The Covid-19 crisis has exposed care labour at its limits. While often naturalised or attributed to obligations of family and the state, care work in the context of medicine combines the clinical dimensions of medical care with the emotional, bureaucratic, and ethical work associated with making medicine possible. It is frequently under-compensated.

Whether carried out by families of patients, by a wide array of actors inside hospitals, or beyond the hospital, closer attention to these forms of care is crucial for redressing the toll of the pandemic across individual, familial, and institutional scales.

Care labour’s uncertain status derives partly from its multiple sources, and recently has manifested in widespread social media requests for oxygen, medicines, and hospital beds by families searching for any possibility to care for their loved ones. The incredible efforts of Good Samaritans during the pandemic demonstrate care ethics in the face of calamity, but should also cause us to pause and ask what horizons these ethics point towards.

In my research on public hospital health care for traumatic injuries in India, I observed that “the injury” was only part of the problem at hand for patients, families, and health care workers. It is one thing to focus attention on the clinical issue as the problem. But moving the problem is also important. How does one make a bed available? Who will transfer patients from the site of injury to the site of care?

When and under what conditions can relatives visit? Doctors will conduct rounds at certain times of the day, moving from patient to patient to assess what must be done. But every hour, in rhythms of regularity and irregularity, nurses and service staff move between the beds, too, bringing care to the bedside. Medicine is a problem of what to move and when. Managing these movements is often the locus of clinical labour and “the pandemic” might be understood as a vital choreography with uncertain outcomes.

Social faultlines

We can see, for example, that public health infrastructure is in dynamic relation to matters of access. Health care access often breaks down along social faultlines such as gender, caste, class, and community. As the pandemic’s toll continues in rural communities, these divides may intensify and shift. Access is also a matter of labour in motion. By law, most public hospitals cannot refuse admission to patients.

But if certain technologies such as ventilators or beds are truly unavailable, best practices dictate that a hospital worker refers the patient and their family to a nearby facility. Given the systemic strain posed by Covid-19, “care” is becoming synonymous with “referral,” with patients and families sent all around cities, towns, and villages in search of drugs and available hospital beds. Efforts to secure vaccines are often in sync with these itineraries.

Meanwhile, for someone with severe coronavirus infection, the clock ticks on their oxygen saturation or critical clinical signs. A patient’s family members constitute a critical but undervalued infrastructure of care work. This work unfolds during the uncertain times of finding testing for Covid-19, of connecting to a health care provider to understand if hospitalisation is necessary, of identifying a hospital with an available bed if it is, of absorbing the ups and downs of a patient’s status during treatment, of discerning truth and rumour to understand what might work as a treatment, and — too often — of facing the world-shaking consequences of a family member’s death. These kinetics of caring for Covid-positive loved ones begin in the act of securing even the most basic of health care entitlements, which can be an uphill battle and a hunt through a maze.

The time invested in this labour pulls on other forms of daily wage labour, as caring for someone with Covid-19 means that spaces and times of work may shift. Covid-19 rescripts daily rhythms and responsibilities in relation to the home and hospital. The disease’s often-oscillating clinical patterns, wherein patients’ vital signs will get worse and then better and then shift again, require constant vigilance. Leaving for day labour or tending to household labour can become impossible.

Maintaining watch

Often, the labour of maintaining watch over one’s family member may get distributed across family members in an effort to have the least-bad impact. This is true for family members both inside and outside India, as members of South Asian diasporic communities are under immense strain as they support their families in India. Via WhatsApp and phone calls at all hours of the day and night, family members are navigating vaccine websites, attempting to source oxygen, and scrambling to communicate with health care workers caring for their loved ones.

Whether enacted from outside the hospital door or across the ocean, their care at a distance is an essential yet fraught aspect of moving pandemic labour. It must be understood in terms of work, and as costs to work.

These matters have become ever more visible during Covid-19 and manifest in multiple, overlapping labour relations between families and hospitals. Once a patient with Covid-related symptoms arrives to a hospital, they will face an array of hospital workers. Social scientists who document “the doctor-patient relationship” often overlook the numerous actors that enable medicine to happen, from nurses, orderlies, chemists, lab assistants and technicians, to sweepers and clerks.

These positions are themselves subject to gender, class, and caste differences. While these health care workers belong to different classes of employment in the hospital system, with specific compensatory affordances and protections, they all are key to making “care” happen, both formally and informally. They calibrate ventilators, check IV drips, carry referral notes, transport patients between wards, and cook and deliver food. They check oxygen tank levels, dispense and ration medication, and manage the blood bank. They sweep the floors, clean equipment, and — under the extraordinary infection control demands of the pandemic — sterilise surfaces. They move medicine so that patients can live.

Patient loads

Given the hierarchical nature of medicine, whereby junior doctors and nurses are often tasked with the heaviest patient loads and are pulled between beds, they may have the most frequent and in-depth contact with patients and families. They may become confidants or advocates for specific needs, doing the listening when no one else can or will. They may be both the right and left hands of the state, given that so much Covid care unfolds in public institutions.

Their labour suffuses a patient’s stay, and some of it continues after death. Some morgue workers have begun informally conducting “WhatsApp funerals” for family members unable to reach the hospital to bid their loved ones goodbye. Care has costs, however. The most frequent patient contact may mean the most extensive exposures. When PPE supplies run short, it is often the lowest class of health care workers who must ration their protections, and who endure increased exposure risks to themselves and their families as a result. Moving medicine means being exposed to the very problem medicine is attempting to treat.

A core aspect of the pandemic in India, and elsewhere, is the health care work implemented outside of hospitals that parallels the efforts undertaken inside. Vaccinators, ASHA workers, testing center workers, and contact tracers are a critical infrastructure of the pandemic. So, too, are the community-based supporters who are delivering tiffins, cooking and distributing langar , and providing home-based care for Covid-positive persons. Auto wallahs who drive patients and families to hospitals, along with ambulance drivers, make care happen too. They endure exposures and overburdening too, and their work must be recognised and protected.

Preventable death

Once one begins to see care in terms of moving labour, it becomes harder to blame illness alone as the source of affliction and the site of its possible treatment. The notion of “preventable death” is often framed in policy conversations as access to treatment; it must also be framed in terms of unequally moving ecologies of care. Too often, we overlook care labour and the need to compensate it when we describe overtaxed medical systems.

This is especially true in contexts wherein care labour shores up resource shortages. Greater value must be placed on the work of nurses, technicians, orderlies, cleaners, and morgue workers in hospitals, as well as the extraordinary efforts of patients’ relatives to secure and fund care. Without these workers, hospitals would grind to a halt and the efforts of patients to breathe and endure would be ever more threatened.

When policymakers discuss rebuilding health care capacity after the pandemic, the discussions often center on vaccines and physical infrastructures. These are crucial. But, equally important, must be discussions about better compensation for care workers who make medicine happen through movements. Programmes are underway to address better compensation for health care workers, but securing the resources they offer remains difficult.

It is not just generic care work that is on the line; the lives of care workers are at stake, too. The lives and labours that constitute the pandemic’s damages must be reckoned together. You can add a bed to a hospital, but caring for the person in the bed is another matter. The impressive techno-wizardry of vaccines does not release us from the collective duty to remember that human beings are our first responders in this crisis.

The writer is Associate Professor of Cultural Anthropology and Global Health at Duke University. This article is by special arrangement with the Centre for the Advanced Study of India, University of Pennsylvania.