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<\/div>Read: America is trapped in a pandemic spiral<\/a><\/p>\n The entire state of Iowa is now out of staffed beds, Eli Perencevich, an infectious-disease doctor at the University of Iowa, told me. Worse is coming. Iowa is accumulating more than 3,600 confirmed cases every day; relative to its population, that\u2019s more than twice the rate Arizona experienced during its summer peak, \u201cwhen their system was near collapse,\u201d Perencevich said. With only lax policies in place, those cases will continue to rise. Hospitalizations lag behind cases by about two weeks; by Thanksgiving, today\u2019s soaring cases will be overwhelming hospitals that already cannot cope. \u201cThe wave hasn\u2019t even crashed down on us yet,\u201d Perencevich said. \u201cIt keeps rising and rising, and we\u2019re all running on fear. The health-care system in Iowa is going to collapse, no question.\u201d<\/p>\n In the imminent future, patients will start to die because there simply aren\u2019t enough people to care for them. Doctors and nurses will burn out. The most precious resource the U.S. health-care system has in the struggle against COVID-19 isn\u2019t some miracle drug. It\u2019s the expertise of its health-care workers\u2014and they are exhausted.<\/p>\n The struggles of the first two COVID-19 surges in the United States helped hospitals steel themselves for the third. Hardened by the crucible of March and April, New York City built up its ability to spot burgeoning hot spots, trace contacts, and offer places where infected people can isolate. \u201cWe\u2019re seeing red flags but we\u2019ve prepared ourselves,\u201d says Syra Madad from NYC Health + Hospitals. Experienced health-care workers are less fearful than they were earlier this year. \u201cWe\u2019ve been through this before and we know what we have to do,\u201d says Uch\u00e9 Blackstock, an emergency physician who works in Brooklyn. And with the new generation of rapid tests, Blackstock says she can now tell patients if they have the coronavirus within minutes\u2014a huge improvement over the spring, when tests were scarce and slow.<\/p>\n Smaller clinics, nursing homes, and long-term-care facilities are still struggling to provide personal protective equipment, including gloves and masks. \u201cAbout a third are completely out of at least one type of PPE\u201d despite having COVID-19 cases, says Esther Choo, a physician at Oregon Health and Science University and a founder of Get Us PPE<\/a>. But larger hospitals are doing better, having built up stockpiles and backup plans in case supply chains become strained again. \u201cThe hospital is probably the safest place to work in Iowa, because we actually have PPE,\u201d Perencevich said.<\/p>\n Most important, COVID-19 is no longer a total mystery. Health-care workers now have a clearer idea of what the SARS-CoV-2 coronavirus is capable of. Protocols that didn\u2019t exist in the spring have become habit. \u201cIt used to be that to do a single thing, people would start email chains and you\u2019d be 100 emails in before we knew the answer,\u201d Choo says. \u201cNow we\u2019re moving faster. It feels a lot more confident.\u201d<\/p>\n Read: The difference between feeling safe and being safe<\/a><\/p>\n There are still no cures, and the best drug on offer\u2014the steroid dexamethasone<\/a>\u2014reduces the odds of dying from COVID-19 by at most 12 percent. But doctors know how to triage patients, which tests to order, and which treatments to use. They know that ventilators can sometimes hurt patients, and that \u201cproning<\/a>\u201d\u2014flipping patients onto their stomach\u2014can help. They know about the blood clots and kidney problems. They know that hydroxychloroquine<\/a> doesn\u2019t work. This cumulative knowledge means that death rates from COVID-19 are much lower<\/a> now than they were in the spring. Flattening the curve worked as intended<\/a>, giving health-care workers some breathing room to learn how to handle a disease that didn\u2019t even exist this time last year.<\/p>\n But these hard-earned successes are brittle. If death rates have fallen thanks to increasing medical savvy, they might rise again as nurses and doctors burn out. \u201cIf we can get patients into staffed beds, I feel like they\u2019re doing better,\u201d Perencevich said. \u201cBut that requires a functional health-care system, and we\u2019re at the point where we aren\u2019t going to have that.\u201d<\/p>\n Intensive-care units are called that for a reason. A typical patient with a severe case of COVID-19 will have a tube connecting their airways to a ventilator, which must be monitored by a respiratory therapist. If their kidneys shut down, they might be on 24-hour dialysis<\/a>. Every day, they\u2019ll need to be flipped onto their stomach, and then onto their back again\u2014a process that requires six or seven people. They\u2019ll have several tubes going into their heart and blood vessels, administering eight to 12 drugs\u2014sedatives, pain medications, blood thinners, antibiotics, and more. All of these must be carefully adjusted, sometimes minute to minute, by an ICU nurse. None of these drugs is for treating COVID-19 itself. \u201cThat\u2019s just to keep them alive,\u201d Neville, the Iowa nurse, said. An ICU nurse can typically care for two people at a time, but a single COVID-19 patient can consume their full attention. Those patients remain in the ICU for three times the length of the usual stay.