Browse the corpus

When I first returned to clinic a couple of months after the COVID-19 pandemic began, the first thing I noticed was that the bowl of candy at the front desk was gone. It had always been kept full, and I reflexively looked for my favourite lemon and orange mints. But that day, the bowl was replaced by hand sanitiser bottles neatly lined up in a row. The waiting area for patients was closed too. Only one staff member in full personal protective equipment sat at the front, screening patients individually and escorting them into examination rooms. As an infectious disease doctor, hopefulness was fleeting during this time in New York City, NY, USA. Our hospitals were buckling under the deluge of COVID-19 patients. Many patients were Black and Brown people, who worked in jobs that were keeping the city running and who did not have the luxury of staying at home. Arriving at the clinic in those first months of COVID-19, I was particularly worried about how patients with HIV would fare dealing with a new pandemic, while still struggling to live with the last one. Ray, a Black gay man with HIV in his 30s, was new to our clinic and the first patient I saw that day. With infection control measures in place, we could not shake hands. We were both masked. His intense brown eyes and his raspy, baritone voice were arresting. Ray said he had been excited to meet me, as I was the first doctor he had visited who was also Black and gay.

to our clinic and the first patient I saw that day. With infection control measures in place, we could not shake hands. We were both masked. His intense brown eyes and his raspy, baritone voice were arresting. Ray said he had been excited to meet me, as I was the first doctor he had visited who was also Black and gay. He told me that he was diagnosed with HIV in 2003 and the first HIV clinic he went to was not a welcoming environment for him, so he never returned. His mother passed away a year later. She had sent him to Catholic school when he was young and nurtured his faith and love of church music. When he came out to her, he described how she told him “I love you regardless”. Ray said she gave him everything he needed growing up without his father, who struggled with substance use and had died years earlier. Ray recalled how he had used the same kind of drugs to blunt the pain of his parents’ loss, eventually checking into rehabilitation. He was on and off his HIV medication for years and his CD4 count was dangerously low. “I wasn't willing. I didn't want to embrace it,” he told me. Ray was often sick and every time he lost a job, he also lost his employer-based health insurance and access to health care. He moved to different cities for brief stints, but always made his way back to New York. He had little money and lived at friends’ apartments for long stretches. When the COVID-19 pandemic hit, he realised “I'm a breath away from death.”

a job, he also lost his employer-based health insurance and access to health care. He moved to different cities for brief stints, but always made his way back to New York. He had little money and lived at friends’ apartments for long stretches. When the COVID-19 pandemic hit, he realised “I'm a breath away from death.” As most people avoided hospitals at all costs, Ray walked a few blocks to my hospital's emergency room as the first COVID-19 wave crested through the city. He noticed “the frantic energy in the halls and the fear in doctors’ and nurses’ eyes,” he told me. He was admitted to the hospital, where he started antiretroviral medication once again. An intern at the hospital made sure that he was linked to our clinic. COVID-19 terrified Ray. Because of his compromised immune system, he told me that simply coming to the clinic felt like a huge risk. I wanted to celebrate the courage it took for Ray to come in but also to understand why Ray had fallen out of care for so many years. “I want to take it day by day this time,” he said. “I've lost both my mother and father, and I don't want the people I love to mourn me too.” I asked Ray how he mourned his parents. “I think about them every day,” he said. “Not a day has gone by I don't think about them.” Alongside his HIV care, I decided to send Ray for psychotherapy to help unpack how grieving the loss of his parents affected the trajectory of his illness.

e people I love to mourn me too.” I asked Ray how he mourned his parents. “I think about them every day,” he said. “Not a day has gone by I don't think about them.” Alongside his HIV care, I decided to send Ray for psychotherapy to help unpack how grieving the loss of his parents affected the trajectory of his illness. I next saw Ray in June, 2020, a few weeks after George Floyd's murder by police. That day, we were first and foremost two Black men commiserating about how racism was still deeply rooted in the country, and how either of us could have been George Floyd. Ray wanted to join one of the Black Lives Matter protests, but was fearful of SARS-CoV-2 transmission, so he stayed at home. COVID-19 presented such novel questions about risk. I told Ray about the protest I went to—cars honking, artful signs, colourful dancers, people handing out masks, and pumping sanitiser into strangers’ palms. He told me that although he could not participate in the protests, taking care of himself felt like his act of protest. Indeed, self-care is itself a form of activism in the spirit of Audre Lorde and other Black American civil rights heroes. I was excited to see Ray again in July, but he missed his next appointment. I learned he missed his therapy appointment too. He did not answer his telephone and I realised I had never actually seen Ray's face during his clinic visits because he was always masked. I feared that he had lost his insurance once again, lapsed back into drug use, or got sick with COVID-19.

