Worldwide, people on the front lines have been working around the clock to contain the spread of COVID-19. With the United States experiencing the worst surge of the pandemic this holiday season, nurses, physicians, and other health professionals will have their hands full. This is their story.
Inequitable access to health care has long been a challenge in the United States. Even before the COVID-19 pandemic struck, the system was plagued by exorbitant prices, lack of insurance coverage, and significant health disparities based on race, income, and ZIP codes. Compared with other developed economies, the U.S. has the highest health care expenditures, yet that investment is not reflected in its outcomes. It has lower life expectancy than the average of the OECD (the group of the world’s richest economies), as well as lower levels of health care coverage.
Now, the COVID-19 virus has cast into sharp relief the extent of the weaknesses of the health care system in the U.S. and how social determinants of health can affect outcomes in entire communities. COVID-19, which has claimed the lives of more than 300,000 Americans and counting, has been the test of a lifetime for the American health care system.
To truly put this into perspective, the United Nations Foundation spoke to front-line workers around the country who are carrying out their jobs amid waves of COVID-19. From a firefighter/EMT simultaneously responding to fires — a byproduct of another deep-rooted challenge, the global fight against climate change — and fielding medical calls, to a nurse practitioner providing guidance on health services to the most vulnerable segments of her community, we will be featuring Americans whose experiences illustrate the urgency of equitable access to quality health care, and why we must #UniteforHealth now.
MEET SARA HEGAB
Dr. Sara Hegab is a pulmonary and critical care specialist at Henry Ford Hospital in Detroit, where she practices both outpatient pulmonary medicine as well as intensive care medicine. Michigan has recorded an increasing number of COVID-19 deaths, and ranks among the top 10 states in the country. We spoke with Hegab about what it means to improvise during a medical emergency; the vicious cycle of poverty and how it feeds into health care access; and the difficult questions around individualism and humanity that the pandemic raises.
Describe your job and day-to-day duties on the front lines of COVID-19.
The past nine months have been really challenging with constant change and flux, requiring quite a bit of pivoting. In the spring, when Detroit was surging, many of us were pulled to staff the ICUs [intensive care units] because we needed all hands on deck to allow us to expand to areas of the hospital where medical ICU patients weren’t typically housed. This necessitated the closing of outpatient clinics and deferring all elective testing and procedures. In addition to planning how to accommodate this rapid influx of COVID patients, we also needed to think outside the box to develop systems and processes that would enable us to continue delivering high-quality care for all our “non-COVID” outpatients, all while continuing to care for hospitals filled with COVID patients. Technology became our best friend and we used telemedicine and virtual visits to help us do this, which allowed for frequent check-ins with our patients. Over the summer and into the fall, there was a bit of a “COVID lull” where we were able to ramp back up to full outpatient capacity again.
What makes the community where you work unique?
Henry Ford Hospital is in Detroit and serves a diverse, predominantly African American patient population. The city was hit very hard in the spring. Everybody was learning about COVID on the fly, in real time. At the time, nobody really knew what made some patients higher risk for developing severe disease, or who would do better or worse. While we didn’t know the specifics of what those demographics looked like, it became very clear early on that certain populations were disproportionately affected and Black Americans were one of those populations.
That could be for a myriad of reasons. There are many social determinants of health that we know impact health outcomes that disproportionately affect minority communities. Some of those same factors are why we see a higher prevalence of certain comorbidities in the African American community; comorbidities we later learned conferred high risk for worse outcomes: cardiovascular disease, renal disease, obesity. We saw entire communities and families in Detroit ravaged by COVID, often with several generations within families all affected at the same time. It is really quite devastating.
What has treating underserved populations taught you about weaknesses in health care?
