Most evenings on her drive to the hospital, Gisella Thomas receives calls from her six children. They call from Las Vegas, Bakersfield, and the cornfields of Nebraska. They ask what she’s seeing at work. They want to know if she’s going to be okay.
As a respiratory therapist at the Desert Regional Medical Center outside of Los Angeles, Thomas, 72, is responsible for assisting to intubate patients diagnosed with Covid-19. Intubating requires her to lean over and thread a tube down the patient’s throat to ensure oxygen flows to their lungs. Her face is inches from their mouth. If the patient coughs, infected droplets will splatter her protective face shield. Her job is among the most dangerous in the hospital.
After caring for up to 15 Covid-19 patients during her overnight shift, Thomas drives home just after sunrise and returns calls from her worried children. While she is old enough to retire, she says she cannot afford to. Three of her six children are unemployed. Two more rely upon her health insurance.
Thomas tells her children not to worry. She’s going to be okay, she says.
In private, though, Thomas is less confident. “I’ve got to believe it will be okay,” she said. “It has to be.”
As Covid-19 overwhelms several hospital systems around the world, public attention has affixed on doctors and advanced practice providers, like nurse practitioners and physician assistants — the hospital’s leaders on the ground whose medical plans shape the field of battle.
Less visible but no less important, however, is the army of support staff like Thomas, whose daily exposure to Covid-19 patients — from changing their clothes to inserting life-saving ventilator tubes — sometimes exceeds that of the doctors they assist.
We interviewed over a dozen hospital support workers, nurses, and academic medical professionals. (Eli Cahan, a co-author of this story, is a fourth-year medical student at New York University.) Many of these support staff earn lower wages, and some have unemployed family members or sick dependents. Others have young children at home with few options for child care because of family leave policies that have lagged behind widespread school closures. Some are older and have preexisting conditions that multiply their risk of severe Covid-19 illness — or dying from it. Lower in status at work than doctors, some feel unable to advocate for greater protections, fearful of provoking their superiors’ retribution.
Protecting these workers is also a larger safety issue. In previous epidemics, unprotected support staff have emerged as hidden “super-spreaders” as they traverse hospital floors serving lunch, cleaning linens, or taking X-rays. During the West African Ebola epidemic of 2014-’15, for example, support staff were up to 32 times more likely to become infected than the general population, according to the World Health Organization — and 48 percent more likely to become infected than doctors. And without these workers, the hospital’s delicate ecosystem would collapse.
Financially and medically exposed, support workers are at risk. And without proper protections, they are putting everyone else within their reach at risk, too.
The support staff behind the curtain of hospital medicine
In a typical hospital admission in the US, a patient enters the emergency room and is greeted by a registration clerk — sitting a foot or so away, behind a desk. Then a triage nurse arrives to ask about their symptoms. Within minutes, a blood-drawing specialist (a phlebotomist) stops by to collect a vial or two. If the patient is admitted, a telemetry nurse wires them up to pulse monitors on a stretcher.
Transport staff may wheel them into the radiology ward for X-rays, where a radiology technologist fashions a lead vest and positions them in the scanner where the pictures are taken. After the patient leaves the darkroom, an environmental technician sanitizes the room behind them while a facilities engineer tightens a creaky hinge. Back in the waiting bay, the patient may snack on pudding delivered by a dietary specialist. After this routine, a doctor appears.
Of course, Covid-19 has scrambled these procedures. To minimize exposures, hospitals have placed plexiglass at the registration desk and wrapped radiology equipment in plastic. Some have started performing intake interviews through video and now only draw blood when absolutely necessary. Others have made makeshift emergency wings separated from negative-pressure “bubbles” for Covid-19 patients.
Yet even after taking these precautions, many hospital tasks remain essential. Admitted patients require IV drips; someone must hang them. Patients will get blood clots if they don’t move; someone must help them walk. Someone must fetch broth and Jello to ensure they eat. Someone must bathe them. Someone must empty their bedpan. Someone must clean their soiled linens.
At Methodist Hospital in Sacramento, that “someone” is often Irene Gourdine.
After a Covid-19 patient leaves the hospital, Gourdine, 63, dons a protective suit and holsters her sanitizer. She sweeps the floors and scrubs the gurneys of the vacated room. If she misses a spot, a patient or doctor could get sick. If she is careless, she could inhale the virus through her nose or smear it on her eyes.
According to GlassDoor, a website where employees anonymously submit their salaries, a typical environmental technician’s salary is $10 an hour.
“I don’t know what people think of me,” said Gourdine, about her role. “Maybe that I’m a housekeeper, or a maid. But without me, this infection would be worse.”
In unspoken hospital hierarchies, staff like Gourdine rank lower in the pecking order than doctors and advanced practice providers. They tend to receive safety information or personal protective equipment (PPE) like gowns, gloves, or masks later than providers do. Few expect to receive prioritized testing or expedited care should they require treatment.
At Montefiore Medical Center in the Bronx, one resident, speaking under the condition of anonymity for fear of backlash from the hospital, shared that amid PPE shortages, support staff “are putting their lives at risk and by extension the lives of their people at home.” They are doing so, the resident continued, without the “security or the praise the doctors or nurses receive.”
