Inside an overwhelmed facility in the worst-hit part of California, where the patriarchs of two immigrant families were taken when they fell sick.
Over the New Year's holiday, the grown children of two immigrant families called 911 to report that their fathers were having difficulty breathing. The men, born in Mexico and living 5km from each other in the United States, both had diabetes and high blood pressure. They both worked low-wage, essential jobs — one a minibus driver, the other a cook. And they both had not realised how sick they were.
Three weeks later, the men — Emilio Virgen, 63, and Gabriel Flores, 50 — both died from Covid-19. Their stories were hauntingly familiar at Martin Luther King Jr. Community Hospital, by size the hardest-hit hospital in the hardest-hit county in the state now leading the nation in cases and on the brink of surpassing New York with the highest death toll. In the intensive care unit on January 21, Virgen became No. 207 on the hospital's list of Covid-19 fatalities; Flores, just down the hall, became No. 208.
The New York Times spent more than a week inside the hospital, during a period when nearly one-quarter of all Covid inpatients there were dying, despite advances in knowledge of the disease. It was an outcome that approached that of some New York hospitals last spring, when the city was the epicentre of the coronavirus pandemic. That rise coincided with a surge of cases in Southern California, a doubling of the mortality rate in Los Angeles hospitals overall and the spread of a new local strain that may be more transmissible than the more prevalent one.
Eight out of 10 of those who died at MLK Hospital were Hispanic, a group with the highest Covid-19 death rates in LA County, followed by Black residents. County data also showed that the most impoverished LA residents, many of them around the hospital in South LA, are dying of the disease at four times the rate of the wealthiest.
Michelle Goldson, an ICU nurse who cared for both Virgen and Flores, said many patients had a "distrust of the health care system, distrust of doctors" and came in only when desperately ill. Severe cases, she said, were not limited to older people. "Everybody's dying here," she said. As she headed home one recent evening, she waved at a 27-year-old patient who was sitting up eating dinner. When she returned the next morning, he was dead. "What kind of virus is this?" she asked.
Right now, it is one that is merciless in dense, low-income neighbourhoods like those where Virgen and Flores lived. Relatives similarly described them as hardworking and upbeat, determined to provide for their families. Virgen raised four children who all went to college, and stubbornly nurtured scrawny mango and lemon trees. Flores was proud that his oldest son — a so-called "Dreamer," based on never-passed proposals in Congress called the DREAM Act — who had been slipped into the country as a toddler, had graduated from the LA police academy.
For MLK's chief executive, Dr. Elaine Batchlor, the inequities in disease and death from Covid reflect those long present in the community. Patients come from what she termed a "medical desert," with acute shortages of primary care doctors and other health services.
In the best of times, her small institution cannot match what many other hospitals offer, from caring for preemies to major heart attack victims. Now, amid the pandemic, the hospital cannot test experimental therapies, cannot draw on a large pool of specialised staff in a surge and cannot offer last-chance care on an external lung machine.
During the peak, MLK treated more Covid patients than some LA hospitals three to four times its size. While Batchlor emphasises that her institution has learned to be nimble, she also said it has been overwhelmed. She has pleaded with the governor for help, tried to shame other institutions into accepting transfers of patients and spoken out about the failings of US health care.
"We've created a separate and unequal hospital system and a separate and unequal funding system for low-income communities," she said in an interview. "And now with Covid, we're seeing the disproportionate impact."
While Flores and Virgen were patients at MLK, their families worried about whether everything possible was being done to save them.
"I want to believe that they did give him the best care, that they did give him a fighting chance," Tiffany Virgen, Virgen's younger daughter, said after his death. "We want to hope that they did."
The legacy of 'Killer King'
When the ambulance crew picked up Virgen, they told his family he was going to nearby St. Francis Medical Center, a large private hospital with a slate of specialised services.
