Warning signs from Alabama
When the coronavirus vaccines became widely available, I thought hospitals such as mine might turn a corner. For a brief moment, things nearly did. Here in Alabama, the pandemic never totally disappeared, but as spring became summer, the number of severe Covid-19 cases in our hospital dropped substantially. At one point, we needed only one intensive care unit solely devoted to caring for people with Covid-19. I'm a pulmonologist, and after serving in the ICU during every surge of this pandemic, just getting to see regular critical-care patients again felt strangely hopeful. My co-workers and I felt like we'd started to regain some control.
Now we're facing down a fourth surge. Hospital admissions have shot up at an unprecedented rate in the state. And the suffering we're seeing is all the more awful because it was preventable.
Alabama has the lowest vaccination rate in the country. Only about half of our eligible population has gotten at least a first dose of the vaccine. We've done a decent job vaccinating older people: Across the state, an average of about 70 per cent of Alabamans over 65, those who are highest risk of death from Covid-19, have gotten a shot — but in some rural Alabama counties, that number is as low as 33 per cent. Meanwhile, fewer than 40 per cent of people between 30 and 49 have gotten at least one dose. That number falls to 27 per cent among 18 to 29-year-olds.
With the Delta variant tearing through the country, younger people are filling up our wards. Just a couple of weeks ago, I had to put a patient in her forties on the ventilator. She hadn't gotten the vaccine yet; she had been in good health and wanted some time to think about it. Then she showed up at the hospital unable to breathe because of Covid-19 pneumonia, and no amount of oxygen support made a difference. She texted her family to relay the news, and we placed her on the ventilator moments later. She wasn't much older than me. The situation was agonising.
I sometimes hear relatively young adults say they would rather take their chances with the virus than take a coronavirus vaccine. I don't know how to get the message across: Deaths from Covid-19 have, thankfully, dropped because a majority of older adults have gotten vaccinated — but death isn't the only possible bad outcome. If you refuse the vaccine, you might get this virus and survive, but you might also experience debilitating complications. For every person who died this past year, I have seen a dozen others who survived but spent weeks or months in the hospital. Some patients ended up requiring tracheotomies and feeding tubes, and suffered post-traumatic stress. Some can't get to the bathroom without significant shortness of breath.
Going into the hospital these days, I feel a horrible déjà vu. In December, we had to convert four ICUs just to care for people suffering from Covid-19 pneumonia. These ICUs were eerily silent: Nearly every person was intubated on ventilators, flipped onto their stomach to improve their oxygenation, on high doses of sedation and on continuous dialysis. They all looked so similar that we had to make extra efforts to remember their identifying details. Smaller rural hospitals were doing their best, but didn't have access to advanced therapies or enough people trained to handle severe acute respiratory distress syndrome. As their patients got sicker, colleagues would phone larger hospitals, including mine, asking if anyone had an open bed. It was excruciating to take those calls when there was virtually nowhere in the state for them to go. Hospital wards were full, and emergency rooms were packed.
With such safe and effective vaccines available, there's absolutely no reason that this summer should have to look anything like last winter. This crisis was completely avoidable. Yet here we are, horribly stuck in the past. Again, we're starting to field phone calls from other hospitals as the Delta variant ravages the South. And again, our attention is turning away from people with other serious illnesses — cancer, heart attacks, chronic obstructive pulmonary disease, strokes — as Covid-19 takes centre stage. I feel frustrated on their behalf; this situation feels especially unfair to them.
I look at Missouri, Arkansas and Louisiana and worry that they're a preview of what Alabama will be going through soon. One hospital in Springfield, Missouri, reported treating more people with Covid-19 in one week in July than any week since the start of the pandemic; at one point, they faced a ventilator shortage. From here in the heart of the Deep South, states with higher vaccine uptake look as if they're in a different universe. I saw a news update from a colleague in Connecticut celebrating that their hospital discharged its last patient with Covid-19. The very next day, we had a person die of Covid-19, someone whose life we couldn't save.
We all try to find some way to cope. At a pulmonary clinic I founded for the underserved, I cope by asking every single patient whether they've gotten vaccinated. My clinic patients all have serious respiratory illnesses. Eighty per cent are Black, and half are uninsured. They're basically the most vulnerable population you can imagine — and 15 per cent to 20 per cent are on the fence about vaccination. A study by the Kaiser Family Foundation found that 78 per cent of people who want to “wait and see” before getting a vaccine say they trust their doctor as a reliable source of information about it. So every clinic visit, I make a point of talking about the vaccines: listening with grace, not judging, addressing their concerns, getting patients to agree and fist-bumping them afterward. I want to make these conversations as casual, and routine, as conversations I have about quitting smoking.
Still, this will come to nothing if we can't meet them where they are. My patients face immense physical, logistical and financial obstacles accessing any kind of healthcare. If I tell them to come back in five days or to make an appointment at some other location down the street, they simply won't make it. So we started a pilot programme to make vaccines readily available at my clinic, right then and there, in a setting they know and trust. This has made a world of difference. Recently, in a single morning, four out of four patients who had been “waiting it out” got their first shots. That number may seem relatively small in the scheme of things, but those are four people who I won't have to see in the ICU later, and that feels like a huge victory.
This surge is different. Thanks to the vaccines, my co-workers and I are facing it with much better armour and — for now — much less fear for our personal safety. But this surge is also different because we feel more demoralised than ever. Every day, I exchange text messages with co-workers — doctors, nurse practitioners, nurses and respiratory therapists — who wonder how we’ll make it through yet another wave, given staffing shortages and the contagiousness of the delta variant. We will make it — but many of us may be permanently scarred. We thought we would hit our physical and emotional limits months ago. Doing this again and again is not sustainable.
We’ll do the best we can and lift one another up. But this phase of the pandemic is taking a toll that none of us could have anticipated. It’s soul-crushing to go into work and see so much agony that did not have to happen.
• As told to Washington Post editor Sophia Nguyen. Anand S. Iyer is a pulmonary-critical care physician, geriatrics-palliative care researcher and junior faculty at the University of Alabama at Birmingham. He is a staff pulmonologist at Cooper Green Mercy Health Services and founded @pallipulm to bring awareness to palliative care for people living with serious respiratory illness
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