Chaos on the Front Line

For decades, America’s hospitals have been underfunded and understaffed in the name of efficiency. An examination of conditions at one public hospital in Oakland show us how unprepared this austerity-starved health care system is for what’s to come.

A firefighter screens a man that is waiting in line to get a COVID-19 test at a free public testing station on March 24, 2020 in Hayward, California. Justin Sullivan / Getty

The Centers for Disease Control estimates that anywhere between two million and twenty-two million Americans will be hospitalized with COVID-19 — in a nation that has less than a million hospital beds. It’s not as if those beds are currently empty, either. In fact, America’s hospitals and health care workers are already stretched thin. The coronavirus epidemic threatens to deliver them to the breaking point.

This crisis represents the convergence of multiple preexisting problems. One of these is that the United States’ uncoordinated patchwork of public and private hospitals has been subject for decades to a “lean production” management approach, borrowed from the private manufacturing sector, which purportedly aims to cut waste, trim fat, and improve efficiency.

In reality, what this has meant is that cost-cutting measures have led to shortages in workers, space, and equipment. Our overwhelmed, understaffed, austerity-starved hospital system is already in bad shape. It’s not ready for what’s to come.

Bad to Worse

All over the country, frontline health care workers are demanding immediate changes to help them prepare for the coming flood of coronavirus patients. They’re focusing especially on one pressing problem: the national shortage of personal protective equipment, or PPE, including masks, gloves, face shields, gowns, booties, sani wipes, soap, and hand sanitizer.

Without these, health care workers can’t treat coronavirus patients without potentially transmitting the virus to noninfected patients, who will then not only be at risk of illness but will become carriers, further endangering the public. Health care workers who lack proper equipment also can’t protect themselves and their coworkers from infection. Frontline workers deserve protection for their own sake, but an additional consideration is that if they’re taken out of commission by illness, their absence exacerbates the understaffing issue and the crisis in general.

“It’s hard to tell how bad the PPE shortage is because hospital administrators aren’t being transparent about what’s going on,” says John Pearson, an ER nurse at Highland Hospital in Oakland, California. “It’s all inconsistent and disorganized. Different managers say different things.”

Highland is one of nine public hospitals and clinics that comprise the Alameda Health System, or AHS. “In all of AHS, workers are having a hard time getting basic PPE,” Pearson says. “Managers are hoarding it, rationing it out. Workers are told to go find their manager if they need more PPE, but on some shifts, especially nights and weekends, there’s no manager on duty.”

“We’re told to reuse single-use masks and store them in paper bags, which just spreads disease from person to person,” Pearson continues. “One manager told people to spray their mask with cleaning fluid which means you’re breathing in cleaning fluid as well as using a dirty mask. Managers got caught watering down hand sanitizer, which makes it completely ineffective. Some managers are telling people they get one sani wipe per day. We use dozens of those a day.”

Pearson is the president of his chapter of SEIU Local 1021, which represents nurses, nurses’ aides, EMTs, respiratory therapists, social workers, housekeeping workers, cafeteria workers, and others. He has created a Twitter account to expose the seriousness of the PPE shortage issue. One post shows a sanitization station bearing a sign that reads “Please take a mask,” but the space where the masks are supposed to be is empty save for one piece of garbage. Another shows hand soap brought by workers from home.

Highland Hospital has been subject to the lean-production approach for two decades now. It’s one of four public acute-care hospitals serving Alameda County, home to 1.6 million people. It provides care to patients who are homeless, have no insurance, or cannot afford to pay medical bills. Like many aspects of our society that serve the poor, Highland is underfunded and understaffed.

Pearson says that before coronavirus, workers at Highland were already used to seeing trash that doesn’t get taken out, including overflowing sharps containers. They were accustomed to seeing blood stains left on the curtains and beds from previous patients, and blood-contaminated water that sits out for days. All of this is incredibly hazardous for patients and workers already, and a pandemic caused by a highly infectious virus adds major new urgency to the sanitation issue.

But instead of stepping up sanitation efforts, Person says hospital management has simply told workers to carry on and make do. One post on Pearson’s Twitter features a photo of a housekeeping worker who was instructed this past week to wipe down beds with reusable washcloths instead of sani wipes. “We are on the front lines of infection control,” reads the sign he’s holding up, “and management won’t give us masks or sani wipes!!!”

Another post on Pearson’s Twitter is a video made by a community health outreach worker at Highland who responds to sexual assault cases in the ER. She and her teammates are being denied proper protective equipment to be around patients during this crisis. “I myself, a sexual assault survivor, would not want to be at a public hospital in the emergency room, and have an advocate respond to my bedside without a mask because they were told that they couldn’t be provided a mask,” she says in the video.

