In the death of a hospital food worker, a microcosm of the pandemic – STAT

This is one in aseries of reportsfrom hospitals responding to the Covid-19 pandemic.

The hospitals first employee to die of Covid-19 was a kitchen worker named Marie Deus. She was 65, and a longtime germophobe. Years before the pandemic, years before the new coronavirus was known to exist, she always kept a stash of masks and Purell in her bag. She was never without paper towels, to shield her hands from whatever unseen dangers lurked on doorknobs, on handholds in the bus. Shed come home from the grocery store with Lysol, Pine-Sol, ammonia, Clorox. She didnt just like rooms tidy; she wanted them spotless and disinfected.

She wasnt that way when she was in Haiti, said her sister, Yolanda Desir. It was only after she moved to Boston in her 20s that her fear arose. Growing up, shed dreamed of becoming a nurse; in a new country, with its unending rush of bills, she needed a job fast, and becoming a nursing home assistant seemed like the next best thing. She liked the work, but she knew how easy it would be for her to catch something, spending days with patients, leaning close enough to spoon-feed them.

She avoided touching things, made a ritual of washing her hands. She kept doing it when she got the job at Brigham and Womens Faulkner Hospital 15 years ago, scrutinizing surfaces, wary of anything that might not be clean. Terrified shed get sick, said her colleague Antonette Brade. Extreme as it mightve been, the fixation made Deus a model kitchen worker, a ringleader of hygiene, a hand-sanitizer-in-chief. Everybody was pleased with what she do, Brade said. When the pandemic arrived, she only seemed more prescient.

Her family had gently ribbed her about her obsession; it almost seemed like a kind of superstition, and they teased her about that too, laughing at the books she used to interpret dreams. Occasionally, shed stop in at the corner store after work to pick out lottery tickets, and the numbers she chose always came from those books. She loved sitting in the kitchen with her niece, watching Nigerian movies, and shed translate the plot twists into auspicious numbers to play. If she had a dream about a car, shed play the digits of the license plate. If she dreamed about you, shed ask how old you were and play your age. Sometimes she won $500, $700, $1,000 nothing huge, no quit-your-job jackpots, but enough to convince her that she was onto something.

Because she knew, if you cant come to work, sooner or later you may be losing your job. Thats the only way we can keep up in America, you know?

Daniel Joseph, lead cook at Faulkner hospital

The morning she collapsed began like any other, getting up before sunrise, catching the bus in the gathering light. She liked being early. She liked arriving an hour before she was expected, whether going to work or taking her niece to ballet. On weekdays, shed leave the house by 5 or 5:15. Shed change into her uniform blue shirt, black pants have coffee, eat a piece of toast. If the opening manager were a minute late unlocking the kitchen, shed be there by the time clock, waiting, ready to punch in. Bonjour, Marie, bonjour, hed often say, his American accent trying to fit inside the French words.

Shed been sick in the days before, tired and sneezing. Allergies, she insisted. Her sister kept asking if she had fevers, chills, anything that could be a sign of coronavirus? No, no, no, Deus replied, nothing like that and it made sense. She was the last person you would believe would have corona, her sister said. She took a few uncharacteristic days off to rest, and by April 1, she was her usual workaholic self, anxious to be back.

Dont forget, were foreigners, said her friend Daniel Joseph, a lead cook at Faulkner, whos also from Haiti. Even after decades in Boston, the feeling could be hard to shake: the constant wariness, the knowledge that at any moment, even the most meticulous life could come apart. Deus often told him that if the hospital cut staff, shed be first. She was older, she said, her English imperfect.

To him, that was why she was always early, always hand-washing, always terrified of getting sick. Because she knew, if you cant come to work, sooner or later you may be losing your job. Thats the only way we can keep up in America, you know?

That morning she hardly made it past the door. She was by the checkpoint where everyone was screened for coronavirus symptoms when she collapsed. A team rushed out of the emergency room with a stretcher, and carried her in. The doctor on duty, Luis Lobon, recognized her right away. She was someone he saw all the time, wheeling a trolley of meal trays to patients, someone he said hi to, but didnt know well. Now, it scared him. I might be the last person she ever talks to, he thought.

She wasnt gone yet. She wasnt lethargic or somnolent or drifting in and out. Instead, she was electric, wide-eyed, using every bit of her energy to keep herself alive. She stared at Lobon with terror, with the knowledge that she was trapped somewhere airless and awful and needed help getting out. That classic look of the really bad asthmatic, Lobon said. This very, very penetrating look, almost like theyre drilling through your brain.

