How a milder COVID variant is creating a health care crisis

0
14

“Give up hope,” the Buddhist nun Pema Chödrön tells us, in her book “When things fall apart», from 1996. It is not a message of despair but of clarity. What she means is that hope can sometimes distract us from what is really going on. “We cling to hope, and hope robs us of the present moment,” she explains. Chödrön wants us to see things and deal with them as they really are, even if it’s difficult.

Right now, the pull of hope is powerful and understandable. After two years of disruption, people are waiting for good news. The emergence of the Omicron variant in Botswana and South Africa seemed to signal another dark winter, but then doctors began to report that Omicron infections may be less likely to result in hospitalization than was the case for Delta. As the variant spread to Europe, the UK, and the United States, other studies have suggested it may be less dangerous. The rise of Omicron in South Africa ended almost as soon as it started, with relatively few associated deaths, and the UK surge has since peaked (although there the number of cases has plateaued rather than fallen). Several US cities with early Omicron waves may also have sharp.

All this is cause for justified hope. And yet, that hope seems to distract us from another disturbing reality: American hospitals have been quietly in crisis for months. I work in a small emergency room in rural New Mexico, and our hospital has long been near or at full capacity. In December, I wrote that a colleague of mine had to call thirty-eight other hospitals looking for a bed for one of our patients. Now we regularly call forty, fifty, even sixty hospitals without success. The problem is not only covid but the price it has taken on the health care system as a whole. Many claimants quit their jobs, exhausted; those who remain are now contracting the virus at a higher rate than ever. This is happening across the country, straining many parts of the system simultaneously.

Even when they walk through the door, I can tell if the patients are going to need a transfer. There may not be room for them or they may need care that we cannot provide. I immediately think of the dozens of phone calls I’m going to have to make, while the waiting room fills with new patients requiring my attention. Some may spend hours or even days in our ER as their condition steadily worsens. A no-covid patient with liver and kidney failure was recently stuck in our ward for three days. Our staff called over sixty hospitals as they deteriorated; eventually, he had to be intubated. Last week, I turned over a patient with internal bleeding to the doctor overnight. I explained that we had called forty-five hospitals looking for a bed, including those in Georgia, California and Wyoming, and found none. He shook his head and said, “That really should be in the news.”

The word ‘endemic’, which descends from the Greek words meaning ‘in’ or ‘among’ and ‘people’, means that a pathogen exists in some sort of permanent equilibrium with its host. Malaria is endemic in parts of Africa; seasonal flu is rampant everywhere. Omicron’s contagiousness has people wondering if it grows covid to the threshold of endemicity. Bill Gates and the Prime Minister of Spain both raised the possibility; the BBC reported that “there is growing confidence that Omicron could usher the UK into the final stage of the pandemic”. Earlier this month, three public health experts, all former advisers to President Biden, called for a change in national strategy support a “new normal” of life with covid. Reports “Omicron parties” even make the headlines. The attitude seems to be that since Omicron is softer and will be with us forever, why not end it?

The possibility that a milder variant will propel us towards the end of the pandemic by spreading widespread immunity is also encouraging. But the reality is not so sunny. In fact, some of us – the unvaccinated or otherwise vulnerable – may be in a very dangerous phase of the crisis. Most of the data showing that Omicron is less likely to cause serious symptoms or hospitalization compares it to Delta. But Delta was on point twice as virulent as the first iteration of the virus. This means Omicron can be about as dangerous as the original Wuhan strain. SARS-CoV-2, but much more infectious.

It is entirely possible that early studies showing reduced hospitalization rates with Omicron may not apply equally everywhere. The severity of any infectious disease is always affected by the characteristics of the population it infects. Today, billions of people have some degree of immunity to the coronavirus from previous infections and vaccinations. But this immunity is unequally distributed. South Africa’s population is relatively young and believed to have a high level of general immunity to coronavirus; in the UK, vaccination rates are higher than in the US. For large segments of the US population – the elderly, the unvaccinated, or those with multiple medical comorbidities – Omicron could prove anything but mild.

The sheer contagiousness of the new variant has an importance that is easy to underestimate. Delta peaked in the United States on August 6, at around two hundred and fifty-five thousand new daily cases. If an estimate two percent Delta cases required hospitalization, these new infections would have created about five thousand new patients. Compare that to Omicron. On January 10, there was 1.37 million new cases in the United States. Even though the hospitalization rate for Omicron is half of what it was for Delta, that still represents 13,700 new patients in a single day of new infections. And, according to the Surgeon General of the United States, the peak of Omicron is still in front of us.

Beyond a certain threshold, the health system becomes overwhelmed. The problem is that patients have nowhere to go. At the start of the pandemic, hospitals and health care providers mobilized to increase the capacity of people with the virus; the system staggered under the pressure but did not break. Now the situation is different. Many hospitals are already overwhelmed. After two years, exhausted healthcare workers quit their jobs in droves. A quarter of all hospitals are reports severe staff shortages. Thousands of hospital beds across the country are empty because there are no nurses to take care of them. Many hospitals now keep employees who test positive at work if their symptoms are mild, because there is no one to replace them. The problem goes beyond the hospital: in Washington State, hospitals are in trouble to discharge patients due to understaffing in nursing homes and rehabilitation centers. Recently a friend of mine who works in New York told me that it took him four hours to transfer a heart attack patient to a larger facility a few miles away – there was no enough ambulance crews.

Along with the exodus of health care workers, another mass movement has taken place. Regular patients – those with kidney disease, cancer or heart problems – have started to return to the emergency room. Many stayed away for the first year of the pandemic and their condition has now worsened. Cancers are more advanced; chest pain turned into heart failure; and people with kidney disease now need dialysis. In short, hospitals are overwhelmed with more patients, with more serious problems, in the midst of an ongoing pandemic, with fewer staff members than ever before.

The situation inside our hospital is grim, and has been for months. Patients fill our waiting rooms, each labeled with a complaint on the computer dashboard: cough, fever, shortness of breath. We lack even basic supplies, including endotracheal tubes for intubation and blood. A few days ago we ran out of covid trials. A courier had to fetch over from another hospital. Ultimately, if you come to our emergency room for care, you may not receive it. This is true not only for covid patients but for all patients. We may simply not be able to get you to an intensive care bed, a neurosurgeon or a cardiologist. The system has become distorted; in many ways, and for many patients, it has already failed. I don’t know how we’re going to take care of the patients who inevitably seem to come our way.

Last week, the Massachusetts Health and Hospital Association released a declaration. “We have never been so afraid of what is to come,” it read. “Every corner of our healthcare system is stretched thin.” The situation may be invisible to most people, the authors wrote; it is revealed only when “they are the ones who need care and bear witness to it”.

Nor is it a message of despair but of clarity. We have to see things and deal with them as they really are, even if it is difficult. We have come a long way and the end of the pandemic may very well be in sight. But we are not there yet and in many places the situation is bad. We have the tools to keep ourselves and others safe, and we must continue to use them. Stay home, wear a mask and get vaccinated. Flatten the curve, for yourself and for everyone else.