The Doctor, The Disease, And The Division

The Doctor, The Disease, And The Division
Illustration: Benjamin Currie

Soon after the coronavirus struck my busy Brooklyn hospital, I found myself caring for an older gentleman with kidney issues. Let’s call him Mr. Johnson. I’m a specialist in kidney medicine, and I knew it should have been a fairly routine visit.

Mr. Johnson’s diabetic kidneys had failed five years ago. To stay alive, he had to come into an outpatient facility three times a week to receive blood-purifying hemodialysis treatments. Toward the end of a recent session he started shivering and feeling unwell, so the nurses sent him to our emergency department.

Beyond dysfunctional kidneys, dialysis patients also have weakened immune systems that leave them prone to severe infections. Those chills could have been the first sign of a bacterial infection in his bloodstream, which is potentially deadly but highly treatable with conventional antibiotics. But lately we’ve also worried that these patients could be infected with SARS-CoV2, the novel coronavirus that causes the disease called Covid-19.

For the next three days he stayed in the hospital and received IV antibiotics, just in case. Blood tests showed no sign of bacterial infection and his chills never returned. He felt fine, in fact, and started getting so antsy from being stuck in an isolation room that he wanted to go home and sleep in his own bed. I was ready to let him. We could’ve really used the bed for the next coronavirus patient, of which we had plenty. The recent explosion of coronavirus in New York City had depleted the supply of hospital beds so severely that some patients were forced to wait in the downstairs emergency department for almost 24 hours.

Mr. Johnson’s SARS-CoV2 result came back the next morning. It was positive.

Even with the virus Mr. Johnson would be free to go home, as he was symptom-free and healthy enough to self-quarantine on his own recognisance. To ensure he was still faring well, a doctor would meet him in quarantine at the dialysis centre.

Leaving the hospital is a bit of a process. The social worker needed to arrange a taxi to drop him off, as well as print his advance directives on special pink paper that made clear his wish to forgo cardiopulmonary resuscitation or invasive mechanical ventilation that might artificially prolong his life.

When his nurse came by his room later that afternoon to deliver his discharge papers, he found that Mr. Johnson had quietly died in the bed.

Mr. Johnson was just one of 285 New Yorkers we lost to Covid-19 that day.

I’ve never seen anything like this.

As I write it’s been about six weeks since the first confirmed Covid-19 case in New York City on March 1. I’ve been working shifts at three Brooklyn hospitals along with my coworkers in the program we’re in for advanced training in nephrology. We’ll eventually graduate as board-certified specialists in kidney disease, which has never felt further away. I’ve watched as the pandemic swept into the outer boroughs, watched as my hospital started with maybe three “persons under investigation,” then filled with hundreds of virus patients in the span of a month. I thought I had been through some hard days in my prior training as a resident in internal medicine. I remember nights during flu seasons past when I wished I could slash the ambulance tires to keep them from bringing me more patients.

Under normal circumstances my job is to take care of chronic dialysis patients who’ve been admitted to the hospital for any reason, making sure they keep getting the regular, kidney-replacing artificial life-support treatments they need to survive. I also help with patients whose kidneys have been acutely injured, with causes ranging from infection to urinary blockage to heart failure. Usually their kidneys recover without much trouble, once the cause is controlled. Occasionally, the damage is severe enough to throw the body’s physiological balance dangerously off-kilter, and these unlucky few may need emergency dialysis for days to weeks until their kidneys heal.

Covid-19 is different. A shocking number of patients now develop sudden kidney failure, often requiring emergency dialysis. We don’t know why. All I know is that most of them don’t get better. Sometimes Covid patients die slowly over weeks, as their lungs inexorably decline. Sometimes over days, as each organ succumbs to the virus. Sometimes they just die suddenly from catastrophic heart failure, like I believe happened to Mr. Johnson.

Outside the hospital, cut off from friends and family like everyone else in New York, I’ve spent much of my social isolation on my PC. I can’t seem to escape disease, even in leisure. I binge-watched the Korean medieval zombie outbreak drama Kingdom and the whimsical hematology-themed anime Cells at Work!. I finally read Albert Camus’ classic novel The Plague. But mostly I keep logging into Ubisoft’s accidentally, unfortunately prescient 2019 online action game The Division 2, set in a United States thrown into violent chaos after a devastating influenza pandemic. As of today, I’ve put 79 hours into the game.

The Division 2"s devastated DC (Screenshot: Kotaku, Ubisoft)

The irony isn’t lost on me. Here I am, a physician in a time of pestilence, spending my few free hours playing a game set in a fictional America torn apart by plague. I first picked up the franchise out of a morbid curiosity a few years ago, after learning the first Division game was set in Manhattan. I wanted to see my hometown recreated as a playground of destruction: partly the privileged novelty of wondering what war might be like in the streets I know, and a healthy dose of “I can see my house from here”-type earnest excitement. The 2019 sequel was set in Washington, DC. I lived just outside DC at the start of my career, so The Division 2 offered the same local appeal.