But when his older daughter, Eunice Virgen, a 35-year-old social worker, called to check, he was not there. The facility was filled to capacity with the Covid surge, she was eventually told, and had turned the ambulance away. Her father instead went to MLK, which is less than half the size of St. Francis and had dozens more Covid inpatients that week, according to federal records.
Virgen was incredulous; she thought of MLK as "Killer King," the derisive nickname of its troubled predecessor, Martin Luther King Jr./Drew Medical Center, a public hospital that had served some of the lowest-income neighbourhoods of LA.
Emilio Virgen and his wife, Lizette, lived about 9.5km away in a modest stucco town house just outside the city line. He arrived from Mexico in the 1970s as a teenager, living in the country without legal permission, but obtained citizenship after an amnesty under President Ronald Reagan. It was at a bus stop in Central LA that he first caught sight of the woman he would marry, a Honduran immigrant doing domestic work at Beverly Hills mansions.
Virgen had gone only to primary school and spoke broken English, which limited his options. While worked as a custodian and at a car dealership, the growing family struggled financially at times, moving from place to place in neighbourhoods rife with drug trafficking and gang violence.
For much of the last decade, he was a driver for AltaMed, a local health care system, busing Latino seniors to doctors' appointments and other activities. He often returned home with gifts of oranges, pomegranates, guavas, tamales and sweets from his passengers. His pandemic duties included delivering medicine and food to them; he also looked after his wife, who was suffering from health problems.
The family first called 911 on New Year's Eve, more than a week after his children believe he was exposed to the coronavirus attending a Sunday service and lunch at a small evangelical church in a strip mall. Within days, the pastor was ill, along with most other attendees; two later died.
Governor Gavin Newsom had ordered houses of worship closed in state hot spots. But LA County health officials reversed the closures December 19 after the US Supreme Court supported a church challenging the order. The fateful service occurred the next day.
Three of Virgen's children had repeatedly begged him not to go to services, which were sometimes held in defiance of the ban. Praying together was essential, said the pastor, Edgar Guaran. He described Virgen as an expressive worshipper who found his mask too confining and removed it.
In dismissing his family's concerns, Virgen invoked his faith. "I'm going to be fine," Eunice Virgen recalled him saying. "The blood of Jesus will cover me."
Awaiting the ambulance, Emilio Virgen had been hunched over gasping for air. He had high blood pressure and diabetes, risk factors for severe consequences of the virus. But when the paramedics examined him, his oxygen level was normal. Hospitals were so jammed that he was likely to wait 10 to 12 hours before being admitted, they warned. So his family kept him home. The same day, Virgen's mother died of Covid in Mexico.
His older daughter bought vitamins and a humidifier and instructed him to lie on his stomach — proning, as many Covid hospital patients do, to improve lung function. A son brought cleaning supplies. Tiffany Virgen, 25, who planned to become a nurse practitioner, treated his cough with teas and coaxed him to inhale steam infused with citrus peels and eucalyptus. She tried repeatedly to reach his primary care doctor; the physician finally responded a few days after New Year's, prescribing antibiotics, a cough suppressant and a refill of blood pressure medication.
On January 6, a fingertip oxygen monitor she had ordered finally arrived and showed that her father's oxygen levels were in the 60s, far below the normal range in the 90s. That was a sign of "silent hypoxia," when dangerously low oxygen levels fail to cause extreme shortness of breath. Alarmed, she called 911 again.
After Emilio Virgen was sent to MLK, his older daughter asked a physician friend if she should try to get him transferred to a hospital like Cedars-Sinai, which is famous for treating celebrities. Her father's job provided health insurance, so he did not need to depend on a safety-net institution. But the friend reassured her that the new MLK hospital was nothing like the old one.
King/Drew opened in 1972 after community activists fought for a public hospital to serve some of LA's poorest neighbourhoods after the 1965 Watts riots. It had a state-of-the-art trauma centre and was a source of hope and pride.