She didnt want to be intubated, didnt want to be taken to the ICU. She wanted to talk to her sister. Though there wasnt much time, someone handed her a phone, and Desir soothed her, said it was OK, a ventilator might help her breathe but then Deus vital signs started plummeting and Lobon interrupted to say sorry, he needed to put her to sleep, she would be OK, she should say goodbye to her sister until they could speak again.

The IVs and sedatives were already in place. As he threaded in the breathing tube, Lobon noticed that the muscles of her airway, which should have been red with oxygen-rich blood, were now grayish. Everyone in the room was tense. If a hospital kitchen worker were infected someone who didnt spend much time with patients what did that mean for them?

Lobon was worried for Deus, worried for his staff, worried for himself. When he caught the eye of a colleague from behind his goggles, what he saw through her face shield wasnt so different from the petrified stare hed gotten from Deus. She looked at me like, Oh my goodness, this is one of us. Whos going to be next?

Her illness was part of a pattern, but not the one her clinicians were worried about. Deus was among their first Covid-19 patients, just as the Faulkners curve of cases was about to get steep, and they expected that they doctors, nurses, respiratory therapists would be at the greatest risk of infection. They were on the front-most of the front lines, pressing electrodes onto skin, listening to the fluid-filled crackle of lungs, suctioning out secretions.

But they werent the employees getting sick at the highest rates. Among the 25,000 or so people who staff the hospitals and clinics of Brigham Health, certain units that didnt have much patient contact were testing positive more than their bedside colleagues. By mid-April, 4.1% of environmental services workers were infected though they wore protective gear when cleaning patient rooms while 1.2% of nurses were. The percentage was 2.7 for those like Deus, who prepared and delivered food, which was similar to that of respiratory therapists, who fiddled with Covid-19 patients breathing tubes.

Overall, about 1% of employees were infected and that proportion stayed the same when you divided those who provided direct care from those who didnt. The transmission didnt seem to be originating with patients. In fact, ever since late March, when theyd started requiring everyone onsite to be masked and to declare any possible symptoms at the door, epidemiologists hadnt seen a worker infection they could trace back to a patient as its most likely source, said Chuck Morris, one of the hospitals pandemic incident commanders, on April 15.

That left the question of where these unexplained cases were coming from. Morris wondered if they might be linked to the citys coronavirus hot spots, or to some unseen crack in the hospitals infection control, or both. Either way, Deus story made the numbers harrowingly real: They contained not only the risk of further spread, but also the possibility of more people like her, sick enough to become inpatients at their own workplaces.

The data werent perfect. Some divisions had 20 or so employees; others had hundreds, and a few had thousands. There were enough cases to show there was a problem, but not enough to pinpoint why it arose. Plus, hospital leaders knew they were probably missing some. While coronavirus testing was accessible to all employees if you had symptoms, you could get swabbed environmental services and food workers werent getting them as much as nurses and doctors. As much as I feel like we try to flatten hierarchies, chief medical officer Sunil Eappen said, there is a hierarchy here.

Tackling the curve, he knew, would mean tackling that, too. If Im symptomatic and I step out of work and I test positive, do I have job security? You do, but are we sure that you know it? Eappen went on. And if I get sick, am I covered? There was definitely reassurance that went out about both of those issues and even despite that, you might still be scared.

When Desir got the call from the emergency room, and heard her sister gasping for air after every word, she immediately thought about her nephew. He was in his 30s, working as a concierge in a downtown high-rise, and hed been coughing, too. They all lived together, with Desirs 11-year-old daughter, four people in a three-bedroom. I thought, Oh my God, what am I going to do?

She was sitting at her desk, at another hospital, where she helps figure out how much of a procedure will be covered by insurance, how much a patient will have to pay. Hearing snatches of what was going on, her boss let her go home. By the time she brought her nephew to Boston Medical Center later that day, he was so weak he sank into a wheelchair. That night, he was back in his own bed, self-isolating, waiting for coronavirus test results.

They were positive. Desir kept her daughter as far from him as the space would allow, but someone had to take care of him. Cautiously, a few times a day, she brought him water and food, so he wouldnt have to leave his room. Shed make him tea from mint and mugwort and bay leaf, have him gargle water with lemon and baking soda and salt.