As the coronavirus has spread and hopefully now plateaued in New York, I’ve kept on playing for a different reason: because I want to win at something, instead of feeling entirely powerless. I can solve every problem in The Division 2 with a bullet, but against the coronavirus my armory is all but empty. As physicians we feel a powerful urge to do something for our patients. This feeling even has a name: The “bias to action” is the impulse to intervene even in cases best left alone, lest you harm instead of heal. But in The Division I can freely fight the plague—or at least the enemy gangs who represent the awfulness of its aftermath—with my sniper rifle and shotgun, no ethical considerations necessary.

I suppose I also find a certain twisted satisfaction knowing that as bad as things are right now they could be even worse. The economy may have ground to a halt, tens of millions left jobless and uninsured, friends and families meeting only through grainy video chat, but the rule of law hasn’t broken down with armed criminals roaming the streets. At this point I’ll take what cheer I can get.

Loading screen. Connecting to Tom Clancy’s The Division® 2 Online Services.

I’m home after a long day in the hospital. Time to check in at the virtual White House, my improvised headquarters in The Division 2, and see what’s new. My friend Matt says he’ll log in from his home in Queens and meet me there.

I’ve known Matt for years, online and offline. We’ve built neighbouring estates on alien hills in No Man’s Sky and left monster blood splattered like spilled jam in Path of Exile. We’ve shared pitchers of watery beer in dive bars in Manhattan’s East Village, and eaten our weight in dumplings in Flushing, the neighbourhood in Queens currently hit hardest by the pandemic. Now, we’re Strategic Homeland Division agents patrolling the disease-ravaged remains of The Division 2’s Washington, DC.

On this particular night we step outside the presidential fence and amble down one of the wide boulevards laid out by L’Enfant, ignoring the rattle of a firefight and the screams of civilians down the next block.

The capital city is battered and filled with detritus, but DC’s buildings still stand. The sickness took thousands, and those who could, the wealthy and well-connected, fled the city, leaving the remaining citizens to a grim fate.

The first Division game, set in New York City, explained the origins of the pandemic. A sociopathic ecofascist virologist obsessed with social Darwinism created a fast-spreading, highly lethal respiratory virus, a strain of influenza (or, depending on the in-game source, oddly, smallpox) dubbed the “dollar flu.” This infection was an unnatural plague, designed as a terrorist weapon to hasten the end of humanity. The sinister scientist infused the virus into cash passed out in Manhattan during Black Friday. The infection spread like wildfire.

Civic unrest soon followed.

Respirators and other breathing masks are plentiful in the post-pandemic New York City and Washington, DC, of The Division series (Illustration: Ubisoft)

In response, the government quickly deployed the Catastrophic Emergency Response Agency, the in-game version of FEMA, and the Joint Task Force, a military initiative coordinating active duty units and the National Guard. Their mission: to provide relief efforts to beleaguered hospitals and enforce a strict national quarantine. CERA and JTF found themselves quickly overwhelmed, and in one of the last official acts before his mysterious death, the president invoked the “Strategic Homeland Division,” or SHD, an ultra-classified band of secret agents embedded in the populace, ready to take up arms to maintain the continuity of government.

Now, seven months after the dollar flu erupted, the largely abandoned city of Washington, DC, is occupied by duelling terroristic factions, with civilian survivors caught in between. (Twisty terrorist plots, mysterious federal agencies, heroic clandestine operatives: These signature elements mark The Division games as part of the sprawling multimedia empire loosely inspired by the weighty doorstop novels of late arch-conservative technothriller writer Tom Clancy.)

Matt and I head over to the battle-scarred fields of the National Mall, where a Division agent, Brooks, has put out a distress call. We rappel into a partly collapsed underground parking garage to aid our wounded fictional colleague in a brutal battle against a group of paramilitary thugs. I deploy a self-targeting automated gun turret. Taking cover nearby, Matt rolls out a protective body armour-restoring device called a hive. With complementary combat skills we’ve become a reliable two-man team. We quickly make our way through the ruined garage, killing waves of enemies, until we reach ground level. The day is ours, and so is the federal relief camp we emerge into. With friendly forces moving in to take custody of the area, Matt and I look around.

I spot CERA shipping containers and trucks, once laden with medical supplies and food. Stripped bare, they now form the camp’s protective barriers. Similar trucks with bold CERA insignia rest abandoned in intersections and parking lots throughout the game.

The most prominent trucks outside the real hospitals of New York are the refrigerated trailers we’re using as temporary morgues. A hospital social worker friend of mine took a picture of one. You can still see a faded Walmart logo on the side.

Throughout the parking garage mission I’ve torn a lot of loot from my fallen enemies. I’ve grabbed more sturdy, high-tech, long-wearing protective respirators in this one 20-minute side adventure than I’ve been issued real disposable N95 masks each day at the hospital. (To this day, I still only get one N95 mask per day, and only if I ask.)

In the game, heavy protective suits with self-contained breathing systems hang forgotten on the walls of abandoned labs and field hospitals.

In real life, the hastily refitted critical care units I work in are partitioned with plastic sheets and duct tape.