Sara Singer, a professor of medicine and organizational behavior at Stanford University, has found that disparities in perceptions of safety are common in health care organizations. As a result of these hierarchies, “we’re seeing the potential for rationing play out,” Singer said, adding, “When facilities are faced with shortages, they have to make decisions that implicitly place a higher value on the skills of some over others.”
Moreover, many hospitals have focused on staffing and maintaining wards containing Covid-19 patients, diverting resources away from auxiliary departments like facilities or nursing. In the short-term, such redistribution provides desperately needed relief. In the long-term, however, it risks creating shortfalls elsewhere.
“The Covid floors, they have the signs, they get the PPE,” said Mary Temple, a post-anesthesia nurse at St. John’s Regional Medical Center in Oxnard, California. “It’s the rest of the hospital I’m scared for. Like dietary. If they go down, we all go down.” (The hospital responded in a statement, “We provide all of our staff the equipment, training, and information they need to care for the patients they are assigned.”)
Temple’s concern is not unfounded. Emerging evidence suggests that when they do contract coronavirus, health care workers are much more likely to die. A study at a hospital in Wuhan, China, the initial epicenter of the Covid-19 outbreak, revealed that 29 percent of those infected were health care workers. In Italy, a Lancet study found 20 percent of the health care workers developed infections. In the United States, nondoctor hospital workers like Gourdine make up a disproportionate share of the health care workforce relative to other countries.
The risks to support staff are exacerbated by inadequate PPE supplies
The morning after the night shift where he was instructed to re-wear contaminated gloves and gown, Frank Bagwell, 28, realized he would catch Covid-19.
Bagwell is a certified nurse’s assistant at Hi-Desert Medical Center in Joshua Tree, California. His responsibilities include spoon-feeding patients and transferring them to the toilet to defecate — along with bathing them and changing their undergarments if they don’t make it. Before Covid-19, reusing contaminated gear could get him fired. Now, he has been asked to reuse protective gear up to 20 times per overnight shift.
Like Thomas, the respiratory therapist, Bagwell’s responsibilities require him to interact closely with confirmed or suspected Covid-19 patients. He can’t bathe or feed patients from six feet away.
Hi-Desert Medical Center did not directly address Bagwell’s complaints. “Like many other health systems, we have temporarily implemented strategies for PPE conservation,” Hi-Desert said in a statement. The hospital claims that these strategies are “consistent with Center for Disease Control (CDC) guidance.” However, the CDC’s guidelines explicitly note that extended use of disposable isolation gowns “can be considered only if there are no additional co-infectious diagnoses transmitted by contact (such as Clostridioides difficile) among patients.” Bagwell noted having a patient with C. difficile on his most recent shift.
Yet even as his PPE allowance is rationed, management is relying on him more than ever. With auxiliary staff furloughed to, in management’s words, “reduce unnecessary exposures,” Bagwell is being asked to unclog toilets and fix broken appliances. Interviewed over video chat, he extends his arms like a zombie, demonstrating how to do something he says is “physically impossible”: safely re-don a contaminated isolation gown.
Bianca Frogner, director of the University of Washington’s Center for Health Workforce Studies, acknowledges that support staff are “lower on the totem pole for getting PPE.” Although they are “a critical group” in the fight against Covid-19, she says, they “don’t get a lot of attention.”
In fact, a National Nurses Union (NNU) survey, focusing on the experiences of frontline registered nurses amid Covid-19, found that only a quarter of respondents — out of about 8,200 total — said their employer had sufficient PPE for a surge in patient numbers, as of March 16.
Advocating for better protection has even gotten some staff punished. Thomas, the respiratory therapist, said that her “hospital has clamped down on the social media” and that posting pictures could “jeopardize [her] position at the hospital.” Jhonna Porter, a charge nurse at West Hills Hospital near Los Angeles, posted a Facebook plea for mask donations directly to the nurses’ association — not to the hospital administration. A few days later, she was suspended for an alleged violation of medical privacy laws.
The timing was suspect, Porter thinks; she believes the goal is to intimidate her colleagues into silence. “The nurses on my unit are terrified to say anything for fear of losing their jobs,” said Porter.
West Hills Hospital disputed Porter’s interpretation. “The issue with Jhonna Porter arose when co-workers expressed concerns about her [sharing] specific information, including room numbers of possible COVID patients,” said West Hills Hospital in a statement. “Her later posts about masking and donations were not the issue.”
Lack of transparency amplifies the hazards support staff face
Transparent and continuous information is just as critical to infection prevention as proper PPE. Yet even under normal circumstances, hospitals face knotted medical privacy laws that strangle communication between departments. In the pandemonium of Covid-19, communication has been stifled in some hospitals and support staff can remain in the dark.
Paul Griffin, a facilities engineer at Trinity Hospital in New Port Richey, Florida, is responsible for fixing air conditioners and plugging leaky faucets. When dispatched to patient rooms, he isn’t told what threat the individuals residing there may pose to him. Instead, he says, he finds out “through the grapevine.” His co-workers clue him in on the rooms with “patients under investigation” — the term, he says, is used for anyone suspected of having Covid-19.
