Watching the news, one sees constant stories about COVID numbers rising yet again now, almost two years into this pandemic, with COVID hospitalizations in some states higher than they have ever been except for the spike last December. In my state of Colorado, the test positivity rate is almost 10 percent, with 1 in 48 infected and if the current trend continues, this will be the worst COVID spike the state has seen.

On the surface, that doesn’t make sense, since nearly 80 percent of eligible Coloradans have received at least one vaccine dose, suggesting the vaccines are not working as well as they should or as advertised, or that vaccine immunity is waning, hence the push for booster injections.

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Scarier still is that Colorado officials reinstated “crisis standards of care” for hospital staffing, allowing hospitals and other facilities to stretch limited personnel and use volunteers, including National Guard and family members, to help care for hospitalized patients. Colorado hospitals are already turning away patients based on an executive order by Gov. Jared Polis.

Neighboring New Mexico is in the same boat, also instituting “crisis standards of care.” Their case counts have climbed 19 percent over the past two weeks.

ICU beds are in desperately short supply, with fewer than 100 beds currently available in Colorado as reported by the Denver Post. Are we headed to a situation where patients will be treated in hallways or sent away from overcrowded hospitals to fend for themselves? COVID made its debut in America in March 2020, now 20 months later, when we should be reaching herd immunity, the situation as dire as it was in the beginning.

With complicated situations, explanations are also complex and multi-factorial. While I don’t have a simple answer, here are some of the factors playing into this current crisis.

How much current hospital care is non-COVID related? Remember that for the past two years, routine care and elective surgery were deferred over fears of catching COVID or the constantly changing rules regarding testing, masks, and vaccines, leading some to wait things out until life returned to normal.

Cancer screenings were deferred with some of those individuals now having cancer and needing treatment. Many suffered from decrepit joints, now finally having them replaced. Those with hernias, gradually enlarging, are now getting them repaired.

Most insurance plan deductibles reset at the end of the year. Those who have already met their deductible are eager to have their elective procedures before Jan. 1, so the cost is covered under their paid deductible, rather than next year when they have a new deductible to meet.

Some people, anticipating an end-of-year surge in surgery demand due to increasing COVID cases, are trying to get in ahead of the wave to avoid having their procedures deferred once again. While simple procedures are done as an outpatient, more complex surgery, including heart surgery, requires hospitalization, and perhaps a few days in the overcrowded ICU.

The ICU isn’t just for sick COVID patients; it serves a wide patient population and, due to the cost of running and staffing an ICU, it needs to be relatively full to justify staff, equipment, and other services. Similarly, airlines prefer their planes to fly with few empty seats, from a business perspective, since the fixed costs of both air travel and hospital care are huge. Hospitals are businesses, too. and need revenues to cover their costs.

The news articles discussing ICU beds don’t mention whether this shortage represents physical beds or the ability to staff these beds, an important distinction. If a 40-bed ICU only has staff to safely care for 20 patients and has a census of 19, they are reported to be full, with only one available bed, ignoring the fact that half of the beds cannot be used due to insufficient staff.

This latter nuance is never reported. Reports are only that ICUs are bursting at the seams. Instead, the news reports, “95 percent of ICU beds filled” without clarifying whether these are physical beds or staffed beds.

If a restaurant only has staff to serve half its tables or is running at reduced capacity due to social distancing requirements, they may be “fully booked,” but when you dine there, you might see many empty tables.

Hospital staffing may be an issue. More than 100 million Americans are out of the workforce and this includes health care workers. Some are burnt out after a hellacious two years on the COVID front lines. Others have reprioritized their lives and activities, choosing to work remotely or in a less stressful environment. Still others are resisting vaccine mandates for health care workers, many of whom had already caught COVID in their jobs and thus, had natural immunity.

For some states, seasonality plays a role. As the weather turns cooler, Coloradans and residents of other northern states are heading indoors, into closer proximity to each other, unlike in the summer which is about hiking in the mountains or strolling on a golf course. This will increase COVID numbers in Colorado and explain the drop in cases in Florida, for example, under the opposite effect of more venturing outside now due to more tolerable temperatures compared to the sweltering Florida summer when many stay indoors.

This also might explain why Vermont, one of the most vaccinated states in the country, serving as a model for its COVID response, is experiencing its worst surge yet. It is convenient to blame the unvaccinated, but as this group shrinks, and includes many with natural immunity, that argument becomes more tenuous.

Waning vaccine immunity is now being acknowledged, suggesting that previous infection with natural immunity may be the best path to herd immunity short of endless booster shots. The CDC reluctantly admitted this inconvenient fact that it has no documentation of an unvaccinated COVID recovered person spreading COVID. Vaccines now appear to offer temporary and limited protection, unlike what we were told a year ago.

I must add the standard and necessary disclaimer that I am not anti-vaccine, having been personally fully vaccinated. Nor am I offering medical advice, only an analysis of current news of COVID cases spiking.

Additionally, many COVID patients spend weeks or months in the hospital, utilizing beds, accounting for many COVID hospitalizations. COVID has created a mental health crisis for a variety of reasons beyond the scope of this essay, but mental health placement is challenging, with few inpatient beds and facilities, meaning patients lingering in hospitals or emergency departments awaiting placement. These factors keep hospital beds filled.

There are many reasons for the recent surge in COVID cases and hospitalizations, and it is prudent to look at the numerous contributory factors rather than simply relying on knee-jerk responses of blaming the unvaccinated or unmasked, balkanizing an already divided country.

To put it another way, if the vaccines work, why aren’t they working? Clearly, this current surge is not just mild COVID cases. It also includes severe cases, which is why hospitals and ICUs are full. The reported vaccine benefit per John Hopkins public health experts is, “All three vaccines are highly efficacious at preventing serious illness, hospitalization, and death from COVID-19.” When conditions on the ground change, those directing the response must adapt and consider new ideas and approaches.

Past case surges peaked and fell over time. Hopefully, these peaks will soon become smaller and less frequent, as we attempt to return to our pre-COVID lives and world. Meanwhile look beyond typical hair-on-fire news stories predicting endless gloom and doom, with explanations that defy reality.

Brian C. Joondeph, M.D., is a physician and writer. On Twitter as @retinaldoctor

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