by Andrew Cuomo
As usual when one deals with a bureaucracy, there were no good answers. Bureaucracy takes comfort in the status quo, relying on an almost arrogant belief that there is an inherent wisdom in the current system. It’s usually quite the opposite. For me, the health-care system was a single chain; if one link breaks anywhere in the system, the whole chain is broken.
In fairness, this was an unprecedented crisis, and the old model simply couldn’t deal with it. While our concept of one coordinated statewide hospital system was a good one, the shift would be more traumatic and difficult than anyone anticipated. COVID was exposing many existing problems. Fundamental ones like a divided country and dysfunctional government, social inequities in health care and education, but also the failure of basic operating systems.
I started speaking to the hospital executives again because I had to educate myself as to exactly how they operated.
What was becoming clear was that for all the talk of a “public health system,” this nation was wholly unprepared for an emergency. How could that be after all the warnings we’d had with Ebola, swine flu, MERS, and SARS? Who knows? But that’s where we were.
It was no time for recriminations; we had to deal with the situation. Winston Churchill came to mind. Imagine how frustrated he was in the early years of the war when he was fighting Germany and he couldn’t get the United States to join forces against the obvious common threat. He was on his own, and he improvised. He needed to cross the English Channel to rescue the soldiers at Dunkirk. I’m sure he wanted to complain about the fact that the government didn’t have enough ships, but there was no time for that. He scrambled and put together a “citizen navy” to form a flotilla of private craft to cross the channel and rescue hundreds of thousands. There is an old saying that you go to war with the army you have, not the army you want.
The breadth and depth of our need was clear. We would have to create an emergency public health system out of whole cloth. We were told by all the experts that we would need between 110,000 and 140,000 hospital beds, and we had only 53,000. If we didn’t accomplish that goal, we would repeat the experience in Italy, where the hospital system was overwhelmed. That couldn’t happen here. I understood fully that it was an impossible task, but we had to do the best we could.
We had sketched out the concepts. All hospitals increasing capacity 50 percent, building thousands of emergency beds and coordinating a unified, cooperative hospital system. But this was a massive and revolutionary undertaking. It would normally take years to implement. The hospital industry is a $100 billion industry in New York with 415,000 employees. You don’t turn it inside out overnight. That was our goal. We had the concept, but we had to do it!
For a plan to work, we would need specific operating procedures and leave nothing to the imagination. As I had learned too many times before, it’s not enough to have a good idea; you have to know how to implement the idea. If you want to make a change, you must know exactly what you want to do and how to do it.
The Northwell hospital system, New York’s largest, was run by Michael Dowling. Luckily, Michael had been a friend for thirty years and was the top health-care professional for my father during his twelve-year administration. As a former government official and now hospital administrator, Michael understood the system from both perspectives. If Northwell bought into a new model, other institutions would follow. We spent many hours talking through the details, addressing all the questions, and leaving nothing to chance. We knew what we needed to do; now we needed to do it.
I called a dozen of my staff into the Red Room. We had to move beyond conceptualization to implementation. We sat—socially distanced—around a square table. The chamber operations team, led by Reid Sims—who has been a dedicated and loyal member of my staff since I was elected governor—can turn the Red Room from a press conference setup to a TV studio to a meeting room in a matter of minutes. I am not sure how they do it so quickly and efficiently, but they do.
I explained to my team gathered in the Red Room my view of the situation: Testing was up; we were now doing more than twenty thousand tests per day. PPE and ventilators were being pursued. Staff was signing up by the thousands on our portal to volunteer. And thousands of new beds were coming online as hospitals increased capacity and new emergency facilities such as the Javits Center opened. As we barreled toward what was projected to be our apex, the problems at Elmhurst showed that it was going to be all about management. The Elmhurst Hospital debacle made that point. I wanted it all done centrally, in one room—no space for miscommunication or errors. Getting it right was a matter of life and death. Many of my most senior staff were wearing two hats at this time; the state budget was due at midnight that night! Melissa, Robert, Beth, and Dana Carotenuto Rico (my adept and tireless legislative director) were simultaneously addressing the COVID crisis while negotiating the final pieces of the budget bill. Rob is an extraordinary talent on the budget and finance. I trust his judgment and it took a major burden off my shoulders. I laid out my vision for a hospital capacity coordination center—a central nerve center where any hospital in the state could call 24/7 to request patient transfers, staff support, PPE, ventilators, or any other need. The operation would be guided by real-time data reporting, and if the center saw a hospital reaching capacity, it would proactively reach out to help support patient movement to a hospital with more capacity.
We called the plan “Surge & Flex.” Not the most artful name, but it was descriptive. We would have to operate the individual hospitals as if they were one health-care system and work to manage the surge of patients and the increased demand. Patient load would increase exponentially, but the surge needed to be balanced throughout the system. As patients came in, we would monitor the numbers and direct them to hospitals that had vacancies and capacity. If patients needed to be moved from one facility to another, we would provide transportation.
