In April 2020, Víctor Santamaría was in an intensive care unit at Weill Cornell Medical Center in New York City with a breathing tube in his throat. His lungs, kidneys, and liver were failing as a result of Covid-19. He was barely hanging on.
Without enough health care workers to keep him hydrated, his lips cracked. Without being turned often enough to shift his weight, his skin eroded.
As if Víctor needed another complication, a clot formed inside one of his blood vessels. Then he began bleeding from the blood thinners used to treat it.
We were two of the harried doctors who, along with nurses and respiratory therapists and other health care workers, darted from room to room, extinguishing a crisis or two as we went, unable to control others. Inside the hospital, we carried the weight of the destruction and death wrought by Covid-19. We carried it home, too.
Víctor’s wife, Alejandra, felt helpless. She wasn’t allowed to visit her husband in the hospital and was caring for their three children. A doctor whose face she would not recognize called to tell her, “Probablemente hoy muera su esposo.” Your husband will probably die today.
Her heart sunk.
How Covid-19 ravaged New York City this spring is a well-known story: overwhelmed hospitals, health care “heroes,” hollowed communities in Queens, the Bronx, and Brooklyn, especially Black and Latinx communities.
Now, as ambulances roam Los Angeles for hours seeking hospitals to accept their patients and ICUs are full, similar tragedies are playing out across the country with similar deadly results.
Since the pandemic began, hospitals in New York — then in El Paso and now Los Angeles — have been too overwhelmed with rising case numbers to address the looming crisis of collective trauma in their surrounding communities. But there is a dire need for hospitals to make amends and regain the trust of the communities they serve. Collective grieving and healing are essential, not only for individual patients and their families, like the Santamarías, but between hospitals and communities because they are so inextricably linked.
There is little guidance on how communities can mend or be mended, or what role hospitals can or should play in that process. As a first step, communities should seek a realignment of hospital accountability. Primarily focused on margins and market share, hospitals need to reconnect with the communities they ostensibly serve, starting with a truth and transparency dialogue to excavate the layers of reasons for such profound disparities in infection and death rates in different parts of a single city.
Two months after Víctor confronted death, we met him in our hospital’s Covid Recovery Unit. As we listened to him tell his story, and witnessed the damage inflicted by the virus, we were reminded of every patient we had cared for during the pandemic.
We bore witness to the same complications across emergency departments where patients were intubated or died on arrival, hospital floors at triple their capacity caring for patients on maximal oxygen support who would normally be in intensive care units, and in pop-up ICUs with enough ventilators but not enough staff. Víctor was lucky he was again able to breathe on his own, his lungs and other organs grateful for the respite after weeks on the brink of dying. But he was far from whole — the trauma was still fresh.
“I had anxiety attacks, panic attacks. I saw shadows. I heard voices,” he said. He unpacked these traumas and fears with psychologists, revealing his resilience and courage as he pushed his physical and mental limits. With pride and relief, we walked with him as he took his first steps on weary legs with the help of outstanding physical therapists. TV crews recorded him leaving the hospital, 30 pounds lighter but waving and smiling behind a mask.
Patients like Víctor are the lucky ones. He survived months in the hospital and was able to walk into his apartment, with help from a cadre of health care providers and psychologists to help him process the trauma and fear.
The communities our hospitals serve are not as lucky. Patients cease being patients as they leave the hospital, retaking the mantle of community members and citizens, grateful for the care they received, to be alive. They thank health care workers and hospitals, not knowing how or whether their care could have been better. Was the hospital prepared for the next wave of patients? Did it stock enough personal protective equipment, medications, oxygen, monitoring, ventilators, ICU beds, and staff sufficient nurses, respiratory therapists, advanced practice providers, and physicians? Did those providers have the critical care resources necessary to give patients a chance at survival?
Studies are increasingly confirming what we suspected in April: Overwhelmed hospitals without enough trained staff, like nurses or the respiratory therapists who support people on ventilators, likely contribute to increased complications and higher death rates. As the New York Times put it early in the epidemic, “surviving the virus might come down to which hospital admits you.”
For the community a hospital serves, questions still linger: Why are some communities hit harder than others? Why were some hospitals overwhelmed while others weren’t? Why do more people in one neighborhood die of Covid-19 than those in a nearby neighborhood? Why don’t our hospitals have sufficient critical care resources to help their neighbors weather the storm?
As yet another wave of Covid-19 washes over the country, these questions become increasingly urgent. Explanations like “we didn’t know it was coming” — perhaps weak but reasonable in March — are unpersuasive as cases continue to rise and hospitals struggle to keep up.
Some are calling for a report in the style of the 9/11 Commission to get to the bottom of the federal pandemic response. While that is necessary, there is still a need for dialogue and a fence-mending process at a local level. This should include three tactics to ensure its success:
First, hospitals should convene a series of community-wide forums, virtually at first while the pandemic is with us and later in person. Inviting both the local community and the loved ones of those who died, these engagements would be opportunities for health care workers to communicate what happened during the pandemic. The goal is not litigation of fault or malpractice, but an opportunity to remember and celebrate those who succumbed to Covid-19 while giving loved ones the opportunity to learn more about their family members’ final days from those who witnessed their last labored breaths.
Second, hospitals should demonstrate their resolve to ensure such a tragedy will never happen again. Since the Affordable Care Act requires each nonprofit hospital to perform a community health needs assessment every three years, hospitals should present their most recent assessment to their local communities, with a focus on addressing the disparities made more evident by Covid-19. To that end, hospitals should work with researchers to better understand these disparities and present them with transparency.
Communities in Queens and the Bronx, for example, should know why more people in their community died compared to others through hospital data sharing and open discussion of the results. The message must be that health care systems can and will do better to once again earn the trust of their neighbors. People need to know that when they call 911 and are taken to the nearest hospital, they will be able to trust the care they receive there.
Third, hospitals should have incentives to undertake such a process. The cutthroat drive for revenue, market share, and brand preservation means that such transparency could pose a risk to hospitals’ bottom lines. But there are various carrots and sticks that can be offered by city, state, and federal governments to ensure this process happens.
For example, municipal or state efforts can help connect researchers to hospitals, ensuring their data are analyzed rigorously and without political bias. Funding could come from any of these levels, but given the widespread economic impact of Covid-19, this could be included as part of an emergency relief package to hospitals in recent and pending federal stimulus bills. Since the federal government administers the Affordable Care Act, it can mandate that addressing disparities due to Covid-19 must be included in nonprofit hospitals’ next community health needs assessment.
Again, this isn’t about malpractice or individual blame. Health care workers did and are doing their best in circumstances unimaginable just one year ago and should be protected. But Gov. Andrew Cuomo’s order suspending malpractice claims during the pandemic does not absolve either us or our hospitals of our responsibility — our obligation — to the communities we serve to do better, to be better. Even when we do our best, we should always question what we can do to ensure those circumstances will never happen again.
As Víctor Santamaría arrived at his apartment in Queens, a mariachi band greeted him playing “Cielito Lindo” as Alejandra and their children embraced him. Neighbors cheered. A news report captured the celebration, recording him walk and finally return home after three months in the hospital.
Local communities deserve to hear how the hospitals they depend on will help them get back on their feet like Víctor. Only then will the collective healing and trust building start to mend the hidden wounds opened by the pandemic.
David Scales and Devin Worster are hospitalists and assistant professors of medicine at Weill Cornell Medical College. Víctor and Alejandra Santamaría gave permission for their names to be used for this article. The views and opinions expressed in this piece are those of the authors and do not necessarily reflect the official policy or position of Weill Cornell Medical College.