Humanities in the Emergency Room

While New York City was the epicenter of the ongoing global Covid-19 pandemic,

Rishi Goyal served as Attending Physician in the Emergency Department at Columbia University Medical Center. Every day, he and his colleagues tended to and cared for patients struck down by this incurable illness as mortalities throughout the city, and throughout the United States, overwhelmed and exposed systems of medical care in America.

At the same time, Goyal is a PhD in English and Comparative Literature, Director of the Medicine, Literature and Society Major in the Institute for Comparative Literature and Society at Columbia University, and a coordinator of CHCI’s Health and Medical Humanities Network. That is to say, these sometimes seemingly unbridgeable continents of knowledge—the humanities and the natural sciences—find a meeting point in Goyal.

Recently, CHCI’s Global Programs Strategist, Jason Rozumalski, had a phone call with Goyal in order to talk about the experience of working in Emergency Medicine during the pandemic and how the humanities not only create important ways to make that experience comprehendible but also have the power to transform those experiences into actions toward better care systems and the reimagining of a better tomorrow.

Jason Rozumalski: I’d like to start by asking if you would briefly describe what the Health and Medical Humanities are and the significance of both of the words ‘health’ and ‘medical’ in this context.

Rishi Goyal: The Health and Medical Humanities is a heterogeneous group of methods and ideas that engage the humanities and the social sciences disciplines—such as history, language, anthropology, sociology—along with scientific disciplines—such as biology, genetics, neuroscience, and biomedical engineering—all in the hope of emphasizing a set of principles or ideas including the vulnerability of human bodies, anti-essentialist approaches to biology, the importance of discursive and rhetorical factors in health, social justice, as well as structural determinants of health. The two terms—health and medical—are important in order to incorporate the recognition that much of the work of caring isn't medicine or what could be defined as medicine. The broader concept of health includes all forms of care and the diverse people who were too often left out of the term ‘medicine’, including palliative care workers, hospital pastors, social workers, physical therapists, and nurses.

JR: Within this broad range of disciplines, could you say what your specialties are and also give us an example of how such a spectrum of disciplines can work together? It might seem more obvious how interdisciplinarity works within the humanities or between the humanities and social sciences, but how do the humanities and the natural science disciplines that you named—genetics, neuroscience, biomedical engineering—work with one another?

RG: Certainly. I'm trained and work as an Emergency Medicine Physician here in New York City, and I also did a doctorate in English Comparative Literature. I am currently at Columbia University with a dual appointment between the Institute for Comparative Literature and Society and the medical school’s Department of Emergency Medicine.

I think that the strength of the interdisciplinarity brought together in the Health and Medical Humanities lies in that so many problems and questions can be vectored through issues concerning health and embodiment. The idea that medicine or medical science might know something through a particular evidentiary standpoint is obvious, but these concepts can be expanded by questioning what counts as evidence. For example, take Coronavirus. We try to understand why certain people get sicker than others. In the medical field, we look to a host of mechanisms, to genetic differences, to susceptibility to illness, and so on. But the inclusion of social sciences has opened up the possibility of asking different kinds of questions including how variations like your zip code, class, or race might affect your illness.

One thing I found fascinating in the early going of the pandemic was that nowhere in the medical literature did I see the suggestion that patients who live in overcrowded settings have a higher propensity to get sick. But, if you talk to Emergency Medical Services workers, it is clear that they were often picking up the sickest patients from housing situations in which multiple people, and multi-generational families, were living together. That kind of evidence is lost immediately when the patient arrives in the emergency room, the ill get turned back into biological bodies with few considerations for class markers. But this kind of social sciences data can inform biomedical thinking. The critical concept of viral load, the measure of the number of viral particles, and its relation to disease severity in black and brown populations in Covid-19, only becomes clear if you include the context of overcrowded housing conditions with poor ventilation. People in medicine often aren't asking those questions, especially up front. So, we have to look backwards, either through oral history projects or other ways of reclaiming that evidence.

JR: You have been working as a physician in an emergency room in New York City throughout the pandemic. Do you mind describing what your experience has been?