She worried he would end up in the same state as his mother, hospitalized, organs damaged, unable to talk. By now, shed been transferred from the Faulkner to the Brigham. The house felt strange without her. Marie the workaholic, leaving for the hospital long before she had to; Marie relaxed on her day off, dredging fish fillets in flour with her niece, rolling meatballs she wouldnt eat herself. Marie, who was 10 years older, part of the reason that Desir had come to Boston from Haiti in the first place.

Theyd lost their parents early, to a car accident, and they were raised in Port-au-Prince by their uncle. He also hosted their cousins from the countryside, whod come down to the capital for school, and the house was bursting with kids, everyone like a sibling to everyone else, swapping clothes and shoes. They grew up minutes from the Palais National, Haitis domed-and-columned answer to the White House, with a line of stately palm trees out front, like sentinels. It was a desirable neighborhood, favored by intellectuals pretty much in the center of everything, Desir said.

Yet it was also at the turbulent center of everything under the Duvalier regime, infamous for the secret police force known as the Tontons Macoutes. Named after a mythological bogeyman, a child-snatcher who stuffs his prey into a big gunnysack, they were agents of disappearance, arriving with machetes and guns and taking people away. Their targets were exactly the sorts of journalists and academics who lived on Desirs street. As a teenager in the late 70s, she would see them near her house, their presence a source of terror. They even come to my school, she said. They come in and they hunt some of the teachers.

The neighborhood they knew began to empty out. Her uncle had already left some 15 years before, fleeing the repression of the Duvalier familys first dictator. Around that time, Haitian scholars say, their country acquired an extra, unofficial province, its territory stretching from the Bahamas to Miami, Brooklyn to Montreal, Dominican sugarcane fields to Parisian arrondissements. As Desir put it, That generation, they moved all over the world. Canada has a lot of teachers thanks to Duvalier.

In 1980, Deus joined their scattered ranks, following her uncle to Boston. Desir wasnt far behind. The city held the third largest enclave of Haitians in the United States, and its epicenter was a neighborhood called Mattapan an area of triple-deckers with its own history of comings and goings.

In the unrest that broke out after the murder of Martin Luther King Jr. in 1968, a group of bankers wanted to look like they were doing something, anything, to address racial inequality. What they did was to draw a blue line around certain tracts of Boston, pinpointing sections of the city where they would offer Black families loans. It was a kind of shadow redlining: Rather than keeping people of color from getting mortgages and buying homes, as governments and banks and realtors had done since the 30s, now these suits-and-ties were providing lines of credit but only within those geographical confines.

The story was often told to explain the re-segregation of Boston, and specifically, how Mattapan went from majority white to majority Black. Yet the shift had already started earlier in the 1960s. Black families, some displaced by demolitions, began settling in areas that white suburbanites-to-be were leaving and speculators dove in, scaring residents into selling, flipping houses at a profit, providing neither repairs nor the inspections that would have revealed the need for them. As demographics shifted, racist officials downgraded property values. Once African Americans start settling in Mattapan, all the white institutions of our society start saying this isnt a desirable neighborhood, said Gerald Gamm, a professor at the University of Rochester, whose book, Urban Exodus, is about that change.

That meant space was affordable for the pioneers of the Haitian diaspora, who founded churches and opened shops, and it was into this landscape that Deus and Desir arrived, staying at their uncles until they could find work and housing of their own. Their current apartment is a 15-minute bus ride north of there. They each had stints in other places, but for the past decade or so, Mattapan has been home. Each wave of new arrivals could talk about the forces in Haiti that brought them here: one Duvalier dictator and then his son, earthquake and hurricane, food shortage and political turmoil.

Back in the day, they understood themselves to be Haitian, first and foremost, no matter how people in the US saw them, explained Carline Desire, executive director of the Association of Haitian Women in Boston. Yet slowly, identities shifted, still Haitian, but becoming American as well.

In many ways, Deus career was familiar in her circle, the years of work in a nursing home, the transition to a more stable job in a hospital. The way Desir was caring for her nephew wasnt so different from what Deus had been doing for a living all along, feeding patients, often surrounded by other Haitian-Americans, some her clients, some her colleagues. When nursing home residents asked, shed make them joumou, winter squash soup. When she got to the Faulkner, and was assembling patient meals on the tray line, shed sometimes sing her favorite Haitian crooner classic, and the others who knew it would join in:

Marie, tu es trs charmante,Tu es une rose san pareil.

Marie, you are so charming,A rose like no other.

