Basic Needs

Looking back on 2020 feels a lot like looking back on two years at once. Or maybe it’s two countries—or, more precisely, dissonant ideas of a country I thought I knew well enough, even with a healthy skepticism, but whose transformation and revelations have made even that skepticism seem naïve. Against the backdrop of a malignant presidency, the year began with familiar emergencies, from environmental (wildfires) to humanitarian (immigration) to diplomatic (Iran). Cut to spring and a national reckoning with the brutal realities of Black life in America, coupled with the existential threat of a virus that by Thanksgiving, in this country alone, had infected almost thirteen million people and killed more than a quarter million. 

This doubling effect stems partly from looking back on the year editorially. VQR’s Spring issue, our first of the year, reached readers in early March, just as the first wave of COVID-19 infections was beginning to peak in the US. In a way, the cover story for that issue—Lauren Markham’s investigation into the effects of secondary trauma among immigration-rights advocates—is emblematic of crises that were pushed to the margins of our attention as the coronavirus forced us to pause, pivot, reprioritize. And yet the theme of Markham’s story dovetails with an emerging concern: that noble professions are grinding down the human beings committed to them. In the case of immigration, that toll includes the lawyers, advocates, and others who have absorbed the horror stories of migrant families seeking sanctuary in the US, only to have their children weaponized—parents whose children were taken, children whose parents were disappeared. 

That emergency, though not front and center, remains quite real. As of Thanksgiving, more than 650 immigrant minors in US custody had no idea where their parents were, because officials themselves had no idea. Compounding the psychological damage done to these children has been the damage done to the adults who for years have been trying to make this right.

As serious as it is, the mental-health crisis among immigration-rights advocates will likely be dwarfed in scale by the one now affecting health-care workers who, in bearing close witness to the havoc the coronavirus has unleashed in their communities, are breaking down and burning out, sometimes contracting the virus themselves only to return to the front lines upon recovery, if not simply quitting altogether. The key terms in this conversation—burnout, compassion fatigue, absorbed trauma—would be familiar to the advocates in Markham’s story. For health-care workers, the stakes are even higher and the trauma more direct, since both the job and the workplace have become deadly. And while it’s true that the financial strain of the pandemic economy has led to the shuttering of family practices, a more general winnowing among clinicians and physicians can be attributed simply to weighing whether the risks are worth it, especially under the working conditions of an already deeply flawed system. 

These conditions were challenging enough before the pandemic, due in part to administrative trends that put enormous pressure on practitioners to perform with assembly-line efficiency. There is, too, the culture of professional medicine itself, in which physicians and clinicians and nurses wrestle with impossible expectations to meet the needs of others, whether patients or bosses, in superhuman fashion. And much like the culture of the legal profession, the culture of medicine has cultivated an unsustainable mythology of invulnerability—and, more importantly, a shame in being vulnerable—that is now, amid the chaos of COVID-19, facing its own reckoning.

One of the motivations for this introduction to the Winter issue comes from a conversation I had with writer and physician Emily Silverman, the founder of the live series and podcast The Nocturnists and current contributor to a new column in VQR called On Becoming. The column addresses a writer’s transformation, usually after it has already begun. In Silverman’s case, she writes about her disillusionment with professional medicine, the fog at the crossroads ahead of her. For her and so many of her peers, the pandemic amplified the toxic consequences of American medical culture. The Nocturnist project, through which health-care workers perform their stories, has become a space where they can explore certain vulnerabilities within the genre of narrative medicine, and in doing so underscore a resilient (if sentimental) truth: that the ritual of storytelling is a ritual of strength, and of healing. 

To the degree that the pandemic has exposed infrastructural weaknesses in the health-care system, Silverman sees, through the larger conversation on mental health in medicine that’s beginning to take shape, an opportunity to reform a medical culture that has deprioritized patients by ignoring their caregivers. “You hear a lot about the horrific experiences on the patient end,” she told me. “But the story told less often is that the physicians are actually just as unsatisfied and kind of spiraling into burnout, despair, working themselves sick, getting mentally sick. And then there’s all this stigma about admitting it. So we’ve been pushed to the edge of exhaustion for a really long time, which is why when COVID hit, we weren’t full. We weren’t in a position to absorb that impact.”

Nearly a year in, we can see how the story of the data generated by the pandemic forecasts a deeper story with a longer arc. Both have been bleak, though recent breakthroughs allow us to tentatively hope that 2021 will be a year marked less by damage than by restoration. If that is the case, I’ll be curious to see, among the lessons of the pandemic, where the theme of vulnerability falls, whether it will be valued differently, maybe even redefined—not just in medicine but in other professional cultures, maybe even the culture more broadly. Could vulnerability be understood as a subtle kind of empowerment? Not just between peers or partners, but within hierarchies and other structures? Is that so radical an idea? Too schmaltzy, even, or frivolous? If so, perhaps that reaction speaks to the larger cultural influences that give vulnerability such a bad rap. One would think that after all we’ve been through in recent years, and this year in particular, admitting a mutual vulnerability to each other, and by extension a need for one another, is as lucid and sober a conclusion as anything that data can tell us. And creating a bit of space for that feeling—that fact—might actually allow us to tap into something as a nation (with all the grandiosity that phrase implies): a strength we’ve long been proud to advertise and will need to conjure in the days to come.

— Paul Reyes