RG: As you know, New York City experienced one of the two or three worst situations in the world at the outbreak of this pandemic. Throughout the whole month of February, New York State had only tested nine people for Coronavirus. So, to say that we were underprepared would be an understatement. By March 10, more and more people were falling ill with the virus. Then, around the middle of March, it was as though somebody had turned on a spigot, and suddenly we were flooded with incredibly sick patients who all had a similar and severe clinical syndrome: severe hypoxia progressing to respiratory failure. For about five weeks more than 80 percent of our admissions were Coronavirus-positive patients who were profoundly sick. Most of the patients that I took care of were patients from nursing homes or from Black and Latinx communities. While we had a number of patients that we were able to discharge immediately, the ones that got very sick did so quickly. That situation was compounded by the fact that it was unclear to what degree we were in a safe situation. I think recently we've found that over 600 healthcare workers—including janitors, social workers, nurses, and doctors—have already died during this pandemic in the US alone.

I have recently written about this in a medical humanities journal that I started with Arden Hegele, a Medical Humanities Fellow also at Columbia. We did a special issue on Coronavirus with all of our writers, and I wrote an extended introduction framing the experience of going back and forth between working with students and also working with patients.

JR: Speaking for myself as someone who has never worked in healthcare, it’s difficult to imagine being at the center of such suffering, urgency, and, in this situation, death. May I ask what that was like for you personally?

RG: It was life altering in the middle of March. When I came home each day, I’d have to strip down and throw my clothes in bleach and hot water, not talk to the family, scared that I could be transmitting the illness home, and also scared at work that all the things we were doing weren't working. I think that was a dual effect. One is the kind of vulnerability of the self, but the fact that so much of our treatment was ineffective, especially for the sickest patients—that’s not the way it's supposed to be. You're supposed to be able to go in there and be able to save lives. When all you could do was ferry people to the other side . . . I think that we had to learn, to re-learn, how to have end of life discussions, palliative care discussions, to take some pride and love in doing those things because that was so hard.

JR: Has your knowledge of the humanities affected your experience of this crisis as a physician? And, if it has, does your work in the humanities also transfer to, or include, the people that you work with in the ER? Are the humanities somehow part of the work culture of the ER?

RG: It's a good question. The emergency room is a unique space in that it's pretty liminal. It's betwixt and between the real world and the hospital world, serving as both a gate of entry and also a barrier. What I've found is that whenever there's a change in societal conditions, one of the first places that one can perceive the change is in the emergency room. For example, in 2009 during the financial crisis, the emergency room was seeing more and more people who had lost their medical insurance because of lost jobs. In the AIDS epidemic of the ‘80s, the emergency room was one of the primary places where people sought care. On account of certain national statutes, emergency rooms are one of the few places in the United States that is guaranteed to offer care, and it's where people go as a last resort for care. So, the ER often deals with the indigent, the marginalized, the undocumented, the homeless; it's where they come to get care—especially large, urban emergency rooms. You have to be aware of all that if you're going into emergency medicine. On one hand, people in emergency medicine want to deal with emergencies: gunshots, strokes, heart attacks, and other kinds of emergent care. On the other hand, emergency room workers are also dealing with what you might call crisis care, by which I mean crises from the standpoint of social determinants of health such as treating those who cannot otherwise get care.

In the context of the Covid-19 pandemic, many of my colleagues were emotionally overwhelmed by how sick the patients who came in were, by their own vulnerability to the illness, and by the fact of the relatively high mortality of the deeply sick who came to us. Under normal conditions, death was a rare occurrence in our ER, maybe one or two in a day. In the early months of the pandemic, we had 15 to 20 deaths in the emergency room per day. That amount of death, morbidity, and mortality happening around us, it impacted everybody. We also had to keep patients’ family members out of the ER to prevent the spread of illness, and people were dying and making end-of-life decisions without their family members. A lot of my colleagues worked hard to make sure that they contacted family members and to see that patients were able to FaceTime. We were also all garbed up in these inhuman costumes barring us from one of the most important things that we do, which is to make connections with our patients, to comfort and diagnose with touch and facial expressions. Staying distant, being sort of fearful of each other and our patients, created a very difficult time and space.

JR: How is it developed now? Have the difficulties slowed down at all?

RG: Yes, there’s been a marked difference. With more and more people following social distancing and wearing masks, we’ve certainly seen a decrease in the overall number of cases. It was, actually, a quick and precipitous drop off, almost like an on-and-off switch. But that’s specific to New York City. The rest of the country continues to have a rising case load, although for now the mortality rate has leveled off.

JR: I want to bring in another aspect of your work, and this is your position as one of the coordinators of the Health and Medical Humanities network for CHCI. Could you talk a little bit about what the goals of that network are and what your participation in it has been?

RG: It's been a fantastic experience with an amazing group of humanities scholars from across the country and across the world who are interested in pursuing this new and emerging nexus of Medical and Health Humanities. Our goals have been to come up with joint projects, to convene an annual summer institute, and to create opportunities where people can share their work. We get new ideas, share syllabuses, and brainstorm collaborations.