Desir imagined her sister had caught the virus in her work at the hospital, but she couldnt be sure. She didnt blame anyone for her sisters illness. No matter how careful you were, she said, there were still risks that came with working in health care, with going to work in general. Thats the thing about corona, you dont know where you can get it, she said. Its everywhere and nowhere.

The hospitals infection trackers sometimes felt something similar. Certain cases were straightforward, with no breaches in personal protective equipment but a clear exposure to a family member whose symptoms clearly predated the employees or, in the pandemics early days, close contact with a surgery patient whod only been revealed to have coronavirus after a while in the hospital. But other cases were fuzzier. Could anyone remember if a specific patient was wearing a mask? What if the employee lived with a family member whose symptoms began right around the same time? What if that family member also worked for the hospital?

Their task lay in the details whod had lunch in the break room, how many minutes spent with a patient, who lived with whom. Just as Deus sister and son had both spent time employed at the Faulkner, one dealing with patients finances, the other wheeling them from place to place, for many, hospital work was a family affair. Yet behind those micro-patterns were larger ones, visible only if you zoomed out.

For years already, the Brigham and its sister hospitals had been tracking the ZIP codes of some patients, geocoding immunization rates and cancer screenings, looking at geographic fluctuations in outcomes for patients with hypertension and diabetes. You are at higher risk of not achieving good blood pressure control if you live in Chelsea, or if you live in Roxbury or Mattapan, said Thomas Sequist, the Mass General Brigham hospital systems chief quality and safety officer. One of his first questions, upon seeing more infections in certain groups of employees, was: Where do our health care workers live?

By late April, after Deus had been on a ventilator for weeks, the hypothesis around illnesses like hers had shifted. Though the number crunchers were still crunching their numbers, they could see the beginnings of a trend. At Brigham Health, just 0.7% of doctors lived in the Boston areas coronavirus hotspots, while 5% of nurses did. Among both environmental services and food workers, that proportion was above 40%. Geography, it seemed, might be a better explanation than job description. It doesnt matter if youre working as a nurse, or a medical assistant, or in food services, said Morris, the Brighams incident commander. Living in certain areas of the city increases your risk.

By June, the numbers would be even more convincing. The nurses who lived in hotspots had a 4.3% infection rate, while it was 2.3% for those whose addresses were elsewhere. Among food workers, 9.9% of hotspot residents had tested positive, while 3.2% of those from other ZIP codes had. For hospital employees, being on the front-most of the front lines wasnt just about the patients you worked with, but also the zones in which you lived.

That didnt mean your job in the hospital was irrelevant. Environmental services and food workers jobs didnt require them to be obsessive email checkers the way physicians did. Try as a manager might to convey official messages about the hospitals ever-evolving pandemic policies, that wasnt foolproof. Hospital leaders had started holding distanced meetings with workers who were most affected. They heard confirmation that some were afraid to be tested, afraid theyd lose their jobs if sick. They set up a multilingual texting service, so that information would ping onto phones in the language of your choice, in a medium these teams actually used.

But that was only part of the story. The other part lay in the very air and architecture of the city, in the discrimination that has shaped who lives where, with how much. It was coiled into the anxiety of keeping up in America, as Deus coworker Daniel Joseph put it, which for him means working two jobs, one full-time at the Faulkner, one part-time at an assisted living facility.

He lives in Mattapan, too a neighborhood of essential workers, where getting to work often means taking the bus, where making ends meet often means a patchwork of nursing home gigs that dont necessarily provide benefits or proper PPE. It was the ZIP code with the second highest coronavirus rate in Boston, where 24.3% of those tested have been positive.

To Dieufort Fleurissaint, associate pastor at Voice of the Gospel Tabernacle, a Haitian church, it was partially a question of economics: The vise-grip of Boston housing prices only becomes tighter if youre sending part of your paycheck back to Haiti, or hosting the newest arrivals as they get on their feet. I know a house of three bedrooms that had two families, and each family has four children, and you can imagine the parents are working in a nursing home, he said. If one person is infected, the whole household is infected.

Thats layered onto a long, long history of structural racism, visible in everything from hypertension geo-data to police violence. The virus that hasnt left anybodys mind. But there are other factors that are just as deadly, said Fatima Ali-Salaam, chair of the Greater Mattapan Neighborhood Council. Ive heard plenty of people say, if its not this virus, its going to be something else look at the average lifespan of communities of color.

She saw that in the 20 people she knew whove died of Covid-19. Fleurissaint saw it in the unending stream of online funerals he and his Haitian pastor colleagues faced: Every day in April, two, three people passed away.

