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Physician Work Environment and Well-Being
October 26, 2020

Medicine and Grief During the COVID-19 Era: The Art of Losing

Author Affiliations
  • 1Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Cambridge, Massachusetts
JAMA Intern Med. 2020;180(12):1573-1575. doi:10.1001/jamainternmed.2020.5635

In a matter of months, coronavirus 2019 (COVID-19) has transformed not just how we live but also how we leave this world.1 Physicians and nurses struggle to accompany patients who die alone and support families who cannot follow the usual customs of grief: gathering at hospitals, attending funerals, sitting shiva.2

As a resident physician, I feel unnerved by these challenges. In the poem “One Art,”3 Elizabeth Bishop writes, “The art of losing isn’t hard to master.” The small losses (like “door keys,” “my mother’s watch,” or “the hour badly spent”) are “no disaster.” But they give way to greater tragedies. During the long months of COVID-19, our tally of losses has accumulated. First, we lost the intimacy of holding hands or hugging our children after work, fearful of skin teeming with invisible harm. We lost the ability to walk into a patient’s room without fretting about the risk hanging in the shared air. And we have lost hundreds of thousands of people to an illness we cannot yet contain.

As an immigrant, I am well practiced in the art of losing. For me, our present uncertainty is intertwined with a history of departures. My parents relinquished the bustling warmth of Kolkata, India, seeking an expanded world of possibilities. I was just a baby. Ten years later, we left the green hills of Wellington, New Zealand, for the flat brush of Houston, Texas. With each flight, I said goodbye to people and places I knew and loved.

Finding strength in one another, my family survived: we adapted to eating new foods, driving on a new side of the road, speaking with a new inflection to our words. There were some goodbyes we could not bring ourselves to say, the dangling ties to our lives back home. Back home: even in the phrase we concealed our muffled grief, until home became a concept as unfamiliar as an infant eyeing her shadow.

Newly emigrated and feeling unmoored, I sought solace in the work of medicine. Frank Netter’s Atlas of Human Anatomy unfolded before me like a map; I exchanged lost towns for new citadels. The cul-de-sac behind our home in Wellington where my sister and I chased sheep was replaced with vallecula (the place popcorn gets stuck). Te Whanganui-a-Tara, the harbor stretching along the southern coast, was swapped with the aorta (the pulsing central artery). A hemisphere switched for a hemidiaphragm (the domed muscle that delivers breath).

Dare I say, I have gotten better at goodbyes over time; I have had the chance, in Bishop’s words, to “practice losing farther, losing faster.”3 I have been harried by residency training and fallen out of touch with close friends. Abandoned dancing, a passion I once felt down to my bones. Lost a first patient—heartbreak for a young physician—then a second, and a third.

In the pandemic’s wake, I find myself revisiting memories of my most personal losses. When my paternal grandfather, dada bhai, abruptly died, I was unable to take leave from medical school in California, so I mourned from afar. He was cremated at the banks of the Hooghly River, a tributary of the holy Ganges that carries souls to eternal life. Over Skype, I watched his body disintegrate to ash on a pyre while a priest shaved my father’s head for the last rites.

A few years later, my maternal grandmother, didi ma, passed away in her bed. Through FaceTime, I witnessed her expression harden to wax as the color left her face. Mourners streamed through her room, wailing, decorating her body with wreaths of white flowers. Both were losses that I faced at a distance. The membrane between virtual grief and everyday life is thin: beyond the glowing laptop screen that framed the rituals of my grandmother’s funeral, a leafy houseplant made mockery of my sorrow and a bowlful of oranges blinked too bright. Far from lost keys or lost continents, the loss of a loved one was gutting, no matter how hard I tried—following Bishop—to avert the pain:

—Even losing you (the joking voice, a gesture

I love) I shan’t have lied. It’s evident

the art of losing’s not too hard to master

though it may look like (Write it!) like disaster.3

I would not wish distance grieving on anyone. Physical rituals of mourning promise catharsis: dressing the body, lighting candles, sprinkling dirt on a casket. Yet there are ways to make meaning in this peculiar mode of distanced grief, by participating in a virtual funeral or continuing well-worn customs belatedly or at a different location.4 In the Hindu tradition, this involved hosting a puja across the ocean, where guests joined my family to sing, pray, light incense, and share sweets.

