Cause & effect: Not every pandemic needs someone to blame

By Daniela J Lamas

NEW YORK: Three years ago, as I stood at the bedside of my first patient with the coronavirus, I struggled to understand why someone relatively young and healthy had become so sick.

The unknown of the virus was frightening enough — to think that severe illness could strike at random was untenable. Even in my personal protective equipment, I held my breath, suddenly aware of my own vulnerability. The air itself felt dangerous.

A couple of months ago, my father called me to let me know that he had tested positive for the virus. I barely reacted — until I realized that a positive test meant that he would not travel to visit my infant as planned. He had been vaccinated and boosted, so I was not worried about his health, but I was frustrated. Quickly I felt my disappointment turn to judgment. He could have been more careful.

As I reflected on my reaction — and on the shift from the coronavirus as mortal threat to inconvenience — I found myself thinking not just about the early days of the pandemic in the intensive care unit, but also about how this virus has become intertwined with morality.

From the earliest reports, the public conversation has so often assigned blame for the spread of the coronavirus, based on ethnicity or underlying health conditions or political party. It is tempting to believe that health care workers are immune to such reactions.

After all, we care for all patients, regardless of their culpability in their own illnesses. But looking forward to the inevitability of another pandemic, we must acknowledge that when faced with fear and uncertainty, those of us working at the bedsides are not entirely different.

Disease has long been weaponised against those who are perceived as “other.” From the bubonic plague of the 14th century to tuberculosis and H.I.V., the examples echo throughout the history of medicine. When people are frightened, they seek someone to blame, to create a narrative — even if that narrative is false — in which disease is punishment rather than a random unlucky event.

Of course, healthcare workers frequently care for patients who are suffering, either directly or indirectly, as a result of actions they have taken.

We transplant organs for those with liver failure after cirrhosis after years of alcohol abuse, with heart failure after decades of poor diet and little exercise.

So much of what we do in the hospital is about second chances, about care without judgment.

And yet the idea of culpability, whether our patients are blameless in their diseases, is still present. When we see patients with lung cancer, for instance, we mention whether they had a history of cigarette smoking.

The young mother with a lung mass who has never smoked represents a tragedy; an older man who develops cancer after 50 years of smoking elicits a different response.

That’s not to say that the medicine we offer is different, not in any way that’s measurable. But the distinction matters. It affects the way we frame the story, the way we understand the world.

Disease that has no explanation in behavior is terrifying. It is a reminder that no matter what we do, no matter how careful we are, any of us could fall ill and die. It is a reminder that none of us are safe. Which is one reason the coronavirus was so frightening to those of us in health care.

The disease did not just break through the boundaries between doctor and patient, it decimated them. We were all vulnerable. And at first I thought that vulnerability might increase empathy, but then, as time went on, that empathy waned. And we, too, began to find an “us” and a “them.”

It happened first with masks. Patients who did not wear masks were, in some ways, responsible for their own illness. We became even more frustrated, and more comfortable with openly discussing that frustration, when it came to patients who were not vaccinated.

There were health care workers who railed against the idea of offering advanced and scarce resources like a lung bypass or transplantation to unvaccinated patients with life-threatening disease.

Even when there was no question of medical resources, the stigma of the unvaccinated was clearly present in the way we discussed a case. When we talked about patients on rounds, we would mention in the first sentence whether they had been vaccinated.

As in the case of the patient with lung cancer, this knowledge would not affect treatment, but it did change the way we framed the story.

The people in front of us had made a choice, and they were sick and even dying as a result. They were not blameless, and so perhaps they were deserving of less of our sympathy.

This pandemic is waning, but there will be another one. I want to say that we will learn and we will be different, both at the bedside and out in the world. I want to say that we will give grace, that we know how assigning blame only tears us further apart, but then I look at history. I think about our perception of the unvaccinated. I think of the stigma that so many diseases bring with them, how little we want to acknowledge the role of luck and random chance. And I have to wonder: When the next pandemic comes, who will we blame?