The following originally appeared on The Upshot (copyright 2020, The New York Times Company)
The ability of the American health care system to absorb a shock — what experts call surge capacity — is much weaker than many believe.
As a medical doctor who analyzes health issues for The Upshot, I strive to place your fears in context and usually tell you that you shouldn’t be nearly as afraid as you are. But when it comes to the nation’s response to the new coronavirus, I cannot be so reassuring.
A crucial thing to understand about the coronavirus threat — and it’s playing out grimly in Italy — is the difference between the total number of people who might get sick and the number who might get sick at the same time. Our country has only 2.8 hospital beds per 1,000 people. That’s fewer than in Italy (3.2), China (4.3) and South Korea (12.3), all of which have had struggles. More important, there are only so many intensive care beds and ventilators.
It’s estimated that we have about 45,000 intensive care unit beds in the United States. In a moderate outbreak, about 200,000 Americans would need one.
A recent report from the Center for Health Security at Johns Hopkins estimated that there were about 160,000 ventilators available for patient care. That may seem like a lot, and under normal circumstances, it is. Pandemics, however, change the calculations.
A few years earlier, the same group modeled how many ventilators would be needed in unusual circumstances. In a pandemic akin to the flu pandemics in 1957 or 1968, about 65,000 people might need ventilation.
Hospitals don’t survive financially in the United States by keeping beds open and equipment idle. They have enough equipment to be cost-effective, but still retain capacity to care for extra people in emergencies. But those emergencies do not account for what we are seeing now. It’s very possible that many of the ventilators are being used right now for patients with other illnesses. They’re also not mobile, and local outbreaks will quickly surpass the numbers of ventilators and respiratory therapists.
Moreover, if a pandemic more closely followed the model of the Spanish flu outbreak of 1918, we would need more than 740,000 ventilators.
Many people are comparing this virus to the flu. The thing to remember, though, is that the influenza numbers are spread out over eight months or more. They don’t increase exponentially over the course of weeks, as the cases of Covid-19 are doing right now.
Further, a greater proportion of people who are becoming ill now are seriously sick. According to some estimates, 10 percent to 20 percent of those who are infected may require hospitalization. In a metropolitan setting, if enough people become infected, the numbers who may need significant care will easily overwhelm our capacity to provide it.
The cautionary tale is Italy. More than 12,000 people have been infected there; more than 800 have died. A little over 1,000 have recovered. Many of the rest are ill. And a significant number of them need to be hospitalized — right now.
This has exceeded Italy’s capacity for care. It doesn’t matter what physicians’ specialties are — they’re treating coronavirus. As health care providers fall ill, Italy is having trouble replacing them. Elective procedures have been canceled. People who need care for other reasons are having trouble finding space.
In an unthinkable fashion, physicians are having to ration care. They’re having to choose whom to treat, and whom to ignore.
They’re having to choose who will die.
Italy, especially Northern Italy, has a solid health care system. It might not be the best in the world, but it’s certainly not lacking in ability. It’s just not ready for the sudden influx of cases. There aren’t enough physicians. There’s not enough equipment.
The United States isn’t better prepared.
Many health experts expect that a majority of people will eventually be exposed to, if not infected with, this virus. The total number of infected people isn’t what scares many epidemiologists. It’s how many are infected at the same time.
An unchecked pandemic will lead to an ever-quickening rate of infection. If, however, we engage in social distancing, proper quarantining and proper hygiene, we can slow the rate of spread, and make sure there are enough resources to properly care for everyone. This can also buy us time for a vaccine to be developed.
South Korea has flattened its curve by engaging in extreme testing and social distancing. It has set up drive-through screening stations so people can check if they’re infected without putting others at risk. As of Sunday, almost 190,000 people there had been tested for the virus. That allowed a more targeted quarantine of infected people.
We have no real idea how many people in the United States are infected. We’re still woefully behind in testing.
Colleges are closing campuses left and right because they’re worried — correctly — about spring break, and the potential for students to travel, become infected and then spread the disease among other students and faculty in the next few weeks. But the rest of us have much harder decisions to make.
Studies show that when children are prevented from being a high-transmitter group, deaths among older people are significantly reduced. But closing elementary, middle and high schools could do more harm than good if parents are still working. This could mean children are left in the care of older people (i.e., grandparents), and of course that places those most vulnerable at higher risk.
Further, many children rely on schools for food. Without planning on how to get them meals if school is canceled, this could result in many going hungry.
What might help the most is comprehensive paid sick leave from work. The people who are ill — or who need to care for children who are ill — need to be able to stay home and not expose others to illness. If that doesn’t happen, everyone is at higher risk.
Of course, general advice still applies. Wash your hands (that can’t be stressed enough), don’t touch your face, cough and sneeze into your elbow, stay away from sick people, and stay away from people when you’re sick yourself.
We have a window to get hold of this, but it’s closing rapidly. The initial travel restrictions to China probably made a big difference, but we failed to follow up appropriately, The decisions made in the last week to increase social distancing — including canceling many large gatherings across the country — are necessary but not sufficient.
We need data, meaning the ability to test more people to understand where community transmission might be occurring. We need to protect those who are most vulnerable, supporting their ability to self-quarantine. We need to convince people who might be sick, even mildly so, to stay home. And we need to make it economically possible for them to do so.
Without quick action, what we’re seeing in other countries may happen here, with terrible consequences.
