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Closure of rural hospitals places Alabama at disadvantage in COVID fight

Chip Brownlee

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Whether Alabama’s health care system will be able to handle the coronavirus pandemic will depend on its people.

The infectious disease specialist leading the UAB Medicine’s response to the coronavirus outbreak urged Alabamians to take social-distancing measures seriously to blunt the exponential growth of coronavirus cases in the state so as to not overload health care facilities.

An unmitigated spread of the virus—not to be alarmest—could cripple Alabama’s hospitals and leave doctors and other medical workers in horrible situations. Blunting the number of new cases in the near term by limiting social interaction and practicing good hygiene is the only way to prevent a health care crisis, experts warn.

On a call with reporters Monday, Dr. Jeanne Marrazzo from UAB said the closure of rural hospitals, the growth in the number of cases in the state and the potential for a ventilator or ICU bed shortage if the growth curve of COVID-19 cases isn’t blunted is “frightening.”

“In Italy, they don’t have enough,” Marrazzo said. “They are actually having to make decisions about taking people they believe are not going to survive off ventilators to reassign them to people. We do not want to be placed in that excruciating situation. It’s about the worst possible thing I can imagine as a physician, talking to a family about that or dealing with that. I don’t believe there’s any indication we’re going to get there. But again, my assurance is all based on my belief that we can deflect this curve and not be where Italy is right now.”

Marrazzo said UAB has about 300 ventilators ready for use, which should be enough if the number of cases is limited through social-distancing measures.

But there remains a larger question about the state, and whether the state as a whole has enough ventilators and ICU beds to deal with the COVID-19 epidemic.

“We well know that many rural hospitals have been closing, right,” Marrazzo said. “We’ve been losing a lot of our smaller hospitals. Even those that have remained open may not have a deep staff to take care of critically ill patients. That’s when things do get frightening, and you do need to think about expanding your capacity at a place like UAB or a central place. We have contingency plans that we have been discussing. So this is basic disaster preparedness that people are actively pursuing. But I want to reassure people, we’re definitely not there. And we will be keeping very close, close track of this and updating you all as it comes on.”

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Earlier Monday, Alabama Department of Public Health state health officer Scott Harris and Emergency Management Agency director Bill Hastings urged the state to take extra precautions to avoid spreading the disease any further.

“This is a human disease that is going to require a human response, which is going to require a whole of government response, which will require a whole of society response,” Hastings said. “A mobilization of all Alabamians, all U.S. citizens to reduce and slow the transmission of COVID-19. So it stays at or below or around the max capacity of our health care system. That is the fight that we’re in right now.”

The Department of Public Health is monitoring the total number of intensive care beds available and ventilators available for use in the state. Hospitals are required to report their numbers to the ADPH daily—sometimes more often. That number is not publicly available, but some estimates have placed the ICU bed capacity in Alabama’s hospitals at between 1,000 and 1,600. In total, there are about 16,000 hospital beds in Alabama. Most of those are already at use today, and a growing outbreak of coronavirus will undoubtedly put a strain on Alabama’s hospital system.

Just how bad that strain will get is not yet known. Experts have said that more than 50 percent of the population could become infected with COVID-19—some have placed that number higher at 70 percent. Research out of China indicates that about 15 percent of people who are infected require hospitalization and about five percent require intensive care. Alabama has a population of 4.8 million. So at some point, 120,000 could require intensive care in the state and 360,000 could require hospitalization.

Of course, all of those cases won’t happen at once, but the number illustrates the importance of reducing the rate at which cases multiply across the state.

Harris, during the press conference on Monday, said there is no reason to be worried yet.

“Do we have enough beds and ventilators? Yes, we have been tracking the number of our bed capacity and our ventilators for about a week now using the Alabama Incident Management System,” Harris said. “At this time, we do not have any hospitals that are having issues with surge capacity that we’re aware of. And we track that daily. So we don’t think that’s an issue at the moment. Clearly, that’s always a concern when you’re dealing with a respiratory illness like this, and so we’ll continue to monitor that.”

This story will be updated.


Transcript of the Q&A

Q: This is Chip Brownlee with the Alabama Political Reporter. Dr. Marrazzo, I was wondering if you were—how you feel about the way that the state has handled this so far. And also, what’s your read on the preparedness level in terms of ventilators? I know you just talked about that. But do have any concerns, for Alabama in particular, that we’ll have enough ICU beds and ventilators to handle the cases?

