Here’s an update on the crisis as many of you have requested. Things are moving very quickly, and I know that we have had to endure so much hardship in such a short time. But I am absolutely amazed at how we have pulled together and the best in us continues to shine through. We are preparing.
The COVID19 virus continues to spread at an exponential rate in the United States, with over 25,000 cases so far. Ten thousand of those were in the last two days. Here in Arizona, we are still at the very beginning. We were at a total of 5 cases last week and now on March 22 are above 100, with one confirmed death. 50 of these were found in the last two days. We appear to be a week or so behind the East and West Coast. Cases have been found in almost every Arizona county. Most scientists believe that for every one person found to test positive, another 10 are undetected in the community, but this is just a best guess. Given than we are not doing widespread testing, we don’t really know.
I continue to work in the Emergency Department so I can understand the challenges first-hand. In the ER, patients are very aware of the crisis and the need to take appropriate measures to protect themselves and their families, including avoiding the ER until truly necessary. They are social distancing and self-quarantining if sick. This means that our public awareness campaign is working. So far, we are not seeing large numbers of patients presenting with severe illness. I have seen many patients with cough, fever or shortness of breath, and I have sent COVID19 tests to private labs, but we face a long wait for results. So far, I have not seen any patients that have required a ventilator. We have personal protective equipment (PPE) available, but our inventories are low in certain places. Fortunately, Arizona received a large shipment from the National Stockpile just today. Our health care workers are in good spirits and have been changing their routines and practices very quickly to adapt.
I have spoken to many of my physician colleagues in New York and California, and it’s like peering into the future. Many are reporting large volumes of very sick COVID19 patients, and they are starting to get overwhelmed. Some of the patients are young and healthy, and some are health care workers. Patients are suffering and dying from overwhelming lung damage and sepsis, even young healthy ones with no prior medical history.
Peering even further into the future, we can look to other countries, where the news is varied and represents one of two futures for ourselves: On one hand, South Korea instituted early and aggressive measures to track and trace the virus with strict quarantine, and new cases have plummeted. China saw almost no new cases in the last few days, which is stunning. On the other hand, Italy has seen a record number of new cases and deaths in a short time because they acted too late and were unprepared. Given those options, I would rather that we model after South Korea. Fortunately, Arizona still has time to continue preparations, but the window is closing fast. So that’s why it’s up to us to practice social distancing and quarantines as aggressively as we all can, to buy ourselves more time.
I have spoken to many of our community leaders too, including representatives from our hospitals and health care organizations. All of them are preparing aggressively for the coming surge. We are creating more bed capacity and staffing resources within the hospitals, but specifically in the ICU where many sickest cases will end up.
However, the real practical problem we face is the slow ramp-up in manufacturing of the critical equipment and supplies. There is no easy solution to this problem. Companies are greatly increasing production of PPE, ventilators, medications, testing kits, and other items. But this takes weeks, as they have to order parts, hire new people, and even build new facilities. The federal government is considering using an old wartime law to compel manufacturing, but has not yet committed to this because there are concerns about further exacerbating the problem.
Most of the questions I have received this week concern testing. Currently in the US, we have only one kind of test available, known as RT-PCR. To test a patient, we use nasal and oral swabs that get put into special test tubes. Those samples then go to labs, and once there, results take at least 24 hours. Add shipping and handling, and now you can see why we don’t have results for several days in most cases. Some good news is that today, the first point-of-care test for COVID19 in the US was approved and made available. This test delivers a quick result in about an hour, and is similar to a rapid flu test. However, these are just starting to be manufactured and shipped out, so they may not be available here for some time.
In Arizona, the State Department of Health Services (DHS) has few RT-PCR testing kits (around 800) compared to the scale of this crisis. Many more tests are being done privately by LabCorp, TGen, Sonora-Quest, ARUP and Mayo Clinic, but they have not released their numbers for capacity nor actual patients tested. This week, machines were brought into Arizona so that samples do not have to be shipped to California. Hopefully this will decrease time to results. However, we simply do not have enough kits to test at a large scale, and this won’t be possible for weeks or months.
People also ask about whether we should be testing, and if so, why? Testing has some benefits for individuals. Many of you want to know whether you have the virus, especially if you have symptoms. You want to protect loved ones and make smarter plans and arrangements. But most likely, the testing will not change your treatment. We treat this disease clinically, meaning that treatment is based on the severity. If you have any respiratory symptoms, you should still self-quarantine regardless of the test. Why? Because the test is not 100% accurate, meaning that some will get a negative result and still have the virus.
Meanwhile, widespread testing would have great benefits for public health, so we should not give up on this goal. With widespread testing, we could quarantine all those who are positive and trace them back to their contacts to stop further transmission. We would also understand much more about the scale of the problem and where to focus resources.
Many have asked about treatments. Several drugs are being studied with some optimism, but our data are far from conclusive. Before saying that a drug truly works, we need quality data from a controlled trial and so far, we have preliminary findings only. We are cautious because many drugs that originally gave us hope ended up failing. Fortunately, I believe we will know more soon as such trials are ongoing now.
At the local level, Phoenix Mayor Kate Gallego declared an emergency and closed bars, gyms, dine-in restaurants, and non-essential services. While this is hard on small business owners, it greatly reduces the transmission of the virus. Similarly, Governor Ducey has now enacted the same rule across the state. He has also closed all schools, activated the National Guard to restock grocery stores, canceled all elective surgeries and dental procedures and delayed driver license expirations. Other states have instituted a full lockdown where most people simply stay home, and Arizona may not be far behind. These decisions took political courage from these two leaders, and I commend them.
At the Arizona Legislature, we are working on a financial package for economic relief. In addition to the $55 million we already allocated to DHS for public health, this new package includes $50 million more to augment housing assistance, prevent evictions, offer support for disability providers and support for small businesses. I hope we also increase unemployment payments. Governor Ducey would have broad discretion in the use of these funds, and he also has access to $1 billion in the “Rainy Day” Fund.
However, our resources here in Arizona are very small compared to the Federal government’s response. The Federal government is currently planning a $1 trillion+ dollar economic rescue package. I have spoken with Representative Stanton and Senator Sinema and they are both working to help. This will include direct cash payments to Americans, as well as money to keep small and large businesses afloat throughout the economy. We have to make sure that all American have access to essential services while we whether this brutal public health and economic storm.
In a matter of weeks, we have had our daily lives upended. We have suffered an economic crash. Many of us have lost our jobs, faced reduced incomes, and have shuttered our businesses. We have had to suffer being lonely or isolated. We face incredible uncertainty and personal risk. And yet, I see Americans ready to take this head on, adapt to circumstances, and do what is asked of them for the sake of others. We have not seen panic nor resorted to criticism and negativity, but rather responded with generosity and understanding. Our morale and our spirit are intact, and I am so proud of our people so far. But this will get much, much harder and will test our resolve. Keep up the fight, and never forget that we are all working alongside one another despite the quarantine that keeps us physically apart.
As for me, I want to express my deepest appreciation for all of the kind and supportive messages I’ve received over the last week after my previous post. I hope I can make all of you proud with my service both politically and medically. I will continue to offer updates despite the dizzying speed at which things are changing. As always, please continue to send me your thoughts and suggestions. Even if I do not respond, I am listening.
Dr. Amish Shah is an emergency room physician and an Arizona state representative from Legislative District 24 in central Phoenix.