Two weeks into my first month of coronavirus. I stopped meeting my patients’ families.

Visitors were quickly banned from most New York hospitals, due to concern for the virus spreading. One day I was following a coronavirus patient, Mr. Diaz (I’ve changed his name and those of other patients in this article). Critically ill, his desperately failing lungs were supported by invasive mechanical ventilation, his other organs besieged by the virus. Looking again at a chart that had become painfully familiar, I reminded myself that he was 83 years old, and that his health had been declining for years as his chronic diseases compounded themselves.

At noon I called his oldest son, who’d taken responsibility for making decisions on behalf of his incapacitated father.

“Right now, your father is too sick to tolerate regular dialysis, so the next option is something called continuous hemofiltration. It does the same thing that regular dialysis does, removing blood from the body and cleaning out the toxins that his kidneys would before the virus injured them, but it does it slowly, more gently, over twelve to twenty four hours. I’ll need your permission to start this process, but I have to be frank with you: “Patients with the severe lung injury your dad has who also have kidney damage, and at his age… they haven’t done well.”

I thought I used to be good at breaking bad news to patients and families, but I don’t know how to tell him that every single coronavirus patient I’ve seen in the intensive care unit and who has needed emergency dialysis has died. Continuous hemofiltration, despite being theoretically better for the critically ill compared to my standard therapies, hadn’t helped either. The intensive care doctors running this unit told me they didn’t feel optimistic about Mr. Diaz’s prognosis. They’d seen this same story play out over and over the past two weeks, and it always ended only one way.

I listened as his son told me his dad is a fighter. He had made it through a heart attack and diabetes, and his family believed he’d pull through, and we should do everything in our power for him.

At a quarter to five I got a call from a critical care resident in that Covid ICU, one of four such dedicated units. There was a problem with the hemofiltration for Diaz. According to the nursing supervisor only one machine was available. They hadn’t started on Jordan yet. What should they do?

Mr. Jordan was 37 years old. He was drowning on dry land as his lungs disintegrated, filling with fluid as the virus attacked, barely able to exchange oxygen even with the most aggressive ventilator settings pushing air into them. His kidneys shut down days ago, first dribbling out blood in the little urine they could make, and then just giving up, leaving water and waste alike trapped in his failing body. Like Mr. Diaz, he was too sick for traditional hemodialysis, his blood pressure barely sustainable, heart racing like a hummingbird’s.

I’d asked the ICU to start continuous hemofiltration on him this morning. Like Mr. Diaz, he would surely die without the machine imperfectly substituting for his kidneys. I didn’t know when. I didn’t even know what his face looked like, since his bed was concealed by cloudy floor-to-ceiling plastic sheets to lock away the virus. (The resident I met in the ICU grimly compared the scene to something out of Resident Evil.)

Mr. Jordan had seen his doctor just recently, and had received a clean bill of health outside of needing to lose some weight. Why a man so close to my age was on the brink of death in the hospital while I stood spared, I couldn’t say. The ICU doctors didn’t feel optimistic about his prospects, either. The damage to multiple organs was too extensive, too severe. Trying to support his virus-brutalized kidneys with dialysis might at best give him a few more hours, perhaps a day, unconscious in a medically induced coma, until his shattered body reached an inevitable tipping point.

“Fuck, you’ve gotta be kidding me,” I said. “They’re both pretty fucked up… We, uh, we should do Jordan first. I’ll… figure something out for Diaz and get back to you.”

I didn’t have anything else.

They both died by the next morning.

Another night and I’m back in the game. Matt dashes ahead to an alley just off of F Street in downtown DC, perhaps three blocks east of the White House. We’re tracking a bounty.

“Dude, if you keep running ahead like that of course you’re gonna pick up the aggro,” I say, reminding him (as he knows damn well) why every enemy nearby had their guns trained on him . “Hold on, I’m comin’ for ya.”

I dart down the alley to behind the dumpster where Matt lay sprawled, weakly waving his hand. Bullets ping off metal. The space is a little snug for two federal agents against a mob of True Sons out for blood. Of course, blood is my currency, too. There’s no arresting anyone in this game: It’s a gunfight every time. I always bring back my marks dead. But at this moment I had to revive my wounded buddy.

“I got you, I got you.”

I hold down mouse button five, hearing a reassuring whirr as I resuscitate him. A round progress bar encircling his body fills with green. He stands and dusts himself off.

A cheerful chime rings out and a notification pops in the corner of my screen. “Hey, did I get some XP for that? Sweet.”

Resuscitation in the real world, of course, isn’t a smooth, one-button exercise. The gritty 2008 first-person shooter Far Cry 2 and its sequels have a more grisly approach to injuries, making you hastily wrench out still-sizzling bullets from flesh with pliers and taping over the wounds before slamming an ampule of morphine. I suppose The Division’s operatives have some sort of magical nanotech that instantly seals and heals major trauma; the lore doesn’t explain.