The system would also have a “flex” capacity. No hospital had significant inventory of ventilators and PPE. We would flex resources as necessary among the hospitals and develop a central supply of materials. All hospitals throughout the state would work together in purchasing supplies. Rather than having separate hospitals competing against one another, we would cooperate.
The flex concept would also apply to staff. If one hospital had a shortage, we would identify staff from other hospitals who could be moved. This would all be coordinated through a daily reporting system where each hospital reported its capacity, vacancy rate, ICU bed availability, PPE, ventilators, and so forth. Every night there would be a coordinating call run by the state with all the hospitals in that region which would allocate and adjust the load across the system. This would be an extraordinary and unprecedented management exercise, but it had to be implemented tomorrow. Like everything else, it seemed, what was impossible yesterday was a necessity today.
We set up a meeting at the Javits Center with all the major downstate hospital administrators to go through our new Surge & Flex plan. It was a large group, and Javits had the space for a socially distanced meeting. This physical setting at the Javits Center drove home the urgency of our situation, without my saying a word. The seemingly endless row of hospital beds and sea of green uniforms took your breath away. They were frightened. We went through the details, and everyone was shocked and dubious, but they were on board to try.
Of course, we received concerning news right after the meeting. Par for the course. One of the hospital executives who was there, Lee Perlman, from the Greater New York Hospital Association, tested positive the next day. I spent time at the meeting in proximity to Lee, as had many of the other hospital executives.
It would be one thing if I got sick. I understood the risk; more troubling would be if it spread to my senior team and the others at that meeting, which included all the key hospital administrators who were running the entire system. Lee’s infection reminded all of us of the power of the virus and how quickly
our situation could get even worse.
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THE NEXT PERSON close to me to contract COVID was very close: my brother, Christopher. He spoke openly about battling the virus on his nightly show: the teeth-rattling chills, how he lost more than ten pounds. What people were seeing in our exchanges wasn’t much different from how we were in private. I was nervous for Chris; he’s my little brother, and I’ve always been there for him. He was staying at home with his three kids and wife, confined to the basement, and he couldn’t see anyone else. It felt unnatural for me not to be able to see him and help him. But that was the curse of COVID.
Chris is relatively young and healthy and not in a vulnerable category, but COVID is frightening nonetheless. He was fortunate to have the best doctors available and all the help he needed. Dr. Fauci also spoke to him. Dr. Fauci is from Brooklyn. I knew him from the 1980s when he worked on the HIV/AIDS crisis. I was talking to him a couple of times a week as it was. He was the best mind on the science.
Chris’s broadcasts and my briefings were the most comprehensive and intimate communications people were receiving about this crisis, and now he was giving people a front-row seat to the disease’s devastating symptoms—even for those who were young and healthy before. Chris recovered after about two weeks, so people saw someone battle the virus from start to finish. They also watched me experiencing it with Chris, so they knew once again that I understood the crisis on a deeply personal level. They were right.
APRIL 4 | 10,841 NEW CASES | 15,905 HOSPITALIZED | 630 DEATHS
“If we don’t stop the spread, then it’s going to burn down our country.”
NONE OF MY TASKS EVER seemed to be finished. They just kept going. It was hard for me to deal with. I am a “closer.” I find comfort in completion. The doctors kept telling me hospital beds without ventilators would be virtually useless. We would need about forty thousand ventilators at a minimum, at the projected apex. That would at least give every ICU bed a ventilator. We had about four thousand to start, and ordered about seventeen thousand, of which about three thousand had arrived, for a total of seven thousand on hand, and the search for more was a daily undertaking.
China remained a major supplier of ventilators. Who could help in China? I contacted Bob Rubin, former secretary of the Treasury, chairman emeritus of the Council on Foreign Relations, and a colleague from the Clinton administration. His partner Blair Effron is an old friend and a wise, trusted investment banker. They were pursuing every contact they had. I also spoke to Elizabeth Jennings at the Asia Society, who has extensive contacts and is indefatigable. They were great and had many good ideas that we pursued together for weeks. In this exercise of manic networking, a gentleman named Jack Ma came forward to help. Mr. Ma founded Alibaba, known as the Amazon of China. The president of his company was a great guy from New York, Michael Evans. Joining together with Joe Tsai, the executive vice chairman of Alibaba, and his wife, Clara, successful Chinese entrepreneurs and owners of the Nets basketball team, they arranged to donate two thousand ventilators. This was welcome news and a big deal. I spoke with him and thanked him very much, and we announced the gift publicly.
Much to my surprise, shortly thereafter President Trump took credit for the gift, saying that his “friend” Joe Tsai gave the ventilators essentially to him. In all the conversations I had with the Tsais, Trump’s name had never come up. I think in the president’s mind, the gift highlighted the federal failure, and he couldn’t bear the idea that he wasn’t included. In any event, when the press asked me if the president was involved, I just never responded. The president’s ego was fragile, and it wasn’t worth the risk of angering him.
