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The United States may soon face a dangerous shortage of health care workers to fight the sprawling Covid-19 coronavirus pandemic.

With the number of confirmed Covid-19 cases in the US surpassing anywhere else in the world, the medical workforce is more strained than ever. Doctors and nurses are reporting gear shortages, lax protocols, and a high level of stress in their workplaces — with the worst still to come. Some of them told Vox that they consider getting infected with the coronavirus an inevitability.

Staffing problems are already becoming acute in New York City, the epicenter of the US pandemic so far. City officials were not able to provide any numbers on how many medical workers there have tested positive for Covid-19, but doctors work in fear for their own safety.

An internal medicine physician at New York-Presbyterian/Weill Cornell Medical Center in Manhattan shared an internal communication with Vox that said staff are being required to wear masks “only when clinically indicated.” This person requested anonymity to avoid potential retribution from their employer. They found the potential for exposure to the virus without protective equipment upsetting. Given how extensive community spread is and how high-risk health workers are, some other hospitals are requiring all staff to keep their masks on at all times.

The New York hospital is also reevaluating its current policy of not having staff wear scrubs when they treat Covid-19 patients, though that is the standard in places like China. And it has required pregnant people on its staff to continue working, though there is limited information about the risk to that population. The hospital cited the 2003 SARS outbreak, Covid-19 cases in South Korea and China, the assessment of the hospital’s senior medical staff, and the effectiveness of the protective gear in an internal communication seen by Vox.

“My frustration is that I have never felt like my safety is important,” this physician said. “When I’m going to work, I could endanger me and my family and I feel like my institution doesn’t even care at all.”

Reached for comment about the concerns of its staff, New York-Presbyterian said it is “treating a large influx of COVID-19 patients, as anticipated. The health and safety of every patient in our care, as well as our entire staff, continues to be our highest priority.”

“We continue to implement measures to increase capacity, including triage tents and reassignment of beds and units, cancellations of all elective surgeries, and utilization of telemedicine if possible,” the hospital said in a statement. “We are also conserving supplies, including personal protective equipment, to help meet this challenge, which we expect to continue.”

New York is living through what other cities may soon experience. Morale is low and the mood anxious across the country, as the pandemic continues to worsen. Based on what we’ve seen already in other countries, a lot of doctors and nurses are highly likely to get sick.

“As soon as you have the first case, you immediately have a staffing problem; you’re probably furloughing people who made the first contacts before you had test results,” Chip Kahn, president of the Federation of American Hospitals, said. “Then as you get further into it, it gets more and more intense.”

And the problem that other countries face may be worse in America.

“With already lower staffing ratios plus the very real risk of losing more [health care workers] due to illness, this could spiral and get much worse,” Jen Kates, who leads the global health program at the Kaiser Family Foundation, said.

If too many doctors and nurses get infected themselves and can’t care for patients, or if hospitals lay off workers because they are losing revenue with many of their other operations on hold, the health system’s capacity is going to deteriorate even further.

Health care workers face more exposure to the coronavirus, and they may also get sicker

Doctors and nurses may have a higher chance of getting seriously ill from the coronavirus if they do get infected. The numbers from the initial Wuhan, China, outbreak indicate 15 percent of the roughly 1,700 Covid-19 cases for medical personnel as of mid-February were critical or severe. Five had died.

The World Health Organization’s report found that health care workers were actually not more at risk of infection than other people. But the WHO also noted that “attention to the prevention of infection in health care workers is of paramount importance in China. Surveillance among health care workers identified factors early in the outbreak that placed [health care workers] at higher risk of infection, and this information has been used to modify policies to improve protection.”

“It’s not that they’re getting infected at higher rates; instead, they’re getting sicker than one might expect on the basis of their age,” says Peter Hotez, the dean of the National School of Tropical Medicine at Baylor College, of health care workers in Wuhan.

One theory for why that could be: Medical staff are exposed to high levels of the virus as they work in hospitals and interact with patients. But we don’t know for sure.