JR: I was really glad to have been able to drop into the network’s virtual meeting, which was in lieu of joining together at CHCI’s Annual Meeting this May, and I thought the conversations were fantastic. Were there any particular highlights, projects, or goals that stood out to you?

RG: Definitely. This was the largest network meeting we have ever held and the conversation and ongoing chat were quite active. Honestly, I could talk for hours about all of the important projects that members of this network have created. I’ll send you some links, which I would appreciate you posting at the end of this interview.

Briefly, though, I’ll say that we currently have a rich repository of activities linked to the network’s website, which we hope to build from. For example, at Columbia University’s Heyman Center for the Humanities, we have just concluded a digital symposium called Care for the Polis, which looked at how the public humanities and the health humanities work within and are affected by changes in cityscape. Another example is the Trinity Long Room Hub, at Trinity College in Dublin, Ireland. They recently partnered with the Heyman Center for the Humanities to combine work they had already been doing on crises of democracy with a response to the pandemic. That program was called Democracy in the Age of the Pandemic, which looks at how Coronavirus might affect our notions of nationhood and citizenship.

JR: Yes, I attended some of the conversations about democracy and pandemic, which were absolutely thought-provoking and, I believe, can still be found online (here, in fact). At the CHCI Health and Medical Humanities Network meeting, I also heard people discussing a project that I think was called a declaration of rights for the disabled. Am I remembering that correctly?

RG: Almost. It’s a project that I’m involved with called The Living Declaration of Disability, Equity, and Resilience. The project is based in a collaboration among a group of scholars, activists, and artists from the disabled community worldwide who are brought together as part of a group called Reimagine based in Denmark. We’ve put together a living document working off of the Declaration of Human Rights but focused on issues impacting the disabled community, which has been incredibly hard hit by Coronavirus and which is often marginalized in terms of resources and responses.

JR: What are the goals of that particular project?

RG: At this point, the first goal is to get the document out and to get as many hands working on it as possible. The second is to see if we can influence policy decisions. The declaration includes specific requests in terms of the WHO and various other national and international organizations to include representatives from the disability community and more viewpoints from the disability community. One simple thing that struck me working with this group in the current pandemic is that while face masks are critical for everybody to halt the spread of the virus, if you are a lip reader, your ability to communicate is going to be greatly stymied by masks. Or, another example, is that while social-distancing-related emergency curfews were put into place, a lot of disabled people who depend on other people to help them with things like meals or activities, cannot have their caregivers help them when those caregivers are not considered essential workers. In some cases that happened.

JR: I’d like to try to draw together some of the different aspects that we’ve been talking about—the harrowing experiences of the emergency room during pandemic, the goals of interdisciplinarity in approaching health and medicine, and these deeply important public initiatives—to ask how you might have been transformed throughout these past months. Has the way that you think about health and humanities been challenged or changed?

RG: What I’ve known about the medical humanities, but what has been reinforced for me through this experience, is the need to take seriously a historicizing stance as well as the critical reasoning of the humanities in order to better understand and emphasize the role of ideologies and cultural assumptions in the production of medical knowledge. Those people most harmed by the illness were already the most vulnerable, and the vast majority of those deaths could have been—should have been—prevented. All that would have required was a public health system, which we don't possess in the United States, that is capable and that cared about testing and contact tracing. Without a doubt, if those actions had been started in March, it would have made a big difference. The sorry state of our nursing homes is a societal choice. Whether that choice comes from our inability to grapple with disease, death, and dying, or with our lack of desire for dealing with the costs associated with human compassion at the end of life—it’s maybe both. But those two things were very striking to me.

A third aspect that has been on my mind is the model of profit-driven hospitals. What was paramount in our experience as health care workers was the degree to which many of us didn't feel protected by the system. We were clearly seen as expendable, and I think that struck home to a lot of people who would never have experienced that before. In the system that we have, physicians in particular have a high social standing, and I think many of them were surprised by, and caught off guard by, the fact that a boardroom calculus was going on regarding personal protective equipment, the costs and the ability to procure protective equipment, as well as who deserved such equipment and who didn't. And that guidance kept on changing. Some of those changes were due to the quickly evolving nature of information, but it was also clear that many corporate hospital systems were more interested in their bottom line as perceived in opposition to questions about healthcare worker safety.

