Amish Shah, MD is an emergency physician at Dignity Health and a member of the Arizona House of Representative elected by the people of LD24 – Central Phoenix and South Scottsdale. On Sunday, May 3, 2020, Dr. Shah shared the message below via Facebook. With his permission, we are sharing it with you.
Once again, I am providing here an update on our situation with regard to the Coronavirus pandemic. In Arizona, we have over 350 deaths and over 8,500 cases, and while we mourn every lost life, we have been spared the worst. We have some good news to share: Our curve has plateaued, as daily cases and deaths remain steady as of this writing. Our hospitals have not become saturated to the point where mortality would have risen rapidly. Speaking from my own first hand experience in the ER and that of my physician colleagues, we have not had anywhere close to the experience that the New York area suffered. An important exception is the Navajo Nation, which continues to be a hotspot. The Department of Emergency Management (DEMA) has been working hard to ensure that supplies keep flowing and patients there are cared for well. Many people have also raised concerns about senior living facilities and prisons, but our data so far seems incomplete. These populations deserve further study and attention.
In America as a whole, the situation is more grim, led by the massive numbers from the New York metro area. We continue to see about 30,000 new cases per day and around 2,300 deaths per day. To put that in perspective, our leading cause of death in normal times, cardiovascular disease, usually kills around 2,300 people per day. Yes, COVID19 has now become the leading cause of death in America, and has been continuing to kill us at this rate for weeks. We have over 1.1 million confirmed cases in the US and over 65,000 total deaths. Compared to my last post (https://www.facebook.com/amish.shah.3956/posts/10158353215211457), the numbers have increased greatly. America has more official cases and deaths than any other country by large margins.
Some have asked why Arizona was so much different. Having been a prior resident of New York City, I believe that one big factor to consider is population density. In Arizona, we are much more spread out and we rely much less on elevators, small apartments in older buildings, and public transportation. We do not have as much international traffic. We also had a few more weeks to prepare and acclimate to the idea of social distancing, whereas New York was quickly caught off guard.
Despite all the hardship that we have suffered, our attitude here in Arizona has been remarkable – for the most part, we have been positive, responsible and caring toward our neighbors. Arizonans deserve to be commended and hear that their sacrifices saved many lives, and the difficulty that we have endured was not in vain.
Has our response been successful?
For the last six weeks, we have been under stay-at-home orders. Naturally, many people are wondering how much of a difference we are making with our lockdown policies. We can get a rough estimate of lives saved in Arizona by studying a unique case. Instead of strict social distancing, Sweden chose to enact a relatively lax set of guidelines. In contrast, all of its neighbors – Denmark, Norway and Finland – chose to follow a path close to Arizona’s policies. Note that the population density of Arizona almost exactly matches that of Sweden.
- Compared to Denmark, Sweden has three times the death rate, and 5.5x the total number of deaths.
- Compared to Norway, Sweden has six times the death rate and 11.5x the total deaths.
- Compared to Finland, Sweden has six and a half times the death rate and almost 12x the total deaths.
Our President agrees with this: https://twitter.com/realdonaldt…/status/1255825648448348161…
While Denmark has a higher population density, the other two are much closer to Sweden.
So now that we have a close comparison, we can calculate how many deaths were likely preventable in Sweden. Had they been like their neighbors, roughly 2,000 Swedish lives would have been saved so far. Over the next few weeks and months, that number is certain to increase. With 90% of their deaths in the senior population, the Swedes have chosen in essence fewer protections for their elderly and vulnerable with clear consequences.
Given Arizona has 70% of Sweden’s population and a similar timeline, we have likely saved about 1,400 Arizona lives with our efforts so far, with many more saved lives to come. This might be a low estimate given we have a large senior population. Moreover, with an estimated 3-4 people hospitalized to every one death, Arizona’s health care system would have been easily overwhelmed without our lockdown measures.
The data so far also suggest that the Swedes have not received a countrywide economic benefit from their policies. According to its own central bank, the crisis has damaged their economy at a scale similar to neighboring countries, though these are just early estimates. Losing lives AND a shrinking economy would certainly be a lose-lose situation.
More importantly, part of the reason for our lockdown was to avoid overwhelming the health care system and allow capacity and supply to catch up. In this sense, we have certainly been successful too. Millions of pieces of personal protective equipment are getting to where they are needed, hospital bed and ICU bed and ventilator capacity have increased tremendously, and testing has increased greatly. We are much better prepared than we were six weeks ago.