The early data from the European countries hit the hardest by Covid-19 indicates health care workers account for a significant share of their Covid-19 cases. In Spain, government officials reported on Tuesday that medical staff accounted for 14 percent of the country’s nearly 40,000 reported cases. In Italy as of March 22, almost 1 in 10 coronavirus cases was a health care worker.

And in America, given our known shortage of protective medical gear and lax protocols reported at some hospitals, we cannot necessarily expect the same resilience among our medical staff as China saw. More than 100 workers in Boston’s three biggest hospitals have already tested positive for Covid-19, according to local news reports on Wednesday.

“The burden it’s placing on our hospitals, with the lack of equipment — we feel ill-prepared for it,” said Stefan Flores, an assistant professor of emergency medicine at Columbia University in New York City.

“It’s like showing up to war with a knife at this point. I don’t know if I am going to have a mask the next day,” Flores said. He keeps two or three masks in a bioprotective bag at the end of the workday, washing it and preventing it from being soiled, because he doesn’t know when they’re going to get more. He leaves them in a designated section of his apartment.

An ER doctor in Pennsylvania told Vox that as hospitals face personal protective gear shortages, incomplete protection from exposure means more doctors and medical staff out sick. That will lead to worse outcomes overall for coronavirus patients.

But they have no choice but to adapt to these circumstances; hospitals and ERs can’t shutter in the middle of an outbreak because they lack protective equipment.

Demand for personal protective gear has been extraordinary; one health care supply company reported it had seen demand for N95 masks double during the outbreak. Some hospitals have reportedly run out of a month’s worth of supplies in just a few days.

Meanwhile, hospitals are already pushing staff to the limit in an effort to keep enough doctors and nurses on call to respond to the pandemic. One nurse at a major metropolitan hospital, who asked for anonymity to avoid angering their employer, told Vox that staff had been instructed to come to work as long as their temperature did not exceed 101 degrees Fahrenheit and they weren’t coughing, regardless of their known exposure to the coronavirus. They were given brown bags to keep their N95 mask in so the mask could be reused.

Flores said that initially, doctors and medical staff at his hospital were asked to quarantine if they were simply exposed to a coronavirus patient. “Obviously, that very changed quickly once we realized with the sheer number of people who actually were infected with [coronavirus] was so high that it was fine; you were going to be exposed. Now, it’s as long as you’re symptomatic.”

It’s not just infections that could shrink hospital staff. Many hospitals are starting to postpone elective surgeries (which can include procedures for serious conditions like cancer and heart disease, as well as less urgent surgeries) so as to free up more staff for coronavirus response and to reduce the risk of more people getting infected.

Canceled surgeries mean a loss in revenue for those hospitals. One rural hospital in Georgia told Modern Healthcare it could lose half of its revenue with elective services delayed. Industry leaders have warned that hundreds of hospitals could close without a huge infusion of cash from Congress. The deal recently struck in the Senate would pump $100 billion into US hospitals in a bid to stave off disaster.

If doctors and nurses can’t work, hospitals can’t care for as many people

Before the coronavirus ever came to our shores, America was at a hospital staffing disadvantage compared to other rich countries. Overall, US hospitals employ as many people or more per capita as our economic peers. But staffing is disproportionately tilted toward administrative work in the United States.

If you focus on health care professionals specifically, US hospitals trail behind most European countries and Canada. Our hospitals employ almost as many administrative staff as medical staff, according to estimates from the Peterson-Kaiser Health System Tracker.

And US hospitals were already at risk of being overrun if the number of Covid-19 cases explodes before fears about staffing shortages fully set in.

America has about 924,000 hospital beds, about 98,000 of which can be used for people who need intensive care, according to the American Hospital Association. The number of Covid-19 cases that will require ICU care could expand far beyond what the US is currently capable of providing.

