Am I Part of the Cure Or Am I Part of the Disease? Keeping Coronavirus out When a Doctor Comes Home Christian Rose, M.D.

The NEW ENGLAND JOURNAL of MEDICINE

Perspective

Am I Part of the Cure or Am I Part of the Disease? Keeping Coronavirus Out When a Doctor Comes Home Christian Rose, M.D.

Keeping Coronavirus Out When a Doctor Comes Home ast year, after a month of dry cough and since I moved to San Francisco as shortness of breath while walking up the a new doctor a few years ago. In a city with housing costs that sky- L steep steps of Fillmore Street in San Francisco, rocketed with the tech boom, Mary, my mother-in-law and housemate, noticed young professionals like me have had to rethink our definitions of that she was becoming more and “What can Mama do to stay personal space. In our home, we more easily winded. When her safe?” my wife asks, in light of have balanced everyone’s needs symptoms didn’t improve over the the coronavirus cases now crop- well, managing odd hours, gro- next several weeks, her doctors at ping up in San Francisco. There cery shopping, and cooking out of the University of California, San are many things we don’t yet know sync with each other’s schedules. Francisco, ordered a CT scan. They about Covid-19. We do know, how- My friends ask Mary, a history pro- found bronchiolitis obliterans, a ever, that like many viral illnesses, fessor at San Jose State University, chronic, progressive lung condi- it is most deadly to people who are for reading recommendations to tion that leads to gradually wors- elderly, already ill, or immunocom- help them compare the current ening lung disease and respirato- promised. And it is especially dan- rise of nationalism with that of ry collapse. There is no treatment gerous to those with lung condi- the early 20th century, and in turn for this disease, whose natural his- tions, given the predominance of she asks us for Ruth Bader Gins- tory ends in lung transplantation pulmonary complications. I rec- burg memes to show her class. We for patients who are young and ommend the guidelines from the watch Netflix together, on mail- healthy enough to undergo it. Centers for Disease Control and order DVDs, after long days. Mary has spent every day of the Prevention, telling my wife, “She We take long walks in the past year and a half focused on can stay home, cover her coughs, neighborhood, through the San respiratory physiotherapy, prac and practice good hand hygiene.”1 Francisco streets Mary has called ticing breathing techniques that Mary and I discuss the situa- home since childhood, and her ease her symptoms but do little tion in the kitchen of the multi- childhood friends join us along to slow disease progression. generational home we’ve shared the way. She treats each step as

