A Healthcare System That Buckled But Held

By on January 4, 2021

Holy Name Medical Center in Teaneck, during the first weeks of the COVID-19 pandemic. (Photo by Jeff Rhode )

This story was written and produced by NJ Spotlight. It is being republished under a special NJ News Commons content-sharing agreement related to COVID-19 coverage. To read more, visit njspotlight.com.

Like something from science fiction, 2020 was upended by a minute, spike-crowned virus that spread aggressively among people, caused unprecedented disease and death, and altered the way we do everything from celebrate holidays to vote for president.

The novel coronavirus put immense stress on all our public structures, but the impact was particularly profound for health care systems nationwide and in New Jersey, which was among the first states to diagnose cases of COVID-19 — the disease caused by the virus — and which remains among those hardest-hit by the pandemic.

Since March 4, when New Jersey announced the first confirmed case of the disease, more than 467,600 state residents have been diagnosed, including nearly 18,800 who have died as a result. Overall, almost 46,500 people have been hospitalized for COVID-19, which takes an outsize toll on Black and brown communities, and many struggled for months to fully recover.

By the time the coronavirus emerged here, Gov. Phil Murphy had formed a task force that had been meeting for weeks under the leadership of state health commissioner Judy Persichilli, dubbed by Murphy “the woman who needs no introduction” in what would eventually become  daily media briefings. Murphy signed an executive order formally declaring a public health emergency on March 9 and ten days later began what would be a near-total shutdown of the state’s businesses, schools and civic spaces. Only services deemed essential were permitted to remain open, under new restrictions. That executive order has been extended every month since.

Why race and racism mattered
The impact of the coronavirus on communities of color was evident by early April, as soon as state officials began sharing demographic details of cases, but how this was connected to social determinants of health became more apparent over time. Studies have shown that decades of racist public policy and economic trends had put Black and brown families, here and across the country, at greater risk for infection, hospitalization and death than their white counterparts. These groups are more likely to live in crowded, multigenerational households that allow for easy spread of the virus; in communities that lack options for health and wellness, and experience underlying conditions like asthma and diabetes at higher rates.

Studies have also shown that Black and brown individuals make up an outsize share of those in frontline jobs, putting them at greater risk working as food servers, home care aides or public transit officials, jobs that can’t be done from the safety of home. Overall, four in 10 frontline workers are people of color and 57% of bus drivers are Black, according to the nonprofit Center for Economic and Policy Research.

In addition, these individuals are less likely to have easy access to COVID-19 testing and care if they are sick, and may not be prioritized for new, more effective treatments with the same frequency as white patients. These factors combine to leave Black and Hispanic residents significantly more likely to contract COVID-19 than white New Jerseyans, at least three times more likely to be hospitalized, and twice as likely to die as a result, according to state data.

“No one is surprised by this. And if they are, they haven’t been paying attention,” Dr. Denise Rodgers, a vice chancellor at Rutgers Biomedical and Health Sciences program and professor of family medicine and community health at Rutgers Robert Wood Johnson Medical School, said in April. “The reality is, COVID-19 could just become another in a very long list of diseases for which there are substantial disparities in outcome by race and ethnicity.”

While public life had slowed to a crawl in March, the pace quickened for many health care and hospital workers. Despite a slow start to testing for the disease in New Jersey as nationwide, diagnoses were ticking up quickly and COVID-19 hospitalizations of very sick patients growing exponentially; clinicians said they had never seen people arrive with such little oxygen in their blood, a sign of severely impaired lung function.

By April, Persichilli and her team were worried that hospitals would run out of space for all the extremely sick COVID-19 patients. Plans were launched to stand up at least three field medical stations, using a common wartime technique to back up a strained civilian system. Other former hospitals were repurposed to provide additional beds, if needed.

Facing unthinkable decisions
With COVID-19 hospitalizations spiraling upward, concerns had begun to emerge about the supply of critical resources, especially masks, gowns, gloves and other personal protective equipment, or PPE, a term Americans would come to know well. Nurses at some New Jersey hospitals and nursing homes were ringing alarm bells, afraid their facility would soon run out of these inexpensive but critical elements, much of which was made or sourced in China, which was also devastated by earlier bouts of the coronavirus.

Persichilli, a nurse who previously ran a large, multi-state hospital system, expressed shock that this was happening in a nation of such bounty. The Department of Health worked with the State Police to find, order and stockpile additional resources; a joint effort with the New Jersey Hospital Association, which represents the state’s 71 acute care sites and other health care facilities, now allows the state to track the use and distribution statewide.

But PPE was only part of the problem. Another concern soon emerged about a potential shortage of ventilators, the mechanical breathing machines that were a primary treatment for many COVID-19 patients early on. Hospital officials were apprehensive and the state empaneled an expert task force to draw up a triage plan to help health care providers decide how to prioritize ventilator use, if a shortage became real. That never happened, officials insist, and the recommended treatment has since shifted to favor other practices over ventilators.

When the resource is scarce, the goal is to save the most lives with the resources available,” Dr. Hannah Lipman, a gerontologist and director of the Center for Bioethics at Hackensack University Medical Center, part of Hackensack Meridian Health, told NJ Spotlight News at the time. “When resources aren’t scarce, those two goals are not in tension.”

