'The Separate and Unequal Health System' Highlighted By COVID-19
On a recent Friday afternoon, the critical care charge nurse at a South Los Angeles hospital tries to send another nurse off to grab lunch. Maria Arechiga is interrupted by the beeping of an alarm, the vitals of a patient declining, organs failing.
She dons a surgical gown and unzips a plastic tarp that hangs from the doorway of a hospital room — a makeshift isolation room on this floor temporarily transformed into a larger intensive care unit to make space for the patients that just keep coming. She slips inside.
Dr. Stefan Richter follows her in, both telling the other nurse to get lunch now, because later may never come.
There are two patients in the room. Within an hour, both patients' organs are failing. Arechiga yells for someone to call a Code Blue, a medical emergency.
"May I have your attention please. Code Blue, Code Blue," booms from the PA system.
Reinforcements arrive. In the urgency, there is practiced calm. A team helps each nurse, doctor and respiratory therapist put on protective gear before they go in to try to resuscitate the patients.
They lose one patient, get the pulse back on another. And then another Code Blue is called. They begin again. Every single person in the critical care unit on this floor is COVID-19 positive.
A deadly, predictable disaster
The intensive care unit at Martin Luther King Jr. Community Hospital is at the epicenter of the coronavirus surge that is ripping through Los Angeles County, the country's most populous.
One in three people in the county have been infected with COVID-19.
But at this hospital in Willowbrook, an unincorporated part of South L.A. neighboring Compton and Watts, the pandemic is preying on the inequities that disproportionately hurt Latino and Black communities. The neighborhoods are densely populated and multiple generations of families live together, making it hard to isolate.
It's a place where most people are on public health insurance and where chronic illnesses are much more prevalent because there is a systemic lack of access to quality health care. Add COVID-19 to that mix and it's a deadly but predictable disaster.
"This is a community that is largely low-income, people of color," says Dr. Elaine Batchlor, the CEO of MLK hospital. "This is where the essential workers live. These are the people that are stocking the grocery stores, driving our buses, cleaning up after the rest of us. And they are continuing to be exposed to COVID on the job."
She speaks in her office where she has been managing the crisis.
"Our small hospital now has more COVID patients than hospitals that are three to four times larger in L.A. County," Batchlor says. "We have added beds to the hospital. We've doubled up single rooms. We've added five tents outside of the emergency department. The staff converted an entire medical floor into a critical care unit. So we've been doing everything we can to create enough capacity to care for all of the patients that have been coming in to see us."
"We are in a crisis situation"
On Christmas Eve, Elaine Batchlor sent an urgent letter to California Gov. Gavin Newsom.
"I'm writing with a critical update on how the COVID-19 coronavirus is impacting our black and brown community in South Los Angeles," Batchlor wrote.
The data she cites in her letter is sobering. Sixty-six percent of patients in the hospital are COVID-19 patients, triple if not quadruple what other hospitals in the county are seeing. She describes a recent day when 70 patients were in the emergency department with just 29 beds. She writes about the meditation room below her office now filled with gurneys, a gift shop turned hospital room.
"We are in a crisis situation, with devastation wrought on caregivers and community alike," she wrote.
She pleaded not just for short-term solutions but also for fundamental change to the health care system that brought the community to this point.
She ends the letter: "It is time to address the separate and unequal health system that has been heartbreakingly exposed by COVID-19."
The state sent temporary help. Three National Guard Medical Strike Teams, some 90 nurses and respiratory therapists. This week, COVID-19 hospitalizations are finally going down — but the number remains high.
"We need to fix it"
Even as Batchlor works to get her hospital through this catastrophe, her focus remains on long-term reforms. Because when this pandemic is over, the systemic problems in health care that are visibly failing this community and communities like it across the country will still be here.
"Our goal is to create the health care structure that's missing here," she says. "We're advocating for the system to be adequately funded so that people in communities like South L.A. can access the same continuum of care that we see in other communities and the same quality."
This hospital has always served more than it was built to, since the day the luminous facility opened in 2015 to replace the hospital that shuttered in 2007 over deadly conditions.
"We've been seeing a bit of a public health crisis in this community for the past five years," Batchlor says.
The year before the pandemic ripped through these neighborhoods and the world, the emergency department saw 110,000 people. It's only set up for some 40,000. The community the hospital serves has the fewest number of hospital beds per 100,000 people in Los Angeles County.
The most common procedures are diabetic amputations and treatment of diabetic wounds. Both are completely preventable with the proper care.
So this moment, this crisis, it's not a surprise, she says.
"We've created a tiered financing system for health care with commercial at the top and Medicaid and uninsured at the bottom," Batchlor says. "And we need to change that, because that's where many of our Black and brown communities are. And that's why they're being harder hit by something like COVID. We need to fix it."
