Portside

When a health-care system crumbles, this is what it looks like. Much of what’s wrong happens invisibly. At first, there’s just a lot of waiting. Emergency rooms get so full that “you’ll wait hours and hours, and you may not be able to get surgery when you need it,” Megan Ranney, an emergency physician in Rhode Island, told me. When patients are seen, they might not get the tests they need, because technicians or necessary chemicals are in short supply. Then delay becomes absence. The little acts of compassion that make hospital stays tolerable disappear. Next go the acts of necessity that make stays survivable. Nurses might be so swamped that they can’t check whether a patient has their pain medications or if a ventilator is working correctly. People who would’ve been fine will get sicker. Eventually, people who would have lived will die. This is not conjecture; it is happening now, across the United States. “It’s not a dramatic Armageddon; it happens inch by inch,” Anand Swaminathan, an emergency physician in New Jersey, told me.

In this surge, COVID-19 hospitalizations rose slowly at first, from about 40,000 nationally in early November to 65,000 on Christmas. But with the super-transmissible Delta variant joined by the even-more-transmissible Omicron, the hospitalization count has shot up to 110,000 in the two weeks since then. “The volume of people presenting to our emergency rooms is unlike anything I’ve ever seen before,” Kit Delgado, an emergency physician in Pennsylvania, told me. Health-care workers in 11 different states echoed what he said: Already, this surge is pushing their hospitals to the edge. And this is just the beginning. Hospitalizations always lag behind cases by about two weeks, so we’re only starting to see the effects of daily case counts that have tripled in the past 14 days (and are almost certainly underestimates). By the end of the month, according to the CDC’s forecasts, COVID will be sending at least 24,700 and up to 53,700 Americans to the hospital every single day.

This surge is, in many ways, distinct from the ones before. About 62 percent of Americans are fully vaccinated, and are still mostly protected against the coronavirus’s worst effects. When people do become severely ill, health-care workers have a better sense of what to expect and what to do. Omicron itself seems to be less severe than previous variants, and many of the people now testing positive don’t require hospitalization. But such cases threaten to obscure this surge’s true cost.

Omicron is so contagious that it is still flooding hospitals with sick people. And America’s continued inability to control the coronavirus has deflated its health-care system, which can no longer offer the same number of patients the same level of care. Health-care workers have quit their jobs in droves; of those who have stayed, many now can’t work, because they have Omicron breakthrough infections. “In the last two years, I’ve never known as many colleagues who have COVID as I do now,” Amanda Bettencourt, the president-elect of the American Association of Critical-Care Nurses, told me. “The staffing crisis is the worst it has been through the pandemic.” This is why any comparisons between past and present hospitalization numbers are misleading: January 2021’s numbers would crush January 2022’s system because the workforce has been so diminished. Some institutions are now being overwhelmed by a fraction of their earlier patient loads. “I hope no one you know or love gets COVID or needs an emergency room right now, because there’s no room,” Janelle Thomas, an ICU nurse in Maryland, told me.

Here, then, is the most important difference about this surge: It comes on the back of all the prior ones. COVID’s burden is additive. It isn’t reflected just in the number of occupied hospital beds, but also in the faltering resolve and thinning ranks of the people who attend those beds. “This just feels like one wave too many,” Ranney said. The health-care system will continue to pay these costs long after COVID hospitalizations fall. Health-care workers will know, but most other people will be oblivious—until they need medical care and can’t get it.

The Patients

The patients now entering American hospitals are a little different from those who were hospitalized in prior surges. Studies from South Africa and the United Kingdom have confirmed what many had hoped: Omicron causes less severe disease than Delta, and it is less likely to send its hosts to the hospital. British trends support those conclusions: As the Financial Times’ John Burn-Murdoch has reported, the number of hospitalized COVID patients has risen in step with new cases, but the number needing a ventilator has barely moved. And with vaccines blunting the severity of COVID even further, we should expect the average COVID patient in 2022 to be less sick than the average patient in 2021.