Marrazzo: Sure. Great, great questions. I think that the governor has taken it very seriously. She’s convened a task force of which I’m a member and Dr. Harris is the leader. We’ve met several times in the last several days and I have a call actually, at one o’clock today. They have been—the leadership has been incredibly receptive to our suggestions and our feedback. So I think based on the state of emergency that was declared last Friday, the administration has been very responsive. I do think that as you’ll hear more emphasis particularly, particularly from local health departments like Jefferson County, on some of the more aggressive social-distancing measures, that the state government is going to need to amplify those messages.

You know, you saw all the pictures of people partying this weekend for St. Patrick’s Day, all the invulnerable people out there at the bars. I’m happy for them. But I’m very worried for us. I really don’t think people should be out doing that right now. And we all have to give a little bit to protect our community. So that’s a really important message. And I think the governor will be very on board with that, given the data.

Your second question about ventilators is a great one. We have, for example, at UAB hospital, I think it’s about 300 ventilators. So we have a lot. Is that going to be enough? In Italy, they don’t have enough. They are actually having to make decisions about taking people they believe are not going to survive off ventilators to reassign them to people. We do not want to be placed in that excruciating situation. It’s about the worst possible thing I can imagine as a physician talking to a family about that or dealing with that. I don’t believe there’s any indication we’re going to get there.

But again, my assurance is all based on my belief that we can deflect this curve and not be where Italy is right now. There are I like your question about the rest of the state though because we well know that many rural hospitals have been closing, right. We’ve been losing a lot of our smaller hospitals, even those that have remained open, may not have a deep staff to take care of critically ill patients. That’s when things do get frightening, and you do need to think about expanding your capacity at a place like UAB or a central place. We have contingency plans that we have been discussing. So this is basic disaster preparedness that people are actively pursuing. But I want to reassure people, we’re definitely not there. And we will be keeping very close, close track of this and updating you all as it comes on.

Q: This is Chip again, I’m wondering what you think about—some people have suggested that some of the hospitals across the state that have closed might need to be reopened. I’m wondering, given your experience, how likely you think that would be to happen, like, what would, what would those places have to do to reopen to deal with this?

Marrazzo: Yeah, I mean, it’s a great question and I think anything’s on the table right now. If we come to that point, and again, we should have much more data in hand over the next week, I would say. If we come to that point, you know, what that means is we’re looking at capacity beyond our immediate medical systems. That means either repurposing existing facilities or creating temporary new facilities, which is also a pretty heavy lift. What would have to happen is you’d have to obviously make sure the infrastructures were capable. And you’d have to more importantly, almost staff them up with people who are capable and willing to do that. So that’s a pretty big step people are, I know, in active discussions about that contingency planning as part of the disaster preparedness response. It’s really no different than thinking about a mass casualty like you might have with a hurricane or an earthquake or something like that. Unfortunately, you have an infectious disease, so it’s a little bit more dynamic and ongoing than either of those things. But I do know that people are talking about it and we will be updating you all as those discussions proceed and if they do proceed to anything more concrete.

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Judge hears testimony over temporary abortion ban during COVID crisis

Eddie Burkhalter

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A federal judge on Monday heard testimony during the first hearing following the judge’s temporary restraining order last week, which temporarily barred Alabama from prohibiting abortions during the novel coronavirus outbreak.

U.S. District Judge Myron Thompson heard testimony from Alabama State Health Officer Dr. Scott Harris and Dr. Yashika Robinson, the named plaintiff in the case who operates an OBGYN office in Huntsville and conducts abortions at the Alabama Women’s Center, one of three abortion clinics in the state. 

The American Civil Liberties Union and the ACLU of Alabama filed the suit on behalf of Robinson, which argues that Alabama is restricting access to abortions under the guise of protecting the public from COVID-19. 

The state is defending Harris’s March 27 and April 3 public health orders, which prohibit elective medical procedures except those necessary to treat an “emergency medical condition” or to “avoid serious harm from an underlying condition.” 

Attorneys with the attorney general’s office argue the order’s purpose wasn’t to target abortion clinics but to prevent the spread of the virus and to save scarce personal protective equipment as health care workers fight the COVID-19 outbreak. 

Harris told the court during the teleconference hearing Monday just that, that his order banned elective procedures to limit the public’s exposure to the virus and to help preserve the state’s limited supply of PPE. 