Recent State and Federal action
In response to our specific circumstances, Governor Ducey has issued an extension of the stay at home order until May 15. In his explanation, he reiterated that we have plateaued but “there is no trend” downward. He has been consistent in his message that a downward trend would be one of the factors he requires before choosing to reopen. He again stated that he has relied on evidence and solid science to make his decisions, and in doing so I believe he has acted admirably. His decision took courage, and he deserves our commendation, continued support and to be credited for the lives saved in Arizona. He specifically asked us for our patience and we should keep in mind that his request is on behalf of the greater good.
The Governor has allowed for elective surgeries to resume May 1, and a phased reopening of retail establishments with limitations next week. Arizona is also conducting a testing blitz each weekend throughout the month of May with a goal of screening 10,000-20,000 people regardless of symptoms. With a widespread and comprehensive program, we will add to our knowledge about the true rate of infection and hopefully contain the virus more effectively. Testing sites may charge, and they will accept insurance. Pre-registration is required at most sites.
Testing locations and more information are available here: https://www.azdhs.gov/…/infectious-disease-epide…/index.php…
In other good news, antibody tests have been introduced last week from several manufacturers including the University of Arizona. Antibody tests provide a different type of information and will add to our armamentarium in fighting the virus. In contrast to the standard RT-PCR nasal / oral swab tests to diagnose an active infection, the antibody tests determine whether a person has an immune response to the virus and therefore has likely recovered. In theory, the tests have the potential to identify people who would be able to move around society freely with little worry of infecting others. Unfortunately, because of the rapid development and early stage of research on the tests themselves, we still have significant concerns about their accuracy and what a positive result might actually mean. The value of the tests should improve over the next few weeks as more data becomes available.
Meanwhile, the Federal government passed its third COVID19 relief package last week. It provides $484 billion to replenish the depleted small business assistance loan program, as well as smaller amounts for testing and hospital support. The Arizona legislature may also meet later this year to take up more COVID19-related legislation.
Looking ahead to reopening
Naturally, many of you are now wondering how much longer our stay-at-home orders will continue in the long term and how long businesses will be shuttered. A spirited political conversation in Arizona and around the country continues with regard to reopening. The economic effects have been devastating to several sectors, but most notably retail, travel, tourism, gyms, personal services such as salons, beauticians, barbershops, and hospitality including bars and restaurants, among others. The spillover then moves into all remaining sectors as overall demand slows.
Over the last month, we have received dozens of constituent calls and emails about help for small business and unemployment. Some are desperate because they don’t know how they will feed their families, and are afraid that their lifetime’s work will be wiped away. We have been busy connecting all of them to available resources. The rollout of the Small Business Administration’s Paycheck Protection Program has been problematic, but funds have started to flow through just as Congress provided another round of financing. Similarly, long wait times and lack of personnel have hampered the unemployment assistance program, though the problems have improved with increased hiring at the Arizona Department of Economic Security.
Clearly, Arizona and the country will need to reopen, as we cannot remain in an economic and social freeze for months. But we do not want to see our sacrifices wasted and eventually experience a greater loss of life. The virus is still out there, and if we suddenly remove all of our restrictions, it will quickly run amok and cause mayhem.
Furthermore, loss of public trust in being able to participate in the marketplace safely could cause even worse long-term economic damage. Governor Ducey in his explanation on the 29th argued that economic recovery depends upon the public’s confidence to interact and conduct business without fear of death for themselves or their family members. In the survey he cited, 30% of people are ready to go out immediately, 40% would require assurances of public safety, and 30% are too concerned to go out until a vaccine becomes available or the pandemic ends.
To reiterate, without credible public assurances, 70% of people would not fully re-enter the marketplace. We would effectively suffer something akin to a large boycott, which would be unsustainable, especially for businesses that normally operate with slim margins such as restaurants. Therefore, I believe that our economic and public health interests converge rather than conflict in the long term.
Please note that the assurances that the public requires would have to come from our health professionals, and as a whole, our medical societies and health organizations are not willing to support reopening without a sound, data-driven plan. Even if political leaders unilaterally were to “open the economy” by decree, we might still face inadequately low demand. If cases and deaths subsequently spike or the health care system becomes overwhelmed, public trust would be further eroded, making matters even worse for the recovery.
So if we can’t simply reopen, and we can’t just stay closed, what can we do?
