Were hospitals overwhelmed during the pandemic?

Newspapers reported at least a few hospitals being overwhelmed during the pandemic, such as Bergamo’s,[1] New York’s,[2] and Spain’s[3].

That said, many questioned those reports, noting that other hospitals didn’t get overwhelmed at all, or that in many countries, aggregate data didn’t show much signs of overwhelm.

Let’s examine those two arguments

Argument #1: Some hospitals didn’t get overwhelmed

Many hospitals didn’t get overwhelmed during the pandemic.

This does not mean, though, that other hospitals didn’t get overwhelmed. As with any pandemic, COVID hit different cities with different intensities.

Moreover, some cities had a larger hospital capacity relative to their population or had a healthier population. Therefore, their hospitals were less stressed during the pandemic.

This means that some hospitals didn’t get overwhelmed, without it meaning that no hospital got overwhelmed.

Argument #2: Aggregate data shows that countries’ healthcare systems didn’t get overwhelmed

The aggregate hospital data of countries that claimed overwhelmed hospitals doesn’t seem to support such claims.

Let’s take the example of Italy. It was one of the hardest-hit countries during the first COVID wave in 2020. Yet, on the worst day of the first wave, only ~10% of Italian public hospital beds were occupied by coronavirus patients.[4] This gives the impression that Italy’s healthcare system didn’t get overwhelmed.

But the reality is more complex. For each overwhelmed hospital, such as those near Bergamo,[5] there were many others, in less-infected areas, that weren’t overwhelmed at all. People looking at average numbers would get the impression that there was no overwhelm, whereas there was, locally.

Local overwhelm matters

The world produces enough food to feed its entire population. Yet, more than 9 million people die of starvation every year[6]. That’s because what matters is not the global average but local spikes of food unavailability.

Similarly, most countries had enough hospital beds to treat their whole population of patients. But what matters is not average capability but local one. If a hospital is overwhelmed, its local community will suffer from additional deaths, no matter the country’s average healthcare capability.

What is 10% COVID occupation, anyway?

Another tricky consideration is that the sentence “only 10% of Italian public hospital beds were occupied by coronavirus patients” seems to give a false impression of calm. That means that 90% of beds were free, right?

No. Most of the remaining beds were not free but occupied by the patients who visited the hospital for other reasons: cancer patients, elderly with various illnesses, injured people, and so on.

In fact, the average OECD hospital bed occupancy pre-pandemic was 76%[7]. That’s the average – that means that some hospitals were 60% occupied and others 90%. Add an average 10% of COVID patients – which can mean 5% in most hospitals and 30% in a few others – and it’s easy to see how many hospitals could get above 100%.

Did they, though?

Not really. Only some hospitals reported an occupancy rate above 100%.

However, this doesn’t mean that the rest weren’t overwhelmed.

Invisible overwhelm

Plenty of hospitals with the prospects of an above-100% occupancy rate faced a difficult choice: overcrowding the hospital or canceling some services.

Overcrowding in hospitals is bad because it means that patients receive less and worse care than they would under normal circumstances. Moreover, the more overcrowded a hospital is, the higher the chances that the patients infect each other and infect the doctors, leading to further stress on the healthcare capabilities.

Therefore, many hospitals chose to avoid overcrowding by canceling some services, such as non-urgent surgeries and cancer diagnostics. Such hospitals showed normal levels of occupancy yet were overwhelmed because they couldn’t provide the services they were expected to provide.

Overwhelm because of the lockdowns, or with the lockdowns?

Suspending non-urgent surgeries, cancer diagnostics, and other medical services came with massive costs in terms of the health of the patients who were denied healthcare.

To avoid incurring these hefty costs ever again, it is important to understand what the root causes were. In other words, did hospitals suspend some services because of the lockdowns or with the lockdowns (i.e., during the lockdowns but due to other causes)?

The answer differs on a country-by-country basis and on a hospital-by-hospital basis. There were hospitals that suspended some of their services because they had too many patients (examples: Bergamo,[8] Madrid[9]) and there were hospitals that suspended some of their services because of top-down governmental policies. There were hospitals that suspended some of their services because their doctors fell sick (example: Poland[10]), hospitals that suspended some of their services because their doctors were called to help other hospitals that were overwhelmed (example: Turin[11]), and hospitals that suspended some of their services because their doctors had to follow strict quarantine policies.

So, hospital overwhelm was only partially caused by policies and at least partially caused by the direct consequences of high viral spread.

That said, it is important to understand that the policies that caused hospitals to suspend some services were also caused by the high viral spread.

Quarantine policies for doctors

Some hospitals had reduced healthcare capabilities because many of their doctors spent time in quarantine. This policy has an obvious reason to be: hospitals are filled with vulnerable patients. We want to protect them, and how could we if sick doctors are allowed to work?

There are two ways to reduce the chance that a doctor has to spend time in quarantine. One is removing testing or the quarantine policy, but that would negatively impact the health of the vulnerable patients doctors care for. The other solution is to reduce the chances that the doctors fall sick, and that includes taking measures to reduce community spread (doctors are members of the community like everyone else), strict masking policies within the hospital (for both doctors and patients), and reducing the number of patients doctors have to see (which means, again, to reduce the number of infections within the community causing people to get sick and need to see a doctor).

Top-down policies that reduced healthcare services

In some places, such as the UK[12], authorities passed policies that required hospitals to suspend certain healthcare services, such as non-urgent surgeries. Were these policies necessary?

It depends. Whereas there were undoubtedly cases in which excessive prudence was used, there were also cases in which such policies were necessary, and hospital overwhelm would have occurred without them.

It also has to be noted that there are many places where such policies were not instituted by governments making guesses about the future but by local healthcare authorities already facing overwhelm. For example, in Lombardy,[13] policies of delaying non-urgent care were an unavoidable response to an already-overwhelmed healthcare system, and only referred to cases in which the doctors instead of staying still, could be redirected to hospitals and wards requiring urgent need.

Avoiding policies that reduce healthcare capability

In 2020, most healthcare systems found themselves in a lose-lose situation, facing only bad options.

Option #1: do not require doctor quarantines and do not suspend non-urgent medical services. The result would have been even more stress on the healthcare system down the road, as the lack of doctor quarantines would have caused more hospital infections, and non-urgent medical services would have caused the patients-to-doctors ratio to reach unsustainable levels where no one could have received good-enough healthcare.

Option #2: Require doctor quarantines and suspend non-urgent medical services, making some healthcare services unavailable.

Once viral spread is too high, healthcare policymakers only have bad options to choose from, and any choice results in suspended healthcare services.

Hence, if one wants to enable healthcare services to run as designed, they should first and foremost prevent viral spread to reach excessive levels.

Stronger healthcare & a healthier population

Of course, there are also other actions that can reduce the chance of hospital overwhelm – for example, building a stronger healthcare system and having a healthier population.

A stronger healthcare system mostly consists of building overcapacity – in other words, of building more hospital beds and hiring more doctors than a community needs in normal times to meet the increased demand for healthcare services during a pandemic.

A healthier population mainly consists of promoting an active lifestyle and a healthy diet.

That said, both a stronger healthcare system and a healthier population require long time frames. Any country that hasn’t started implementing them years before a pandemic begins will find itself with only costly options after the pandemic arrives.

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