In the U.S., many health-care workers told me that they’re already seeing that effect: COVID patients are being discharged more easily. Fewer are critically ill, and even those who are seem to be doing better. “It’s anecdotal, but we’re getting patients who I don’t think would have survived the original virus or Delta, and now we’re getting them through,” Milad Pooran, a critical-care physician in Maryland, told me. But others said that their experiences haven’t changed, perhaps because they serve communities that are highly unvaccinated or because they’re still dealing with a lot of Delta cases. Milder illness “is not what we’re seeing,” said Howard Jarvis, an emergency physician in Missouri. “We’re still seeing a lot of people sick enough to be in the ICU.” Thomas told me that her hospital had just seven COVID patients a month ago, and is now up to 129, who are taking up almost half of its beds. Every day, about 10 patients are waiting in the ER already hooked up to a ventilator but unable to enter the ICU, which is full.

During this surge, record numbers of children are also being hospitalized with COVID. Sarah Combs, a pediatric emergency physician in Washington, D.C., told me that during the height of Delta’s first surge, her hospital cared for 23 children with COVID; on Tuesday, it had 53. “Many of the patients I’m operating on are COVID-positive, and some days all of them are,” Chethan Sathya, a pediatric surgeon in New York, told me. “That never happened at any point in the pandemic in the past.” Children fare much better against the coronavirus than adults, and even severely ill ones have a good chance of recovery. But the number of such patients is high, and Combs and Sathya both said they worry about long COVID and other long-term complications. “I have two daughters myself, and it’s very hard to take,” Sathya said.

These numbers reflect the wild spread of COVID right now. The youngest patients are not necessarily being hospitalized for the disease—Sathya said that most of the kids he sees come to the hospital for other problems—but many of them are: Combs told me that 94 percent of her patients are hospitalized for respiratory symptoms. Among adults, the picture is even clearer: Every nurse and doctor I asked said that the majority of their COVID patients were admitted because of COVID, not simply with COVID. Many have classic advanced symptoms, such as pneumonia and blood clots. Others, including some vaccinated people, are there because milder COVID symptoms exacerbated their chronic health conditions to a dangerous degree. “We have a lot of chronically ill people in the U.S., and it’s like all of those people are now coming into the hospital at the same time,” said Vineet Arora, a hospitalist in Illinois. “Some of it is for COVID, and some is with COVID, but it’s all COVID. At the end of the day, it doesn’t really matter.” (COVID patients also need to be isolated, which increases the burden on hospitals regardless of the severity of patients’ symptoms.)

Omicron’s main threat is its extreme contagiousness. It is infecting so many people that even if a smaller proportion need hospital care, the absolute numbers are still enough to saturate the system. It might be less of a threat to individual people, but it’s disastrous for the health-care system that those individuals will ultimately need.

Other countries have had easier experiences with Omicron. But with America’s population being older than South Africa’s, and less vaccinated or boosted than the U.K.’s or Denmark’s, “it’s a mistake to think that we’ll see the same degree of decoupling between cases and hospitalizations that they did,” James Lawler, an infectious-disease physician in Nebraska, told me. “I’d have thought we’d have learned that lesson with Delta,” which sent hospitalizations through the roof in the U.S. but not in the U.K. Now, as then, hospitalizations are already spiking, and they will likely continue to do so as Omicron moves from the younger people it first infected into older groups, and from heavily vaccinated coastal cities into poorly vaccinated rural, southern, and midwestern regions. “We have plenty of vulnerable people who will fill up hospital beds pretty quickly,” Lawler said. And just as demand for the health-care system is rising, supply is plummeting.

The Workers

The health-care workforce, which was short-staffed before the pandemic, has been decimated over the past two years. As I reported in November, waves of health-care workers have quit their jobs (or their entire profession) because of moral distress, exhaustion, poor treatment by their hospitals or patients, or some combination of those. These losses leave the remaining health-care workers with fewer trusted colleagues who speak in the same shorthand, less expertise to draw from, and more work. “Before, the sickest ICU patient would get two nurses, and now there’s four patients for every nurse,” Megan Brunson, an ICU nurse in Texas, told me. “It makes it impossible to do everything you need to do.”