Attempting to revive someone in real life is, of course, tougher than just pressing a button. We fail at it a lot, and that failure is hard to process. Death is, naturally, a regular part of working in a hospital. Learning how to live with it, to come to terms with it as best you can, is part of the silent curriculum of medicine, the things no lecture or textbook can teach you.

To give you a sense of the scale of death we’re seeing, the human cost of this pandemic, I want to share a typical scenario with just one person in extremis, a scenario that played out dozens of times in my training. A scenario much like my colleagues now face up to a dozen times a day.

Flashback to before the virus came and changed everything. Step into the shoes of a resident physician in internal medicine.

It’s 4 p.m. and you’re sitting down to eat for the first time that day. You’re starting to open the graham crackers and chocolate pudding you lifted from the unit pantry but first you hear the hallway speaker calling out the alert for a cardiac arrest and realise with horror that the room number is where your patient is, but you just saw him this morning and, while he didn’t look too great, he didn’t look too bad, either.

You abandon your food and speed walk down the hall and up the stairs and around the corner. Running is always a bad idea in hospitals, with far too many things to bump into or trip on. Not to mention that it would be deeply embarrassing to be admitted to your own workplace.

Your patient’s lying there in his bed, looking waxen, with a burly young intern rhythmically plunging his hands deep into the old man’s frail chest. A nursing aide stands awkwardly next to a portable vital signs monitor that chimes constantly: heart rate zero, blood pressure unreadable, oxygen level critical. Ping, ping, ping.

The critical care attending physician is already there, a dark look in her eyes, calling out time until the next pulse check, asking where the fuck the primary team is. Primary team: That’s you. You flip through the patient’s chart on your phone, explaining that his pneumonia had been getting better, he had needed less oxygen, his labs only had some minor abnormalities… well, mostly minor.

Interns are forming a line to take turns on chest compressions. Nurses pass medication vials from the crash cart. The white line of the EKG on the defibrillator only shows some vague wriggles (but it doesn’t beep, or emit a long tone when there’s a flatline; no one ever turns on that feature). There’s no point in shocking him. The heart’s electrical system isn’t the problem right now. The anesthesia team shows up, here for an advanced airway. They pry open his slack mouth the moment the respiratory therapist pulls away the oxygen mask, probing deep into his throat with a broad metal hook. Haltingly force a thick plastic tube down his airless trachea, lifting and pulling and pushing aside those thin flaps that gave him a voice once, in better times.

Time passes. The petite intern now doing chest compressions can barely reach over the bed. Someone finds a footstool for her to stand on, but no one can shuffle it underfoot.

A code is called a code for a reason. You follow an algorithm. You do certain things in a certain order over and over, hoping this round will be the last. But even if they’re well organised, somehow codes always feel chaotic. Maybe it’s the rubberneckers standing around in the hall, other nurses and doctors peering through the door, watching and wondering, whispering that he was too old, too sick, this is wrong, but what can you do about it?

Fifteen minutes go by. Pulse check. Not even a faint flutter in the heart. Five minutes ago this already passed from terrifying to monotonous. People are sweaty and tired. Side-eye is spreading. Can we be done? The critical care attending says she’s calling it. The resuscitation team that came together starts to drift apart, heading back to their day jobs. Maybe it’s better this way. His suffering is over now, instead of prolonged for a few miserable hours before the end.

Sometimes you do a debriefing to review how everyone did, but not tonight. No one calls out a time of death. You look up at the clock on the wall and write it down. You’ll need it to file the death certificate before you leave for the day. Hopefully the chart’s cell phone number for the next of kin is correct. Hopefully they’ll pick up.

Those fortunate enough to survive cardiac arrest without major brain damage often suffer depression or post-traumatic stress disorder even months afterward. I’m hardly surprised: The powerful medications that we administer in massive doses to restart the heart are the same chemicals the body makes to invoke the fight-or-flight response, our most base animal instinct. But the trauma for those participating in the code is more insidious. Self-doubt creeps in. Did you miss something that led to this? Could you have prevented it? Done a better job saving him? And if a stopped heart was inevitable, perhaps for someone racked by incurable cancer or terminal emphysema or destroyed liver, did you just ensure that they died alone, violated by needles and tubes, in a long spasm of fear and terror and pain? The patient and their family said they wanted to live at any cost, and now you’re left to tally up the bill.

Each failed resuscitation you’ve participated in, and most of the successful ones too, tears at you a little. You have to find your own time to grieve, because the job certainly doesn’t give you any. Sometimes it’s staring at the sorrow in the mirror, alone. Sometimes it’s a toast after your shift with your comrades in arms, raising a glass with Edgar Allen Poe’s last words: “Lord, have mercy on my poor soul.” For your patient, or for you? Perhaps both.

Once a month, once every few weeks—infrequent but unfortunately still expected—is already too many to bear. Now you deal with it several times a day.

Back in Washington, DC. After the dollar flu.

