Lectures

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

This article is part of the series:

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.1City of New York, “COVID-19: Data Summary – NYC Health,” NYC Health, last updated June 7, 2020. https:www1.nyc.gov/site/doh/covid/covid-19-data.page Since even before COVID-19 was declared a pandemic, the American public was repeatedly told that over 80 percent of cases were mild.2Vivian Wang, “Most Coronavirus Cases Are Mild. That’s Good and Bad News,” The New York Times, February 27, 2020. https://www.nytimes.com/2020/02/27/world/asia/coronavirus-treament-recovery.html.3Paul Specht, “Are 80 Percent of Coronavirus Cases ‘Mild?’” PolitiFact.com, March 13, 2020. https://www.politifact.com/factchecks/2020/mar/13/viral-image/are-80-percent-coronavirus-cases-mild/. This was interpreted by the Centers for Disease Control and Prevention as indicating that the majority of individuals infected need not be hospitalized.4Centers for Disease Control and Prevention, “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19),” CDC.gov, last updated June 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. 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.5Wei-jie Guan, Zheng-yi Ni, Yu Hu, Wen-hua Liang, Chun-quan Ou, Jian-xing He, Lei Liu, et al.,“Clinical Characteristics of Coronavirus Disease 2019 in China,” New England Journal of Medicine 382, no. 18 (April 30, 2020): 1708–20. https://doi.org/10.1056/NEJMoa2002032. 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.6Gwynne Hogan, “Staggering Surge Of NYers Dying In Their Homes Suggests City Is Undercounting Coronavirus Fatalities,” Gothamist, April 7, 2020. https://gothamist.com/news/surge-number-new-yorkers-dying-home-officials-suspect-undercount-covid-19-related-deaths.

As NYC’s COVID-19 death toll (over 20,000)7Centers for Disease Control and Prevention, “Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak — New York City, March 11–May 2, 2020,” Morbidity and Mortality Weekly Report 69, no. 19 (May 15, 2020). https://doi.org/10.15585/mmwr.mm6919e5. exceeds that of the 1918 influenza outbreak over a similar timeframe,8Michael Wilson, “What New York Looked Like During the 1918 Flu Pandemic,” The New York Times, April 2, 2020. https://www.nytimes.com/2020/04/02/nyregion/spanish-flu-nyc-virus.html. 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.9Alan Feuer and Jesse McKinley, “Virus Deaths Mount, but N.Y. Avoids Predicted Surge at Hospitals So Far,” The New York Times, April 10, 2020, https://www.nytimes.com/2020/04/10/nyregion/new-york-coronavirus-hospitals.html. This does not mean that hospitals across the city did not run dangerously low on necessary supplies including drugs,10Lois Parshley, “You Can’t Use Ventilators without Sedatives. Now the US Is Running out of Those, Too,” Vox, April 6, 2020. https://www.vox.com/2020/4/6/21209589/coronavirus-medicine-ventilators-drug-shortage-sedatives-covid-19. dialysis machines,11Fred Mogul, “Shortage Of Dialysis Equipment Leads To Difficult Decisions In New York ICUs,” NPR.org, April 19, 2020. https://www.npr.org/sections/health-shots/2020/04/19/838103327/shortage-of-dialysis-equipment-leads-to-difficult-decisions-in-new-york-icus. and, of course, personal protective equipment (PPE).12Suhas Gondi, Adam L. Beckman, Nicholas Deveau, Ali S. Raja, Megan L. Ranney, Rachel Popkin, and Shuhan He. “Personal Protective Equipment Needs in the USA during the COVID-19 Pandemic.” The Lancet 395, no. 10237 (May 23, 2020): e90–91. https://doi.org/10.1016/S0140-6736(20)31038-2. 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).13Michael Rothfeld, Somini Sengupta, Joseph Goldstein, and Brian M. Rosenthal, “13 Deaths in a Day: An ‘Apocalyptic’ Coronavirus Surge at an N.Y.C. Hospital,” The New York Times, March 25, 2020. https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html. 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.14The City of New York Office of the Mayor, Emergency Executive Order No. 100, March 16, 2020. https://www1.nyc.gov/assets/home/downloads/pdf/executive-orders/2020/eeo-100.pdf. 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.15National Center for Health Statistics, “Table 89. Hospitals, Beds, and Occupancy Rates, by Type of Ownership and Size of Hospital: United States, Selected Years 1975–2015.” CDC.gov, 2017. https://www.cdc.gov/nchs/data/hus/2017/089.pdf. Research has demonstrated that this practice of reserving beds contributes to downstream overcrowding and congestion in the emergency department – a problem known as “boarding.”16Richard Klasco and Richard Wolfe, “Sorry, ER Patients. People with Elective Procedures Get the Hospital Beds First,” Washington Post, February 24, 2019. https://www.washingtonpost.com/national/health-science/sorry-er-patients-people-with-elective-procedures-get-the-hospital-beds-first/2019/02/22/643d1460-2a25-11e9-984d-9b8fba003e81_story.html. 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.17Michael Rothfeld, Somini Sengupta, Joseph Goldstein, and Brian M. Rosenthal, “13 Deaths in a Day: An ‘Apocalyptic’ Coronavirus Surge at an N.Y.C. Hospital,” The New York Times, March 25, 2020. https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html. 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-19.18Jada Yuan, “Amid New York’s 42,400 Hospitalizations, the Military Handled 3 Percent. But It Helped in Immeasurable Ways,” Washington Post, May 2, 2020. https://www.washingtonpost.com/national/new-york-javits-center-usns-comfort/2020/05/02/55abfe54-88af-11ea-8ac1-bfb250876b7a_story.html. 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,19Jeff Goldsmith and Richard Bajner, “5 Ways U.S. Hospitals Can Handle Financial Losses from Medicare Patients,” Harvard Business Review, November 10, 2017. https://hbr.org/2017/11/5-ways-u-s-hospitals-can-respond-to-medicares-mounting-costs 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.20Caleb Melby, Jackie Gu, and Mira Rojanasakul, “Mapping New York City Hospital Beds as Coronavirus Cases Surge,” Bloomberg.com, last updated April 28, 2020. https://www.bloomberg.com/graphics/2020-new-york-coronavirus-outbreak-how-many-hospital-beds/.