If we are ever going to make an impact, we must approach health care in a comprehensive way, which will require addressing all of the socioeconomic factors that also impact health, because it’s about much more than making sure someone can go to the doctor. For example, in the beginning of the pandemic, we had people who couldn’t perform handwashing because the water to their homes was cut off due to inability to pay their water bill. Handwashing — a basic lifesaving intervention when it comes to preventing infections, wasn’t available to some people. In my mind, there’s no reason why anyone in this country should not have access to clean running water. These are not problems we should be having in the wealthiest country in the world. [Michigan’s] Governor [Gretchen] Whitmer issued an executive order in those early days restoring water services to all occupied residences where water had been shut off due to nonpayment. While that undoubtedly saved lives, it’s not a problem that should have ever existed.
I can counsel a patient about high blood pressure, and making healthier lifestyle choices, but if grocery stores are not easily accessible in lower-income communities, then how can people be expected to make those healthy choices? Not everyone can drive to the next town or city over to go grocery shopping.
How can we expect people to maintain good health when they have to choose between buying their medications or putting food on the table for their families? Even when we transitioned to virtual care, it quickly became apparent many in the community did not have access to reliable internet, a smartphone, or computer, things that many take for granted.
This pandemic forced us as a country to consider what were deemed essential jobs to keep basic services running during the shutdowns. Many of these essential jobs are low-paying jobs and many of our essential workers come from economically disadvantaged and minority communities that are at higher risk for developing severe disease. The clerk at the grocery store, for instance, had to go to work so everybody could have groceries. So as a society, we asked people to continue working during a pandemic, in roles that put them at higher risk for contracting the virus, with many already at higher risk for developing severe disease if they contracted it due to underlying health issues. It’s the same segment of society where many don’t have access to health insurance, aren’t paid a living wage, or don’t have access to affordable childcare.
This pandemic forced us as a country to consider what were deemed essential jobs to keep basic services running during the shutdowns.
Dr. Sara Hegab
Pulmonary and Critical Care Specialist
How are your residents and fellows reacting to working in the middle of a brand new pandemic? What’s going through their minds?
I will say that our resident and fellow physicians have truly risen to the occasion. It has been all hands on deck with many of them being asked to care for patients that they wouldn’t normally care for in their specialties and they have done so with courage and grace. Many physicians who trained during the HIV epidemic in the 80s have drawn parallels to what is happening now with COVID. In both cases, you’re seeing this new disease, learning about it and what it does to the body in real time. Every patient is teaching you something different that you take with you to the next patient. You’re recognizing these patterns and building this knowledge base over time. And I think that’s exactly what happened in the spring, except it was all so much faster with COVID.
I remember rounding with a resident team early on and saying: “None of us know much about this disease, but we will learn together. You don’t have the answers, because nobody really does, but we will figure out how to take the best care of our patients that we can.”
Information at that point wasn’t being disseminated in the traditional way that we’re used to in the scientific community. Things weren’t going through rigorous peer review processes prior to being disseminated, because there was a sense of urgency to get information out. People were sharing observations and experiences on social media. Physician groups were created on various platforms where people were sharing information and asking questions of their peers. I told my team to share any information they thought could be relevant, and we would vet it together and see if it made sense for our patients. It was certainly a double-edged sword because while we needed information disseminated as quickly as possible, it meant that there was that much more responsibility to scrutinize the data we were seeing to ensure quality.
How did it feel to be in the “unknown” and have to improvise in some ways?
I think back to the first couple of weeks and how we really didn’t understand how this disease affected people and how best to treat it. We didn’t know what the clinical course was going to look like. So every day we were just discovering these new patterns and trying to put it all together. It was challenging because as physicians, we are trained to know what to do for patients and how best to help them, so not knowing caused some moral distress that weighed on many of us. There was this stress of: Is what I’m doing the right thing, and is this helping this person, or is it hurting them?
There were treatments that we were using back then that we later found weren’t helpful. We’ve had to remind each other to allow ourselves some grace for not knowing those answers early on, because in reality, no one knew.
