My body lurched and pressed against the young male doctor in training next to me, an overly intimate touch given the two of us had just met. Cars zig-zagged with rickshaws, multi-membered families on motorcycles – most without helmets – horse drawn carts and pedestrians outside the window. Our driver muttered in Tamil and added to the chorus of soft but incessant beeping emanating from the street’s many vehicles.
“You see,” my soft-spoken host explained, breaking the awkwardness between us, “Here in India, we do not have, as you in America call, a lane system.”
Over the coming months, I volunteered as a medical student in the emergency department at one of southern India’s largest hospitals. Daily, we treated victims of road traffic accidents, many with head injuries. Each one made me wonder if a lane system would have made a difference.
Besides accident victims, I saw other familiar patients: individuals with cardiac emergencies, strokes, alcohol withdrawal. I also saw an average of 3 patients per week with paralysis and bleeding from snake bites, a manifestation of both the tropical climate and the lack of an Emergency Response System able to deliver timely anti-venom.
In the afternoons, I conducted research in the basement of the medical records department amongst stacks of charts so laden with moisture that they disintegrated at the touch.
One night, I awoke coughing, the sensation of air moving in and out of my chest — an effort usually unnoticed and unappreciated.
“That’s weird,” I thought, rolling over and trying to fall back to sleep, a testament to the invincibility that comes with being twenty-five years old.
“Sounds like asthma,” my friend said the next morning over our breakfast of parathas and curry. I didn’t have asthma, but the tiny aerosolized particles from the charts triggered wheezing all the same.
That afternoon, I joined a pack of fellow medical students on a field trip to the pharmacy in search of an inhaler. Many medications didn’t require a prescription in India and so we routinely pooled our collective rudimentary knowledge and picked through pharmaceutical offerings to treat our various rashes and gastrointestinal symptoms.
“Hey guys, what generation Cephalosporin do you think this is?” another student asked the group.
“I don’t know how to use this,” I admitted holding up my purchase, despite my three and a half years of medical school.
“Here, you need to shake it first,” my friend explained. I practiced, a skill I would demonstrate countless times to families in the years to come.
Walking back to the bus, young men called out to our conspicuous group of foreigners, friendly and beckoning for money, some with hands missing fingers. On the corner, we spotted an older man with skin changes from leprosy, a disease we had only previously read about in medical texts. Middle-aged women adorned with jasmine deftly weaved through the crowded streets with one arm holding heavy parcels securely to their heads; the sweat marking their stiff silk saris the only indication of toil.
One day, I placed my hands on a patient’s neck and felt a rock hard collar of lymph nodes. He had come in after a road traffic accident for a shoulder x-ray.
“Do you…?” I stopped myself. Even in all my naiveté, I knew it was ridiculous to ask if he had noticed his neck had swollen to twice its usual circumference.
He explained oncology care was prohibitively expensive to pursue. He went home with his arm in a sling.
I thought to myself: people wear the hardness of the world so close to the surface here. The difficult circumstances manifest directly in illness. They’re not separate from their environment.
Two years later, in 2009, now a seasoned intern in the public hospital of San Francisco, my classical medical school training took a backseat to my trial-by-fire education on the social safety net.
The knowledge that kept me above water was not which medications were most efficacious in studies, but which would be covered by public insurance. We were lucky; San Francisco had recently enacted Healthy San Francisco, which enabled all residents of the city health coverage while within city limits. When my husband did a stint as a moonlighter across the Bay Bridge, he started each shift by loading up the Walgreens’ 4 dollar medication list – the only veritable option for the uninsured. I learned with precision the criteria for placement at Laguna Honda, the city’s public long term care facility. This, I learned, was often the most effective way to reduce readmissions for patients who spent more time on our hospital service than in their homes.
Our patients had various end-stage organ failures, complex psychiatric disease and substance use disorders. But if I looked just past the neat and tidy scrawl of my three-page history and physical forms, like looking through the Magic Eye drawings of my childhood, I saw the beating drum of poverty, trauma and racism every time.