While hospitals in poorer neighborhoods21Leslie Hook and Hannah Kuchler, “How Coronavirus Broke America’s Healthcare System,” Financial Times, April 30, 2020. https://www.ft.com/content/3bbb4f7c-890e-11ea-a01c-a28a3e3fbd33. 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.22Jordan Rau, “Amid Coronavirus Distress, Wealthy Hospitals Hoard Millions,” Kaiser Health News (blog), April 28, 2020. https://khn.org/news/amid-coronavirus-distress-wealthy-hospitals-hoard-millions/. 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.23Ben McVane, “Opinion | I’m a Doctor at the ‘Epicenter of the Epicenter,’” The New York Times, April 5, 2020, sec. Opinion. https://www.nytimes.com/2020/04/05/opinion/coronavirus-elmhurst-queens.html. 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.24William Feuer, “Doctors Worry the Coronavirus Is Keeping Patients Away from US Hospitals as ER Visits Drop: ‘Heart Attacks Don’t Stop,’” CNBC, April 14, 2020. https://www.cnbc.com/2020/04/14/doctors-worry-the-coronavirus-is-keeping-patients-away-from-us-hospitals-as-er-visits-drop-heart-attacks-dont-stop.html. 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.25Ruirui Sun and Herbert S Wong. “Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015.” Healthcare Cost and Utilization Project, Statistical Brief, 238 (2018): 1-11. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb238-Emergency-Department-Age-Payer-2006-2015.pdf. 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.26Esther Hing and Pingyao Rui, “Emergency Department Use in the Country’s Five Most Populous States and the Total United States, 2012,” National Center for Health Statistics Data Brief, 252 (June 6, 2019). https://www.cdc.gov/nchs/products/databriefs/db252.htm. 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,27Safiya Richardson, Jamie S. Hirsch, Mangala Narasimhan, James M. Crawford, Thomas McGinn, Karina W. Davidson, Douglas P. Barnaby, et al., “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area,” JAMA, April 22, 2020. https://doi.org/10.1001/jama.2020.6775. 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.28Pam Belluck, “32 Days on a Ventilator: One Covid Patient’s Fight to Breathe Again,” The New York Times, April 26, 2020. https://www.nytimes.com/2020/04/26/health/coronavirus-patient-ventilator.html. 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 Wei-jie Guan, Zheng-yi Ni, Yu Hu, Wen-hua Liang, Chun-quan Ou, Jian-xing He, Lei Liu, et al.,“Clinical Characteristics of Coronavirus Disease 2019 in China,” New England Journal of Medicine 382, no. 18 (April 30, 2020): 1716. https://doi.org/10.1056/NEJMoa2002032. in contrast to only about 4 days for patients in New York.30Safiya Richardson, Jamie S. Hirsch, Mangala Narasimhan, James M. Crawford, Thomas McGinn, Karina W. Davidson, Douglas P. Barnaby, et al., “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area,” JAMA, April 22, 2020: E6. https://doi.org/10.1001/jama.2020.6775. 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-19.31Jim Mustian, Jennifer Peltz, and Bernard Condon. “NY’s Cuomo Criticized over Highest Nursing Home Death Toll,” AP News, May 9, 2020. https://apnews.com/4042f05613ee4259b7a44d4466a0a02a. This practice has had devastating consequences: nursing home residents account for about a third of all coronavirus deaths in the US.32Karen Yourish, K. K. Rebecca Lai, Danielle Ivory, and Mitch Smith. “One-Third of All U.S. Coronavirus Deaths Are Nursing Home Residents or Workers,” The New York Times, sec. U.S. Accessed June 10, 2020. https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html.