Griffin’s approach is mirrored by other support staff interviewed for this story. Gourdine, the environmental technician, “listens in at the nursing desk” for “chatter.” Aleida Morales, a phlebotomist in Southern California, relies on her colleagues for “tips” before making her rounds.
Many of these workers emphasized that procedures were changing daily. While workers differed in their assessment of their hospitals’ handling of internal communication, few felt that the hospital had communicated too much. In a questionnaire sent to 83 support staff across 28 hospitals conducted in collaboration with the Service International Employees Union (SEIU) in late March, nearly three in 10 felt that their hospitals’ safety standards were “minimal” during the Covid-19 pandemic — and over two-thirds felt these standards were “confusing.”
Support staff carry the dangers of coronavirus home with them
Kaila Brown, a patient care technician in New Port Richey, has struggled with a different sort of communication: explaining to her 7-year-old son the risks mom faces at work.
Her son, Jeffry, had noticed his mother wiping down the door handle after returning home. When she told him about the pandemic, he asked her if it was “like the flu.” She said it was. Sort of.
In previous pandemics, health care workers have often emerged as “super spreaders” as they shuttle between hospital wards and the wider community. The original “Typhoid Mary,” Mary Mallon — who infected over 25 patients, families, doctors, and staff at New York’s Sloane Hospital for Women during the 1915 typhus outbreak — was a cook in the medical center’s kitchens. During SARS in 2003, a single hospital laundry worker accounted for many of Taiwan’s earliest cases. During Ebola in 2014, nurses and midwives ignited the disease’s rapid spread throughout West Africa. If these workers aren’t protected, the greater community is a risk.
And their household members face great risks, too.
Hospital support staff seem intimately aware of this fact. Almost everyone interviewed adopted a similar routine upon returning home: They stripped near-naked at the door, threw all clothes into the laundry, then showered immediately. Workers with enclosed porches considered themselves lucky not to have to strip in front of their neighbors.
Many families of support staff are physically vulnerable. Gabe Montoya, an emergency medical technician (EMT) at Kaiser Permanente Downey, checked into a hotel to protect his husband and elderly mother. Tonya Moore, a telemetry nurse at the University of Miami Hospital, returns home to an 18-year-old daughter on immunosuppressive drugs.
Support staff are not just in physical danger. They are in economic danger too. Like many American workers, thousands of nurses and other support staff have been furloughed, flexed, or fired as hospitals transform to treat Covid-19 patients.
Temple, the post-anesthesia nurse from Oxnard, lost six shifts after her unit was redesigned to accommodate a surge of Covid-19 patients that had not yet arrived. Temple borrowed money from her sister to pay the rent. If she is furloughed again next month, she’ll miss rent then, too.
While unions have sought to protect vulnerable workers by advocating for home safety protocols and resources to support child or elder care — Mary Kay Henry, international president of SEIU, described protecting workers as a “patriotic and moral requirement in this moment” — many hospital support staff face a daunting choice. If they go to work, they risk infecting themselves and their families. If they stay home, they protect their families but risk their livelihoods.
Even if they could stay home, many workers say they would feel guilty abandoning their patients. Bagwell, the nurse’s assistant, never considered taking leave. Though his girlfriend’s mother, who lives with him, has diabetes and asthma, he nevertheless shuffles in and out of patients’ rooms, handling bodily fluids and applying lotion to denuded backsides.
“My patients need help,” he said. Quitting his job would be a “cop-out.”
Last week, Bagwell self-quarantined in his garage after being exposed without PPE to a patient with Covid-19. A few days later, he tested negative for the coronavirus. The result offered scant reassurance. Three coworkers tested positive, he said.
Bagwell concluded he will inevitably become infected. He says he cannot risk exposing his girlfriend’s infirm mother to the virus. If she were to contract the virus, he confessed, “I’m not sure how we’ll deal.”
To make sure that doesn’t happen, Bagwell has a plan.
If he catches the virus, he’ll live out of his girlfriend’s mother’s car: a red Dodge SUV with interiors that he calls “pretty roomy.” His girlfriend, Donna, will bring food to the driveway. He’ll pull up to the curb and pick up the meal. Then he’ll find a spot by the roadside, park the car, and wait out the fevers.
“I’m making some life changes,” Bagwell said, “but ... I’m fine for now.”
Correction, April 15: A earlier version of this article misstated Mary Temple’s current employer. She now works part-time at St. John’s Regional Medical Center in Oxnard, to which her comments refer.
Eli Cahan is a Knight-Hennessy scholar at Stanford University completing a master’s degree in health policy and a fourth-year medical student at New York University. His work has been featured in PBS, Scientific American, TechCrunch, JAMA, and Health Affairs, among other publications.
Matt DeButts is a Knight-Hennessy scholar at Stanford University. He previously worked in China as a special correspondent, writing for the Los Angeles Times, Sixth Tone, and Foreign Policy, among others.