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\begin{document}

\title{Touch in the Era of COVID-19}



\author[1]{Shilpi Mehta-Lee}%
\affil[1]{NYU Langone Health}%


\vspace{-1em}



  
  \date{June 07, 2024}


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I moved out of our shared bedroom of nearly 10 years on 3/22/2020. It
was not a difficult decision as we have two young children and wondered
what would happen if both of us became ill at the same time. As a
Maternal-Fetal medicine physician in New York City, I was acutely aware
of the coming COVID-19 crisis, and its potential ramifications on the
health of my family, friends, patients and community. I am trained to
function well in emergencies, and in this case, it was a quick and
seemingly logical next-step to sleep separately.

This decision also comes along with an already in place full-scale
decontamination effort that begins as soon as I enter our home. This
involves minimizing what jewelry, clothing, food and bags go back and
forth between the hospital and my home, 3-shoe changes, stripping off my
clothing and placing everything into the wash, and then running to the
shower. None of these choices were rooted in years of medical science,
given the novelty of the virus, and paucity of data on the SARS-CoV-2
(COVID-19). I used early data regarding transmission as well as
anecdotal reports from friends in Asia who seemed to suggest that it was
highly contagious and highly transmissible. Thus, when I recently
learned that there is a science and a history surrounding how pathogens
have shaped human psychological adaptations. As we are forced to
confront the longstanding evolutionary pressure of pathogen avoidance
regarding what to eat, and touch and who to be intimate with, it no
longer feels theoretical.\textsuperscript{1}

Looking back at what I've gained and what I'm missing over this last
month, I am acutely aware of how much less we are touching as a family
and in my medical practice, and I miss it. As I say goodnight to my
family and retreat to our windowless den, I am both thankful for a place
to sleep that is near enough to be able to peek at their beautiful
sleeping faces, while sad that I feel less at ease hugging or kissing
them. While every health care worker on the front-line of this crisis
has drawn different boundaries (some more or less extreme), my decision
to sleep in a separate room, create a decontamination routine, and be
less physically affectionate with my children was the only way I could
feel in control in an uncontrollable situation.

Medical professionals know that touch, rooted in the amygdala of the
brain, cannot be separated from the expression of empathy and solidarity
that it provides.\textsuperscript{2} In medicine, touch has long been
hypothesized to have an impact on health and development over our
lifespan. Dr. Cascio and her team at the Vanderbilt Kennedy Center for
Human Development describe social touch as ``a powerful force in human
development, shaping social reward, attachment, cognitive,
communication, and emotional regulation from infancy and throughout
life.\textsuperscript{3}'' Many of the babies of the mothers I care for
will begin their lives in the Neonatal Intensive Care Unit where the
science surrounding touch as part of healthcare is widely accepted and
engrained in the culture. Skin-to-skin and kangaroo care, the act of
carrying your child in a pouch-like device, have been shown to improve
breastfeeding, bonding, and neurocognitive
development\textsuperscript{4,5} In fact, the World Health Organization
currently has an ongoing international trial looking at the benefits of
survival on low-birthweight infants of kangaroo care initiated
immediately after birth on survival of low birth weight
infants.\textsuperscript{6} Later in life, touch, relationship quality
and intimacy continue to drive good health and have been associated with
improved cognitive function in the Rotterdam
Study\textsuperscript{7,8}and improved cardiovascular outcomes in the
National Social Life Health and Aging Project.\textsuperscript{8} Their
findings suggest physical touch may have positive health implications
for older adults.

Prior to the pandemic, physicians were already sounding alarms about the
loss of medical touch in modern medicine. In a 2011 TED talk with over
1.7 million views, renowned author and physician Abraham Verghese
discussed the power of physician touch and the physical exam as he tried
to revive the culture of bedside medicine.\textsuperscript{9} With this
pandemic all of that has changed. We are all exceedingly careful to
prevent transmission and yet try to provide care and solace in new ways.
At the bedside, a gloved hand continues to provide care and comfort. I
am happily finding ways to connect with patients through smiling eyes
behind a mask, and jokes or phrases that now replace touch. I find
myself more commonly expressing words of empathy in telemedicine visits
to fill in for the gaps that touch might have provided before. I ask
many, many questions to understand symptoms if I cannot see the patient
in person. Due to the surrounding events, I am undertaking the
fulfilling process of learning a new skill in medicine, to express my
emotions on a screen and affect patients' lives in ways similar to that
of an in-person visit.

