Hierarchy, class, race and PPE in an American hospital in the early days of COVID-19: What the pandemic stress test can teach us about building equitable health systems.

Because hospitals are spaces where life and death are routinely at stake, social hierarchies, pressures, and cultural norms are heightened. This was particularly true in the early days of the COVID-19 pandemic. Examining the dynamics in that era can provide insight into the nature of race and hierarchy in hospital structures. In the large literature on the experiences of hospital staff in the COVID-19 era, class and racial dynamics in hospitals are often sidestepped. In addition, the experiences of service staff such as environmental service workers and food service workers are severely under-represented. Here, we explore hierarchy, class, race and risk in two hospitals in the city of Baltimore in the first months of the pandemic in 2020, through the lens of availability of PPE. We draw on a survey of 403 staff in two Baltimore hospitals, and semi-structured interviews with 57 of those staff. Respondents worked in a variety of roles, from administration to clinical to service staff. A large majority of non-clinical service staff identified as Black, in contrast to a small minority of clinical staff with advanced degrees. The experience of access to PPE in the early pandemic differed across cadres of workers. Everyone in the hospital had to ration PPE, but many service staff felt that they were not prioritized in the same ways as clinical staff. PPE availability took on powerful symbolic resonance as a demonstration of how different cadres of workers were valued. The COVID-19 pandemic threw social and class dynamics within the hospital into relief, shedding light on what so often ran below the surface. Thus, it could also potentially be an impetus to examine these fault lines, and to push hospital structures a bit more in the direction of justice.