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part of her physiotherapy. It seems is avoid the places where sick care system will face further to make this convalescent period people go. stress, and patient outcomes will that much more bearable for her, There’s only one problem: every suffer. to be able to reexperience her tran- day when I return home from Nevertheless, I see the horror sitions from girlhood to woman- work, I’m coming back from a in my wife’s face whenever I hood, from motherhood to grand- busy emergency department (ED). scratch my nose with the end of motherhood, while maintaining The irony is that despite health my glasses or sneeze into my el- some form of normalcy. Though workers’ being “the glue that holds bow. It’s as though she’s hearing the stairs up to the poetry section the health system and outbreak the police tell her that “The call at City Lights have gotten harder response together,” per Tedros is coming from inside the house!” to climb, at least Ginsberg and Ghebreyesus, director-general of The virus’s threat is as ominous Kerouac are still there when she the WHO, 41% of the Covid-19 as a gun’s — both far more dan- arrives. cases in Wuhan resulted from hos- gerous to you when they live in But now that coronavirus has pital-related transmission.2 Health your home than when wielded by crept into San Francisco like Karl care providers are at increased an invader. Yet the wounds these the Fog, visiting a bookstore can risk for developing the condition pathogens inflict and the diseases feel like a risk. Is it worth it? Mary and spreading it.3 Work stress is they spread are what my colleagues wonders before stepping out the believed to weaken their immune and I have devoted our lives to door. What if someone at Cal-Mart has systems, and close, intimate care treating. Are we being irrespon- it? Has my student who was coughing of patients can lead to exposure sible to our families and friends in the back row been traveling? “I’ll to a higher viral load. Despite by going out to dinner, by hugging need to cancel my trip to Berlin,” performing selfless work on be- or kissing them good night? she says, imagining the recircu- half of their communities, health Mary and I talked about what lated airplane air and the crowds care workers have faced social it would mean if she were to be- moving through travel hubs and stigma during this outbreak. come infected. Breathing might be responding to evolving travel re- As a colleague and I go through as difficult as marching up Mount strictions. Travel — especially to the 17 steps for donning personal Everest without an oxygen tank. that once-war-torn city with its protective equipment and the sub- She might cough so much that famous wall meant as a form of sequent 11 steps for safely doffing her chest would feel like she had barrier protection from the infec- it in the back corner of the ED, just ducked out of the ring with tious spread of capitalism — is Coldplay’s “Clocks” comes through Muhammad Ali. She might need one of Mary’s passions. on my overnight playlist: Am I a to be hospitalized. Her lung re- She is undeterred, however, part of the cure, or am I part of the dis- serve is so low that she would since she has some control over ease? We wonder whether our com- most likely wind up on a mechan- these risks, and she vows to keep mitment to our community puts ical respirator in an intensive care living her life and being involved our families at risk at home. But unit, probably on the 13th floor in her community, if even re- who would manage the triage at UCSF, where I trained several motely, until she’s told she can’t. tents, resuscitate the respiratory years ago. Perhaps the team would The only restriction she is sure failures, and manage the inten- attempt extracorporeal membrane that she’ll avoid, at all costs, is sive care units if health care pro- oxygenation (ECMO), hoping that visiting the hospital, where virus- fessionals steered clear? Who more time would be the answer. es jump around waiting rooms would study the disease spread, It is not unlikely that she would and hide in white coats and Half investigate novel therapies, devel- die, that this invisible invader, this Windsors. “We’ve always said the op the disaster plans, or manage microscopic enemy would be the real point of entry for coronavirus all the other health issues that end of her story. All this just be- is a busy emergency room,” noted continue to occur without regard cause I came home. Mike Ryan of the World Health for the virus? If some physicians I stand in the ambulance bay Organization’s Health Emergen- or nurses or physician assistants outside the hospital at 6 a.m. and cies Program. All Mary has to do stop coming to work, the health begin to call friends from resi-

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dency. I’m looking for a room responsibility to our families — 1. Coronavirus disease 2019 (COVID-19): prevention & treatment. Atlanta: Centers for where I can stay: last night, I was a no man’s land where a col- Disease Control and Prevention, 2020 (https:// exposed to a patient with possible league’s spare bed may be the www.cdc .gov/ coronavirus/ 2019 - ncov/ about/ Covid-19 who needed intubation. closest approximation of home that prevention- treatment .html). 2. Wu Z, McGoogan JM. Characteristics of The music still plays in my head: we can find. and important lessons from the coronavirus Home, home, where I wanted to go. Disclosure forms provided by the author disease 2019 (COVID-19) outbreak in China: “I have space at my apartment, are available at NEJM.org. summary of a report of 72 314 cases from the Chinese Center for Disease Control and and if you’re exposed, I guess I Prevention. JAMA 2020 February 24 (Epub am, too,” Sam, my fellow over- From the Center for Health Policy, Freeman ahead of print). Spogli Institute for International Studies, night doc, says as she walks 3. Chang D, Xu H, Rebaza A, Sharma L, and the Center for Primary Care and Out- Dela Cruz CS. Protecting health-care work- through the sliding doors behind comes Research, School of Medicine — ers from subclinical coronavirus infection. me. Times like this can leave phy- both at Stanford University, Stanford, CA. Lancet Respir Med 2020;8(3):e13.

sicians stranded between our com- This article was published on March 18, DOI: 10.1056/NEJMp2004768

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