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What happens when hospitals can't help each other?

by Athena Aktipis and Lee Cronk

In an Albuquerque hospital recently, the Intensive Care Unit was full, and yet more COVID-19 patients rolled in who needed beds. “We’ve been handling it so far,” a friend who works there as an emergency room physician said. “But if it gets worse….”

This is not an isolated incident. Hospitals around the country have been running out of room for months. Early in this wave, hospitals in Jackson, Mississippi ran out of beds, and the nearest available bed was in Pensacola, Florida, more than 200 miles away. It's only gotten worse from there. Hospitals in Los Angeles are so overwhelmed that lobbies and gift shops are now being used as places to treat patients.

What happens when hospitals are all hit simultaneously by the current surge in COVID-19 cases? We can find some answers by looking at how people deal with catastrophes through mutual aid and how social networks deal with the strain of simultaneous shocks.

Since our species’ early days as hunters and gatherers, our social networks have served as informal insurance systems, helping us survive through crises. Such systems exist today in small-scale societies and also among large-scale institutions like hospitals. When hospitals are short-staffed or otherwise overwhelmed, they transfer patients to other hospitals or call in additional health care workers.

In normal times, over-taxed hospitals like those in Mississippi would rely on neighboring hospitals. In the early days of the pandemic when New York was hit hard, health care workers were able to travel, coming from states as far away as Utah, New Mexico and California. But when every hospital is in need, all the slack in the system is taken up and hospitals are not able to help each other.

This underscores the more general problem: If everyone is in need at the same time, eventually the social fabric of cooperation can break down because there are simply not enough resources to go around.

Consider Maasai herders in East Africa, who have a mutual aid system that they call osotua. In normal times, a herder whose livestock is decimated by a disease can ask his more fortunate osotua partners for help. But more than a century ago the Maasai experienced droughts and diseases that were so widespread that their mutual aid networks could not handle the strain, ultimately triggering civil war. Fortunately, when the crisis abated, those networks were able to recover.

In the early 1960s, something similar happened to the Ik, a small group of hunter-gatherers and farmers in northern Uganda who have strong ethics of generosity and mutual aid. Deprived of access to their ancestral hunting territories when British colonial authorities created a national park, the Ik entered a period of famine that led to a temporary breakdown of their social fabric.

One of the important lessons from small-scale societies is that -- if shocks are simultaneous -- we can’t just depend on others to help in times of need because they might not have the capacity. If shocks are simultaneous, we must work together to manage risk by reducing collective vulnerabilities.

For Mongolian herders, one of the main risks is devastating winter storms called dzud. When a dzud strikes, no one is in a position to help anyone else. Knowing this and recognizing their interdependence, herding families work together during the summer to build shelters for their livestock and to harvest hay that they can feed their livestock should they face a dzud.

We are on the precipice of a simultaneous catastrophe in hospital systems around the country -- a dzud of our own. Not only are COVID cases skyrocketing, but doctors and other health care workers are quitting because of stress and inadequate supplies to keep themselves and their patients safe. Many are considering early retirement because of burnout. The systems that we do have are breaking down.

Acknowledging our fundamental interdependence can help us see our way through now and prepare for future pandemics. Nobody should have to make the decision of whether to give the last ventilator to a beloved grandmother or a young college student with her whole life ahead of her.

In addition to doing everything we can to reduce the demands on hospitals (wear a mask!), we also need to think about how to set the system up so that it won’t be so vulnerable to future shocks. That means building capacity and taking care of the workers that take care of us. Removing regulations that prevent the expansion of hospital capacity (such as the Certificates of Need that are required by many states) would help. We also must make it economically and emotionally viable for health care workers to continue working in these essential jobs, and train and recruit more people into these jobs. The current economic and regulatory structures of hospitals -- and our health care systems more generally -- are not poised to deal with the growing reality of pandemics and other health catastrophes. Like Mongolian herders preparing in advance for a dzud, we need to work together to shore up our vulnerabilities before the next crisis hits.

No doubt, expanding capacity, changing regulations and setting up better safety nets will require a lot of cooperation. Even as hospital resources are increasingly stretched as we head into this record-breaking third wave, human resourcefulness and cooperation need not be limited. By recognizing our interdependence and working together to manage risk, we can develop new, more resilient systems for dealing with large-scale shocks. Lessons from small-scale societies show us that our humanity depends on it.

Athena Aktipis and Lee Cronk co-direct The Cooperation Science Network and the Human Generosity Project, an interdisciplinary project looking at how humans help one another in times of need. Aktipis is an Associate Professor of Psychology at Arizona State University and Cronk is a Professor of Anthropology at Rutgers University in New Brunswick.