ssed his next appointment. I learned he missed his therapy appointment too. He did not answer his telephone and I realised I had never actually seen Ray's face during his clinic visits because he was always masked. I feared that he had lost his insurance once again, lapsed back into drug use, or got sick with COVID-19. Black patients in the USA have worse outcomes at each step along the HIV care continuum due to the same daunting structural and social factors Ray faced—the housing instability, the poverty and unemployment, the food insecurity, the structural racism. It is no coincidence the burden of HIV in the USA is heavily concentrated among Black gay and bisexual men. After 2 weeks of my unanswered calls, Ray reappeared at the clinic. His roommate had kicked him out of the apartment and he lost his medication during the move to a hotel, but was determined to get back on track. “When we get your viral load undetectable, that's not the end, that's just the beginning,” I reminded him. Around this time Ray also met a new love interest online who lived across the country in California. “I think we have a connection, but is it safe for me to fly?”, he asked. “Maybe we can wait until your CD4 count improves a bit more,” I replied. It was motivation to stay on his medication. I also got him back into psychotherapy and had our social worker help him find a new apartment. As I examined Ray, I asked if he would mind pulling his mask down very briefly so I could see his face, to be able to recognise him in the future.

improves a bit more,” I replied. It was motivation to stay on his medication. I also got him back into psychotherapy and had our social worker help him find a new apartment. As I examined Ray, I asked if he would mind pulling his mask down very briefly so I could see his face, to be able to recognise him in the future. Ray's viral load was undetectable by autumn. He achieved this while other patients of mine who had been stable for years were having difficulty staying on their medication during the pandemic. When I told him the news, he looked up to the ceiling, his voice becoming shaky with emotion. “I have my life back,” he said. He started planning his California trip. This felt like a triumph, both the viral load and the stirrings of love. On Christmas morning, in the middle of the next COVID-19 surge, I saw an email from Ray. “To my entire care team. As I paused today, a rush of gratitude ran over me. You opened my eyes to what a great loss it would've been had I not started to take care of myself. This luminescent, vibrant, impassioned music is arranged by yours truly for Christmas 2020. I dedicate it to each of you.” Ray, it turns out, is a classical pianist and pipe organist, and a talented musician. I clicked the YouTube link and there he was sitting at a grand piano, his body heaving and shifting while playing. The scene brought tears to my eyes.

music is arranged by yours truly for Christmas 2020. I dedicate it to each of you.” Ray, it turns out, is a classical pianist and pipe organist, and a talented musician. I clicked the YouTube link and there he was sitting at a grand piano, his body heaving and shifting while playing. The scene brought tears to my eyes. When I saw Ray after the new year, he had received his first COVID-19 mRNA vaccine. His new long-distance relationship was going well and he was moving to Washington, DC, for a dream job. At the same time, I was moving to a new clinic at Bellevue, New York City's main public hospital. I thought the distance meant the end of our doctor–patient relationship, but Ray decided to keep coming to New York for his appointments. I was overjoyed. In the USA, universal approaches to HIV care and treatment have led to overall improvements in morbidity and mortality. But we have left communities behind. And those communities are filled with patients like Ray, whose lives matter and who must be invested in. Ray had struggled to envision what a healthy life could look like—one not simply defined as the absence of disease. In his case, acknowledging the trauma and excavating the pain were part of his journey to achieving and maintaining an undetectable viral load and establishing a foundation for human flourishing. © 2022 Michael Natter/https://www.mikenattermedical.com2022

In the USA, universal approaches to HIV care and treatment have led to overall improvements in morbidity and mortality. But we have left communities behind. And those communities are filled with patients like Ray, whose lives matter and who must be invested in. Ray had struggled to envision what a healthy life could look like—one not simply defined as the absence of disease. In his case, acknowledging the trauma and excavating the pain were part of his journey to achieving and maintaining an undetectable viral load and establishing a foundation for human flourishing. © 2022 Michael Natter/https://www.mikenattermedical.com2022 The COVID-19 pandemic challenged my belief in the capacity of systems to centre our most vulnerable patients in their greatest time of suffering. However, in caring for Ray I found renewed inspiration, appreciating that even in the darkest times, medicine still provides the opportunity to make a difference in the confines of an examination room.

enged my belief in the capacity of systems to centre our most vulnerable patients in their greatest time of suffering. However, in caring for Ray I found renewed inspiration, appreciating that even in the darkest times, medicine still provides the opportunity to make a difference in the confines of an examination room. I was not sure if Ray would come to our Bellevue appointment in late 2021. I peered into the waiting room, called his name, and there he was. He walked confidently towards me in a stylish black top-hat. We hugged each other, a fleeting moment during the pandemic when such a gesture felt necessary. His relationship with the man in California had ended, but the new job in Washington, DC, was everything he wanted. I reminded Ray of the Christmas gift he sent a year before. Reflecting on it, he said “I sat watching myself, this healthy creature, and I felt like I had my mother's eyes, watching me, proud. I want to live in honour of her.” In the midst of the pandemic, his life finally felt settled.