Socio-economic inequality in cities has exacerbated the uneven impacts of the COVID-19 pandemic, with people in poverty and people of colour more likely to be exposed to and more likely to die from the virus. Accounting currently for nearly ten percent of the confirmed cases in the US, New York City has been the epicentre of the pandemic. The pandemic has also shed light on the condition of New York City’s already stretched health system, straining to care for those who have fallen ill. Throughout the crisis, hospitals have been crowded, refrigerator trucks have lined the nearby streets once morgues reached capacity, and ambulance services have been overwhelmed and short-staffed as front line workers fall ill.

The New York City health system: a brief background

Two important challenges facing the New York City health system help to explain why and how the pandemic has impacted the City so severely. The City has experienced a series of hospital closures over the past two decades that has transformed how residents access health care. As well, the health system in New York, the US, and much of the Global North, has stretched nurses and other health care workers thin for decades.

Nearly two dozen hospitals in the City have closed over the past 20 years, as the hospital system has become increasingly financially fragile since the 1990s. This has drastically reshaped how and where New Yorkers access health care. Hospital services to each of the City’s five boroughs is unequal. Manhattan has many more hospitals, particularly speciality facilities. Meanwhile the two most populous boroughs, Queens and Brooklyn – which currently lead in number of COVID-19 deaths per county in the US – have fewer hospitals and fewer beds per 1,000 residents. These boroughs have been hit hard with closures, especially since the 2008 recession. Many of these closures occurred because of a confluence of two events.

First, in 2006, a state commission, whose mandate was to update New York State’s hospital and long-term care systems, targeted a number of New York City hospitals for closure. The second event was the 2008 financial crisis. When the financial crisis hit, more facilities proved financially unstable and were let to close. Even though people in the US access health care through a mix of public and private care providers, the government is still responsible for managing and coordinating much of the system. This management happens through a variety of means, including public insurance payments, regulations, licensing, and accreditation – and assisting facilities that are struggling financially. Some facilities, such as Brooklyn’s Interfaith Medical Center, get state assistance to get back on solid financial ground. Others are considered too expensive to bail out and subsequently let to close, such as Manhattan’s St Vincent’s Hospital.

Community hospitals – generally smaller, non-specialist facilities with a range of services and clinics that serve local populations – have been hit the hardest with closures. For many residents, these are often a first stop for care. People without health insurance or a GP often depend on the emergency room for basic care, since the ER cannot turn them away. Community hospitals are also hubs of health care, housing many other health clinics. While urgent care clinics have opened across the city, the COVID-19 crisis shows the limits of living without a local hospital. Such clinics are no replacement for hospitals when people need emergency or acute medical care. Closures have left residents farther away from the nearest hospital and facilities under greater pressure. This is not to forget the important economic and social roles hospitals fill in communities. They employ often thousands of people and occupy major infrastructure. Hospitals are hubs of economic and social activity. Surrounding businesses benefit greatly from the activity a facility brings to the area.

Closures, crisis, COVID-19

Elmhurst, Queens exemplifies how communities of colour and lower income neighbourhoods have felt the brunt of the impacts of these closures. It has been cited as New York City’s worst impacted neighbourhood by COVID-19. Elmhurst’s St John’s Queens Hospital closed in 2009, leaving the public Elmhurst Medical Center as the only hospital serving the area. Elmhurst is vibrant and diverse and also home many new immigrants to the City. Language barriers, lack of health insurance, crowded living conditions, and poverty have created a perfect storm for COVID-19. In the past two months, key workers have called Elmhurst the ‘epicentre of the epicentre’ of the COVID-19 pandemic. The public hospital has been stretched beyond its limits; people are disproportionately vulnerable to infection; funeral homes are overwhelmed; and workers exhausted, sick, and worse.

Hospital closures are not the only long-standing health crisis facing the city. A chronic under-investment in health care workers also makes the health care system fragile. Shortages of health care workers, especially nurses, have been an ongoing issue for not only New York’s health system, but health systems around the world. Decades of underinvestment in nursing education and difficult working conditions have meant that the US overall does not train enough nurses and has trouble retaining them in the profession. Like many Global North countries, the US has dealt with cyclical nurse shortages since at least the 1970s. Often, facilities have turned to hiring migrant nurses to help fill staffing shortages, and this is especially true in New York.

Care deficits

Staffing shortages are a symptom of what feminist scholars refer to as ‘care deficits’. Care deficits describe the conditions when individuals, families, populations, or systems (such as a health care system) lack sufficient resources. Those resources could be money, workers, or supplies such as ventilators and personal protective equipment. A care deficit is different from a labour shortage: a facility might hire more nurses to fill vacancies, but patients may still not receive enough care. A unit might still need more nurses working each shift. Nurse unions have been at the forefront of advocating for better labor protections to solve care deficits. Regulating the number of patients a nurse can be responsible for has been a central strategy to improve working and caring conditions. ICU and especially ventilator patients require an immense amount of care and attention. Imagine the difference in care for your mother, grandmother, or uncle if a nurse has to care for two or three other ventilator patients compared to just focusing on your loved one. A staffing shortage directly impact a nurse’s working conditions – and a patient’s quality of care.

Nurse shortages and hospital closures are not separate issues. Just as when jobs are lost when a manufacturing plant closes, when a hospital closes, jobs are also lost. Given the work that happens in a hospital, the stakes are so high. Nurses are just one example of care workers who are essential to providing sufficient, safe, high quality care. COVID-19 has helped many people see just how essential certain jobs are to meet everyday needs. Within a hospital, nurses, nurse assistants, physicians, cleaners, lab techs, phlebotomists, food workers, and more are essential to keeping a hospital, its workers, and its patients safe. Each worker is part of the team ensuring patients and loved ones receive high quality care. A hospital isn’t a hospital without workers making it a place for care, treatment, and healing. At the same time, if hospitals and beds aren’t available, health care workers can only do so much to treat patients. If a hospital closes, a care deficit can open in its place. Surrounding hospitals only absorb so much of these patients and newly unemployed key workers.

Austerity is bad for your health

This context means that New York City’s health system was already under strain, with fewer hospitals and a stressed labour market. The closure of hospitals and the insufficient funding and resources for training, supporting, and hiring health workers are not isolated trends. Rather, they are intertwined and together, they have made New York’s health system fragile and uneven across the city. While Governor Andrew Cuomo might be celebrated as a leader in the US recently, history reminds us to be mindful of long-standing and repeated cuts and restructurings to essential safety nets like community hospitals and Medicaid, the state-provided health insurance for people in poverty.

Moreover, deadly austerity policies have made the COVID-19 outbreak in New York City even more deadly for residents and workers. It didn’t have to be this way. The protests in cities all over the US against police brutality against racialized people must be understood in a context of racism as a public health hazard and the disproportionate harm of austerity politics on people of colour and their communities. COVID-19 abandonment, thus, has long histories in, among other things, a destabilizing and defunding of health care systems. Public health experts and community health workers have been sounding the alarm for years. Now, as health workers are called ‘heroes’, perhaps leaders will listen more to the great ideas that workers have been advocating to make health care more just, equitable, and accessible in New York and beyond. 

Caitlin Henry, June 2020.

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