Alabama Assistant Attorney General Jim Davis asked Harris whether the Alabama Department of Public Health defined what is and isn’t an elective procedure, to which Harris said, “We did not specify. We just said all procedures” and the department instead “left that to the discretion of the provider.” 

Harris told the court that it’s up to health care providers to determine if their patient meets one of the two of the exceptions spelled out in his April 30 order. 

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“Specifically,  can a woman who gets an abortion experience complications that require a followup?” Davis asked Harris, who said yes. 

Harris said one of the goals of his order was to prevent stress on the state’s health care system in the event an elective procedure requires emergency care. 

“We didn’t try to think of every possible procedure or every possible scenario, but I think, generally speaking, procedures do consume PPE,” Harris said. 

Alexa Kolbi-Molinas, an attorney with ACLU, asked Harris about an ADPH directive regarding the COVID-19 outbreak that state health care providers are to seek guidance from organizations including the American College of Obstetricians and Gynecologists.

“Were you aware that ACOG and other organizations have issued a joint statement stating that they do not support COVID-19 responses that cancel or delay abortion procedures?” Kolbi-Molinas asked Harris. 

“No. I’m not aware of that,” Harris said. 

Harris agreed during questioning that he cannot say how long his order barring elective procedures might last, and said that China’s ability to slow the spread of the virus was the result of strict travel restrictions that would be difficult to implement in Alabama.  

Kolbi-Molinas asked Harris about Alabama’s infant and maternal mortality crisis, which preceded the COVID-19 outbreak and noted that Alabama women die from childbirth complications at more than double the rate of women nationally, and rank third-highest in the nation in maternal death rates. 

Kolbi-Molinas pointed out through questioning that ADPH licenses abortion clinics and has the authority to take action against a clinic that violates an emergency order, and that prosecutors could also take action against them if ADPH declined to do so. 

Kolbi-Molinas asked Harris about the inclusion of gun stores as “essential” businesses in his April order, which allows the stores to remain open. 

“There are more than three gun stores in Alabama, aren’t there?” she asked. 

“I think you’re probably right about that,” Harris said. 

Kolbi-Molinas asked whether Harris knew if gun stores in the state are screening employees or customers for fevers, and Harris said that he did not. 

She asked if he was aware that the FBI conducted background searches for more than 100,000 gun purchases in Alabama during March, in which a customer must come into the store in person. Harris said he was unaware of that figure. 

“Would you say the decision to designate gun stores as essential retailers was driven by public health considerations?” Kolbi-Molinas asked. 

“I think the whole list of non-essential versus essential businesses was something that we’re trying to do as quickly as possible, and we really concentrated mostly on what we thought were close-contact professions,” Harris said. “Clearly, there are actually, literally hundreds of exceptions here, and we may not have gotten them all correct, but I think we were trying to do them as quickly as possible.” 

Dr. Yashika Robinson told the court that she has canceled some appointments during the COVID-19 crisis that she considers elective, including hysterectomies and tubal ligations. 

“They weren’t considered emergencies,” Robinson said. 

Asked why she hasn’t canceled abortions, Robinson said “they are time-sensitive. They cannot be delayed without causing harm.” 

Alabama law bans abortions beyond 21 weeks and six days, Robinson said. 

Robinson said complications from abortions are “less than one percent” and abortions are about ten times safer for women than carrying a pregnancy to term. 

Approximately 20 percent of pregnant women will miscarry, and about half of those will require medical attention, Robinson said. 

Robinson said women decide to have an abortion for a variety of reasons, from “a pregnancy that is just not developing correctly” and some “already have children” and decide to have an abortion so they can better care for the children they have.

“Some women, they just know it’s not the time for them to start a family, or increase their family size,” Robinson said. Most of the women she provides abortions for are low-income and many have no insurance. 

A delay in getting an abortion increases health risks for the woman, she said.  

“Every week matters for these patients,” Robinson said. 

Some women try and self-induce an abortion if they don’t have access to care, Robinson said, and can injure themselves badly doing so, requiring emergency room care. 

“Those patients usually require multiple days of hospitalization,” Robinson said, which uses more PPE than would an abortion in a clinic. 

The state filed an additional clarification with the court Sunday regarding how the state would determine which procedures are covered by one of the two exceptions.

“Defendants would clarify that while reasonable medical judgment of all healthcare providers will be treated with respect and deference, a health care provider’s assertion that a procedure meets one of the exceptions is not conclusive proof that the procedure meets one of the exceptions in the March 27 order or the current April 3 public health order,” the state’s filing reads.

