The massive medical tents in the parking lot are no longer needed — the few coronavirus patients still arriving are easily cared for within the aging brick hospital. A nurse who was the first volunteer in those tents is vaccinated and finally feels calm. After a year of quarantining from his wife and children, the emergency room doctor went on a family vacation.

This small community hospital has come out on the other side of a pandemic that was particularly devastating for majority-Black populations such as those it serves. Now, Adventist HealthCare Fort Washington Medical Center faces its next battle: winning resources and approvals to create a bigger, more advanced hospital — a small step toward bridging racial disparities in medical care that have existed here for generations.

Fort Washington opened as a 16-hour emergency room in 1983, expanding to a full-service hospital in 1991. As Prince George’s County grew, transformed by an influx of Black professionals, the hospital did not. It was just one example of a health-care landscape in which more sophisticated facilities were built elsewhere, drawing medical talent, and residents, in search of top-rated care.

Today Prince George’s, 84 percent Black and Latino and with the lowest median income in the area, has about half as many hospital beds per capita as Montgomery County, and less than one-fourth as many as D.C. The county’s hospitals are, on average, older and in worse condition than those in neighboring jurisdictions; its residents have far fewer doctors to choose from.

That reality was layered on top of other factors that made Prince George’s vulnerable to covid-19, including a large population of essential workers and a disproportionate number of residents who have conditions like heart disease and diabetes. The county would ultimately see higher per capita coronavirus case and death rates than the District or its other suburbs.

“The inequalities repeat themselves over and over again,” said Genevieve P. Kanter, an assistant professor at the University of Pennsylvania Perelman School of Medicine who studies disparities in health care.

Fort Washington expanded its staff and launched renovations in 2019, when it was acquired by Adventist HealthCare, which is now building a facility at National Harbor — also in Prince George’s — that will include cancer specialists and surgery services. A long-awaited hospital run by the University of Maryland Medical System opened in June in Largo, 20 miles away in the county of 900,000 people.

But Prince George’s was still badly strained when covid-19 patients began arriving last spring — and arguably no hospital more so than Fort Washington, the suburb’s smallest, with 28 licensed beds.

The county sent in a freezer truck when the morgue filled. Some Fort Washington patients were transferred outside the county, infuriating County Executive Angela D. Alsobrooks (D), who wants top-level treatment available to people close to home. An outbreak among staff led to a beloved nurse’s death. New beds were added, but there were challenges staffing them. And when a vaccine arrived, with the seemingly miraculous power to hold the virus at bay, most employees were at first unwilling to get their shots.

Hospital President Eunmee Shim is working to help the hospital emerge stronger — meeting with community members and state and local lawmakers to push her vision for a new, glass-paneled facility where more doctors would want to work and more patients would seek care. She is fighting a medical establishment that traditionally cared less about county borders than overall number of hospital beds in the region and keeping medical costs under control — but which in an era of calls for racial justice could be shifting its position.

Shim is counting on both the deep inequities revealed by the pandemic and sustained calls to root out systemic racism to help make her case.

"The chronic conditions are just piling up … and the community doesn’t have access points,” she said recently, sitting in her office near a rendering of her dreamed-of facility. “We’ve gotten to the point where everyone understands: This really has to be corrected.”

‘How are we going to do this?’

During the initial spike last spring, the hospital could not find anywhere for the sickest coronavirus patients to go.

Bigger hospitals were struggling with their own crush of patients and refusing to accept transfers from Fort Washington, Shim said. So the hospital, which had just one waiting room, four intensive care beds and 14 emergency room bays separated by curtains, had to improvise.

Employees taped plastic sheets over the curtains, hoping to create stronger barriers to limit transmission of the virus. They used HEPA air filters and plastic sheets to create makeshift “negative pressure” rooms designed to keep the virus from spreading outside them. And they found a spare room to set up on-site coronavirus testing, reducing test turnaround times that sometimes stretched a week or more.

“Everyone knew we were vulnerable,” said Shim, who joined other hospital leaders to warn county lawmakers they might not have the capacity to meet surge projections. “It was like, ‘Okay, how are we going to do this?’”

Emergency room doctor Tuan Vu said the hardest part was not knowing how best to care for the patients, many of whom had eerily low oxygen levels and were struggling to breathe. The virus was still new, and treatment options were extremely limited.

“Every shift, there was someone coding or who I was putting on a ventilator,” said Vu, 48, who slept in a different bedroom for months and ate separately from his wife and children to protect them. “In the first month, I saw more death than I had in five years. … They were not just older people, but young people too.”

Employees were falling sick as well, including Annie Carroll, 73, a beloved member of the cleaning staff who believes she contracted the coronavirus in the emergency room in March, when personal protective equipment was still scarce.

“I thought at first it was my diabetes acting up. Then I started getting worse and worse,” said Carroll, who eventually recovered and now works in the hospital’s dietary department. “It took me down … when we were into that crisis, we were not geared up and stuff like we are now. We were exposed to certain things.”

Shim said gloves, masks and gowns were closely rationed in those days, and communications errors sometimes meant hospital staff did not know where to find equipment they needed.

The situation changed after the death in May of Pilar Palacios Pe, a 63-year-old nurse whose family had been urging her to retire to protect herself. Her death shook the community, said Prince George’s County Council member Monique Anderson-Walker, who represents the area and whose mother was one of the hospital’s first Black board members in the 1980s.

“What was so scary was that she was not unlike everyone else there — she was there to take care of people, she was dedicated,” said Anderson-Walker (D-District 8). “For the rest of us looking in, the assumption was that the hospital staff were protected, that they had what they needed. But that wasn’t the case.”