Whenever he had a difficult phone call to make, Joseph Kim would find a secluded spot, away from the hum of doctor talk and foot traffic. One of his favorites was a storage closet on Brigham and Womens ninth floor, which held an ultrasound machine and a stand of oxygen tanks and just enough unimpeded floor for him to pace.

He was 28, an internal medicine resident, and hed found himself ducking in there more and more lately, to update families who couldnt visit their Covid-sick relatives. That was where he told Desir that, as her sisters health care proxy, shed soon have to make a choice. Deus heart and kidneys were fragile from their lapse in oxygen, her lungs papered with scars. After weeks at anchor in her windpipe, the ventilators plastic tubing posed an ever-growing risk of injury that would eventually outweigh its help.

You cant keep someone on a ventilator forever, Kim said. It has to be a bridge to something. He hoped it would be a bridge back to unassisted breathing, but when they tried tapering the airflow, her lungs couldnt draw in what they needed on their own. That left two possibilities, diametrically opposed. The doctors could keep trying, with even more instruments food entering the gut by surgical conduit, breath whizzing in through a slit in her throat or they could withdraw all treatments but those that helped her stay comfortable.

For Desir, it was hardly a choice. Deus years of nursing-home work had left her with a profound fear of becoming one of the people she cared for, daily rhythms dependent on aides and tubes. When Desir relayed the doctors description more time in the ICU, a long stretch of rehab if she recovered her family said, no, no, no, you couldnt do that to her. They would have to put her in one of those houses she never liked, Desir said. She work in them, she doesnt want to be in them. She just feel that if she cant live the way that she like, she might as well go to the Lord.

Every coronavirus case, Kim knew, was a fuzzy snapshot of a life. He couldnt talk to Deus herself. Often, he couldnt even see her up close, but only from a protective distance, peering in through the window of her room, examining her through her lab values, hearing her voice through his storage-closet calls with her sister. He couldnt know her Port-au-Prince self, her Mattapan self. He hardly knew her at all. Yet hed rotated through the Faulkner, knew the wards and hallways where she had spent her days. Always, he carried some bit of hurt home with him, but this time, the loss felt closer, more personal.

The priest came on a Tuesday evening, to give Deus the last rites. Kim called Desir afterward to say her sister was sleeping, that she should try to sleep, too. The next morning after a final, unsuccessful attempt to coax Deus lungs into breathing on their own the clinicians asked whether Desir and her nephew wanted to come in for a last visit. It was April 22. They hadnt seen her in three weeks.

She wasnt awake when they arrived. They spoke to her anyway, through their layers of protective gear, telling her they loved her, each putting a reassuring hand on her skin. Her sister prayed for her, asking God to receive her, to make sure she would be cared for the way she had always cared for them. And I said my goodbye, she said, told her I would see her on the other side.

Then, they gathered up the things shed had with her on the day she collapsed. That morning had been cold, the air near freezing at dawn as shed left her house. They took her blue jeans, her puffy gray coat, the long wig she liked to fit over her hair and tie into a ponytail. The nurses said they were sorry that the circumstances were so difficult. One nurse came to me, Desir recalled, he said, When I told her that her son is fine and that hes back to work Id never seen her so peaceful.

In the long days afterward, Desir forced herself to go into her sisters room, to pack up her belongings, so a friend could take them back to Haiti and give them away. Everywhere, she found the remnants of germophobia: Purell bottles in pockets, masks and disinfectant wipes at the bottom of a purse. It was too much. Just before Deus had gotten sick, the four of them were about to move, out of their apartment in Mattapan to a single-family house in the suburb of Randolph, with a garden and a basement and what felt like a cavernous amount of space. They were supposed to sign the papers on April 30. All we had to do was the closing, Desir said.

But neither she nor her nephew could stomach moving into those rooms, where theyd imagined Deus picking out curtains, queuing up an endless stream of Nigerian films. Nor could they keep living where they were, remembering, every time they passed her door, how Deus liked to sleep with the light on, how they would always see the comforting yellow glow of it filtering out into the hall.

They started their search from scratch. It was a strange mourning ritual, clicking through listings, looking at square footage and pictures. On weekends, while waiting for the church to reopen so they could hold a proper funeral, Desir drove from town to town to town, passing through kitchens and backyards, trying to imagine what their lives might be like if this were where they lived.

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In the death of a hospital food worker, a microcosm of the pandemic - STAT

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