<\/p>\n Nurses and doctors are also falling sick themselves. \u201cThe winter is traditionally a very stressful time in health care, and everyone gets taken down at some point,\u201d says Saskia Popescu, an infection preventionist at George Mason University, who is based in Arizona. The third COVID-19 surge has intensified this seasonal cycle, as health-care workers catch the virus, often from outside the hospital. \u201cOur unplanned time off is double what it was last October,\u201d says Allison Suttle of Sanford Health, a health system operating in South Dakota, North Dakota, and Minnesota. Many hospitals have staff on triple backup: While off their shifts, they should expect to get called in if a colleague and their first substitute and the substitute\u2019s substitute are all sick. At least 1,375 U.S. health-care workers<\/a> have died from COVID-19.<\/p>\n The first two surges were concentrated in specific parts of the country, so beleaguered hospitals could call for help from states that weren\u2019t besieged. \u201cPeople were coming to us in our hour of need,\u201d says Madad, from NYC Health + Hospitals, \u201cbut now the entire nation is on fire.\u201d No one has reinforcements to send. There are travel nurses who aren\u2019t tied to specific health systems, but the hardest-hit rural hospitals are struggling to attract them away from wealthier, urban centers. \u201cEveryone is tapping into the same pool, and people don\u2019t want to work in Fargo, North Dakota, for the holidays,\u201d Suttle says. North Dakota Governor Doug Burgum recently said<\/a> that nurses who are positive for COVID-19 but symptom-free can return to work in COVID-19 units. \u201cThat\u2019s just a big red flag of just how serious it is,\u201d Suttle says. (The North Dakota Nurses Association has rejected the policy<\/a>.)<\/p>\n Read: This overlooked variable is key to the pandemic<\/a><\/p>\n Short-staffed hospitals could transfer their patients\u2014but to where? \u201cA lot of smaller hospitals don\u2019t have ventilators or staff trained to take care of someone in critical condition,\u201d says Renae Moch, the director of Bismarck-Burleigh Public Health, North Dakota. \u201cThey\u2019re looking to larger hospitals,\u201d but those are also full.<\/p>\n Making matters worse, patients with other medical problems are sicker than usual, several doctors told me. During the earlier surges, hospitals canceled elective surgeries and pulled in doctors from outpatient clinics. People with heart problems, cancers, strokes, and other diseases found it harder to get medical help, and some sat on their illness for fear of contracting COVID-19 at the hospital. Now health-care workers are facing an influx of unusually sick people at a time when COVID-19 has consumed their attention and their facilities. \u201cWe\u2019re still catching up on all of that,\u201d says Choo, the Oregon physician. \u201cEven the simplest patients aren\u2019t simple.\u201d<\/p>\n For many health-care workers, the toll of the pandemic goes beyond physical exhaustion. COVID-19 has eaten away at the emotional core of their work. \u201cTo be a nurse, you really have to care about people,\u201d Neville said. But when an ICU is packed with COVID-19 patients, most of whom are likely to die, \u201cto protect yourself, you just shut down. You get to the point when you realize that you\u2019ve become a machine. There\u2019s only so many bags you can zip.\u201d<\/p>\n As the pandemic moved out of big coastal cities and into rural communities, health-care workers were more likely to treat people they knew personally\u2014relatives, hospital colleagues, the bus driver who drove their kids to school. And across the country, doctors and nurses have struggled with the same anxieties as everyone else\u2014loneliness, extra child-care burdens, the stress of a tumultuous year, fear. \u201cThe lines between our personal lives and our careers have completely gone,\u201d says Laolu Fayanju, senior medical director in Ohio of Oak Street Health, a national network of primary-care centers. \u201cWe\u2019re often thinking about how we protect ourselves, our families, and our neighborhoods\u201d from the pandemic.<\/p>\n After SARS hit Toronto in 2003<\/a>, health-care workers at hospitals that treated SARS patients showed higher levels of burnout and posttraumatic stress up to two years later, compared with those at hospitals in nearby cities that didn\u2019t see the disease. That outbreak lasted just four months. The COVID-19 pandemic is now in its tenth month. \u201cI\u2019ve had conversations with people who\u2019ve been nurses for 25 years, and all of them say the same thing: \u2018We\u2019ve never worked in this environment before,\u2019\u201d says Jennifer Gil from Thomas Jefferson University Hospital in Philadelphia, who contracted COVID-19 herself in March. \u201cHow much can meditation or mental-health resources help when we\u2019re doing this every day?