We reincarnate at the Theatre Settlement, one of two major civilian encampments holding out against the chaos. Before going back out to the free-fire zone where we met our temporary demise, I stop to admire our handiwork. This once-shoddy fortress of the desperate and destitute now features a hydroponic herb garden, a children’s play area, even a pirate radio station. We’ve unlocked each upgrade over hours of gameplay, battling through story missions and clearing enemy outposts. The civilian settlement’s tough-as-nails leader, Odessa, is a former SHD agent herself, sidelined by a combat wound that cost her a foot. The PA system plays announcements she recorded, words of pride at her people’s resilience, their accomplishments together to build a home (with just a little heavily-armed help from us). Smiles and cautious optimism replace the downcast eyes and fear that met us when we first came here.

The Division 2 (Screenshot: Kotaku, Ubisoft)

But it doesn’t feel like the living, vibrant District I knew, a DC I still love: a city proudly majority minority, welcoming and growing with immigrant communities, sharing a living legacy of arts and culture and cuisine. The city where my adult life really began. The District of gin rickeys and half-smokes, the home of Bad Brains and Fugazi and Duke Ellington. The first home I had unsupervised by parents or the structure of college life. A District that couldn’t be further from the besieged museum city where Matt and I regularly put down armed insurgents by the dozens.

Almost none of this side of DC seems to have made it into The Division 2, and whether out of ignorance or by design this was probably a wise choice. The Washington of monuments and legislators belongs to the public imagination, but the District belongs to the people who’ve made their life there, carrying the city’s memory and history on their shoulders. I only caught a glimpse of its heart in my short time there.

On our way out of the settlement, as the gate lifts, we hear one of the recordings that hasn’t changed since we first arrived. Odessa warns visitors that if you need a place to stay, go elsewhere; we can give you food and water for the road but traveller, you will find no solace here.

With the global spread of the coronavirus and the faltering response of the American government, The Division 2 has unavoidably become a mirror to current events and public policy, a game with inherent political messaging despite a few prior, feeble objections from its creators. Of course, video games have always been political. From the already-dated frontier thesis mythology of Oregon Trail, to the delightfully unsubtle Martian analogue of the Iraq insurgency in Red Faction Guerrilla, this is not a challenging concept to comprehend.

Of course, medicine has always been political, too.

Every time I practice medicine I practice politics. Every time I’ve called a pharmacy pleading for my patient’s insulin not to cost as much as their monthly rent. Every time I’ve told someone their kidneys are slowly failing and their life is about to change forever and we have ways to keep them alive and kicking, but I can’t offer them the best and ultimately cheapest treatment—a kidney transplant—due to their immigration status.

Now it’s every time I ask my nursing colleagues to put their health, safety, and families at risk by dialysing a virus patient who might not survive anyway, wondering if I’m denying someone else a chance at life instead. Now it’s when my resident physician colleagues, working for New York’s largest and wealthiest hospital systems, ask for fair hazard pay for the backbreaking, heartbreaking work we trainees all risk our lives to do now for barely above minimum wage, only to see their pleas coldly dismissed by senior leadership.

Did it matter that I fully upgraded the Theatre Settlement if Odessa is still turning refugees away?

The Division 2 (Screenshot: Ubisoft)

Here’s a puzzle for you.

You’ve spent the day at a hospital that’s full of Covid patients. SARS-CoV2 floats through the air. It sticks to surfaces, remains infectious there for… hours? Objective: Get home without bringing any virus with you.


  1. Wash your hands, soap and water, 20 seconds minimum, dry with a paper towel, then turn off the faucet with the paper towel and gingerly open the bathroom door with the paper towel etc. etc.

  2. Get alcohol swabs. Wipe down your phone, your ID, your shoes, the computer keyboard, the office phone, anything else you think you might have touched.

  3. Get home. Take your shoes off before you open the door. Take off your scrubs and toss them in a special bin. Take off everything else, hell, put it all in the bin. Wash hands again. Take a shower.

  4. Oops, you forgot to clean your pager.

  5. [Dark Souls-style] YOU DIED

Maybe I’m fatalistic, but I haven’t been doing most of these things. I wash my hands with care, of course, and spritz alcohol sanitiser foam in my hand every time I pass a dispenser in the hospital hallway. I strip off my scrubs when I get home, and they go in the regular hamper (the floor). I don’t wipe off my shoes. Why do all this hygiene security theatre when I’ve already been in a building guaranteed to have coronavirus patients, working in a shared office just down the hall from a Covid ward? Each step past washing your hands and changing clothes has diminishing returns.

That said, I can probably afford to be a little more cavalier than most. I have the good fortune of being able to do most of my work without direct physical contact with patients, and I need not fear infecting loved ones at home, since my only roommate is a cat.

Sunday morning. Matt and I wander Foggy Bottom, on our way to finding a hidden cache of SHD technology, when the building we’re approaching through the fog, a curved modern facade next to a plaza with a Metro station, strikes me with a sudden sense of familiarity.

“Matt, that’s the George Washington University Hospital… I had a fellowship interview there last year. I was here.”

The virtual hospital, whose real-world analogue is famed for treating presidents, senators, and cabinet secretaries, now sports the red biohazard icon that denotes a quarantine zone. Each zone has a dark nickname; this one’s named “The Slaughterhouse.” Silent ambulances are parked haphazardly on the curb, empty stretchers tipped over.

