Severely burned and at risk for HIV, Mary was isolated by the routine intended to protect her.

In the summer of 1998, Mary suffered second- and third-degree burns on her upper chest and arm, the result of an accident while freebasing cocaine (a practice that involves purifying cocaine with ether and inhaling the heated vapors). Following initial stabilizing treatment in the local ER, she was transported to a regional hospital that had a burn center. There the goals of treatment were to prevent infection, avoid further injury to damaged tissues, and close the wound as quickly as possible through primary excision (the surgical removal of necrotic tissue). Since blood loss from the surgical removal of dead skin is common and the cause of Mary's injury suggested a history of drug use, there was concern whether Mary might be HIV infected. At least 38 states require informed consent prior to HIV testing of a patient, even when a healthcare provider is at risk for HIV infection because of contact with potentially infected bodily fluids. Mary refused consent to HIV testing. At their initial meeting, the burn unit team noted Mary's refusal; they agreed to the presumption of a positive HIV status. Because of her refusal to consent to testing, and since a burn patient has a high risk of infection due to a compromised immune system, everyone was reminded to closely follow the infection control procedures governing most serious risk. These were posted on Mary's door. At a subsequent session, several staff reported that Mary seemed uninterested in her condition and uncommunicative, and she bordered on being noncompliant. A week or so later, at the nurses' station, a hospital volunteer hesitantly mentioned that she had no trouble communicating with Mary and revealed the patient was angry because she felt she was being treated like a leper.

To cross the threshold of Mary's room and provide care required something more than the usual perfunctory knock. There was good reason for caution: as a result of immune dysfunction, infections of burned skin are common, as are infections involving a burn patient's lungs and bloodstream. Because these last two carry very high mortality rates, patients must be protected from infection. Thus, infectious disease control procedures, posted on the door, dictated the manner in which a visitor should wash, glove, mask, and gown before entering Mary's room and how sanitary gear should be removed when leaving.

In the same way that rituals reify certain actions and set them apart, the infection control policy's flip side was that it served to set Mary apart. It erected physical and psychic barriers between caregivers and patient, barriers symbolized by the sign on the door, the procedure itself, and the thin layer of latex and gauze separating patient and caregiver. In this case, the one who was brought within an institution popularly associated with hygiene — the hospital — was the person ordinarily on the outside of conventional norms of moral behavior: the drug user — a drug user who refused to be tested for a disease that places her caregivers at risk. Although its routes of transmission are generally well understood and widely accepted, the risk of HIV transmission via bodily fluids evokes the ancient fear of pollution that usually resulted in the isolation of the "polluted" individual. In such emotionally charged situations, people feel that they are teetering on the edge of danger. What should be on the inside is now on the outside. Because Mary needed to be contained, isolated, or sanitized, there was the potential for her to be stigmatized, even dehumanized.

It is through specific intention that we engender a particular type of ritual activity. While the intent in Mary's case was primarily to provide her physical care, the carefully followed procedures also served to protect caregivers from infection, easing fears of contagion. If the price paid for this gloving, masking, and gowning was to be interpersonally (and symbolically) distant, they reasoned, so be it. The room was a space to enter, in which to work, and from which to leave as quickly as possible. The goal was to leave intact, untouched by the patient and her disease.

The volunteer's intention, on the other hand, was to help the person. Like the doctors and nurses, the volunteer solemnly gloved, gowned, and masked, carefully adhering to the policy. But the volunteer broke a barrier, perhaps because she had more time or understanding (since volunteers often are former hospital patients or the family of former patients). Even though literally and symbolically separated from Mary, in a situation delineated by the risks of her condition and the requirements of policy, the volunteer sat and talked with her. For this caregiver, the procedures became a ritual activity that prepared her to enter a dangerous space and touch the person inside.

A key factor in this case: No one had explained to Mary the reasons behind the precautions. While the use of antibacterial agents reduces its incidence, infection remains one of the most serious complications of burns. In Mary's case this was further complicated by the possibility of HIV. No one told her the procedures were designed to protect her. Since blood loss is common during burn treatment and Mary's HIV status was unconfirmed, caregivers were fearful of HIV infection of themselves, of other patients, and staff. No one told Mary the adoption of careful barrier precautions was prudent and necessary for them.

Raised a Southern Baptist in a small west Texas town, Mary had renounced her religious upbringing, a renunciation confirmed for her when some church leaders claimed that AIDS was God's judgment on homosexuals and drug users. She worried about her mother's reaction to her drug use. Fearing abandonment, disfigurement, and death, Mary was depressed. She wanted a reconciliation with her family and with the faith that had been an important part of her life, but she felt cut off by the people on whom she depended for help. Not only did the concrete presence of the gloves, masks, and gowns set Mary apart, but the attitudes she sensed on the part of some caregivers reinforced her antipathy.

Unlike the healthcare professionals caring for Mary, the volunteer recognized the way in which the ritual of gowning served to diminish the patient. Because she saw the infectious disease control policy as an opportunity to intentionally break the barrier created by the procedure — to share something, in a sense, of the disordered world of an isolated burn victim, she connected with Mary in a fruitful way. Because of the volunteer's visits and conversations, Mary called her mother and told her of her condition and of her need for her. The volunteer was present when Mary's mother, after careful coaching on proper precautions, donned the protective gear and entered the room to hold her daughter's hand.