A Measured Path Forward
I believe the real question before us is not whether or when exactly we should reopen. Let’s focus instead on WHAT WE NEED in order to open safely and execute that plan as quickly as possible. Logically, the following elements appear crucial for public health:
- The 4 T’s: Test, Track, Trace and Totally isolate. The ability to conduct widespread and rapid testing as part of a comprehensive strategy to track and trace all results followed by complete isolation for the positive cases would effectively and surgically remove the virus from circulation. This is how several Asian countries reopened and minimized further outbreaks. New York State under the decisive management of Governor Andrew Cuomo is currently hiring thousands of workers to perform these functions. Arizona’s DHS has an initial plan to hire 400 contact tracers. Our efforts will take training and ramp-up time, but ultimately allows us to assure the public will be as safe as possible. COVID19 will still be with us, but any further exponential spread would be quickly nipped in the bud. A word of caution: Individual states will struggle on their own with these endeavors – we will need much more Federal government support for logistics, CDC guidance, coordination than has been provided so far.
- Downward trend in cases and deaths. This would allow our contact tracers to chase down the virus. If the virus is spreading exponentially, our contact tracing teams would never catch up with caseload without ever-increasing resources. With a flat curve as we have now, we would simply need more tracers to find every case and catch up to the virus. We seem to be on the verge of a downward trend, but only time will tell.
- Adequate hospital bed, ICU bed, staffing, PPE supply and vital equipment capacity. In Arizona, we currently have adequate available hospital and ICU bed capacity as well as staffing. PPE supply is tenuous but remains overall adequate with the reuse programs and increased manufacturing. We have 1500 ventilators to adequately meet current use, up from the 300 we started with. We have added over 1500 hospital beds, but as we reopen, we will need to keep constant vigilance over these numbers. Fortunately, DHS currently keeps track of real-time data on a daily basis.
- A system for controlling entry of the virus from travel. Across the country, foreign and even possibly domestic travelers will need to be screened, monitored and quarantined when necessary. Asian countries also employed these tactics to keep their populations safe. Again, the Federal government may need to train TSA to execute these efforts at airports and other checkpoints. Governor Ducey has issued a self-quarantine order for New York area travelers so far.
- Clear new marketplace rules. In the upcoming weeks, we will need to establish rules to allow businesses to reopen in ways that generate only a very minimal risk of viral spread. This will require creativity, trust and partnership among our government, business and public health communities. Barbershops and golf courses are quite different in terms of risk, and I hope that following evidence will allow us to identify opportunities for progress.
My hope is that the above measures are established rapidly but carefully with a watchful eye to respond nimbly to the many upcoming fits, starts and bumps in the road. Repurposing unemployed workers for contact tracing and unused capacity such as hotel rooms for quarantines to accomplish the above goals could also represent creative economic solutions.
When I first began to post these updates 6 weeks ago, I wanted everyone to understand upfront that we would face serious hardship, and we have indeed. Beyond the economic effects, people are suffering from loneliness, frustration, and anxiety related to the isolation and sudden change in our way of life. We miss each other and being able to be close to our friends and family and strangers too. We miss activities and sports that make life enjoyable. We do not want this to become our new normal, and it is trying our patience to a tremendous degree.
In the face of such tiresome adversity, I ask you again as my friends, fellow Americans and constituents, please let’s continue to summon our inner fortitude. We are a strong people and I continue to believe that this situation will show us our capability and resilience. We are not quitters. We have shared goals of a vibrant economy and confidence in our public health and safety, and we will not abandon them. We are not complainers either, but rather innovators who have thrived throughout history because we see opportunities where others see obstacles. The pandemic has forced upon us a new normal, but I know Americans will adapt and succeed. There is a solution and an end to this, and it is within our reach. Let’s choose a path that will deliver us with our national fabric intact so that our posterity will remember our ingenuity, bravery and resolve with pride and reverence.
(And please, order a meal from your favorite restaurant today if you are able. I just did. They need your support!)
Past Posts from Dr.Shah:
COVID-19 Update #3 shared by an Arizona Emergency Physician and Legislator
COVID-19 Update shared by an Arizona Emergency Physician and Legislator
Amish Shah, MD is an emergency physician at Dignity Health and a member of the Arizona House of Representative elected by the people of LD24 – Central Phoenix and South Scottsdale. On Saturday, March 20, 2020, Dr. Shah shared the message below via Facebook. This Facebook post is republished with permission from Dr. Shah. .
Insights and Priorities Related to COVID-19 shared by an Arizona Emergency Physician and Legislator
Amish Shah, MD is an emergency physician at Dignity Health and a member of the Arizona House of Representative elected by the people of LD24 – Central Phoenix and South Scottsdale. On Friday at 5:17 PM, Dr. Shah shared the message below via Facebook. With his permission, we are sharing it with you.