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.33Joshua Rhett Miller, “Javits Center Hospital to Close after Treating Nearly 1,100 Patients during Coronavirus,” New York Post (blog), May 1, 2020. https://nypost.com/2020/05/01/javits-center-hospital-to-close-after-treating-1000-patients/. 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.34Julie Watson, “Navy Hospital Ships, Once Thought Critical, See Few Patients,” AP News, April 30, 2020.

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,35Hui Xiao, Su Wang, Ning Zhao, and Jie Ding, “Jiu Wuhan, Shehui Zizhu Wangluo Zheyang Zhicheng [To Save Wuhan, This Is How Social Self-Help Networks Develop],” Caixin Weekly, February 24, 2020. http://weekly.caixin.com/2020-02-22/101518909.html. 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 3,36Simiao Chen, Zongjiu Zhang, Juntao Yang, Jian Wang, Xiaohui Zhai, Till Bärnighausen, and Chen Wang, “Fangcang Shelter Hospitals: A Novel Concept for Responding to Public Health Emergencies,” The Lancet 395, no. 10232 (April 18, 2020): 1305–14. https://doi.org/10.1016/S0140-6736(20)30744-3. 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).37NCP Relief, “Hubei Sheng Xinguan Bingdu Weiji Zhuoming Xingshi Baogao Si [Fourth Report on Clarifying the Critical State of the Novel Coronavirus in Hubei Province],” February 26, 2020. https://shimo.im/docs/DJAz4bnyKMIMFeqy/read. Nearly every active COVID-19 infection was being treated in a hospital on the government’s tab.38Pinghui Zhuang, “A Lesson from China: Don’t Make Patients Pay for Virus Tests and Treatment,” South China Morning Post, March 11, 2020. https://www.scmp.com/news/china/society/article/3074506/coronavirus-lesson-china-dont-make-patients-pay-tests-and. By late March, no new cases were being reported in Wuhan.39Emily Rauhala, “China’s Claim of Coronavirus Victory in Wuhan Brings Hope, but Experts Worry It Is Premature,” Washington Post, March 25, 2020. https://www.washingtonpost.com/world/asia_pacific/china-wuhan-coronavirus-zero-cases/2020/03/25/19bdbbc2-6d15-11ea-a156-0048b62cdb51_story.html. 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 Lantai Zhang and Wei Han, “Wuhan Declared Free of Virus After Blanket Testing of 10 Million,” Caixin Global, June 3, 2020. https://www.caixinglobal.com/2020-06-03/wuhan-declared-free-of-virus-after-blanket-testing-of-10-million-101562317.html.

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,41ABC7 Eyewitness News, “Coronavirus New York: NY Landmarks Light up in Honor of New Yorkers’ Work to Flatten Curve of COVID-19,” June 7, 2020. https://abc7ny.com/landmarks-light-up-new-york-why-are-lit-one-world-trade-center/6236242/. 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.42Ailsa Chang, “U.S. Hospitals Hit By Financial ‘Triple Whammy’ During Coronavirus Pandemic.” NPR.org. Accessed June 10, 2020. https://www.npr.org/sections/coronavirus-live-updates/2020/04/23/843012119/u-s-hospitals-hit-by-financial-triple-whammy-during-coronavirus-pandemic. 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.43Matthew Klein, “Health Care Was the Biggest Drag on First-Quarter GDP. Here Are 4 Other Highlights From the Report,” Barron’s, April 29, 2020. https://www.barrons.com/articles/health-care-was-the-biggest-drag-on-first-quarter-gdp-here-are-4-other-highlights-from-the-report-51588195277. 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.”44Milton 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. “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.


