Empty Beds and Mounting Deaths: COVID-19 and U.S. Healthcare’s Systemic Failures

It was afternoon in early April and I was only two-thirds of the way through my 12-hour shift. Between checking on how one patient was breathing and whether another was ready for discharge, I paused at the edge of an open walkway conjoining three diamond-shaped towers. Taking a deep breath behind my face shield and two layers of masks, I looked down from the tenth floor. The world-renowned architect who designed the Manhattan hospital where I work as a resident physician ensured that our offices would be deprived of the space and light afforded to its public areas. A set of skylights brought in enough illumination to nourish evergreen fig trees without brightening the perennial gray of the brick and limestone walls. Down below on the first floor concourse with its coffee shop converted to a workstation were two hundred hospital beds awaiting their occupants. If this was all you saw, you might be forgiven for forgetting that we were at peak pandemic.

How was it, you may wonder, that at the height of the COVID-19 pandemic in New York, when about 5000 new cases and 600 deaths were added every day across the city, were there so many empty hospital beds? On April 7, according to data from the New York City Department of Health and Mental Hygiene, 1513 out of 5921 patients diagnosed with COVID-19, or around 26 percent, were hospitalized.¹ Since even before COVID-19 was declared a pandemic, the American public was repeatedly told that over 80 percent of cases were mild.²³ This was interpreted by the Centers for Disease Control and Prevention as indicating that the majority of individuals infected need not be hospitalized.⁴ A closer look at the Chinese data undergirding this assumption reveals a crucial distinction – 94 percent of the 1,099 patients with COVID-19 in China were hospitalized with over 40 percent of them receiving supplemental oxygen.⁵ In contrast, we were barely admitting all of the severe cases in the United States. No wonder reporters noticed that deaths at home in New York City not officially attributed to COVID-19 were on the rise.⁶

As NYC’s COVID-19 death toll (over 20,000)⁷ exceeds that of the 1918 influenza outbreak over a similar timeframe,⁸ our only consolation might be that the city did not run out of ventilators and hospital beds. By April 10, only 19,000 beds were occupied despite earlier warnings from Andrew Cuomo, the Governor of New York State, that almost ten times as many would be required.⁹ This does not mean that hospitals across the city did not run dangerously low on necessary supplies including drugs,¹⁰ dialysis machines,¹¹ and, of course, personal protective equipment (PPE).¹² Supply shortages were serious and the result was preventable deaths. But a lack of coordination across different healthcare organizations to redistribute supplies additionally meant that hospitals experienced scarcity and overcapacity to variable extents.

Most significantly, hospitals in New York City did not — and still do not — respond to the pandemic as if it were their task to suppress it. Instead of operating as an essential layer of a public health infrastructure, they act like businesses trying to control cost. The consequence has been disastrous by every meaningful metric.

Creating Capacity

One of the first patients I admitted to the hospital for COVID-19 was a healthcare worker. At the time of admission, he recalled his interactions with a patient he only later found out had COVID-19. He was not wearing a protective face mask. Days later, he became an early casualty to the pandemic, his death precipitated by the systemic dysfunctions that depleted the stock of masks, gowns, and other personal protective equipment in his hospital without timely replenishment. The PPE shortage spelled a catastrophe for maintaining healthcare capacity, but like every other systemic failure in healthcare, its ripples would be felt unevenly.

By the end of March, I along with many residents in my program were raising money on crowdfunding websites to purchase masks from motley suppliers. When we got our hands on a batch of over a hundred thousand surgical masks, they were disbursed over a single weekend to a dozen hospitals around NYC. Elmhurst Hospital Center, a city-run public hospital in Queens, was one of our first recipients. Earlier in the week, tales of Elmhurst being overwhelmed by COVID-19 patients, resulting in shocking daily death tolls, were substantiated when a camera crew was invited to film inside their distressed emergency department (ED).¹³ Colleagues of mine who had the misfortune of being assigned to Elmhurst in late March – many of them working on a floor that had been converted to a temporary intensive care unit without the benefit of necessary staffing and supplies – recall having to take care of dozens of COVID-19 patients who would all be dead within days.

Hospitals in Manhattan fared better. At its peak, over 150 patients required ventilators in my hospital, forcing our intensive care capacity to more than double. But our 1,100-bed hospital cruised above Elmhurst’s level of chaos. Once NYC hospitals started postponing elective procedures mid-March, indefinitely delaying everything from cardiac catheterizations and cancer biopsies, capacity opened up.¹⁴ Pending retrospective confirmation, this measure probably had the single biggest impact in shielding wealthier hospitals from the initial surge of the pandemic.

In ordinary times, only about 65 percent of beds in American hospitals are occupied on average. This is because on days when surgeons and specialists schedule procedures that make up the most lucrative activities in the hospital, a portion of hospital beds have to be kept on reserve for post-operative patients. This practice has become increasingly problematic over time. Hospitals were 77 percent full in 1975 even though there were 1.7 times more beds back then.¹⁵ Research has demonstrated that this practice of reserving beds contributes to downstream overcrowding and congestion in the emergency department – a problem known as “boarding.”¹⁶ When there are no available beds upstairs, patients admitted in the ED have to “board” downstairs, sometimes waiting days before a bed opens up.

