To be worried sick

To be worried sick

ALL IN THE MIND Treating infectious diseases is dangerous. But irrational
feat of them is a bigger threat, contends Abraham Varghese

Observing my patient through the chicken wire, I saw that the front half of his scalp was shaved - and the long gray hairs behind that equator were

gathered in a “kudumi,” or knot. He was a temple priest. All these years later, I can still see that tuft and the three broad white stripes of “vibhuti,” or holy ash, smeared across his forehead, proclaiming his Shaivite faith, a reminder that the world was all “maya” - illusion. But his discomfort was real. In my recollection, he sits cross-legged on his mat in that locked room, groaning, restless, his trunk swaying, his features anxious, grimacing as if he’d

tasted something bitter.
It was just me and the seasoned orderly who ran the ward. All that chaos and
cacophony of a hospital was mysteriously kept at bay; even the crows didn’t venture close. The orderly assured me that this was classic rabies: The patient had asked for his cup and plate to be removed from his room. He had symptoms of hydro-
phobia - the sight of water, the thought of swallowing, caused excruciating throat spasms.

The rabies ward was effectively a jail. As I walked through the maze of corridors, I was frightened. What, I wondered, if my patient was foaming at the mouth? What if he attacked or bit me in the “furious” stage? This was 1980, before the era of Hazmat suits and the like. At best, had I been thinking ahead, I might have brought gloves.

But then, strangely, in the presence of a human being in distress, all those fears vanished. Inside the room I found a patient as upset by his confinement as by his
symptoms. “I just came for some help. Why did they bring me here?” Did he
want something to drink, I asked. He waved away that idea quickly. He was
spitting, drooling, too scared to try

swallowing his own saliva.
I can’t recall what it was I injected.

Thorazine, I am guessing. Or was it
Valium? Those were the two palliatives we cycled between most frequently. (Rabies is typically fatal once the virus takes hold.)  Squatting by his mat, I was ashamed of my earlier fear and hesitation. I was glad to spend some time with him. By the next morning he was comatose and convulsing.

By nightfall, he’d transcended the mortal world.
In hindsight, I realise that contagion was all around me that year. Just living in the third-floor house-officers’ quarters above the hospital presented risks; that part of town was endemic for filariasis

and malaria, and I’d contracted both.
Tuberculosis was a possible diagnosis in every patient with a cough. A fellow
medical student and I scoured the

respiratory wards after hours, applying our stethoscope to so many wicker-basket chests, trying to sharpen our skills, seeking out “cavernous” or “amphoric” breathing. (Imagine someone blowing over the mouth of a large flask.)

To hear that was to strike diagnostic gold: It spoke of a cavity in the lung caused by tuberculosis. We must have theoretically understood that such cavities were highly infectious,

teeming with millions of tuberculosis
bacteria so that every cough was laden with them, but I don’t recall worrying about it. I knew of several doctors who contracted hepatitis B through a needle stick. A rash you touched might be highly infectious - secondary syphilis or a case of scabies. Why had I been so fearful of

rabies, given all the other diseases that lurked close at hand?
A couple of years later, in July 1983, I was pursuing specialty training in

infectious diseases at Boston City Hospital, and I saw a patient with a new syndrome called AIDS. The cause was unknown. I was scared and, yes, excited as I was, at the front line. My fear was superseded by an impulse to take on a disease that others were happy to sidestep.

The fact that AIDS first manifested in intravenous-drug users, gay men and blood-transfusion recipients suggested it spread very much like
hepatitis B: through blood and body fluids, not casual contact. Nevertheless, many medical professionals in those early years, even the occasional senior physician,
covered up with masks, gowns and gloves. I tried to set an example, feeling for lymph nodes in sweaty armpits with my bare

fingers, just as I might with any other
patient. Still, I wondered if my newfound zeal in caring for patients who were
ostracised might be foolhardy, putting

me at risk. I would come to know two
physicians and a nurse who contracted HIV after exposure to infected blood.
Now we are faced with Ebola, and once again the impulse to shun the disease and the impulse to help its victims arise

together. I have the urge to sign up, to head to Liberia or Sierra Leone; the call for doctors seems personally addressed to me. When I tell my mother, who is in her 90s, that I am thinking of volunteering in West Africa, she clutches my hand and says: “Oh, no, no, no. Don’t go!” I’m

secretly pleased. Perhaps I want her to forbid me to go. In the evenings when I visit my parents, we watch the news as the

Ebola story sputters, catches fire, sputters ... and then it lands on our shores, in Dallas! And a doctor who served, stirred by the same impulse brewing in me, returns to New York infected with the virus. “See?” the devil on my left shoulder says. “You don’t have to go anywhere. It’ll come to you.” I am disturbed. Sleepless. Bothered.

Have I lost my altruistic impulses, or is it that naive innocence has been supplanted by wise caution?

We doctors feel the pull. But each of us has reasons to stay back, reasons that get bigger as we age: children, partners,

parents, grants. The yellow medical
armour may not suffice, even when donned on our shores in the best facilities. And the possibility now exists of

quarantine when we return - no “Welcome back, our hero” signs at the airport, but straight to house arrest. Employers are gently pointing out that if we choose to volunteer, that is admirable, but we’re

effectively on our own, not covered by our health insurance. If we fall sick in Africa, there is no guarantee of being evacuated, no promise that even our bodies would be flown back. I fear that volunteers who get any fever out there will be quarantined with others who might be infected, waiting on the test. And if it is Ebola, they will be moved to the infected tent - no ICU, just confinement. From there, who knows.

The impulse to serve must now compete with the public perception of recklessness and irresponsibility. 

Diseases are now global almost as soon as they are local, and efforts to control the disease must be global, too. That effort puts medical personnel at risk for dying and, yes, possibly even spreading the thing they set out to conquer. But Ebola would have come to our shores anyway.

The world is listing, gently, toward where you sit - privileged, at least for now, to read these words in peace with your morning coffee and bagel.
NYT

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