She started funneling personal protective gear to the hospital, including face shields manufactured by Honda that she secured through a friend who is an executive there.

By the time the nurse died, Fort Washington had volunteered to become the first hospital in the state to pioneer a new type of medical tent and temporary intensive care unit.

Three massive white tents — sometimes used in military settings and capable of withstanding 90 mph winds — were erected in the hospital parking lot. The temporary intensive care unit, with private rooms and new equipment, was in many ways a step up from the hospital’s regular ICU. Within a few weeks, the hospital had added 46 beds.

“It was relief on the one hand, knowing we had the capacity,” Shim said of the new spaces, “and worry on the other hand knowing we had to staff them.”

Nurse Jonae Cussaac, 31, was the first to volunteer. The Prince George’s native spent the initial weeks of the pandemic terrified by all the unknowns and by the possibility of transmitting the virus to her husband and five children. The tents were a last resort, she said. “So I donned my PPE and got to work.”

The second spike

Caseloads eased in the summer and early fall. But after Thanksgiving, patients again began arriving in droves. Everyone resumed working overtime. Leaders eyed the tents, wondering if they would have to use them again — and how they would hold up in the snow.

Cussaac hardly saw her husband. She could tell that her 4-year-old missed her — clamoring for attention, but also backing away from a hug one day to ask if Cussaac had washed her hands. At work, the nurse practiced coping techniques, including one called the “wet noodle,” where you release the tension in your body before reacting to stressful situations.

“It’s been a little rough,” she said in an interview in December, after a month and a half of working four 12-hour shifts a week instead of the usual three. “A little taxing, and I’m feeling it. … I think that is pretty much the same for everyone in health care right now.”

Jonae Cussaac, an assistant nurse manager at Adventist HealthCare Center, Fort Washington Hospital has been caring for patients throughout the pandemic. (TWP)

In many ways, the situation had improved since the spring. There were established treatment plans. The state had created a centralized system to coordinate transfers and opened three overflow sites for overwhelmed hospitals to send patients. The Fort Washington staff was using their new ICU.

But the hospital struggled to find employees to staff those beds, hiring expensive traveling nurses with mixed results, said Robbin Young, director of nursing services.

In early December came a new blow: Fort Washington was not among the two dozen Maryland hospitals given early doses of the Pfizer-BioNTech vaccine, because it didn’t have the necessary cold storage. And when Adventist HealthCare surveyed the hospital’s 400 employees, two-thirds said they were not ready to be vaccinated — suspicious of how quickly the vaccines had been manufactured, and mindful of historical racism in medicine dating to Tuskegee experiments and beyond.

Robbin Young, the director of nursing services at the hospital, received the vaccine after it was available. Some among her staff were more hesitant. (The Washington Post)

Shim and Chief Medical Officer Griffin Davis organized town halls. Davis answered texts and calls from worried employees and talked publicly about his decision to get vaccinated, as did Young, 40, who was hospitalized with the virus in April and missed two months of work. Cussaac was among those who were initially reluctant — until her uncle, who was in his 50s, died of covid-19 in January.

Today, about 77 percent of Fort Washington’s staff is fully vaccinated.

The next chapter

Shim plans to submit a “certificate of need” application to the Maryland Health Care Commission in October for a hospital with 20 more licensed beds — 48 in all. Her long-term goal is to get some of the residents who have been leaving the county for medical care, an estimated half of the population, to come to Fort Washington, and then to keep growing the hospital as more patients come in.

She has the backing of Alsobrooks, who has said she will prioritize improvements to medical infrastructure as the county emerges from the pandemic. “They shouldn’t have to be shipped anywhere,” she said in an interview, recalling the decision to move some covid-19 patients out of the county last spring. “They deserve to be treated at home.”

But it’s an expensive vision that leaders say would cost hundreds of millions of dollars. Other hospitals could contest the application, worried about losing market share. And state regulators are typically skeptical about adding beds, especially as health care increasingly focuses on outpatient treatment.

Ben Steffen, executive director of the state health-care commission, said it is “probably not particularly useful to divide up the beds on a per capita basis,” because many residents leave Prince George’s for care.

Maryland Hospital Association President Bob Atlas said that “raw counts of beds are not a measure of adequacy of health-care capacity," noting that the state avoided the overflowing emergency rooms that abounded in some other parts of the country. “The proof is in the pudding,” he said.

Some public health experts, though, say the number of hospital beds is crucial, in part because it influences how many doctors open their offices nearby. Alan Sager, director of the health reform program at the Boston University School of Public Health, described a “downward spiral” of physicians leaving areas with fewer beds and said doctors want to locate close to thriving hospitals.

“It’s not a choice between doctors and hospitals — they are symbiotic,” Sager said.

On a recent day, Shim offered Steffen and other state officials a tour of the hospital, showing them the cramped emergency department and the ancient CT scanner, and noting the lack of MRI machines.

In an interview later, Steffen called the tour “eye-opening” and said the physical space “is not what one would hope to see in a Maryland hospital in 2021.”

He declined to predict whether the commission would support the hospital’s expansion plans. But he said it is increasingly clear to him that more attention needs to be paid to communities, like Prince George’s, with disproportionate rates of underlying conditions.

“The recent pandemic,” he said, “ripped the bandage off a wound that had been festering for a long time.”

Lola Fadulu contributed to this report.

correction

A previous version of this article said that Pilar Palacios Pe was 64 when she died. She was 63. This article has been corrected.

About this story

Story editing by Debbi Wilgoren. Photo editing by Mark Miller. Graphics by Maria Aguilar. Videos by Jayne Orenstein. Copy editing by Stu Werner. Design by J.C. Reed.