The way the medical community came together was really inspiring. At our hospital, we had conference calls with groups of doctors from China and Italy where we discussed what they had seen and shared what they’d learned; what seemed to work and what didn’t. The Middle East seemed to get hit after we did, and I participated in a virtual COVID summit held in Lebanon, sharing some of the lessons we had learned in Detroit. So while this was never an experience any of us imagined going through, it was inspiring to be a part of it all.
How are you handling misinformation, and communicating with people who — despite the warnings of health professionals — don’t believe in the severity of the pandemic?
It’s been hard. There is so much misinformation that’s out there, and unfortunately, we’re in this situation because a public health crisis has been politicized to the extent that it has been. That’s another layer of dogma that you have to cut through to some degree. I think most of us have just continued to try and share what we know and continue to message how real this is. COVID is here and it’s real. We are continuing to encourage people to do the things that we know work: wear masks and social distance, which is hard when, for example, wearing or not wearing a mask has gone from common sense practice to a political statement.
Truthfully though, there’s a sense of feeling betrayed by the public.
In the very beginning, we were hearing about the Italian experience and how health care workers were getting sick and many died. My colleagues and I were discussing this and realized that it was likely one of us was going to get COVID and that it might not go well. We discussed what each of us would or wouldn’t want done should we become severely ill. One of my colleagues said: If I get sick, I might just want to stay home and be made comfortable because I wouldn’t want to take a ventilator from somebody else who needs it and wouldn’t want to burden you with taking care of me. We were making plans, drafting wills, writing letters to our children, and getting affairs in order. More than being scared for ourselves, we were scared of bringing this home to our families.
More than being scared for ourselves, we were scared of bringing this home to our families.
Dr. Sara Hegab
Pulmonary and Critical Care Specialist
So here we are, having this conversation about our worst-case scenarios, meanwhile, people are refusing to wear masks and refusing to social distance. In my own town, you hear about parents of high school students renting out party buses for their teenagers “so they don’t miss out on homecoming,” and it feels like a betrayal. We took an oath, and we will do what we need to do to cure, care for, heal, and comfort people. But we also need the support of our communities. It’s not fair to ask countless front-line workers to be martyrs in vain, so to speak. Everyone has to be willing to do their part.
I think there is a sense of individualism that has become so apparent to me. I don’t think I had realized the depth of it before this happened. There is a sense of “all that matters is what I need and want” and much less of a sense of community. That’s not an indictment on anyone. I think it speaks to where we are socially and culturally, where we have gone as a society. You can’t fix that in the middle of a pandemic. I think it will take a significant amount of reflection when this is all said and done, where we will have to look back and say: Is this really who we want to be? And if not, how do we as a society shift towards more cohesive community-minded thinking?
How does this sense of community translate over into the need for equal access to health care?
The predicament we find ourselves in is that as it stands, health has been monetized in our current health care system. Complicating the issue is this narrative that has emerged over the years, that if we are to provide health care to everyone, it is somehow disadvantaging those who can afford to pay for it while unfairly giving an advantage to those who cannot. Newsflash: We are all collectively paying for it one way or another.
We can all seem to agree that every child has a right to a free public K-12 education. The vast majority of people would never voluntarily give up their Medicare coverage once they’ve qualified. These are not free. We as a society have decided these are important and agree to fund them, so it’s a matter of shared values — it’s a shared value to ensure our children are educated and to provide health care for our elderly. Yet somehow, ensuring access to basic health care for all Americans isn’t within that shared value system? There truly isn’t a single justification in my mind why in the wealthiest country on earth, every single person does not have access to basic health care. We have to agree on the shared value that access to basic health care is a right for every American. That has to be the starting point. We can have many debates about how to accomplish that. There are many ways to get to the same endpoint, but we must agree on that starting point. If we can’t agree, we must accept what not having that as a shared value says about us and our society.