Robinson told the court that she fears her medical judgment wouldn’t be recognized by the state were she to decide to conduct an abortion.

Assistant Attorney General Brad Chynoweth asked Robinson about screening procedures she’s adopted for patients at her clinic, which include her request for a patient who might present with COVID-19 symptoms to postpone the procedure. 

“You’re taking into account risk for others. Not just the patient herself, correct?” Chynoweth asked. 

“Absolutely,” Robinson said. 

Chynoweth asked if physical examinations are done before a medication abortion, and Robinson said they are and that appropriate PPE is used during the exams. 

Chynoweth noted during questioning that during surgical procedures 6 feet of distance between a doctor and the patient isn’t possible and PPE must be used. 

Chynoweth asked if she has any N95 masks at the clinic, and Robinson said “we have a few” but that they’ve not been used as she’s not seen any patients who presented with symptoms of COVID-19. 

Asked if any abortion could be postponed, Robinson said some abortions could be postponed, but any delay of weeks or even days could mean a higher likelihood of health complications for women. 

Judge Myron Thompson at the close of testimony asked attorneys on both sides about who or what agency would handle a criminal complaint resulting in the order, and was told the state Attorney General’s office has the authority to do so. 

Thompson asked for proposed opinions from both sides to be filed with the court by 8 a.m. Wednesday.

The Fifth Circuit Court of Appeals in Texas last week ruled that the state’s temporary ban on abortions amid the COVID-19 crisis could continue.

Judges in Ohio on Monday ruled that most abortions could continue following a lower court’s ruling that upheld the state’s temporary ban.

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Alabama COVID-19 cases surpass 2,000; 53 deaths reported

Chip Brownlee

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The number of confirmed coronavirus cases in Alabama surpassed 2,000 on Monday, marking another grim milestone in the outbreak.

At least 53 deaths have been reported.

Cases of COVID-19 have been confirmed by lab testing in 66 of the state’s 67 counties. At least five of the state’s counties have at least a hundred lab-confirmed cases. Jefferson County has reported 438 cases.

The number of cases per capita remains higher in some rural counties, though. Eleven counties have higher per capita cases than Jefferson County. Chambers County and Wilcox County have the highest number of cases per capita in the state at 289 cases per 100,000 people in Chambers County and 125 cases per 100,000 people in Wilcox County.

Of the counties with at least 50 cases, the number of cases has grown fastest in Mobile County, where testing was slow to get off the ground.

Over the last week, the number of cases in Alabama has grown by 112 percent.

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Cases jump in Alabama nursing homes, tests still scarce, association says

Eddie Burkhalter

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Confirmed COVID-19 cases in Alabama nursing homes have jumped in recent days, and delays in getting test kits and test results is putting lives at greater risk, according to the Alabama Nursing Home Association.

As of Monday, 31 nursing homes in 17 counties had confirmed COVID-19 cases, according to a statement from Alabama Nursing Home Association President Brandon Farmer.

The last update from ANHA on March 28 noted eight confirmed cases of COVID-19 in six nursing homes across the state.

John Matson, director of communications at ANHA, told APR in a message Monday that the organization was uncertain how many individual COVID-19 cases were currently in the 31 homes.

“These reports involve residents, staff members or both at nursing homes in rural and urban locations. These nursing homes are following the reporting guidelines and implementing isolation procedures,” Farmer said in the statement. “I predict the number of nursing homes with cases will grow as more tests are administered and the results are returned. As previously stated, the delays in receiving test kits and test results are beyond our control yet places our residents and employees at great risk.”

State nursing homes have stopped visitations and early on began screening staff for symptoms of the virus and strengthening infection control measures, Farmer noted in the statement.

“They continue to practice infection control guidelines from the Centers for Disease Control and Prevention and isolate residents who test positive or are believed to have been exposed to someone who is COVID-19 positive. Like other health care providers, nursing homes need a sufficient supply of personal protective equipment (PPE). Infection control measures will only be as effective as our ability to secure PPE,” Farmer said.

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Behind the model that projected 5,500 deaths in Alabama — and why it changed

Chip Brownlee

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Stock photo

Early last week it said 7,500 would die in Alabama by August.

This modeling from the University of Washington’s Institue for Health Metrics and Evaluation has been cited by the White House’s coronavirus task force.

This modeling — that last week suggested somewhere between 100,000 and 240,000 Americans could die — spurred President Donald Trump’s decision to extend social-distancing guidelines through April and served, at least in part, as a call to action for Alabama to issue its stay-at-home order Friday.