But over the years, the quality of care deteriorated. The hospital closed its trauma unit and cut other services. In 2004, The Los Angeles Times documented the hospital's failings, finding a pattern of errors, neglect and incompetence that resulted in horrifying injuries and deaths. Among those who died were a 9-year-old girl who was oversedated, a 27-year-old woman with clear signs of a heart attack that went ignored, and a patient whose colon was stitched through instead of her ovaries. Medical errors occur everywhere, but King/Drew had more state health violations than nearly any other hospital. Regulators ranked it among the nation's worst. In 2007, it was shuttered.
Eight years later, the new MLK opened. The modern, smaller, 131-bed hospital was built by the county but managed privately. Batchlor raised funds for physicians' salaries, attracting those who had trained at UCLA and other top institutions.
But the hospital offered limited services: emergency surgery only, no paediatric care, no neonatal intensive care, no trauma center, and no inpatient psychiatric or addiction treatment. For many medical problems, patients had to go elsewhere. Other institutions often rejected them, though, because only 4 per cent of MLK patients had private insurance, which typically reimburses care at higher rates than public insurers.
Flores, a father of three who arrived in MLK's emergency room on New Year's Day, was a typical patient. An immigrant from Mexico living in the country without legal permission, he worked long hours as a restaurant cook. He had diabetes, high blood pressure and obesity, the top three high-risk conditions among MLK's Covid inpatients, and relied on the state's Medicaid coverage for health emergencies.
Flores' oldest child, Manuel, 24, asked whether his father could get convalescent plasma, a therapy that won federal approval last summer for emergency use. The family knew people who had been transfused with it and survived. But MLK did not offer the treatment, which studies have suggested may be effective when given early in someone's illness.
It was unclear how long Gabriel Flores had been infected with the coronavirus. He and his 8-year-old son had felt achy and feverish shortly before Christmas. Soon his wife, Gabriela, had symptoms, too. After the family went to Dodger Stadium for testing, only hers came back positive.
Weeks later, the county halted the use of the Curative oral swab tests the family had been given. The Food and Drug Administration had alerted providers to the risk of false negative results with the test, which could delay treatment and increase the virus's spread.
Even with the one positive result, no one informed the Flores family about the need to isolate or quarantine. The parents, who did not speak English, and their two younger children continued sleeping on bunk beds in the single bedroom of their tiny apartment. Gabriel Flores, believing he did not have Covid despite feeling ill, continued working at the restaurant. The family lived paycheck to paycheck on his weekly earnings of US$580 ($800). He had recently bought a taco truck, hoping to build up a catering business, but demand fell off during the pandemic. He also bartered, trading his carnitas for services like car repairs.
While MLK did not offer convalescent plasma to patients, it did have a similar, more targeted treatment: monoclonal antibodies. President Donald Trump received it last fall when he developed Covid, before the therapy gained federal emergency approval.
It should be given when someone is mildly ill, not requiring oxygen or hospitalisation, according to federal guidelines. MLK had administered just over 140 doses to emergency room patients and found evidence that it reduced the chances they would return seriously ill, according to hospital data.
But MLK has not promoted community awareness of the therapy. "If we publicise it," said Dr. K. Kevin Park, a vice president for medical affairs, "we wouldn't be able to handle" the volume if many people showed up. The treatment requires an hour long infusion and another hour of observation, creating additional demands for space and staff.
Some other institutions in LA, including Cedars-Sinai, have given hundreds of doses. "Obese Hispanics with diabetes -- they're the ones that get really sick, and they're the ones you can help," said Dr. Peter Chen, director of pulmonary and critical care medicine there and the lead author of a journal article published last month reporting promising interim trial results for the treatment. Despite being safe and paid for by the federal government, the antibody regimen has not been widely adopted.
One exception is Houston. The city's largest medical system, Methodist, administered approximately 3,000 doses since late November, according to hospital officials, who scrambled to create specialised infusion centers throughout the region. They estimate that the drug helped prevent 300 hospitalisations and 30 deaths in Methodist's system alone.