Omicron has turned this bad situation into a dire one. Its ability to infect even vaccinated people means that “the numbers of staff who are sick are astronomical compared to previous surges,” Joseph Falise, a nurse manager in Miami, told me. Even though vaccinated health-care workers are mostly protected from severe symptoms, they still can’t work lest they pass the virus to more vulnerable patients. “There are evenings where we have whole sections of beds that are closed because we don’t have staff,” said Ranney, the Rhode Island emergency physician.

Every part of the health-care system has been affected, diminishing the quality of care for all patients. A lack of pharmacists and outpatient clinicians makes it harder for people to get tests, vaccines, and even medications; as a result, more patients are ending up in the hospital with chronic-disease flare-ups. There aren’t enough paramedics, making it more difficult for people to get to the hospital at all. Lab technicians are falling ill, which means that COVID-test results (and medical-test results in general) are taking longer to come back. Respiratory therapists are in short supply, making it harder to ventilate patients who need oxygen. Facilities that provide post-acute care are being hammered, which means that many groups of patients—those who need long-term care, dialysis, or care for addiction or mental-health problems—cannot be discharged from hospitals, because there’s nowhere to send them.

These conditions are deepening the already profound exhaustion that health-care workers are feeling. “We’re still speaking of surges, but for me it’s been a constant riptide, pulling us under,” Brunson said. “Our reserves aren’t there. We feel like we’re tapped out, and that person who is going to come in to help you isn’t going to, because they’re also tapped out … or they’ve tested positive.”

Public support is also faltering. “We once had parades and people hanging up signs; professional sports teams used to do Zooms with us and send us lunches,” Falise told me. “The pandemic hasn’t really become any different, but those things are gone.” Health-care workers now experience indifference at best or antagonism at worst. And more than ever, they are struggling with the jarring disconnect between their jobs and their communities. At work, they see the inescapable reality of the pandemic. Everywhere else—on TV and social media, during commutes and grocery runs—they see people living the fantasy that it is over. The rest of the country seems hell-bent on returning to normal, but their choices mean that health-care workers cannot.

As a result, “there’s an enormous loss of empathy among health-care workers,” Swaminathan said. “People have hit a tipping point,” and the number of colleagues who’ve talked about retiring or switching careers “has grown dramatically in the last couple of months.” Medicine runs on an unspoken social contract in which medical professionals expect themselves to sacrifice their own well-being for their patients. But the pandemic has exposed how fragile that contract is, said Arora, the Illinois hospitalist. “Society has decided to move on with their lives, and it’s hard to blame health-care workers for doing the same,” she said.

The System

In the coming weeks, these problems will show up acutely, as the health-care system scrambles to accommodate a wave of people sick with COVID. But the ensuing stress and strain will linger long after. The danger of COVID, to individual Americans, has gone far past the risk that any one infection might pose, because the coronavirus has now plunged the entire health-care system into a state of chronic decay.

In Maryland, Milad Pooran runs a center that helps small community hospitals find beds for critically ill patients. Normally, it gets a few calls a night, but “now we’re getting two an hour,” he told me. In Swaminathan’s emergency room, “we routinely have 60 to 70 people who are waiting for six to 12 hours to be seen,” he said. Other health-care workers noted that even when they can get people into beds, offering the usual standard of care is simply impossible. “Yes, sure, if you’re the patient who puts us at 130 percent capacity, you still technically get a bed, but the level of care that everyone gets is significantly diminished,” Lawler said. Some doctors are discharging patients who would have been admitted six months ago, because there’s nowhere to put them and they seem temporarily stable enough.