Works Cited

[1] City of New York, “COVID-19: Data Summary – NYC Health,” NYC Health, last updated June 7, 2020. https://www1.nyc.gov/site/doh/covid/covid-19-data.page.

[2] Vivian Wang, “Most Coronavirus Cases Are Mild. That’s Good and Bad News,” The New York Times, February 27, 2020. https://www.nytimes.com/2020/02/27/world/asia/coronavirus-treament-recovery.html.

[3] Paul Specht, “Are 80 Percent of Coronavirus Cases ‘Mild?’” PolitiFact.com, March 13, 2020. https://www.politifact.com/factchecks/2020/mar/13/viral-image/are-80-percent-coronavirus-cases-mild/.

[1] Centers for Disease Control and Prevention, “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19),” CDC.gov, last updated June 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.

[4] Wei-jie Guan, Zheng-yi Ni, Yu Hu, Wen-hua Liang, Chun-quan Ou, Jian-xing He, Lei Liu, et al.,“Clinical Characteristics of Coronavirus Disease 2019 in China,” New England Journal of Medicine 382, no. 18 (April 30, 2020): 1708–20. https://doi.org/10.1056/NEJMoa2002032.

[5] Gwynne Hogan, “Staggering Surge Of NYers Dying In Their Homes Suggests City Is Undercounting Coronavirus Fatalities,” Gothamist, April 7, 2020. https://gothamist.com/news/surge-number-new-yorkers-dying-home-officials-suspect-undercount-covid-19-related-deaths.

[6] Centers for Disease Control and Prevention, “Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak — New York City, March 11–May 2, 2020,” Morbidity and Mortality Weekly Report 69, no. 19 (May 15, 2020). https://doi.org/10.15585/mmwr.mm6919e5.

[7] Michael Wilson, “What New York Looked Like During the 1918 Flu Pandemic,” The New York Times, April 2, 2020. https://www.nytimes.com/2020/04/02/nyregion/spanish-flu-nyc-virus.html.

[8] Alan Feuer and Jesse McKinley, “Virus Deaths Mount, but N.Y. Avoids Predicted Surge at Hospitals So Far,” The New York Times, April 10, 2020, https://www.nytimes.com/2020/04/10/nyregion/new-york-coronavirus-hospitals.html.

[9] Lois Parshley, “You Can’t Use Ventilators without Sedatives. Now the US Is Running out of Those, Too,” Vox, April 6, 2020. https://www.vox.com/2020/4/6/21209589/coronavirus-medicine-ventilators-drug-shortage-sedatives-covid-19.

[10] Fred Mogul, “Shortage Of Dialysis Equipment Leads To Difficult Decisions In New York ICUs,” NPR.org, April 19, 2020. https://www.npr.org/sections/health-shots/2020/04/19/838103327/shortage-of-dialysis-equipment-leads-to-difficult-decisions-in-new-york-icus.

[11] Suhas Gondi, Adam L. Beckman, Nicholas Deveau, Ali S. Raja, Megan L. Ranney, Rachel Popkin, and Shuhan He. “Personal Protective Equipment Needs in the USA during the COVID-19 Pandemic.” The Lancet 395, no. 10237 (May 23, 2020): e90–91. https://doi.org/10.1016/S0140-6736(20)31038-2.

[12] Michael Rothfeld, Somini Sengupta, Joseph Goldstein, and Brian M. Rosenthal, “13 Deaths in a Day: An ‘Apocalyptic’ Coronavirus Surge at an N.Y.C. Hospital,” The New York Times, March 25, 2020. https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html.

[13] The City of New York Office of the Mayor, Emergency Executive Order No. 100, March 16, 2020. https://www1.nyc.gov/assets/home/downloads/pdf/executive-orders/2020/eeo-100.pdf.

[14] National Center for Health Statistics, “Table 89. Hospitals, Beds, and Occupancy Rates, by Type of Ownership and Size of Hospital: United States, Selected Years 1975–2015.” CDC.gov, 2017.https://www.cdc.gov/nchs/data/hus/2017/089.pdf.