There’s a quip I used to tell new interns as a senior resident, my weary thousand-yard stare greeting their fresh faces. “I thought I had seen some shit in med school, that I knew how the medical sausage is made. Guess what: I was wrong. I didn’t know nothing. Today, you’re starting work in the slaughterhouse. Get ready.”

Was that really only a year ago? It feels like so much longer, now.

“You know what, Matt, I don’t think I’m ready for this. Let’s go find a control point or something to raid instead.”

Another afternoon, four weeks into the coronavirus outbreak.

I went to the emergency department to speak with one of my patients, hoping I could just shout my handful of questions across the hallway at her. The place was crammed with stretchers, coughing patients everywhere. I was wearing my N95 mask (covered with a surgical mask), a hair net, and a plastic face shield. I hadn’t planned to get closer than six feet from her, but unfortunately she was dozing. Next to her was a man freshly intubated, occasionally stirring to gag and gnaw on the tube driven down his throat. I asked a resident if I should get a gown before I moved closer to wake her up. He told me that I was already in the worst place in the hospital. It didn’t matter at this point.

These days I try to avoid physically seeing patients unless I absolutely have to. Those are the orders from the top to minimise staff exposure. I recently called a patient on her cell phone to ask how she was feeling. She was staying in a hospital room two floors up.

For all of us, here on the front lines, it feels like it’s not a matter of if, but when we get infected. Two of my close friends I trained with in residency are infectious disease medicine specialists, one in Manhattan, one in New Orleans. Every time I don’t hear from them for more than a few hours I wonder if the virus has come for them. Are they gasping for breath on the floor at home? Imprisoned in a drug-addled sleep in the ICU, a machine forcing air into their clogged chests? Maybe they just got busy.

Every scratch I feel in my throat, twinge I feel in a joint, ache in the back of my head: Is this the harbinger, or do I just need to get a good night’s sleep? Perhaps I already had the virus and didn’t notice, the infection coming and going silently like a burglar casing the joint and finding nothing worthwhile to steal.

Word is that anosmia—losing your sense of smell—is an early and sensitive sign of an active infection. I try to go find things to smell to make sure I’m still alive, and remember what they’re like if the day comes when I can’t.

One sense video games have hardly ever engaged with is smell, I suppose for obvious practical and technical reasons. Probably not a bad thing, as Matt and I tactically advance down the hallway of an abandoned field hospital once run by the “Department to Control Diseases,” aka the “DCD.” It’s occupied by a faction called the Outcasts, whose motivations perplex me.

Apparently they want to weaponise the dollar flu virus, which was already created as a bioweapon, as some manner of elaborate vengeance? The mission coordinator is worried that they could find dangerous viral samples in improperly disposed bodies. There are plenty of bodies here: neatly sealed up in long black bags with the CERA logo, crude skulls spray painted on them, piled high in corners like so much garbage. DC isn’t known for its balmy summer weather, and I can only imagine the astonishingly awful odor this morgue turned pressure cooker must have (perhaps like gingko tree fruiting season).

A challenge in The Division 2 (Screenshot: Kotaku, Ubisoft)

The environmental hazard of countless marinating corpses passes without comment, as always, from the silent agents we play. I’ve killed 3,911 enemies in my time playing this game. Who’s been taking away all the bodies I’ve left in the street?

A group of yellow-jacketed Outcast goons charge in and we add a few more bodies to the pile.

The leader of the Outcasts is apparently an asymptomatic carrier of the dollar flu, which SHD leadership seems to think makes her a walking bioterror weapon of some sort. Asymptomatic carriers are not exactly uncommon with viral illnesses, or for that matter even some bacterial infections. The best known of those is the Irish immigrant cook Mary Mallon, notoriously dubbed Typhoid Mary. If I’m an asymptomatic carrier for SARS-CoV2, I might be putting all my co-workers at risk every time I go into the office we all share—but they could be asymptomatic carriers, too. Only those few of us who developed concerning symptoms have been tested. All negative—so far.

This crisis was a long time in coming, fed by short-sighted hospital and government policies over many years. “Lean” management strategies for staff and supplies, either to compensate for budget cuts or maximise revenue, created a perfect storm of perverse incentives. Frontline medical workers are at high risk of getting sick during a pandemic, yet highly trained, experienced staff like dialysis nurses and critical care nurses, already in short supply, aren’t easily exchanged or replaced. Nor are essential medications and equipment. One task every resident physician knows is keeping up with which commonly prescribed medications are on national shortage that month. Will it be an antibiotic, a sedative, an opioid, a heart medication?

Sometimes it’s as simple as the 100cc saline bags we use to reconstitute IV medications. These small plastic envelopes, which hold about a half-cup of sterile fluid, were missing for months in 2018 after Hurricane Maria devastated the supply chain of their primary American manufacturer in Puerto Rico. We learned to make do with substitutions and workarounds, like ordering alternative, sometimes inferior medications, or having nurses slowly infuse a syringe of medication by hand instead of with a programmed pump.