Then it was revised downward again to 5,500. As recently as this weekend, the model projected that Alabama would have the highest per capita death rate in the country and the fourth-highest total death toll.

But by Monday morning, it was adjusted again — this time projecting fewer than 1,000 will die by August from the novel coronavirus that causes COVID-19. Instead of the highest per capita death rate in the country, Alabama is now projected to fall somewhere in the middle — 22 out of 51.

The changing numbers and the shifting projections can tell us many things but one is this: that modeling a pandemic is hard, especially when how it pans out depends heavily upon how state governments and the people adhere to social-distancing guidelines. No one knows how this will end.

I spoke with Dr. Ali Mokdad, one of the senior scientists at IHME and a former official at the Centers for Disease Control and Prevention. He helped develop the model. (We spoke before the model was revised downward for Alabama.)

IHME’s model is live. It is updated regularly. It was never meant to be interpreted as a comprehensive prediction of the future. It was intended as a planning tool to help policymakers, hospital officials and the public plan ahead. In fact, the people who made the model hope their projections at present are wrong — that they will be revised downward more.

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“By reducing the number of people who have infections by staying at home, you can help the medical system,” Mokdad told me. “And when the peak comes, that shortage that we are projecting will not be as big as we are seeing right now because social-distancing is working.”

The updated modeling shows how social-distancing is working, not that it was never possible that 5,000 or 7,000 people could have died. Had we not acted, had people not changed their behavior, had the state not implemented a stay-at-home order, that could have surely been the case — and it still could be.

State Health Officer Dr. Scott Harris said the model has been helpful in planning for the peak.

“I think the thing that’s been most helpful about that model is really the timelines,” Harris said in an interview with APR.

“The margin of error they have on there is tremendous,” Harris said. “I don’t necessarily think it’s incorrect, but you can almost read what you want to on there. We could have 50,000 deaths or 5,000 deaths or any number. But the timeline makes sense, seeing when we’re expected to have a surge. That was what was most useful to us.”

The shaded area indicates uncertainty in the modeling, ranging from 1 to 247 deaths per day on April 25.

A model is only as good as its inputs. Last week, IHME’s model for Alabama had little data to work off of. The state had only just begun to report deaths. And when the state changed its reporting of deaths, and the death toll spiked as a result, IHME’s model — which is primarily based on deaths per day — adjusted.

“So one day they just kind of flipped the switch, and suddenly our numbers changed dramatically in one day even though the situation on the ground was the same,” Harris said. “I am not saying they are wrong, but the timeline is most useful.”

Even though the number of deaths per day is still increasing, the state hasn’t seen a similar jump since last week. The model, as a result, has stabilized, too.

The shaded area indicates uncertainty in the modeling, ranging from 400 to 2,000 total deaths by August.

As more data becomes available, the model will adjust again. The projections could worsen if deaths begin to spike, or the projections could get better if deaths level off before the projected peak in mid-April.

“People are working tirelessly not only to make sure that we’re going to be able to handle the need for ventilators in the coming weeks but also that we have the surge capacity to figure out if we do exceed the number of beds that we have, how we can deal with that,” Dr. Jeanne Marrazzo, the director of the infectious diseases division at UAB, said last week. Marrazzo is also a member of Gov. Kay Ivey’s coronavirus task force.

There are a number of assumptions in the model, including complete adherence to social-distancing measures through August. If Alabamians flout the stay-at-home order that began Saturday evening, the projections could surely be wrong — the reality could be worse. The death toll could be much higher than nine hundred because Alabama remains particularly susceptible to the virus.

“When you look at Alabama, there are more people who have risk factors in Alabama and the Southeast in general,” Mokdad said. “More obesity, more high blood pressure, more diabetes and more cardiovascular disease, and more cancer there than really anywhere else.”

If we try to return to normal earlier, then the projections could be worthless because the model assumes social-distancing continues through August. If we stop social distancing, about 97 percent of the population would still be susceptible to the disease. The virus would surge again. Until a vaccine becomes available, the virus and the threat of mass casualties could return.

“Our bodies as a species, we have never seen this virus,” Marrazzo said. “And that’s why so many people are having such a hard time handling it after getting infected.”

That threat could be mitigated by a nationwide mass testing regime, which would enable widespread contact tracing and targeted quarantines. That testing regime would have to include the large number of people who show no symptoms. We are nowhere near the capability of testing the number of people we would need for that to work.