I am guardedly hopeful about the future of the health humanities. I think many people across the country, from hospital administrators to practitioners, have come to see how the health and medical humanities might promote compassion, critical self-reflection and even support and augment the biomedical mission. I am excited about a vaccine hesitancy project that I am working on with Dennis Tenen, who’s an Associate Professor of English at Columbia and a Digital Humanist. The concerted, global effort to produce a coronavirus vaccine will be undermined by vaccine refusal and hesitancy. Through computational methods, we are collecting a database of anti-vaccine rhetoric, which we will analyze as a cultural, linguistic phenomenon to propose and implement new ways of presenting vaccines to the public that increase acceptance and participation.

JR: I would love to hear more about the techniques that you’re using in that project. But, drawing from what you were saying about who has been most harmed by the pandemic so far, the exposure of U.S. health systems, and this model of profit-driven hospitals, I am wondering if you anticipate any serious repercussions from these experiences?

RG: I think that everyone who worked through the pandemic was changed by it. I don't know if ‘traumatized’ is the right word; it's certainly the kind of the language that we’re speaking now, this language of DSM-5.

I think that people will leave healthcare as a profession. Physician burnout has been a topic of conversation in the last few years as people who work in healthcare have found it not as satisfying as it once was, which is often due to what might be called a moral injury: the experience that your values and principles come into clash with the values and principles of the institution that you work for, and when you're put in situations where you can't provide the care that you'd like to. So, I think some people will leave healthcare.

Are we going to see larger structural change? That's a bigger question. I think that we need to. But we're a strongly profit-driven society. The fact that states were competing with one another and vying for ventilators in early April is not just concerning, it's damning.

JR: Is that process of understanding, assessing, and imagining alternatives fundamentally based in humanities methodologies?

RG: The humanities have a strong role, as do the social sciences, in critiquing those ideologies and in revealing the inequalities and injustices. At the same time, there are even more active and immediate ways that humanities programs can affect these situations, for example the Student Service Corps at Columbia in which students run various projects to help people that have been harmed or hurt by COVID. I've been doing a project on Narrative Medicine, which is a weekly reading session with some of those students. That's been so helpful to talk through problems and to read texts together.

JR: What have you read together most recently?

RG: Actually, last time we looked at paintings. We looked at, and talked about, three paintings, all of them abstract: “Cage 1” by Gerhard Richter, “River Mist” by Romare Bearden, and “Excavation” by Willem de Kooning. We were trying to use the encounter with abstraction as a way of thinking. It was around the time of the beginning of the protests as well. That kind of mental transition from dealing with Covid to dealing with Covid and the protests was overwhelming for a number of people.

JR: What was the effect of looking at these paintings together? A catharsis? A mediation?

RG: More of a meditation. They somehow brought everyone back to a kind of violence, to difference and protest, but in a way that was thoughtful about the potential for productive dialoguing. The conversation started off, as often these sessions do, with a lot of concern and worry. But, by the end, there were these moments of recognition of possibilities for dialogue, for conversation, for reimagining a kind of better world.

P. S.: Goyal can indeed talk a mile on the topic of initiatives and projects created by members of CHCI’s Health and Medical Humanities Network. Here is some of what he had to say about the most recent network meeting, which took place in May 2020:

We heard brief but captivating summaries of ongoing health humanities projects and coronavirus responses across our member organizations. Alison Jameson, Hester Oberman, and Kristy Slominski discussed curricular initiatives at the Institute for the Study of Religion and Culture, University of Arizona (they were also a co-sponsor for our meeting). Deborah Jenson, Amanda Starling Gould, Kearsley Stewart and Cuquis Robledo updated us on the important work of the Duke Health Humanities Lab; Rita Charon inspired us with the range of ongoing coronavirus responses and resources developed by Columbia’s Program in Narrative Medicine; Johanna Rian, Sara Mensink, and Dan Hall-Flavin described how they integrated arts into the healing environment through the Mayo Clinic Lavins Center for Humanities in Medicine; Carolyn Halpin-Healy explained how the Arts and Minds Initiative, which is a museum based program for people with dementia and their caregivers, was moving towards an online environment; Isabelle Galichon attended from France where she discussed the important initiatives in Narrative Medicine at the University of Bordeaux; Phillip Barrish and Pauline Strong of the University of Texas at Austin described a Pop-Up Institute to conduct an interdisciplinary exploration of the impact of humanistic approaches to medicine on patients and healthcare workers; and finally Gina Camodeca and Briana Jegier told us about their new Healthcare HUB at D’Youville College in Buffalo. This was followed by engaging breakout sessions where we discussed key humanistic problems emerging from the Covid-19 pandemic.