Compounding matters is the complex fee-for-service payment system for hospitals, in which revenue-generating enterprises like elective procedures, outpatient imaging, and cancer treatments essentially subsidise the cost of money-losers like intensive care units. Take away routine colonoscopies and suddenly the fragile financial balance collapses. “Safety net” hospitals in less affluent neighbourhoods and rural areas can’t compete against massive (often ostensibly non-profit) healthcare conglomerates, and have been regularly acquired (and then sometimes closed) by these medical giants. America’s long legacy of systemic racism created many of these inequities, and continues to sustain them—I’ve borne personal witness to this in my career. Caring for the sickest and most vulnerable people, with the least ability to pay, might be medicine’s most important mission, but it’s a poor business proposition.

For years, dedicated caregivers have found ways to keep things going, but the coronavirus has laid bare how broken the system really is. Under stress at every point simultaneously, the American healthcare apparatus simply can’t compensate. This week, anticipating running out of protective gowns, my hospital started issuing plastic ponchos instead.

We each received one poncho.

I’ve felt for a long time that 2013’s Surgeon Simulator is perhaps the most accurate depiction of the experience of practising medicine in the United States. Contrary to its name, Surgeon Simulator is an absurdist comedy game with an intentionally convoluted control scheme using individual keys for each finger of the one hand you use to awkwardly pick up surgical instruments and household tools to perform increasingly bizarre and complex medical procedures.

Surgeon Simulator (Screenshot: Bossa Studios)

It’s not unlike navigating the real healthcare system: Things that should be straightforward are made bafflingly, overwhelmingly difficult by a system seemingly designed to be as clumsy and discouraging as possible, and you drop things and break things and slap them back together and just hope that you didn’t do any permanent damage to someone who’s trusted their life to your flailing hands. You rage and laugh at the surreal efforts it took to do the right thing. Perhaps a claw hammer isn’t the best tool for a heart transplant, but that and a power drill and a coffee mug are all you’ve got.

I could always cope with the heartbreak before, believing that we could keep muddling through until it became obvious to everyone else that we couldn’t go on this way. I guess I never expected it would come so soon, with so much death in so little time.

The timeline of The Division 2’s dollar flu lore is at best confusing, but the in-game evidence of the federal government’s action at least seems like it was rapid, visible, and vigorous, in stark contrast to the Trump Administration’s disoriented and delayed response to the coronavirus. I’ve visited, in the game, sprawling quarantine refugee camps, abandoned wards filled with sophisticated medical equipment, mobile triage centres. Meanwhile in real life, confusion has marred even the better efforts of the federal and state government responses, like the drive-through viral testing centre that New York State set up in a parking lot in my neighbourhood that flatly refused to take people on foot or bicycle, in a borough where barely two in five households own a car. One pedestrian turned away was told to call a cab if she wanted a test.

Of course, all of CERA and JTF’s efforts are purely fictional. Perhaps these pretend lettered agencies were as sluggish responding to the dollar flu as FEMA and others have been with the coronavirus. Obviously they ultimately failed, since the game’s fictionalised New York City and DC are reduced to anarcho-primitivist hellholes.

Headlines from a virtual pandemic (Screenshot: Kotaku, Ubisoft)

For me, the most surprisingly painful fictions portrayed in the Division are of basic competence and preparedness. In this branch of the greater Clancyverse the dollar flu exploded, shaking the foundations of American society, pushing its brave civil servants beyond their already great efforts as the union collapsed. And out from the shadows, by secret executive order, steps the Strategic Homeland Division, ready and willing and able, trained and primed. It’s the very image of a state fully prepared for even unimaginable contingencies, and the very opposite of what we’ve just seen in real life.

That said, the America we see in the game isn’t exactly admirable. The core concept of The Division is alarming to even the most casual of civil libertarians. Its idea of thousands of sleeper agents of the “Deep State,” now activated and empowered with an indefinite mandate to act as judge, jury, and executioner in the defence of American society, is like something out of an Alex Jones fever dream. But as a premise for an open-world online game centred around collecting exotic firearms and warfighting technology to unleash against increasingly robust domestic enemy combatants? That works for me.

They knew this was coming, and they did next to nothing.

We were warned, we all saw the evidence coming right from ground zero, well in advance, and the president alternately dithered and raged during the weeks when intervention might have made a difference. In January his closest advisors frankly informed him of the possibility of millions of Americans dying should the virus spread unchecked. Epidemiologists estimate that implementing stay-at-home orders a few weeks, even just days earlier, could have cut deaths up to tenfold.

As the healthcare supply chain stretches to the breaking point, the president is encouraging rebellion against the very restrictions that are saving lives, tweeting “LIBERATE MICHIGAN” soon after small bands of protesters, egged on by conservative lobby groups, gridlocked the streets of Lansing, blocking ambulances entrance to a local hospital. Incredibly, the federal government is now accused of seizing shipments of protective gear ordered by hospitals and state governments and spiriting them elsewhere for mysterious redistribution after insisting that states are on their own to obtain equipment.