It soon became clear that equipment wasn’t the only issue. As the virus spread, health care workers became sick or exposed, requiring them to quarantine for two weeks before they could return to work, if they were healthy by then. This problem compounded, prompting an ever-growing shortage of workers — particularly nursing staff and respiratory therapists. Efforts to call in retired nurses or trained volunteers provided some extra hands, but eventually New Jersey officials called in nurses from other states and arranged with clinical personnel from the U.S. military to help care for patients in the short term. (Staffing shortages continue to be a concern, as hospitalizations are again increasing, but with the pandemic affecting almost all states, reinforcements are now hard to find.)

Hospitalizations peaked in New Jersey on April 14, when more than 8,000 COVID-19 patients were in acute care facilities, nearly a quarter requiring intensive care. (Predictive modeling suggests the current wave will peak sometime in January, with fewer hospitalizations than in the spring.) As the impact of the statewide shutdown — coupled with constant reminders from health officials to keep distance, wash one’s hands and wear a mask, something that had been a point of debate early on — began to take effect, the impact on hospitals began to decline. In the end, the field hospitals and auxiliary sites, with space for nearly 1,000 people altogether, would treat just over 500 patients before closing in May.

Warming weather and declining virus counts brought some relief, and by mid-May the Murphy administration took steps toward reopening the state’s economy and public spaces. At the same time, public health leaders and the families of nursing home residents were raising the alarm about conditions at the state’s 650-plus long-term care facilities. In New Jersey and nationwide, these sites — with frail elderly and medically fragile individuals in close quarters — were an easy target for the virus. Nearly 7,500 residents and staff at these facilities have died of COVID-19, or 40% of the state’s total fatalities.

Institutions rally, flaws exposed
While hospitals in New Jersey were largely celebrated for the extreme measures they took to protect and save lives — working together to share PPE, ventilators and treatment tips, despite long-standing regional competition — nursing homes have generally faced criticism for their response to the pandemic. Some long-term care facilities, including at least one of the three state-run veterans homes, reportedly failed to implement universal mask use or properly separate sick residents from those who were well, exacerbating the spread of COVID-19. Others suffered serious shortages of PPE and staff, resulting in sub-par care, with residents not receiving meals or medication on time and lying in dirty diapers for hours on end. Communication with family members also ground to a halt at some facilities, leaving loved ones — who were unable to visit in person — at a loss for information.

By May, the situation had reached such a critical point that the Murphy administration hired experts from Manatt Health, who spent nearly a month compiling a detailed report on New Jersey’s nursing homes, with short- and long-term recommendations to improve the response. The report, which cost $500,000, identified a host of long-standing problems at these facilities, including inadequate funding, lack of staff and problems with infection control. Manatt’s recommendations prompted legislative hearings and multiple bills, many of which Murphy has signed, and the governor has pledged to spend at least $10 million in federal funds to better these facilities.

As spring turned to summer, the daily case count kept declining and the impact on health care facilities ebbed, leading Murphy to take steps to reverse the statewide shut-down. Reopening continued during the summer months and state officials encouraged local school leaders to take steps so that children could safely return to classrooms in the fall. But the progress was tempered by new outbreaks — initially linked to a few high-profile private parties — and then growing viral spread in the community. Murphy instituted new limits on gatherings in mid-November and eventually begged people to limit private gatherings indoors and rethink plans for the approaching holidays.

“As the governor has stated, this will not be a normal Thanksgiving. With the alarming surge in our cases, we all need to be vigilant and take all of the public health precautions that helped us to limit the spread of the virus last spring,” Persichilli said at that time. “Our lives — and the lives of our loved ones — depend on it.”

Vaccines here at last
The controversial presidential election — unprecedented itself, with voting in New Jersey mostly by mail — served as a diversion of sorts from the battle against the virus. And by Thanksgiving, the promise of a vaccine offered hope to many here and beyond, despite widespread distrust for the process under which vaccines had been developed and were being approved. By mid-December, federal officials had approved for emergency use two highly effective vaccines from the drugmakers Pfizer and Moderna. Vaccinations for health care workers at risk for infection began on Dec. 15, at University Hospital in Newark; immunizations at nursing homes started last week with 103-year-old Mildred Clements at Roosevelt Care Center in Old Bridge.

According to the state vaccination plan, the priority, or 1a group, includes health care workers at risk for infection and residents and staff at long-term care centers — although Persichilli conceded on Monday there was some confusion over who was covered in this category. As of Monday, more than 46,000 individuals had been vaccinated in the state.

The state Department of Health is now working to delineate who will be part of 1b, the next group to have access to vaccinations, which could begin in the weeks to come. These vaccines will be administered at community clinics, county health departments, drugstores and six state-run “mega sites” which Murphy has said will be set up in the weeks and months to come, based on vaccine availability, logistics and demand.

The governor closed his briefing on Monday this week with another warning to avoid large gatherings on New Year’s Eve, imploring people to celebrate responsibly and get tested if concerned.

“We have a lot to look forward to in the new year, but it must start with our staying focused on the practices that have gotten us through most of 2020: social distancing, wearing our face masks, washing our hands with soap and water, using common sense — meaning if you’ve been exposed, take yourself off the field. If you don’t feel well, take yourself off the field,” Murphy said. “But make no mistake, better days are ahead. Let’s make sure that we make it to those days together.”

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