In the midst of this, the state of Oregon and its governor, Kate Brown, announced they would donate 140 ventilators to New York, an act that displayed that we are all in this together. Now, if only the federal government had that perspective, leadership, and credibility to bring such a message to the American people, imagine how much better we would be. What if there had been a national effort, with states working together to help other states in need and implement a national Surge & Flex program? It was infuriating that every state needed to scramble for equipment, staff, and material when we knew the timetable for each state’s critical need would be different. We would lose lives; that was unavoidable. But not doing the best job that we could was unacceptable.
APRIL 5 | 8,327 NEW CASES | 16,837 HOSPITALIZED | 594 DEATHS
“It’s been a long month.”
I WOKE UP FEELING AS IF I hadn’t slept a wink. I went into the bathroom, looked in the mirror, and saw my father’s face, that face of lines and crevices. Some call it character, but to me it just looked like old age. For fifty-five years of my life, I was always “the son,” and the son is perpetually young. In my mind I was still in my thirties. How could this be?
I asked Michaela later that day, “Do I look older to you?”
“Oh, no, Dad, you just look a little tired.” That’s Michaela, so sweet that sugar wouldn’t melt in her mouth.
I asked Cara the same question later when we were alone.
She said, “Yes, Dad, you look older, but maybe when this is over and things are normal, you will look better.” That’s Cara, kind but realistic, even if it’s hard.
I felt that every death from COVID took a little piece of me. I believed we did everything we could to save every life, but it didn’t give me peace. A bus driver died from COVID. He was an “essential worker.” I determined that buses had to operate. He went to work because I said he should. If he stayed home, maybe he would be alive. I was committed to beating this thing, but it was harder and more debilitating than I had even imagined.
I still very much wanted to do the briefings every day. It was my way of being present and saying to people that I knew every day was a struggle for them and I respected and appreciated that reality and I was living it with them. But every morning when I first opened my eyes, I lay there and thought, “Maybe I could skip today. Let me sleep in just once and catch my breath. And I will be better for it tomorrow.”
I would review in my mind the many reasons to give in to that urge:
I was too tired and I would convey the wrong tone.
I could not deal with the stupid press questions today.
The team needed a break and skipping one day would be good for them.
But the sense of obligation and commitment to the relationship I had formed with the public was paramount. It was personal. I was reading their emails, taking their phone calls. I knew people relied on me. They never quit on me, and I would never quit on them. My instinct was that consistency was important. People needed to comply with these new rules every day, and I wanted to be there for them every day. Some days I was just exhausted. I tried to keep my tone factual and calm. Other days I just didn’t have the strength to control my emotions, and they were apparent. Some days I was so exhausted that I was in a daze.
These were not only long and exhausting days; the information was so extreme and extraordinary I was actually finding it hard to compute. If I had not been in the room hearing for myself, I don’t think I would’ve believed it.
Many times, I just had to get away from it, at least to the extent possible. I didn’t want to seem distressed for my team or family. That would alarm them. I would take my dog, Captain, on long walks just to restore my sense of reality and try to clear my head. But even on a walk with the dog, everything seemed strange. There were fewer people on the streets, stores closed, people who were out were social distancing, but at least the walks presented the semblance of normalcy. There were still trees and buildings and familiar landmarks. The entire world had not gone mad, yet.
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NEW YORK CITY was a surreal place at the height of the pandemic. The streets were largely empty of cars and people; storefronts and offices were shuttered and dark. But the quiet was
punctured by the constant blare of sirens as emergency vehicles answered COVID calls, one after another after another. Sirens were the new sound of the city. EMS workers who might handle four or five calls in a day were handling dozens. As the death rate spiked into the hundreds every day, many more than the city’s morgues and funeral homes could handle, we had to call in refrigerator trucks to store the overflow of bodies. The last time New Yorkers saw refrigerator trucks to store the dead was after 9/11, and this dwarfed that in numbers. 9/11 was horrific and traumatic and this was worse. It was just incredible to me. People’s loved ones went into the hospital and died, and they were never seen again. The closure that comes with the ritual of a funeral was no longer possible. We had to bring in funeral directors from out of state, waiving the licensing requirements. I had to sign an executive order that allowed for expedited cremations and electronic signatures for orders to dispose of a family member’s remains, and the crematoriums were allowed to operate twenty-four hours a day. For hundreds of COVID victims whose families couldn’t afford burial, or were simply unclaimed for any number of reasons, a mass grave on Hart Island, a public cemetery off the Bronx, was their final resting place. It was heartbreaking at a level I had never imagined.
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WE HAD LOST SIX hundred people overnight—a staggering amount. A reporter asked me at the briefing if people would get numb to the number of deaths. I was shocked by the question. For me it has been the opposite. The death toll was a constant weight on my chest and made it hard to breathe. An ironic coincidence given the primary symptoms of the invisible beast we were battling. Every day I had conversations with family members, hospital staff, and union representatives asking them to be strong and helpful. I understood my role and obligation, but I didn’t wish my role on my worst enemy.