So here are two different models of a failed state: The Division’s, in which the crumbling state has lost its monopoly on violence, and ours, the fatally embarrassing confusion of a state stripped of expertise. I’m not an economic analyst, epidemiologist, or any sort of special expert on public health or healthcare administration (outside of a policy class in medical school). But it seems pretty obvious that a coordinated, effective response to a pandemic disease isn’t supposed to look like this.

Trump, and perhaps a distressing proportion of the American public, have decided that qualifications are meaningless. But deciding the experts were overrated came with heavy collateral damage.

After this is all done, the last of the mass graves tilled over, the curve flattened into oblivion, will there be an equivalent of the 9/11 commission, delving into the systemic failures and willful, arrogant blindness that led to tens, perhaps hundreds of thousands of Americans dying?

Maybe instead of demanding accountability it’s just easier to imagine a conspiracy in which the virus is the singular product of a deranged scientist, and a highly prepared and technologically adept secret arm of government already has a strategy to fight back, with plans upon plans and scenarios prepared all the way up to and beyond the collapse of contemporary civilisation.

If only we could blame this all on something so simple as a conspiracy. In the real world, no one designed the coronavirus, no monologuing villain unleashed it. There’s no Deep State waiting in the wings to save us when all hope is lost. The institutions that were meant to protect us against the biblical threat of plague were instead deliberately and systematically dismantled for reasons of greed and cowardice, experience and expertise thrown out and replaced by obsequious incompetence, in a decades-long project that has now inevitably resulted in avoidable catastrophe.

Now, all we have is each other.

Friday night, my first full weekend off in a month. Matt and I find ourselves on the Mall, as I stare utterly flabbergasted at the neoclassical edifice housing the Smithsonian’s National Museum of Natural History, apparently transformed into a dedicated flu field hospital, exterior wrapped in quarantine-yellow tarps like a Christo installation. The entrance is protected by an airlock with a searing ultraviolet biocidal light. My hospital doesn’t have an airlock! (We probably don’t need one, virologically speaking, but still.) We drop down and move inside, automatically putting on respirators as we cross the border. Just five minutes ago outside we were in a brutal firefight, and I keep checking the angles for hostiles, but the only thing here is the eerie quiet of the tomb.

For a tomb is precisely what this place is. Bodies wrapped in shrouds, neatly stacked. Humans now as extinct as the dusty mammoth in the foyer.

The Division 2 (Screenshot: Kotaku, Ubisoft)

The murmur of voices leads us into a deeper room, faintly glowing with the dim light of life. A lone nurse still stands vigil here, tending to a scant few patients yet suffering from the flu, asking for any help we might provide.

The game tells us our goal here is to find three audio recordings, to hear them and remember the voices of the dead, to bear witness to the grief and loss each and every survivor still holds within.

We gather our collectibles and leave as silently as we came.

Games have been a part of my life from a very young age. They’ve brought me some of my most joyous memories, and helped me through some of my lowest hours.

In these grim days of social distancing, playing The Division 2 has been my way to reconnect with friends, to put aside for a little while the awful things I’ve seen that day, and to chuckle at how darkly appropriate it is playing a game set after civilisation is destroyed by a pandemic. Three dollars well spent.

Regarding my work, I don’t want to give the impression that tragedy’s my only lot. I’ve witnessed quite a few of my hospitalised Covid-19 patients perk up and go home on their own two feet. Facebook friends have reported how they suffered through the symptoms at home and are now back to baseline. And my own hospital liberated its first two critically ill viral patients from the ventilator about three weeks ago after they slowly but steadily improved, hopefully for good, and hopefully the first of many.

Two nights ago, I finally got around to something I’d been avoiding for almost a month: I pulled a certain patient’s chart to find out if they’d survived. It felt unbearable to think he might’ve suffered another intubation, forced to depend on mechanical ventilation for what would likely prove his final hours. But my fears didn’t come to pass. He went home, alive and well, a few days after regaining the ability to breath on his own.

Still, the tragedies are what stick with me, and the hurt never really fades.

I could always cope with the heartbreak before, believing that we could just keep muddling through until it dawned on everyone that we couldn’t keep going on that way. But I guess I never expected that moment would come with so much death, and in so little time.

“I know, but what do you want me to do? I mean, seriously Jon, let’s get real, what do you want me to do?” —Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases

¯\_(ツ)_/¯ —Emoticon, frequently seen as graffiti in The Division 2

Siddhartha Bajracharya is a nephrology fellow in Brooklyn. Look for his gaming and culture thoughts at @postwaranemone.


  • Wow. This was excellent and frightening.

    And it also makes me want to go play The Division 2 some more (I barely played any, but then it didn’t seem like real life at the time).

    • As someone with a science background (including lab work on malaria way back in my yoof) I love a good pandemic bit of fiction, but I was enjoying the Division a lot more when we weren’t having daily pandemic bulletins on the news…

      …still in and out a bit though. If you’re PS4 then I could be persuaded to provide covering fire or cannon fodder…

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