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On the Front Lines of the Coronavirus Pandemic: A Doctor’s View

Coronavirus has officially hit the United States. Throughout the country, there have been anywhere between 1600 and 3600 confirmed cases and 41 deaths. This number is likely a gross underestimate of the actual number of cases, as the U.S. has only tested a small proportion of the population. Meanwhile, top health officials in Ohio estimate 100,000 people could have potentially already been infected with the virus. Researchers at Johns Hopkins estimate there could be between 50,000 and half a million cases in the U.S. at this time, and that number only looks like it will grow. Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases and top member of Trump’s coronavirus task force, recently stated it’s possible millions could die in the United States. I hope that we do not see things get worse in the U.S., but based on what I personally have seen and what my colleagues report, I cannot help but believe things will get worse than they are now.

Take it from a U.S. physician working on the ground in communities hit by COVID-19: the U.S. is woefully unprepared for this pandemic. During a recent press conference, after being pressed around the limited availability of coronavirus test kits, Dr. Fauci said, “The system does not — is not really geared to what we need right now, what you are asking for. That is a failure.” The U.S. has only been able to test five individuals per million, while South Korea has tested more than 3,500 per million people. This is largely due to the fact that the U.S. declined to use WHO tests used around the rest of the world.

Testing is not the only place where the U.S. is lacking. It has been reported in multiple outlets that there are critical shortages in personal protective equipment (PPE) for health providers, ventilators, and ICU beds. These shortages are especially concerning, as they risk overwhelming critical care sectors of the healthcare system. Nurses, physicians, and other healthcare workers on the front lines are speaking out about what they need to provide adequate care, but the system is unable to respond. It appears these cries are falling on deaf ears. The U.S. healthcare system has always been horrid, but this pandemic is serving as a magnifying glass to expose its multiple failures.

Corona Overwhelming Other Countries

While COVID-19 has hit over 140 countries, we can see the extent to which it can overwhelm a healthcare system by looking at a country like Italy. The Italian healthcare system, which ranks second in quality in the entire world, has been completely overburdened by the virus. It was recently reported that the virus claimed 368 new deaths on Sunday, which was the largest 24 hour increase in the country to date. The country has over 21,000 cases as of today, and physicians on the ground are reporting there are simply too many patients for each of them to receive adequate care. Recently, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) even published guidelines likening decisions physicians may face to “wartime triage” deciding who lives and who dies. Physicians in Italy are reporting that up to 80 percent of hospital beds in some provinces are occupied by coronavirus patients, and intensive care units are completely overloaded and short of supplies.

The strain the coronavirus causes on health systems also leads to increased deaths from other illnesses not related to coronavirus. There are stories around the world of patients with various illnesses such as cancer that are turned away from care. Other acute and chronic illnesses do not take a break during viral pandemics such as this. In other parts of the world such as China, the strain is not just leading to deaths of patients, but also medical workers dying from a combination of infection and fatigue.

There is potential for this same tragic dynamic to play out in the U.S., but in an even worse fashion given our disjointed profit-centered model of care. As discussed in a recent analysis published on Statnews.com, the U.S. has about 2.8 hospital beds per 1,000 people — with a population of around 330 million, 1 million total hospital beds. While the number of patients needing hospitalization vary in reports depending on the country, anywhere from 50 percent (Italy) to 15 percent (China) of patients required hospitalization. Based on the rates of spread in the U.S., even if 10 percent of patients required hospitalization, hospital beds would be filled by May. This is not to mention the drastic drain on supplies that such a rate of infection would put on the U.S. healthcare system.

Healthcare Workers Already Noticing Shortages

The Trump administration’s Department of Health and Human Services has been extremely behind on ensuring healthcare workers have the necessary supplies to treat the large number of patients that will be coming to hospitals in the near future. For example, they only recently issued a request for contracts for 500 million face masks to help protect workers against the virus when seeing patients. The proposals for these contracts are not due back until March 18th. Requests for information around available medical gowns, masks, respirators, etc. from the Domestic Strategic National Stockpile’s Office of Resource Management are not even due back until March 24th. These clearly serve as delays in a time of crisis, when delays and shortages mean increased viral transmission, increased spread of illness, and increased death.

Short supplies of protective masks are hitting hospitals around the country. Staff must often obtain management approval before using N95 masks used to protect against airborne pathogens. In one New York hospital, management advised staff to “reuse” N95 masks with a distributed document saying “N95 masks will be reused by staff until they are soiled, moist, or compromised,” and to obtain a new mask an associate must “request a mask from their supervisor.” Policies such as this one pose great risk of infection for healthcare workers, who would then potentially spread the infection to patients. It doesn’t stop at the special N95 masks, nurses in Chicago are now even reporting they are even running out of regular surgical masks, which is unconscionable in a healthcare setting. I’m part of a discussion group of health care workers; a nurse in New York City recently contacted us, saying, “Ok, so now we get two masks each and that’s it!!! WHAT THE FUCK IS GOING ON????” That is a great question.