In America, we are not separate from our environment either.
Now, over a decade later, I see patients in a gateway community outside of Boston. My patient panel is made up of waves of people who have come to the United States seeking refuge and a better future: elderly Italians who emigrated in the mid-1900s, Vietnamese who came after the war, recently arrived Latin Americans, Brazilians and Africans. Many live in multi-family units; their descendents filling the other floors and our waiting room.
“Gateway community” is code for many things. Currently it is code for “high Covid-19 transmission rates.”
Through my PPE, I talk with Tyler and his Mom, Bea, during Tyler’s eight year old well child check. Despite 70% of Massachusetts schools offering in-person learning, Tyler, like the majority of students of low-income school districts, has been strictly remote since March. “It’s alright,” he says. “But I like going to school better.” His mother shares the family lost one grandmother to COVID and the other is now recovering in a skilled nursing facility after a prolonged COVID hospitalization.
Tyler’s weight for height measurement, which met criteria for pediatric oObesity last year, has increased. His blood pressure is borderline. The family is trying to make changes, but Tyler has very little opportunity for physical activity. After remote school, Tyler sits in the backseat as his Dad makes Amazon runs to try to patch the family’s finances, which have become rockier after he was furloughed from his job.
After the visit, Bea catches me by the arm. “Can we talk in private?” she asks. She is my patient also.
She is struggling. Bea’s job as a nursing assistant puts her at high COVID exposure risk. Everyone at work is stressed. She is worried about her family, about everything.
“I’ve been taking pills to take the edge off,” she says. “Percocets. I stopped a couple days ago. I’m so ashamed. But now I feel terrible – shaky and dizzy.”
I search my tools: I increase her antidepressant dose, connect her to my recovery nurse and start Suboxone, a life-saving medication proven to decrease risk of overdose and relapse for patients struggling with opioid use.
I think, as I often do, how, as a doctor, I frequently diagnose and label, sometimes manage and mitigate, and rarely cure, particularly our chronic diseases, which are all diseases of our environment.
During the coronavirus pandemic, the discourse has focused on a binary choice: the economy or health. Open up or lock down. But Covid shows us that the economy is health, and it has been all along. Risk of Covid and the economic consequences of the crisis can be mapped right onto our unequal society.
In India, I saw a lack of infrastructure – no lanes. In America, I see our infrastructure seized, carved up and unequally distributed.
America has a lane system and it’s working exactly as it was designed.
We’re not separate from our environment, nor our environment’s history. Our deepest transgressions — slavery, state-sanctioned discrimination — continue to be passed down through our policies and our DNA, which is changed by the trauma it absorbs.
Increasingly, we see our sickness is from our environment. We are sicker because our environment is sicker. COVID-19 is just a focusing event that – in its acuity – allows us to see it.
One way to quantify our sick environment is through the Social Progress Index, a measure of a country’s social and environmental health. In 2020, the United States dropped precipitously in rank from number 19 to number 28, the most significant drop of any country in the world.
We’re not separate from our environment. Our five senses are designed to receive it. We taste food grown in its soil and raised on its farms. We breathe its air.
COVID-19 belies the truth we have avoided: try as we might, the air — and the environment — cannot definitively be seized and carved up. It connects us all. Even the bubbles created by the best-resourced among us to shield us from COVID — places like the White House and the NBA — are penetrable. And life in a bubble, it turns out, is barely a life at all.
Our environment shapes our health.
But we shape our environment.
When will we decide to harness our collective power and heal our environment?
Profits – we think about them as what gets paid for — are really about what doesn’t get covered. They run like a razor blade through healthcare, carving out what we do and what we don’t.
No one benefits from creating an environment to keep people — all people — healthy.
Except here’s the thing Covid can teach us if we are willing to see it: it turns out, we all do.
Sarah Matathia, MD, MPH, is a family practitioner at Massachusetts General Hospital.