Canceling elective procedures not only freed up inpatient beds, it also freed up ventilators in the operating room. Anesthesiologists usually working in the operating room could also be reassigned to monitor COVID-19 patients on the ventilators they knew how to operate best. Gowns and masks allocated for surgeries appeared on the wards as PPE.

Hospitals that did not routinely perform many elective procedures in the first place did not fare so well. They include public hospitals in low-income neighborhoods. During the fourth week of March, healthcare workers at Elmhurst Hospital Center were caught off guard by a deluge of patients.¹⁷ A hundred ventilated patients waited in the ED for beds to open up in this 550-bed hospital, sometimes with a single nurse to look after a dozen patients at a time. Sedatives ran out, as did other critical drugs like vasopressors and analgesics. By early April, Federal Emergency Management Agency (FEMA) descended on Elmhurst to provide ventilators and support staff. Patients should have been immediately transferred out to facilities like the USNS Comfort and the Javits Center, but their egress was impeded by a hyper-selective 49-item criteria that initially excluded patients with COVID-19.¹⁸ There was moreover no process in place to transfer patients to hospitals in Manhattan – a mere 15 minute car ride away – that still had supplies and staff to spare.

Resident physicians from my hospital board a shuttle bus to Elmhurst every morning to staff the hospital and ride back to Manhattan in the evening. For patients, this same journey is all but prohibitive. Crossing the Triborough Bridge from Manhattan to Queens is to cross into a different healthcare reality. A larger percentage of the patient population in Queens are on public insurance or have no insurance at all. Hospitals incur average losses of about 3 percent for every Medicaid patient admitted and 10 percent for every Medicare patient,¹⁹ disincentivizing hospitals from expanding in areas with a large proportion of such patients. For every hospital bed per person in Queens, there are four in Manhattan.²⁰

While hospitals in poorer neighborhoods²¹ run on a shoestring budget and need government bailouts to make ends meet, wealthy health systems in this country have deep investment portfolios and enough liquidity to fund their operations for a year without any income.²² For those of us accustomed to this pattern of disparity, the disproportionate strain on public hospitals in poor neighborhoods and the high death toll from COVID-19 hardly come as a surprise.²³ Piecemeal measures, such as canceling elective procedures and outpatient visits, did little to reverse years of defunding to public health insurance and infrastructure.

Saving Beds

By late April, when it was my turn to work in the emergency department, most people still stayed home out of fear of COVID-19. With all the elective procedures canceled, the pandemic ironically proved to be the most effective solution to overcrowding in EDs around the country.²⁴ I saw around six patients for every 12-hour shift, out of which two or three would turn out to have COVID-19. Most of these patients would be told to return home. When it came to admitting patients from the ED, the logic of resource rationing held sway by the force of habit.

To be eligible for admission in ordinary times, patients must satisfy some objective metric meant to catch those whose conditions might imminently deteriorate. For example, a patient with an acute exacerbation of a common lung condition like chronic obstructive pulmonary disease (COPD) may need to exhibit increased rate of breathing to warrant admission. While there were no uniform criteria for admitting COVID-19 patients, a similar gestalt was applied. As a rule of thumb, only patients sick enough to require supplemental oxygen were admitted.

The stringent admission criteria for COVID-19 patients is merely the continuation of older trends. Federal data shows that over the past 20 years, the number of ED visits has steadily risen even though the percentage of those visits leading to an admission has declined.²⁵ In the 65 and older population, 42 percent of ED visits led to an admission in 2006 whereas only 33.6 percent were admitted in 2015. Over the same period of time, the percentage of patients in the ED covered by Medicaid increased from 45 to 62 percent, with a corresponding drop in those covered by private insurance. Since the majority of patients in EDs around the country do not have private insurance, hospitals incur net losses by admitting them.²⁶ When it comes to admitting from the ED, one is often too well and seldom sick enough.

There is an obvious problem with only admitting those COVID-19 patients who are “sick enough.” With a disease we know so little about, a person not sick enough today could be a candidate for a ventilator the next. Once admitted, COVID-19 patients often require prolonged hospital stays, receiving supportive treatments like oxygen and blood thinners that prove unprofitable for hospitals. With the extraordinarily high COVID-19 mortality rates across NYC hospitals,²⁷ it has been difficult to determine exactly how many people were saved by these treatments or if they would have recovered on their own. But most hospitalized patients do survive COVID-19, sometimes against all odds.²⁸ For them, hospital-based treatments might have made all the difference.