"It feels like we're starting to play offense," said Vicki Brownewell, a vice president who oversees the program.
But when Flores was experiencing symptoms early on, his worried wife could not even reach the physician he saw at a clinic offering low- or no-cost care. She was told the doctors were busy doing remote visits.
"They had a long waiting list," she said. "They hung up on me."
'We're kind of out of tricks'
The day after he was hospitalised, Flores was transferred to the ICU. Doctors believed his only chance of survival was to go on a ventilator. But he had a "Do Not Resuscitate/Do Not Intubate" order on his chart because he had heard that people on ventilators with Covid "were just passing away," his adult son, Manuel Flores, later said.
Refusing intubation was most common among the hospital's male Hispanic patients, according to Dr. Jason Prasso, an ICU doctor. "They say, 'If it's my time, I don't want to be on a ventilator for three weeks before I die.'" Some extremely sick patients even asked to leave the hospital to return to work, afraid of missing a paycheck and getting evicted.
Still, 86 per cent of Covid patients who had been intubated at MLK had died, according to hospital statistics. That week, 12 in the ICU had died in three days.
"That is a tragedy," Dr. Nida Qadir, co-director of the medical ICU at Ronald Reagan UCLA Medical Center, said of the MLK statistic. Her hospital had mortality levels "a lot lower than that," she said, though the hospital had not publicly released the figure. A new study of patients at 168 hospitals found that about half of Covid patients on ventilators died, and survival varied widely among hospitals.
Dr. Theodore Iwashyna, a critical care physician at the University of Michigan, said the differences in hospital outcomes reflected a "system choice." He and others have studied patients with complex pulmonary conditions and found that those treated at smaller hospitals with fewer resources and less experience in managing them tend to have poorer survival rates.
"Big hospitals should have been accepting those patients and pulling those patients out" of MLK, he said.
During the Los Angeles surge, hospital mortality also rose because fewer mildly ill patients were hospitalised, said Dr. Roger J. Lewis, a professor of emergency medicine at Harbor-UCLA Medical Center who helps analyse Covid data for the county. That was likely even more the case at small hospitals like MLK in areas with high rates of chronic illnesses, he said.
The medical team invited Flores' wife to the hospital, usually closed to visitors during the pandemic. She found her husband frightened and shaking. He was not getting enough oxygen, a doctor explained, and without a ventilator he could die in two days. Flores told her he wanted to go home, then changed his mind. He was exhausted and had chest pain, he said. He would try the ventilator because he wanted to live longer for his family.
Still, his oxygen levels remained low. Doctors gave him steroids and drugs that counter blood clots. They turned him on his stomach and even paralysed him for periods to help the ventilator work more effectively. But nothing seemed to make a difference. Flores had "cut-and-dried Covid pulmonary failure," Prasso said.
Some Covid patients have one last option: treatment using a machine that gives the lungs a chance to rest and, hopefully, repair. The procedure, extracorporeal membrane oxygenation, or ECMO, is typically offered only in larger hospitals.
Flores might have been a candidate for it at one point, according to Dr. Christopher Ortiz, a critical care specialist from UCLA, a top-ranked hospital, who pitched in at MLK. But Prasso said he had stopped considering the treatment. Earlier in the pandemic, he had pushed to transfer some MLK patients to hospitals providing ECMO but finally gave up.
"We've never been successful," he said. "Nobody wants their insurance."
Dr. Vadim Gudzenko, medical director of the adult ECMO service at UCLA, said his hospital had treated about 30 Covid patients with the technique, two-thirds of whom were still alive. Nearly all had been transferred from other hospitals, and one or two were uninsured. However, he acknowledged, several patients referred to UCLA had been turned down because their insurance did not cover treatment there.
"This is the ugly part of what medicine is in this country," he said.