This pandemic has disclosed so many problems in our system that we can no longer turn a blind eye to. We have now found ourselves in a situation where many people across the country do not have access to health care in the middle of the worst public health crisis in a century and where many hospital systems across the country are in grave financial distress.
This pandemic has disclosed so many problems in our system that we can no longer turn a blind eye to
Dr. Sara Hegab
Pulmonary and Critical Care Specialist
This moment, in the middle of a pandemic, may not be the right time to try and fix it. But once we get through this, we need to look back and really take a look in the mirror and see what this pandemic has taught us: about ourselves and our system, about what is working and what isn’t, and whether the stories we’ve told ourselves about why ensuring health care for everyone is not possible are true, or are they just that, stories.
Tell us about an overwhelming moment you’ve had on the job.
Normally, when a patient in the ICU isn’t doing well, we call the family to come for an in-person meeting to discuss what’s going on and come up with a care plan together.
Today, what is really hard is that people drop their family members off at the ER, oftentimes watching them walk in. Then, a few weeks later, we are talking to them — remember they haven’t seen them since — and we are now telling them, “Your family member is dying and isn’t going to survive this.” There is a disconnect there because normally, a family would see that progression, that day-to-day deterioration. Now, however, we are asking them to trust us in a way that we have never asked people to before. They’re having to make difficult decisions such as withdrawing life support without having been present to witness that decline. While we use video conferencing to show people their loved ones in the ICU, it just isn’t the same. I don’t think the public realizes how hard it is to witness the amount of suffering that has happened over the past nine months. Witnessing patient after patient dying alone in the hospital, holding phones up to patients’ ears to allow their loved ones to talk to them during their last moments, to hold the hands of the patients whose families can’t be there is soul-crushing and such a source of moral injury to our health care teams that we will spend years to come recovering from.
Can you point to an optimistic or hopeful moment you’ve experienced working during this pandemic?
As much as this whole experience disclosed vulnerabilities in our system and some negative things about us as a society, I think we have also seen people come together in a pretty remarkable way. I had neighbors asking about me and offering to help in whatever way they could. I remember at the beginning of the pandemic, you couldn’t get a grocery delivery slot if you tried. A friend whose son played soccer with my son texted and said that her husband was going to the grocery store. She knew I was at the hospital, and she offered to have him pick up supplies for me and leave them on my porch. All of my neighbors were constantly texting and calling, making sure my son and I were OK. It was so heartwarming to know that our communities were coming together in this way.
Medical students were volunteering to run errands for front-line physicians, and provided child care so people could work at the hospitals. People in painting, construction, and dentistry were donating their masks and supplies so we wouldn’t be left without. Other people sent in handmade masks and surgical caps, and others donated food.
At the hospital, our clinic patients would call us and just want to make sure we were OK. They would send us notes, emails and leave messages saying: Please know we are praying for and thinking about all of you, please stay safe. I think just hearing that and knowing that our patients were supporting us and rooting for us in that way filled our hearts and motivated us to keep going.
I had a patient who was dying in the ICU. We had this huge conference call with 13 of his family members to walk them through everything (we had to do it via conference call because no visitors are allowed in person). The patient clearly wasn’t going to survive so we were discussing the futility of CPR and during the conversation it also came up that CPR was high risk to the medical team because of the chance of aerosolizing the virus. Knowing that his brother was dying, this gentleman made the decision to change the code status to “Do Not Resuscitate” saying (and I‘m paraphrasing), “I know he’s not going to survive and that you’ve all tried your best, but we can’t risk all of you becoming infected and getting sick, especially since it won’t help him. Who will take care of all the others? We need all of you to take care of everyone else.”
It was one of the most humbling experiences of my life. I had just told this man that his brother was not going to live, and his focus was us and our safety.
This holiday season, let us recognize the essential workers who are tirelessly working every day so we can be safe during this pandemic. They provide lifesaving care to those in need — often in precarious conditions. We are all safer and stronger when we #UniteforHealth.