coronavirus pandemic, I’ve avoided entering rooms more than once a day, but today I vow to return.
Outside, I rub foam sanitizer into my hands and remove my face shield. I forget that the interpreter is still on the line.
“Will that be all, doctor?” she says, a minute later, from my pocket.
“Yeah, thank you,” I reply. “That was pretty rough, right?”
“Yes,” she says. “There have been a lot of those conversations lately.”
In New York City, social distancing is working. The virus has claimed at least twelve thousand lives, but single-day deaths have declined steadily since April 7th, when nearly five hundred and sixty people died of covid-19. New cases and hospitalizations have also fallen in recent weeks, even though many hospitals remain nearly full.
But, as this wave of the coronavirus starts to slow, I can’t help but notice that many of the people still getting infected are those who don’t have the luxury of distance—those who, by necessity or by trade, expose themselves and their families to the virus every day. We’re now debating whether it’s safe to reopen the economy, but for essential workers it never closed. Each morning, during the apex of the deadliest pandemic in a century, these men and women have been venturing out into the epicenter of disease, to cook and clean, deliver food and carry mail, drive buses and stock shelves, patrol the streets and tend to the ill. Many have paid with their health—some with their lives.
It’s becoming clear that essential workers experience a disproportionate share of death and disease owing to covid-19. During one week not long ago, I cared for a police officer, a grocery-store clerk, and a bus driver. During another, my clinical service of fifteen patients included three food deliverymen. (The last time I can recall caring for a delivery worker was more than two years ago: his leg was broken after he was hit by an S.U.V. at a busy Manhattan intersection.)
The burden falls unevenly among racial and ethnic groups: in New York City, people of color comprise three-quarters of the city’s essential workers. Three-fifths of cleaning workers are Latino; more than forty per cent of public-transit workers are black. Latinos comprise twenty-nine per cent of the city’s population, but thirty-four per cent of all cases; black people are twenty-two per cent of the population but represent twenty-eight per cent of covid-19 deaths. Many factors contribute. Communities of color have higher rates of poverty, housing instability, and chronic disease. They’re more likely to consist of dense or multigenerational households, in which the virus spreads more easily. These communities have experienced frequent, sometimes egregious, bias from the health-care system, which has engendered lasting mistrust and leads some people to forgo needed care.
In a pandemic, just going to work is risky. “All one has to do is stand on a platform and you’ll see that the trains are filled with black and brown and low-income people going into communities to service those who are able to telecommute,” Eric Adams, Brooklyn’s borough president, recently said. (About a hundred of the city’s public-transit workers have died of covid-19 since the first M.T.A. worker death was reported, on March 26th.) And yet many essential workers have little choice but to stay on the job during the pandemic—either because they can’t afford to take time off or because they’re told that they aren’t allowed to. One study found that fifty-five per cent of retail and food-service workers, many of whom have been declared essential, have no paid sick leave, and fewer than ten per cent of them can take two weeks off—the recommended covid-19 quarantine period.
The basic process by which doctors collect a medical history has not changed in a century. You start with a patient’s “chief complaint”—the primary reason for seeking medical care. You make your way through the “history of present illness,” exploring the onset, pace, character, and severity of symptoms. (When exactly did that cough start? What color is your phlegm? Does your chest hurt more when breathing deeply or walking quickly?) Then you move to preëxisting conditions, medications, and allergies.
Tucked somewhere down below is the social history. At its best, the social history is how we explore who patients are as individuals—how their jobs and hobbies and lives intersect with their current predicaments. It’s meant to illuminate how nonmedical factors may have contributed to illness, but also to give us a more complete understanding of what’s important to the person we’re caring for. For busy doctors, though, it’s often reduced to a few mechanical questions: Do you smoke? Drink alcohol? Do drugs? The entire social history in a doctor’s note might read, “No toxic habits.”
It’s turning out that, in this pandemic, social history is profoundly important. As we learn more about the epidemiology of the virus, I find myself exploring these details with great interest. Where do you live? How many rooms? How many people are in those rooms? Does your work require you to come in close contact with others? The answers reveal how much risk specific households and families are shouldering.
One of the many new faces in my hospital belongs to Khalid Haynes, a softspoken African-American man in his mid-twenties. covid-19 has created administrative demands in addition to clinical ones; Haynes is one of many new patient coördinators who have arrived to keep the hospital running. (Other new hires have been helping to build new I.C.U.s, or transfer patients between facilities.) He began his career as a personal trainer, before starting work as a patient coördinator at an integrative-health clinic. There, he answered phones, greeted patients, and verified insurance; as the coronavirus began to spread across the city, his clinic turned to telemedicine, and he began working remotely. In late March, he received a call from his manager saying that he was being dispatched to the hospital as an essential worker. In his new role, he’d help troubleshoot and distribute iPads to doctors, so that their patients could see their families.