As Flores struggled, MLK Hospital was also under enormous strain. On one Friday afternoon, the 29-bed emergency room was packed with 104 patients, 44 of whom had been admitted and were lining hallways or in outdoor tents awaiting beds in the ICU or medical wards. Patients had been stuck in the emergency department for up to two weeks. An ER doctor was assigned to respond to "code blues" — calls for resuscitation efforts — around the hospital. There were 12 in that day's 12-hour shift. Nurses were caring for more patients than regulations typically allowed, after the governor loosened the rules to help hospitals cope.
MLK cleared out an entire medical ward to create an expanded intensive care unit, mostly for ventilator patients — two to a room, with thick plastic sheets hanging over the open doors. The makeshift ICU at its peak held 40 patients, four times the usual pre-pandemic census and far sicker overall than what the staff was used to handling. Dozens of other patients requiring high-flow oxygen who typically would be in the unit were treated on other floors. "Everybody has been pushed out of their comfort zone," Prasso said of the medical team, adding that they had worked hard and risen to the occasion.
Ortiz, the visiting UCLA specialist, said that on arrival he "literally felt like it was a war zone," with more deaths, fewer resources and staff under far greater stress than in the ICU at his much larger hospital. "It was a form of critical care I'd never witnessed," he said.
Being so overburdened and understaffed meant that emergencies among the sickest patients drew attention away from preventing problems in others, all requiring nearly constant monitoring. Missing "even something seemingly trivial" in the critically ill, he said, "can be deadly."
One morning just before rounds, Flores' roommate died. His own condition was perilous. That afternoon, a code blue was called for him. His oxygen levels were in the 70s. His kidneys were failing. His heart was beating in the 140s, its upper chambers fibrillating. The team shocked him to restore a normal rhythm.
Prasso could not think of much more to do. "We're kind of out of tricks," he said. He called Flores' wife to warn that the situation was grave. He and the other ICU doctors delivered such news multiple times a day.
"You're going to take away her medicines and kill her?" one relative responded to a doctor who had suggested stopping aggressive care.
"It's a historically disenfranchised community," Prasso said, "so the idea of pulling back is often viewed not as compassionate but as withholding."
That evening, Flores' wife and his older son came to visit him. Gabriela Flores held her husband's hand and stroked his forehead. "Mi amor," she repeated. "Te amo."
Saying goodbye
Down the hallway, Virgen, the minibus driver, was also unconscious on a ventilator. After initially improving, his condition had suddenly declined.
Like Gabriel Flores, he had developed acute kidney injury, a common complication of severe Covid that can require temporary dialysis to replace the work of the kidneys. MLK had only three machines to deliver continuous dialysis, a form of the treatment used for the most unstable ICU patients. That forced the hospital to prioritise whom to put on the machines — and for how long — and to manage other patients with medications.
At UCLA's flagship hospital, there was no such shortage. "It's really amazing technology," Gudzenko said. "It's remarkable how differently you can practice medicine when you have enough resources."
Doctors managed Virgen's kidney failure conservatively, without needing to use dialysis. But as other problems developed, they told his family he did not have long. On a Zoom call January 20, with a tablet computer next to his bed, his children tried to reassure one another that they had done everything they could and lamented how quickly he had declined.
"I don't want to say goodbye," Tiffany Virgen told her siblings. "I don't want to live a life without him."
"He was my strong, Mexican, tall, handsome dad," said her sister, Eunice Virgen, crying. "He thought he was invincible. He thought he was Superman."
Early the next morning, they lost him.
Five hours and five minutes later, Flores also died.
His mother, Maria Alcalan Magallon, arrived from Guadalajara the next day. With the help of the hospital, she had obtained a visa to say goodbye but could not get there in time. Mother and son had not seen each other for more than two decades; now she wanted to bury him back home in Mexico.
But that, too, would have to wait. Funeral homes in LA had long lists of grieving families waiting to claim the remains of their dead.
"They told us in two or three months," she said. "That doesn't sit right with me."
Written by: Sheri Fink
Photographs by: Isadora Kosofsky
© 2021 THE NEW YORK TIMES