There is another problem with hospitalizing the bare minimum, one not limited to the individual lives on the line. Sending patients back into the community assumes from the outset that hospitals have no role in interrupting the virus’s chain of transmission. COVID-19 patients in New York were sicker when they were admitted and spent less time in the hospital compared to their counterparts in China. Among admitted patients in China, their median length of stay inside hospitals was around 10 days²⁹ in contrast to only about 4 days for patients in New York.³⁰ Because a negative COVID-19 test is not necessary for discharge in New York, many patients leaving the hospital return to their communities to endanger those close to them. For instance, before May 10, nursing homes in New York were required to accept residents who tested positive for COVID-19.³¹ This practice has had devastating consequences: nursing home residents account for about a third of all coronavirus deaths in the US.³²

Coronavirus transmission could have been curtailed if patients were hospitalized or quarantined until they recovered, and facilities for such purposes were not hypothetical. Manhattan’s Javits Convention Center was converted to a 1000-bed makeshift hospital in March, but it discharged its last patient in early May without ever being more than half-full.³³ The naval ship USNS Comfort that docked in the Hudson River on March 30 contributed another 1000 beds. It only saw 182 patients before departing a month later.³⁴

The contrast with measures taken in Wuhan could not be more striking. Three years ago, I lived in Wuhan for a year conducting ethnographic fieldwork at a hospital that would go on to become one of the largest coronavirus treatment centers in China. In mid-February, I spoke with a friend in Wuhan who was volunteering as a tele-medical counselor for NCP Relief,³⁵ one of the scores of grassroots organizations that emerged in the wake of the COVID-19 outbreak. As hospitals in Wuhan ran out of beds for COVID-19 patients by the beginning of February, their organization received hundreds of messages every day from patients anxious to find a hospital that would accept them and, in turn, shield them from their families. Once the first makeshift hospital opened on February 3,³⁶ the number of messages fell. On February 26, I received a report compiled by her organization based on local government data that showed that out of 47,071 total confirmed COVID-19 cases, 34,691 were hospitalized; the rest had either recovered (10,337) or died (2,043).³⁷ Nearly every active COVID-19 infection was being treated in a hospital on the government’s tab.³⁸ By late March, no new cases were being reported in Wuhan.³⁹ Factoring in the possibility of under-testing and data manipulation, we can still say with confidence almost three months out that the first wave of the COVID-19 outbreak was successfully contained at its original epicenter.⁴⁰

Obviously there is room to argue that hospitalizing every COVID-19 patient could be counterproductive. Patients with mild symptoms should have the choice to stay home, especially if they have extenuating circumstances such as having dependents to look after. Patients with severe illnesses not related to COVID-19 should not be crowded out of hospitals. But in the rush to avoid an infrastructural meltdown of the sort seen in Northern Italy, hospitals in New York underachieved by every meaningful metric. As New York State Governor Andrew Cuomo congratulated his constituents about bending the curve and preserving the healthcare infrastructure,⁴¹ the unmentioned cost was a record shattering death toll.

Time for Radical Change

I was biking home from the hospital in early April when the sound of cowbells and banging pots suddenly filled my street. It started with a few clangs, then came the eruption of an invisible chorus. Over the months of spring in New York City, this ritual has started at 7 PM sharp and lasts for about 3 minutes every night. I usually leave my shift too late to witness it in person. This was the first and only time I experienced the city’s spontaneous performance for frontline healthcare workers as its primed audience. My eyes welled up with tears even though deep down, I felt undeserving. If only they saw the empty beds.

Empty beds serve as a reminder that the “health” of this country’s economy is antagonistic to the health of the public.⁴² Contraction in the healthcare sector contributed 2.3 percent to the overall 4.8 percent decline in US gross domestic product (GDP) during the first quarter of 2020, making it the largest source of GDP loss.⁴³ Trying to extract economic growth from healthcare means that delaying knee replacement surgeries for wealthy clients generates more cost than the value created by making sure senior citizens on Medicare can breathe. Add up all the revenues and expenses and our economy fails to register the value of collective survival.

A market fundamentalist as impeccable as Milton Friedman would have found this absurd. In a seminal piece lambasting the idea of corporate social responsibility, Friedman drew the line at corporations “for an eleemosynary purpose – for example, a hospital or a school.”⁴⁴ “The manager of such a corporation,” he wrote, “will not have money profit as his objectives but the rendering of certain services.” The pandemic has shown some of us on the frontlines of healthcare how far we have swerved from these once indisputable objectives. This instead has become indisputable: healthcare in the US is due for radical change.

Miao Jenny Hua is an internal medicine resident at the Mount Sinai Hospital in Manhattan. She defended her PhD in anthropology from the University of Chicago. For her dissertation on the integrated Chinese and Western health care system in China, she spent over a year living in Wuhan. Since the lockdown of Wuhan on January 23, 2020, she has been in regular communication with her physician friends at the original epicenter of the COVID-19 pandemic.

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[44] Milton Friedman, “The Social Responsibility of Business Is to Increase Its Profits,” In Corporate Ethics and Corporate Governance, edited by Walther Zimmerli, Markus Holzinger, and Klaus Richter, 173–78. Berlin, Heidelberg: Springer, 2007. https://doi.org/10.1007/978-3-540-70818-6_14.

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Empty Beds and Mounting Deaths: COVID-19 and U.S. Healthcare’s Systemic Failures

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