The problem is glaringly obvious, she says. The majority of patients in this community are on public health insurance. And while a hospital gets supplemental funding if a patient is so sick they have to be admitted, it is a fraction of what private insurance pays for outpatient care. That includes the emergency department triaging below her office and the preventative medical care that keeps people healthy.
"We're getting paid adequately to amputate someone's leg," she says. "But we're not getting paid adequately to prevent that leg from being amputated."
The hospital loses some $10 million a year operating the emergency department. It loses money for the specialty care and primary care programs it offers for things like behavioral health care or nutrition programs to prevent diabetes.
"You can't send these patients to other places, no other places will take them ... Why? Because we lose money on these patients," Batchlor says. "Our goal is to create the health care infrastructure in the community that's missing here."
To bridge the gap, the hospital relies on millions of dollars in philanthropic donations to subsidize doctors' and nurses' salaries, bring in cutting-edge technology and create disease management and prevention programs.
"This is not a sustainable model," she says. "This will not work forever. It works for a limited period of time when you have that philanthropic funding."
Nowhere else for patients to go
Outside the hospital grounds, it's a health care desert. Doctors won't set up in communities where they can't make money.
"Physicians can't sustain a practice in a community like this. So that's why they aren't here," Batchlor says. "That's why we're missing 1,200 physicians."
So there's nowhere else for patients to go.
The lack of options is on display in the emergency department. The halls are lined with beds. An older woman yells out in Spanish "please, no." She's scared and alone. Nurses calm her as medical staff move quickly to tend to dozens of people.
Dr. Ryan McGarry compares this moment to battlefield medicine.
"We're surrounded here by multiple tents and tubes and lines and, effectively, temporary structures to handle overflow on overflow," he says. "Unfortunately, we're having to make sometimes decisions about who we can move inside or who's sickest between 10 sick patients. That's not an easy decision to make for anybody, let alone when you're trying to help everyone get through this."
Despite the overflow, the hospital has found a system to expand what they have to accommodate what McGarry calls "a surge, on a surge, on a surge."
"If you need the ICU here, you're going to get it. It just means that maybe that ICU will be here in the emergency department," he says.
"It's been horrible"
Back in the ICU, Arechiga's shift has gotten progressively busier, progressively deadlier.
And this day is not the worst that she has seen.
"Tough is an understatement. It's been ..." Arechiga pauses. "It's been horrible."
Most of the patients who end up here, she says, look like her.
"I grew up in Compton," she says. "I know the community. So potentially, you know, this could be any of my family."
In addition to supervising nursing staff, tending to patients and recording vitals, Arechiga also finds herself translating.
"Some of our doctors don't speak Spanish and I feel like 90% of the population is Hispanic," she says. "I have to sit there — or one of the nurses that speak English and Spanish — with a straight face and tell them: 'Your family member is going to die.' It's just really hard."
That bears out in the numbers. Take this Wednesday for example: More than half of the deaths reported that day in Los Angeles County were Latino.
In the tragedy, the nurses and doctors have found the bond that comes with getting through hardship together — hardship the rest of the world may never understand. They console one another, some dealing with their own losses due to COVID-19, and then they keep going.
"I feel like this time around, people are coming in sicker and dying quicker," Arechiga says. She's comparing what she's seeing now to the smaller surges of patients that came before. This time, the deluge is unparalleled.
Trying to prevent things from getting worse
Nearby Dr. Stefan Richter goes back and forth to one room. He's monitoring a patient whom he expects will soon pass away.
"When her heart stops, we will be doing chest compressions, even though the understanding is that probably they aren't going to help," he says.
Most of the patients on this floor are on ventilators and many are on dialysis.
"We've been taking the brunt of a kind of medical epidemic for years," Richter says. "A lot of the diseases that we see here during nonpandemic times are preventable, but they've gone untreated for years and years and years. And so the fact that we're continuing to see the brunt of this pandemic doesn't really surprise me that much in a really unfortunate way."
The vaccine is a providing a sliver of hope, but the county rollout has been slow. Health care workers have gotten it here, but no one knows how long it will be before this community has access.
By the end of the shift on this day, five people are dead. Four are Latino, one is African American. The hospital gives the families a one-time exception to visit when end of life is near.
Jason Prasso, an ICU doctor, is often the one that makes the call and breaks the news.
It's time to come in. Time to say goodbye.
"Modern medicine has a lot of a lot of interventions and a lot of therapies that we can offer, but this virus has proven resistant and extremely difficult to manage," he says. "Realistically speaking, there isn't a whole lot that I can offer besides supportive care as an ICU doctor and trying to prevent things from getting worse. It hurts as a doctor to say that."
Prasso is cut off by the sound of another Code Blue call.
"Excuse me," he says. It's a bad day, a familiar day.