The U.S. has had months to prepare for this pandemic. From the outset, there should have been a mass mobilization of mask production, ventilation production, and PPE (protective personal equipment, e.g., masks, gowns, gloves, face shields, etc.) production. There should have also been a conversion of buildings or building of new sites for ICU beds, but capitalism is showing it is incapable of mobilizing adequately. Around the world, other countries are taking drastic measures to fight the virus. In Spain, they have even decided to even take over private industries that are putting profits over patient lives. In the U.S., we are seeing “requests” and “contracts” for money to be funneled into inefficient for-profit companies that cannot and will not respond fast enough, while the government leaders and media pundits continue to tout the brilliance of “public-private partnerships.”

Confusion from Management

Even the type of mask to be used for COVID-19 patients has been up for debate. Hospital administrations direct staff to use regular surgical masks, eyeshields, and PPE for suspected or confirmed COVID-19 cases because according to CDC guidelines, N95 masks should only be worn for “aerosol generating procedures.” This concerns many healthcare workers because at least one study in conjunction with the National Institutes of Health (NIH), but yet to be peer reviewed, suggests that the coronavirus can survive in the air, which would necessitate N95 masks. Healthcare workers speculate the laxity in recommendations results from hospital administrations attempting to save the already short supply of N95 masks.

These issues, along with poor lines of communication resulting from the highly bureaucratized and corporatized U.S. healthcare system, have led to confusion, delays in care, and even some healthcare workers being exposed. As one worker recently shared with me:

I’m an RN in a MICU in New York. We currently have 3 positives on unit. There has been a lot of fear regarding lack of equipment and PPE [protective personal equipment]. Throughout our facility we have found no plans in place for this. The union has been working on demands. One of the things that has been most difficult is the discussion… is it droplet or airborne. Our institution has gone back and forth, provided misinformation about masks and appropriate PPE. Over the last week we have been told re-use masks. Last night they said the rooms no longer need airborne precaution and only droplet/contact precautions needed. Now, at 11am they have placed the rooms back on airborne.

We are worried they have exposed a lot of us. They aren’t testing a handful of people who might be positive.

Masks (droplet/surgical vs. airborne/respirator) are not the only problem. ICU beds around the country are quickly filling. New York Governor Andrew Cuomo recently stated that 80 percent of ICU beds in the state are occupied. While hospitals rightfully attempt to make more space on units, administrations have been reported converting units to handle ICU level patients without first ensuring nurses are comfortable or trained to handle the care involved with such patients. As reported, nurses throughout the country are already chronically understaffed due to capitalists continually trying to cut staff as much as possible to lower costs and increase profits.

Hospital administrations have repeatedly ignored nurses’ calls for safe staffing ratios, which, if instituted, would have made handling a pandemic more tolerable. Now, around the country they are scrambling, putting out calls for retired nurses to return to work to help fill staffing gaps. Capitalists’ consistent push for profits is now coming home to roost, manifesting as staff shortages during this crisis.

All Staff at Risk

And it’s not only nurses being harmed under these poor working conditions. Resident physicians, supervising/attending physicians, medical assistants, technicians, and other front line healthcare staff are also at risk. Patient care associates — these are often the individuals who take vital signs and perform other crucial services — in hospitals in New York City have noted the absence of training in protecting against the virus. One recently stated, “We haven’t gotten any training. The N95 respirators are on lockdown. They can only be used for ‘more serious cases.’”

Resident physicians, who often work 80+ hours per week in the hospitals, are at particular risk. While many residency training programs across the country are now appropriately pulling residents off of “nonessential rotations,” so they can be prepared to respond to the crisis, many working on the front lines are put at risk. As per a resident who recently contacted me:

We have a patient that is being admitted for pneumonia but her story sounds really good for COVID-19. I called the infection control line and they were like “This line is only for attendings only. Call your attending if you want to challenge it.” They’re not doing shit to protect us if I can’t say “I think a patient should be reconsidered for a COVID rule out” and have them seriously discuss it as one.

Decisions such as these put staff on the front lines at risk of contracting and subsequently spreading COVID-19 to other patients and staff.

COVID-19 Magnifies Capitalism’s Rot in Healthcare System

What is currently unfolding in the U.S. is what happens when you develop a healthcare system predicated around extracting profit from sick bodies — one that continually attempts to drive down costs whenever possible. A system that only reacts to disease instead of preventing disease. Dr. Fauci stated that our “system is not built for this,” but healthcare workers dedicated to treating patients have been condemning this system for years. Our healthcare system has always been a complete disaster, but a pandemic like this just magnifies that fact. We not only need a new healthcare system, but a new economic system that values life over profit. Capitalism will never give us what we need. Hopefully, this wake-up call does not cost too many innocent lives.

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Michael Pappas is a Michael resident physician at Mount Sinai in New York.

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