The revision of the death toll from 5,500 down to 900 should not be taken as an all-clear. The modeling is based on the actual death toll, which could change if our behavior changes.


Below is a Q&A of our conversation. It was edited for length and clarity.

Q: Why does the modeling look so bad for Alabama?

Dr. Mokdad: It doesn’t look good, but let me explain why. We are modeling mortality. We take the death rate and model off that. We project the death rate into the future.

Then we back-calculate the number of beds, ICU beds and ventilators that are needed. Because we know from hospitals right now how many people with COVID-19 showed up at the hospital, how many were on a ventilator, how many of them needed to be in an ICU bed, how many died and how many survived. So we can do that by calculation.

The reason we are modeling mortality and not how many cases we have is because we are concerned that we are not testing everybody who needs to be tested. So the number of confirmed cases that we are releasing as a country is not totally reflective of reality. And this is not a criticism of the country; it’s just the reality. But we are reporting as positive the people who came and got tested. And we have still a shortage of tests.

Second, there are people out there who may have COVID-19 but are asymptomatic. We have studies showing that they don’t have any symptoms. We know people who were tested here in our hospital, who were positive, but they never had any symptoms. They were tested and they were found out to be positive. But they can still pass the virus, even though they don’t have any symptoms. We also know that many have mild symptoms and may not require hospitalization. Or some who have symptoms but may think it’s something else, like allergies, especially in a state like Alabama, which is beginning its allergy season.

So we decided to model mortality. We project a peak of demand — demand of the medical system — in mid-April.

The reason why Alabama would be much worse than most other places is a number of factors. When you look at Alabama, there are more people who have risk factors in Alabama and the Southeast in general. More obesity, more high blood pressure, more diabetes and more cardiovascular disease, and more cancer there than anywhere else.

So we would expect people who are high risk to use more resources because they have conditions that would make mortality higher and there will be more demand for resources.

Q: Gov. Kay Ivey just issued a stay-at-home order. A lot of people have said that came too late. How does that play into this model?

Dr. Mokdad: So in our model, we monitor all of these decisions. We know that you closed schools. We know that you closed non-essential businesses and services should be closed. But at this time, we have not added the stay-at-home order. That happened today.

It’s really too late, unfortunately. From our perspective, it should have been done much earlier. We cannot change the past, but we can change the future. So the lesson here is that these orders should have been in place earlier, but from now on, what we really need to stress for people in Alabama, is by staying home and adhering to these social distancing guidelines, you can reduce the number of deaths. The most important part for Alabama is that it could have a shortage of facilities to take care of patients.

By staying at home, you can reduce the burden on the hospital system. You can allow your physicians to have at hand the resources they need to deliver the best medical care for everybody who needs it. By reducing the number of people who have infections by staying at home, you can help the medical system and when April 17 comes, that shortage that we are projecting will not be as big as we are seeing right now because social distancing is working.

Q: Can you talk about the timeline and why this might have come too late for the peak demand?

Dr. Mokdad: I’m not saying it’s too late to do anything. The decision was made too late. It should have been done much earlier. I’m not picking on Alabama. Even in Washington, I would have liked my governor to make that call much earlier.

I and everybody in this country, we saw a pandemic unfolding in China. We saw how aggressive their measures were. We know they suffered. We saw it. So why didn’t we prepare ahead of time for it? We knew this was coming in December or January. We had January and February.

We had over a month and a half to prepare. Let’s be realistic and say a month because the first case was in Seattle. So let’s say we had a month. Why are we having this discussion now about our capacity to produce ventilators? We are the United States of America. We have the best resources. We have the best minds here. We are a resilient population. If you inform the public and give them the right information at the right time, Americans love their country and want to protect each other. So they would have stayed at home. All of us should have made this call much earlier. It’s too bad that Alabama did it on April 4th, when other states started doing it in mid-March. Even those states should have done it earlier.

Q: What should people take away from your modeling?

Dr. Mokdad: We can still make a difference here by staying at home. We have to be very careful. At this time, especially in a state like Alabama, where I worked a lot with the CDC. I worked a lot in Alabama. We know the state has underserved populations. It has many minorities and vulnerable populations. We need to be compassionate.

It’s time for all of us right now, all of us in other states, to help Alabama. Alabama should not be left alone to deal with this burden. It’s time for us to focus on Alabama. I know New York is in the media, and they deserve that, but we should still not forget Alabama. You should not be left alone to deal with this.

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