key: cord-0841961-y9gwxecw
authors: Minkoff, Howard
title: Life in Epidemics: Infections Change, Front-Line Docs Remain the Same
date: 2020-04-24
journal: Obstet Gynecol
DOI: 10.1097/aog.0000000000003927
sha: a2adfd3f9728ffd1c970c5bc486e331eccb5a79c
doc_id: 841961
cord_uid: y9gwxecw

Physicians working in the era of coronavirus 2019 (COVID-19) have proven as heroic as those who faced acquired immunodeficiency syndrome (AIDS) a generation ago.

M y career has been bookended by two epidemics.

I was a Fellow in maternal-fetal medicine when acquired immunodeficiency syndrome (AIDS) was first reported. Because of my academic interest in infectious diseases, and because I was training in a community that quickly became endemic for women with human immunodeficiency virus (HIV) infection, I was invited to participate on local and national guideline committees. I co-chaired the Public Health Service committee that made azidothymidine, or AZT, the first standard in the United States for prevention of mother-to-child transmission of HIV infection, chaired the American College of Obstetricians' Committee on HIV, and served for many years on the U.S. Public Health Service panel that authored guidelines for the care of women with HIV infection. Now, at the tail end of my career (having recently announced that I will be retiring as chair of obstetrics at two hospitals), I find myself once again in a community at the center of an epidemic. Having lived through HIV and coronavirus disease 2019 (COVID-19), I believe that the similarities are greater than their obvious biologic and social differences.

Perhaps the starkest difference is in the nation's attitude toward women with infection. In the 1980s, if they were thought of at all, women with HIV infection were thought of merely as vectors, people who transmitted a lethal disease to "innocent" children. They were poor and minority and largely disposable. Pres-ident Reagan wouldn't say the word "AIDS" for a number of years, and only after thousands of deaths. 1 People felt immunized against HIV by their race and their income. AIDS was a disease of "them"; COVID-19 is a disease of "us."

But the epidemics were not totally sui generis. Like COVID-19, AIDS also snuck up on the nation, with the first reports of a handful of cases of Pneumocystis carinii pneumonia in June of 1981 hardly recognized as harbingers of the disastrous decade that loomed thereafter. Coronavirus disease 2019 went from a localized outbreak in a faraway province to the nation's first epidemic-based national emergency in just a matter of months. The manner in which the epidemics changed people's lifestyles trace similar temporal arcs.

In both epidemics, there were medical heroes, some of whom would not have been expected to play that role. First among those in the AIDS era was C. Everett Koop, the Surgeon General appointed by Mr. Reagan. His pre-AIDS reputation was based on his stalwart anti-abortion views and didn't augur well for those looking to him for leadership. Ultimately, his oath as a physician superseded his political views, and he became the inspirational public health voice, articulating the urgency of the moment. At one taskforce he hosted, I remember him saying that he didn't have executive, legislative, or judicial power. All he had was the power of moral suasion. But in his hands, that proved a powerful weapon. Admiral James Watkins, who chaired the first Presidential AIDS Commission, similarly subsumed political considerations in the face of the overwhelming evidence that witnesses brought before his committee. 2 Some of the proffered testimony was impressive in its detail and breadth, painting a statistically unimpeachable record of national suffering. Some of the most compelling testimony came from the clinicians. Testifying just before me at one session was Margaret Haggerty, a pediatrician from New York City who ended her testimony with these words, "So you see, I felt I had to use the short time to see if I could get you, with your power and influence, to worry about them and to love them with us. For on Monday evening as the child died, all of us on the 17th floor of the Harlem Hospital felt alone and lost. I ask you to join us in our concern for these the least of us."

Others figures from that era, such as Anthony Fauci and Robert Redfield, early leaders in the fight against AIDS, are now leading the battle against COVID-19. Having seen them at work a generation ago, I am confident that, if they are unfettered, the nation will have skilled experts at the helm. The fact that their expertise, which was earned at a tremendous national and personal cost, is now informing policies, is reassuring and highlights for me what is the key similarity between these two epidemics: the people on the front lines.

I have heard older physicians (ie, Gen Xers and above) lament the entitled, narcissistic, and self-absorbed behaviors of the millennial physician-a canard similar to those that every generation of physician has lobbed against their successors. But I have now seen this younger generation in action, taking on risks that they could honestly say they had not signed up for. And every day, just like their colleagues of yore, they remember their oath, don their protective gear (or ersatz version thereof), and face whatever risks they must in order to serve their communities. There is a Twitter joke making the rounds, designed to encourage people to stay sheltered at home: "Would you want to be intubated by a gynecologist?" Admittedly that is not a reassuring prospect. Yet, those young obstetrician-gynecologists, with minimal relevant training and understandable fears about what they may bring home to their loved ones, are volunteering to put themselves in harm's way, because that is what it means to be a physician.

Years ago, I had the opportunity to serve on panels that crafted HIV-AIDS policies for my city, state, and nation, and I recognize the value in that service. However, what meant much more to me was what James Lee, a member of the President's AIDS Commission, who went on to be the physician to the President, said after he heard the testimony of four of us before the Commission. He called us, "people who are as deep in the trenches as anybody I know in my medical career." For the frontline doc, those words are dear. The true measure of our contribution will always be how we care for patients. As Camus wrote in The Plague, "I have no idea what's awaiting me, or what will happen when this all ends. For the moment I know this: there are sick people and they need curing." 3 At the height of the AIDS panic among health care professionals, the bioethicist John D. Arras wrote that, if physicians stood by their oath and rendered care to the ill regardless of the risk entailed, those physicians could, "proceed to tell a story, to relate a history, of a profession that has incorporated a willingness to take risks for the benefit of patients as a constitutive element in physicians' self-understanding.According to this story, physicians, if queried about their commitment to accept risk in the line of duty, would simply respond, "This is who we are; this is what we do." 4, 5 At that time, Arras lamented that such a selfless reply was not yet widespread, that is, this was a story not yet told. Now, in the time of the COVID-19 panic, I see young docs taking supererogatory risks, and animating that story, day in and day out. So while I sense the fear lurking beneath their masks, I know my colleagues are not focusing on the challenges they face and bemoaning the shortages of personal protective equipment or the ineptitude of some politicians. Instead, they are people like Dr. Li Wenliang, a Chinese physician who was admonished by his government for warning the world about a severe acute respiratory syndrome-like illness in December 2019 and who returned to serve his patients before losing his life to COVID-19, 6 and they are the physicians, nurses, midwifes, and other frontline health care professionals who have assumed their assigned roles in hospitals and health centers or who have volunteered for service in medical ground zeros the emergency departments and intensive care units in endemic communities. They have become that story of altruism that Arras had imagined.

Ronald Reagan and AIDS: correcting the record

Presidential Commission on the Human Immunodeficiency Virus Epidemic. The Presidential Commission on the Human Immunodeficiency Virus Epidemic report

The plague