As we raise our family in this time of pandemic, I am thankful that my
husband is doing ``double-duty'' in the realm of hugging and kissing,
and has always been a physically affectionate father to our children. I
try to tell them how much I love them with greater frequency and despite
the concerted effort there are days it's almost impossible to share our
apartment without being physically close. The psychological impact this
crisis will have on them is yet to be determined. I hope time will find
them healthy, more resilient and grateful at the end of this journey.

But tonight, as they sleep soundly in their beds for another night, I am
still saddened that I'm not doing the usual kissing and hugging as I
tuck them into bed, and it feels like a true loss, among the many
others. I am not sleeping as soundly these days for a multitude of
reasons including the guest bed, the strangeness of being alone after so
many years, and the exponential rise in screen time for work and media
consumption. I am truly hopeful we will return to a time when we can
more freely touch and care for the people we love and the patients we
value so much. In the simplest of internet searches, touch has so many
definitions. Touch can mean to be in close contact, but it can also mean
to affect.\textsuperscript{10} COVID-19 has affected us in innumerable
ways, and as healthcare workers navigate a post-COVID landscape, I'm
hopeful we can continue to innovate and find safe ways to incorporate
medical touch into a practice that will be forever changed.

\par\null

\textbf{Acknowledgements} : I would like to acknowledge our patients for
their immense flexibility in this changing landscape, the support of my
division and department, and my family. I'd like to thank Dr. Gwendolyn
Quinn and my husband David Lee, for their significant editorial
assistance.

\textbf{Conflict of interest statement:} Dr. Mehta-Lee has no conflict
of interest to report.

\textbf{Contribution to Authorship:~}This work was wholly conceived of,
planned and written by SML as a reflection on her state and feelings
after a month of living as a health-care worker during the COVID-19
pandemic.

\textbf{Details of ethics approval:} This work involved no research
involving patient care or patient information and thus is exempt from
need for IRB approval.

\textbf{Funding:} There were no funding sources for this work.

\par\null

\textbf{REFERENCES}

1. Lieberman D, Billingsley J, Patrick C. Consumption, contact and
copulation: how pathogens have shaped human psychological
adaptations.\emph{Philos Trans R Soc Lond B Biol Sci} 2018; \textbf{373}
(1751).

2. Singh C, Leder D. Touch in the consultation. \emph{Br J Gen
Pract}2012; \textbf{62} (596): 147-8.

3. Cascio CJ, Moore D, McGlone F. Social touch and human
development.\emph{Dev Cogn Neurosci} 2019; \textbf{35} : 5-11.

4. Kusko M, Benko R. Skin-to-Skin Contact for Improved Duration of
Breastfeeding. \emph{Am Fam Physician} 2019; \textbf{100} (3): Online.

5. Pineda R, Wallendorf M, Smith J. A pilot study demonstrating the
impact of the supporting and enhancing NICU sensory experiences (SENSE)
program on the mother and infant. \emph{Early Hum Dev} 2020;\textbf{144}
: 105000.

6. Group WHOIKS. Impact of continuous Kangaroo Mother Care initiated
immediately after birth (iKMC) on survival of newborns with birth weight
between 1.0 to \textless{} 1.8 kg: study protocol for a randomized
controlled trial. \emph{Trials} 2020; \textbf{21} (1): 280.

7. Freak-Poli R, Licher S, Ryan J, Ikram MA, Tiemeier H. Cognitive
Impairment, Sexual Activity and Physical Tenderness in
Community-Dwelling Older Adults: A Cross-Sectional
Exploration.\emph{Gerontology} 2018; \textbf{64} (6): 589-602.

8. Lee JE, Cichy KE. Complex Role of Touch in Social Relationships for
Older Adults' Cardiovascular Disease Risk. \emph{Res Aging} 2020:
164027520915793.

9. TED.Com. A Doctor's Touch. 4/16/2020 2011.
https://www.ted.com/talks/abraham\_verghese\_a\_doctor\_s\_touch?utm\_campaign=tedspread\&utm\_medium=referral\&utm\_source=tedcomshare.

10. Stevenson A, Waite M. Concise Oxford English dictionary. 12th ed.
Oxford ; New York: Oxford University Press; 2011.

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