It was also important for me to develop my own rituals. I ordered kebabs from a takeout counter to savor Kolkata on my tongue. I climbed a mountain to find peace amidst groves of towering redwoods, a place neither grandparent had been. These rituals were intimate. They were mine.

Despite attempts to heal, loss remains a wound, reopening in the strangest places: while drinking an ice-cold soda in Bangladesh during a summer research trip and recalling didi ma’s voracious appetite for sugar, or on a vacation to Iceland to chase the Northern Lights and suddenly sobbing at the night sky—after many years, feeling the pull of dada bhai’s spirit.

The pandemic has made us contend with loss in new and unexpected forms. Calling primary care patients for virtual appointments, I walk into sudden eruptions of grief, like minefields—entire families who succumbed to COVID-19 infection, elderly adults confined in isolation and fear, and patients whose treatments for other illnesses have been deferred to disastrous effect. With distance precluding the comfort of community, we bear witness to these casualties through private rituals, whether a postshift shower to wash away the enormity of pain or a moment of stunned reflection after hanging up the telephone. Ultimately, we must make peace with the volatility of grief and its messy presence. In medicine, the art of losing is still the hardest one to master.

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Article Information

Corresponding Author: Amrapali Maitra, MD, PhD, Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 (amaitra@bwh.harvard.edu).

Published Online: October 26, 2020. doi:10.1001/jamainternmed.2020.5635

Conflict of Interest Disclosures: None reported.

Acknowledgements: I thank Amy Ship, MD, and Kham Kidia, MD, for thoughtful input and Jennifer Claytor, MD, for her skillful guidance. None was compensated for their work. I thank my parents for granting permission to share my grandparents’ stories.

References
1.
Ungerleider  S.  Virtual grieving: is there no closure if there is no goodbye?  San Francisco Chronicle. April 14, 2020. Accessed September 24, 2020. https://www.sfchronicle.com/opinion/openforum/article/Virtual-grieving-Is-there-closure-if-there-is-no-15198399.php
2.
Levitz  J, Berger  P.  “I’m sorry I can’t kiss you”—coronavirus victims are dying alone.  Wall Street Journal. April 10, 2020. Accessed September 24, 2020. https://www.wsj.com/articles/im-sorry-i-cant-kiss-youcoronavirus-victims-are-dying-alone-11586534526
3.
Bishop  E. “One Art.” In:  The Complete Poems 1926-1979. Farrar, Straus, and Giroux; 1983.
4.
COVID Paper Virtual Funeral Collective.  Death, grief, and funerals in the COVID age.  Updated June 10, 2020. Accessed September 24, 2020. https://www.covidpaper.org/
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    2 Comments for this article
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    Intimate Rituals
    Marta Rondon, M.D. M.SC. | UNIVERSIDAD PERUANA CAYETANO HEREDIA
    Thanks for a very relatable piece. This is indeed a time for grief. I grieve for many fantasies, that I used to think were certainties: that authorities know or will find out what's in the best interest of the people, that preserving the dignity of fellow human beings is the ultimate consideration when all else is lost- unfortunately reality showed otherwise. These disenchantments, of course, come along with the personal loss of the sense of efficacy and power that came with being able to relieve the suffering of the patients and their families in many countless, small, ways. I am a psychiatrist: people come to me when life seems too much to bear and, let me tell you, the confinement in crowded quarters, with their aggressor, the children without access to lessons, small vending posts shut, or without customers, no health services available, make life very difficult these days. Whenever I am too overcome with grief, I read something, more or less randomly chosen. Today I came across your column and I consider myself very fortunate and much less lonely.
    CONFLICT OF INTEREST: None Reported
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    ‘Where the mind is without fear and the head is held high …’
    Samar Basak, MD (Ophtha), FRCS | Disha Eye Hospitals, Kolkata-700120, India
    The virus has indeed expanded the human understanding of ‘distances’. Perhaps the most difficult aspect of this pandemic and our new normal of distancing and isolation is the way it has radically changed our grieving processes across all cultures, countries and traditions.
    Loss, grief and fear have therefore turned into unchartered territories, and we have been forced to lose 'vast realms' psychologically. The mental health toll on front line health workers, care-givers and other essential service providers is something that we must indeed be aware of, constantly.
    As I read the essay, I was reminded of Tagore’s line, ‘Where
    the mind is without fear and the head is held high …’ As hard as it is to master the art of losing, we will draw strength from one another and with our minds conquer the many distances and challenges of these times.
    CONFLICT OF INTEREST: None Reported
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