[15] Richard Klasco and Richard Wolfe, “Sorry, ER Patients. People with Elective Procedures Get the Hospital Beds First,” Washington Post, February 24, 2019. https://www.washingtonpost.com/national/health-science/sorry-er-patients-people-with-elective-procedures-get-the-hospital-beds-first/2019/02/22/643d1460-2a25-11e9-984d-9b8fba003e81_story.html.

[16] Michael Rothfeld, Somini Sengupta, Joseph Goldstein, and Brian M. Rosenthal, “13 Deaths in a Day: An ‘Apocalyptic’ Coronavirus Surge at an N.Y.C. Hospital,” The New York Times, March 25, 2020. https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html.

[17] Jada Yuan, “Amid New York’s 42,400 Hospitalizations, the Military Handled 3 Percent. But It Helped in Immeasurable Ways,” Washington Post, May 2, 2020. https://www.washingtonpost.com/national/new-york-javits-center-usns-comfort/2020/05/02/55abfe54-88af-11ea-8ac1-bfb250876b7a_story.html.

[18] Jeff Goldsmith and Richard Bajner, “5 Ways U.S. Hospitals Can Handle Financial Losses from Medicare Patients,” Harvard Business Review, November 10, 2017. https://hbr.org/2017/11/5-ways-u-s-hospitals-can-respond-to-medicares-mounting-costs.

[19] Caleb Melby, Jackie Gu, and Mira Rojanasakul, “Mapping New York City Hospital Beds as Coronavirus Cases Surge,” Bloomberg.com, last updated April 28, 2020. https://www.bloomberg.com/graphics/2020-new-york-coronavirus-outbreak-how-many-hospital-beds/.

[20] Leslie Hook and Hannah Kuchler, “How Coronavirus Broke America’s Healthcare System,” Financial Times, April 30, 2020. https://www.ft.com/content/3bbb4f7c-890e-11ea-a01c-a28a3e3fbd33.

[21] Jordan Rau, “Amid Coronavirus Distress, Wealthy Hospitals Hoard Millions,” Kaiser Health News (blog), April 28, 2020. https://khn.org/news/amid-coronavirus-distress-wealthy-hospitals-hoard-millions/.

[22] Ben McVane, “Opinion | I’m a Doctor at the ‘Epicenter of the Epicenter,’” The New York Times, April 5, 2020, sec. Opinion. https://www.nytimes.com/2020/04/05/opinion/coronavirus-elmhurst-queens.html.

[23] William Feuer, “Doctors Worry the Coronavirus Is Keeping Patients Away from US Hospitals as ER Visits Drop: ‘Heart Attacks Don’t Stop,’” CNBC, April 14, 2020. https://www.cnbc.com/2020/04/14/doctors-worry-the-coronavirus-is-keeping-patients-away-from-us-hospitals-as-er-visits-drop-heart-attacks-dont-stop.html.

[24] Ruirui Sun and Herbert S Wong. “Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015.” Healthcare Cost and Utilization Project, Statistical Brief, 238 (2018): 1-11. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb238-Emergency-Department-Age-Payer-2006-2015.pdf

[25] Esther Hing and Pingyao Rui, “Emergency Department Use in the Country’s Five Most Populous States and the Total United States, 2012,” National Center for Health Statistics Data Brief, 252 (June 6, 2019). https://www.cdc.gov/nchs/products/databriefs/db252.htm.

[26] Safiya Richardson, Jamie S. Hirsch, Mangala Narasimhan, James M. Crawford, Thomas McGinn, Karina W. Davidson, Douglas P. Barnaby, et al., “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area,” JAMA, April 22, 2020. https://doi.org/10.1001/jama.2020.6775.

[27] Pam Belluck, “32 Days on a Ventilator: One Covid Patient’s Fight to Breathe Again,” The New York Times, April 26, 2020. https://www.nytimes.com/2020/04/26/health/coronavirus-patient-ventilator.html.

[28] Wei-jie Guan, Zheng-yi Ni, Yu Hu, Wen-hua Liang, Chun-quan Ou, Jian-xing He, Lei Liu, et al.,“Clinical Characteristics of Coronavirus Disease 2019 in China,” New England Journal of Medicine 382, no. 18 (April 30, 2020): 1716. https://doi.org/10.1056/NEJMoa2002032.