\u201d<\/p>\n Even after cases stop climbing, health-care workers will have to catch up on a new round of procedures that didn\u2019t happen because of COVID-19\u2014but without the adrenaline that a packed hospital brings. \u201cEveryone talks about fatigue during the surge, but one of the hardest things is coming down from it,\u201d Popescu says. \u201cYou\u2019re exhausted but you still don\u2019t get that mental break.\u201d<\/p>\n Read: Long-haulers are redefining COVID-19<\/a><\/p>\n As hard as the work fatigue is, the \u201csocietal fatigue\u201d is harder, said Hatton, the Utah pulmonary specialist. He is tired of walking out of an ICU where COVID-19 has killed another patient, and walking into a grocery store where he hears people saying it doesn\u2019t exist. Health-care workers and public-health officials have received threats and abusive messages accusing them of fearmongering. They\u2019ve watched as friends have adopted Donald Trump\u2019s lies<\/a> about doctors juking the hospitalization numbers to get more money. They\u2019ve pleaded with family members to wear masks and physically distance, lest they end up competing for ICU beds that no longer exist. \u201cNurses have been the most trusted profession for 18 years in a row, which is now bullshit because no one is listening to us,\u201d Neville said.<\/p>\n Trump is still falsely claiming victory over the virus that ran amok because of his incompetence, and he is unlikely to do anything more to control it during the dusk of his presidency. Neither a vaccine nor a Biden administration will arrive quickly enough to turn the current surge around. The next months will be bleak. But Biden\u2019s election \u201chas given me a second wind,\u201d Fayanju says.<\/p>\n Biden openly wears a mask, and has urged Americans to do the same. He has released a sound COVID-19 plan<\/a> that, he said during his acceptance speech, is \u201cbuilt on a bedrock of science.\u201d He has assembled a coronavirus task force composed of 13 people with medical expertise. He has committed to rejoining the World Health Organization. His presidency, many health-care workers hope, will mark a newfound commitment to stopping the pandemic, restoring the humbled Centers for Disease Control and Prevention, and ending a steady stream of gaslighting and misinformation from the federal government itself. \u201cI slept this weekend like I haven\u2019t slept since February\u2014without the same demons,\u201d Choo says. \u201cI woke up doped up on sleep.\u201d<\/p>\n Choo also studies the impacts of health-care policy, and has found that health-care systems sometimes react to imminent policies months before they are actually come into force. Could that happen with Biden\u2019s pandemic plan? \u201cIt absolutely could, and there\u2019s precedent for it,\u201d she says. She expects that state leaders will start to coalesce around his plan and consult with his task force.<\/p>\n Still, \u201cyou can\u2019t just fix a pandemic this far down the rabbit hole,\u201d Popescu says. \u201cI\u2019m hopeful, but I don\u2019t expect this to suddenly turn itself around overnight.\u201d Biden will inherit a health-care system that is battered at best and broken at worst, a polarized electorate, and many local leaders who are doubling down on bad policies. Trump won Iowa by eight points, which Governor Kim Reynolds took as validation of the state\u2019s COVID-19 response<\/a> thus far. Bars, restaurants, and schools in Iowa are still fully open, and a recently announced mask mandate applies only for gatherings of 25 people or more. \u201cThat takes away my hope,\u201d Perencevich said.<\/p>\n \u201cWe can\u2019t just sit on our hands and wait for Jan. 20 to come,\u201d said Megan Ranney, the Rhode Island physician. Several health-care workers I spoke with are trying to keep mild cases of COVID-19 from becoming severe enough to warrant an ICU bed. The Oak Street Health primary-care centers deliver fluids, pulse oximeters, and smart tablets to the homes of newly diagnosed COVID-19 patients, so doctors can check on their symptoms virtually. In North Dakota, South Dakota, and Minnesota, the Sanford Health network has set up outpatient \u201cinfusion centers\u201d where elderly COVID-19 patients or those with chronic illnesses can get drugs that might slow the progression of their disease. These drugs will include the antibody therapy bamlanivimab<\/a>, which received an emergency-use authorization from the FDA on Monday, Suttle told me.<\/p>\n But the best strategy remains the obvious one: Keep people from getting infected at all. Once again, the fate of the U.S. health-care system depends on the collective action of its citizens. Once again, the nation must flatten the curve. This need not involve a lockdown. We now know that the coronavirus mostly spreads through the air, and does so easily when people spend prolonged periods together in poorly ventilated areas. People can reduce their risk by wearing masks<\/a> and avoiding indoor spaces<\/a> such as restaurants, bars, and gyms, where the possibility of transmission is especially high (no matter how often these places clean their surfaces). Thanksgiving and Christmas gatherings<\/a>, for which several generations will travel around the country for days of close indoor contact and constant conversation, will be risky too.<\/p>\n