Imperial College London projections from mid-March, while just one set of estimates among many and based largely on modeling for influenza outbreaks instead of the current facts on the ground, painted a grim picture. It found even the most aggressive mitigation strategies — general social distancing, quarantines, closing schools — would not be enough to prevent US hospitals from eventually being overwhelmed unless the country is willing to commit to these drastic measures until a vaccine becomes available.

For people 60 and older, between 17 and 25 percent of cases are expected to require hospitalization; of those, 25 percent or more will require intensive care (as many as 70 percent for patients 80 and older), according to this analysis. The ability of hospitals to provide that care will be imperative if we are to protect those most vulnerable populations.

Italian hospitals could provide a frightening preview of what’s to come in the US as their system is overwhelmed by coronavirus and medical personnel are put at risk. A group of doctors from a hospital in Bergamo, Italy, facing 4,305 Covid-19 cases in their city with just 48 ICU beds available, painted a grave picture in a March 21 New England Journal of Medicine op-ed:

We are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. Patients are transported by our regional system,1 which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die, including young people, which increases the stress of those on the front line.

The toll on hospital workers will manifest in many ways. Research out of China found high levels of stress and depression among health care workers who were responding to the coronavirus outbreak.

Already, US doctors are on edge. Kevin Tien, a pediatric resident at a hospital in Houston, Texas, which has so far seen a small number of cases, described the mood as “a quiet simmering of anxiety.”

“Everyone is on edge, waiting for the crest of the wave to crash.”

What we can do to fix it

The highest priorities right now are to prevent any more health care workers from getting sick, and to help ill hospital staff return to swabbing noses, running tests, and treating patients. But these efforts remain hampered by shortages in critical equipment, so resolving these shortfalls is essential to slowing the spread of Covid-19.

President Trump has invoked the Defense Production Act but has not yet used it to order US manufacturers to make more medical supplies to address these shortfalls. But whether there is an official order or not, it will take some time for assembly lines to spool up.

Testing could also help health care workers who were sick with Covid-19 return to the job. In particular, serologic tests can establish whether someone has been infected and has mounted an immune response to the infection. These tests look for antibody proteins to the virus. They aren’t as accurate for diagnosing active infections since it can take days for an infected person to produce antibodies, but serologic tests are useful for finding out who has fought off the virus.

Some researchers are optimistic about using these tests in exposed health workers, but only if they can know for sure that surviving the virus grants immunity from future infections.

“I’ve publicly stated that I support that if we can verify that [testing positive for an immune response to Covid-19] really is protective” against the disease, said Marc Lipsitch, a professor of epidemiology at Harvard University. “We need to check to make sure the protection is real before doing that on a large scale, but I do think that will be an important part of the strategy because we’ll need to keep health care workers in action.”

But Covid-19 tests remain in short supply, which means hospitals and health officials will have to decide whether to use what they have to find out who has the virus, or to probe past infections.

States and localities are also preparing for this oncoming staffing crisis by trying to recruit retirees and even medical students to fill the voids, when they happen. In New York, Gov. Andrew Cuomo said on March 25 that 40,000 people have signed up to be part of the state’s health care reserve. New York University is allowing some medical students to graduate early help with coronavirus patients, provided they can get the proper certifications.

However, one of the most important ways to protect hospital workers remains public health measures to slow the spread of the virus. Proper hand-washing and social distancing can reduce the number of simultaneous cases of Covid-19. Flattening the curve of cases will help ensure that there are enough beds, ventilators, protective equipment, and medical staff to attend to patients at a given time. That, in turn, will reduce stress on doctors, nurses, and orderlies and allow them to spread out potential exposures to the virus.

So everyone else staying home from work can help keep hospitals working.

Still, new Covid-19 cases are increasing, and the situation for health workers seems poised to get worse before it gets better. “It’s almost a question, I feel like, for us as health care workers: not if we get sick, when we get sick,” Flores said.

“It’s definitely anguishing, and it’s definitely scary,” he added. “But just like anything, too, I think it will pass. I think we’re taking appropriate measures. It’s just unfortunately going to get worse before it gets better.”

Eliza Barclay and Brian Resnick contributed to this report.