[29] Safiya Richardson, Jamie S. Hirsch, Mangala Narasimhan, James M. Crawford, Thomas McGinn, Karina W. Davidson, Douglas P. Barnaby, et al., “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area,” JAMA, April 22, 2020: E6. https://doi.org/10.1001/jama.2020.6775.

[30] Jim Mustian, Jennifer Peltz, and Bernard Condon. “NY’s Cuomo Criticized over Highest Nursing Home Death Toll,” AP News, May 9, 2020. https://apnews.com/4042f05613ee4259b7a44d4466a0a02a.

[31] Karen Yourish, K. K. Rebecca Lai, Danielle Ivory, and Mitch Smith. “One-Third of All U.S. Coronavirus Deaths Are Nursing Home Residents or Workers,” The New York Times, sec. U.S. Accessed June 10, 2020. https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html.

[32] Joshua Rhett Miller, “Javits Center Hospital to Close after Treating Nearly 1,100 Patients during Coronavirus,” New York Post (blog), May 1, 2020. https://nypost.com/2020/05/01/javits-center-hospital-to-close-after-treating-1000-patients/.

[34] Julie Watson, “Navy Hospital Ships, Once Thought Critical, See Few Patients,” AP News, April 30, 2020. https://apnews.com/72c81d0efb123d1564b1e196d9f5e4f5.

[35] Hui Xiao, Su Wang, Ning Zhao, and Jie Ding, “Jiu Wuhan, Shehui Zizhu Wangluo Zheyang Zhicheng [To Save Wuhan, This Is How Social Self-Help Networks Develop],” Caixin Weekly, February 24, 2020. http://weekly.caixin.com/2020-02-22/101518909.html.

[36] Simiao Chen, Zongjiu Zhang, Juntao Yang, Jian Wang, Xiaohui Zhai, Till Bärnighausen, and Chen Wang, “Fangcang Shelter Hospitals: A Novel Concept for Responding to Public Health Emergencies,” The Lancet 395, no. 10232 (April 18, 2020): 1305–14. https://doi.org/10.1016/S0140-6736(20)30744-3.

[37] NCP Relief, “Hubei Sheng Xinguan Bingdu Weiji Zhuoming Xingshi Baogao Si [Fourth Report on Clarifying the Critical State of the Novel Coronavirus in Hubei Province],” February 26, 2020. https://shimo.im/docs/DJAz4bnyKMIMFeqy/read.

[38] Pinghui Zhuang, “A Lesson from China: Don’t Make Patients Pay for Virus Tests and Treatment,” South China Morning Post, March 11, 2020. https://www.scmp.com/news/china/society/article/3074506/coronavirus-lesson-china-dont-make-patients-pay-tests-and.

[39] Emily Rauhala, “China’s Claim of Coronavirus Victory in Wuhan Brings Hope, but Experts Worry It Is Premature,” Washington Post, March 25, 2020. https://www.washingtonpost.com/world/asia_pacific/china-wuhan-coronavirus-zero-cases/2020/03/25/19bdbbc2-6d15-11ea-a156-0048b62cdb51_story.html.

[40] Lantai Zhang and Wei Han, “Wuhan Declared Free of Virus After Blanket Testing of 10 Million,” Caixin Global, June 3, 2020. https://www.caixinglobal.com/2020-06-03/wuhan-declared-free-of-virus-after-blanket-testing-of-10-million-101562317.html.

[41] ABC7 Eyewitness News, “Coronavirus New York: NY Landmarks Light up in Honor of New Yorkers’ Work to Flatten Curve of COVID-19,” June 7, 2020. https://abc7ny.com/landmarks-light-up-new-york-why-are-lit-one-world-trade-center/6236242/.

[42] Ailsa Chang, “U.S. Hospitals Hit By Financial ‘Triple Whammy’ During Coronavirus Pandemic.” NPR.org. Accessed June 10, 2020. https://www.npr.org/sections/coronavirus-live-updates/2020/04/23/843012119/u-s-hospitals-hit-by-financial-triple-whammy-during-coronavirus-pandemic.

[43] Matthew Klein, “Health Care Was the Biggest Drag on First-Quarter GDP. Here Are 4 Other Highlights From the Report,” Barron’s, April 29, 2020. https://www.barrons.com/articles/health-care-was-the-biggest-drag-on-first-quarter-gdp-here-are-4-other-highlights-from-the-report-51588195277.

[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.


Leave a Reply

Your email address will not be published. Required fields are marked *