To be clear, these problems are not affecting just COVID patients, but all patients. When Swaminathan’s friends asked what they should be doing about Omicron, he advised them about boosters and masks, but also about wearing a seat belt and avoiding ladders. “You don’t want to be injured now,” he told me. “Any need to go to the emergency department is going to be a problem.” This is the bind that Americans, including vaccinated ones, now face. Even if they’re unconcerned about COVID or at low personal risk from it, they can still spread a variant that could ultimately affect them should they need medical care for anything.

These conditions are contributing to the moral distress that health-care workers feel. “This pandemic is making it almost impossible to provide our best care to patients, and that can become too much for some folks to bear,” Ranney said. A friend recently told her, after seeing a patient who had waited six hours with a life-threatening emergency, “How can I go back tomorrow knowing that there might be another patient in the waiting room who might be about to die and who I don’t know about?”

From outside the system, it can be hard to see these problems. “I don’t think people will realize what’s happening until we fall off that cliff—until you call 911 and no one comes, or you need that emergency surgery and we can’t do it,” Swaminathan said. The system hasn’t yet careened over: “When the trauma patients, the cardiac arrests, or the strokes come in, it’s a mad shuffle, but we still find a way to see them,” said Kit Delgado, the Pennsylvania emergency physician. “I don’t know how sustainable that’s going to be if cases keep rising everywhere.”

Measures that worked to relieve strain in earlier surges are now harder to pull off. Understaffed hospitals can hire travel nurses, but Omicron has spread so quickly that too many facilities “are pulling from the same labor pool—and if that pool is sick, where are the reinforcements?” Syra Madad, an infectious-disease epidemiologist in New York, told me. Hospitals often canceled nonemergency surgeries during past surges, but many of those patients are now even sicker, and their care can’t be deferred any longer. This makes it harder for COVID teams to pull in staff from other parts of a hospital, which are themselves heaving with patients. Brunson works in a cardiac ICU, not a COVID-focused one, but her team is still inundated with people who got COVID in a prior surge and “are now coming in with heart failure” because of their earlier infection, she said. “COVID isn’t done for them, even though they’re testing negative.” Hospitals aren’t facing just Omicron, but also the cumulative consequences of every previous variant in every previous surge.

Newer solutions are limited, too. Joe Biden has promised to bolster hard-hit hospitals with 1,000 more military personnel—a tiny number for the demand. New antiviral drugs such as Pfizer’s Paxlovid could significantly reduce the odds of hospitalization, but supplies are low; the pills must also be taken early on in the disease’s course, which depends on obtaining rapid diagnostic tests, which are also in short supply. For people who get the drugs, “they’ll be great, but at a population scale they’re not going to prevent the system from being overwhelmed,” Lawler said. So, almost unbelievably, the near-term fate of the health-care system once again hinges on flattening the curve—on slowing the spread of the most transmissible variant yet, in a matter of days rather than weeks.

Some experts are hopeful that Omicron will peak quickly, which would help alleviate the pressure on hospitals. But what then? Ranney fears that once hospitalizations start falling, policy makers and the public will assume that the health-care system is safe, and do nothing to address the staffing shortages, burnout, exploitative working conditions, and just-in-time supply chains that pushed said system to the brink. And even if the flood of COVID patients slows, health-care workers will still have to deal with the fallout—cases of long COVID, or people who sat on severe illnesses and didn’t go to hospital during the surge. They’ll do so with even less support than before, without the colleagues who are quitting their jobs right now, or who will do so once the need and the adrenaline subside. “Right now, there’s a sense of purpose, which lets you mask the trauma that everyone is experiencing,” Pooran said. “My fear is that when COVID is done with and everything does quiet down, that sense of purpose will go away and a lot of good people will leave.”

There’s a plausible future in which most of the U.S. enjoys a carefree spring, oblivious to the frayed state of the system they rely on to protect their health, and only realizing what has happened when they knock on its door and get no answer. This is the cost of two years spent prematurely pushing for a return to normal—the lack of a normal to return to.

The Atlantic’s COVID-19 coverage is supported by grants from the Chan Zuckerberg Initiative and the Robert Wood Johnson Foundation.

Ed Yong is a staff writer at The Atlantic, where he covers science.

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