One crucial piece of protective equipment is called a PAPR, a powered air purifying respirator. PAPRs greatly reduce the risk of inhaling airborne pathogens, and are especially needed when performing aerosol-generating procedures like placing an emergency airway in a patient who is in respiratory failure. That’s exactly what happens to critical COVID-19 patients — but the Highland ER does not have enough PAPRs.

“What this means is that only three people are allowed inside with potential COVID patients right now, because we only have three PAPRs,” says Pearson. “The absence of this equipment is lowering the speed and quality of care per patient already. And things haven’t even gotten bad yet.” The situation is so dire that this week a GoFundMe sprung up overnight, started by a family member of a doctor, to buy more PAPRs for workers in the Highland ER.

Surge Red

For years Highland has had a problem with understaffing and overcrowding. Situations frequently arise in which patients are stuck waiting for hours in the ER before receiving treatment. In 2017, Pearson says, “Management finally put a name on it and started calling it an ‘internal disaster’ or ‘surge red.’”

Executives used to take surge reds somewhat seriously. “They would meet in a room on a top floor far from the ER, call it a ‘command center,’ and get a catered lunch — we know because they would send down the leftovers from their catered lunch,” says Pearson. “But then they stopped meeting in person, and tell us instead that they have a ‘virtual command center.’ They have stopped taking it seriously, and the overcrowding remains a persistent problem.”

During a typical surge red, Pearson says, “Patients end up stuck in hallways. Patients get discharged early who need to stay. Patients get deprioritized who need to be seen quickly. I’ve seen patients wait in the ER for thirteen hours to be treated. There are some months where the majority of days have this happen.”

Highland and the other facilities under the AHS umbrella are technically public sector, but AHS is no longer run by the county itself. As Nick French explains in East Bay Majority, it is instead run by a board of trustees. The move was supposed to make the hospital more efficient, but as French observes, “Things have not worked out that way: making AHS an independent entity has led to massive dysfunction.” Because the hospital can’t directly access the county’s general fund, it must borrow. Debt has led to budget cuts, which has exacerbated the understaffing and overcrowding issue.

Now as the hospital is prepared to be overwhelmed by coronavirus patients, Pearson says that understaffing is posing serious threats. For example, the ER at Highland already had only one part-time nurse educator, whose job it is to train nurses on new procedures and new pathologies like COVID-19. Hands-on, on-the-spot training is necessary to equip hospital workers to deal with both this novel virus and the frightening new hospital conditions that will be created by the pandemic. But the only nurse educator has just been issued a layoff notice.

Because there’s so much concern about a rapid surge of COVID-19 patients, workers have taken it upon themselves to get trained. “Workers are training each other on how to use equipment and about COVID-19, while the only form of training management is offering is over email,” says Pearson.

AHS is also dangerously short on respiratory therapists. When a patient can’t breathe, the respiratory therapist is the one with the knowledge and expertise to keep their lungs working and run life-sustaining ventilators. The entire country is experiencing a shortage of ventilators, demand for which has skyrocketed as people around the world succumb to COVID-19. Without the staff or the equipment to help people breathe, Highland and hospitals like it are unprepared for an influx of patients who struggle to do it on their own.

In the lead-up to the coming crisis, chaos is mounting. Ad-hoc isolation rooms are being set up, but health care workers are struggling to find enough HEPA filters, the medical air purifiers that reduce airborne pathogens. Workers are left to improvise all by themselves: in the emergency department at Highland, there are vacant manager and director positions, and only two assistant managers. The hospital isn’t ready for the greatest American public health crisis in a hundred years.

Reversing Austerity

Like frontline health care workers all over the country, the staff at Highland Hospital are terrified of what’s to come. Their spirits have been lifted by displays of solidarity, such as when one coworker who works in a basement office away from patients took it upon herself to collect PPE for workers who are at the bedside, and when members and leaders of the community began collecting and sending in supplies.

Pearson says these examples of people pulling together are helping, and he hopes they will continue. But donations will not be enough to prepare Highland for the chaos to come. Through their union, workers are demanding that management supply them with more equipment, better staffing, and more training to deal with the crisis.

And Pearson says the state must step in as well. The state of California must “take control of the state’s supply chain for PPE and direct factories in California to produce essential equipment,” says Pearson. California must also “locate and requisition stockpiles of essential supplies” held by the private sector and distribute them where they’re needed, and “create a central tracking system to distribute tests and equipment based on need, not ability to pay.”

Pearson also says that to weather the crisis, the state of California will need to start treating its hospitals differently, operating at high staffing levels in contravention of the lean-production model. He thinks the state should fund free medical training and create a fast-track licensing program to fix the understaffing issue, and reopen all of the hospitals it has closed in the last five years.

Austerity got the hospital system and all of the patients who depend on it into this mess. It will take a reversal of austerity to get out of it.