On a conference call with reporters Tuesday, Gov. Kay Ivey explained why she wouldn’t issue a “shelter-in-place” or “stay-at-home” order in Alabama.
“Folks, we have no current plans to do so,” Ivey said. “We have seen other states in the country doing that as well as other countries. However, y’all, we are not California. We are not New York. We are not even Louisiana.”
Well, the rate at which new cases are being reported in Alabama is beginning to look a lot more like Louisiana than other southeastern states like Georgia and Florida.
The graph above uses a log scale to show the number of cases reported in each of the four states—Alabama, Georgia, Florida and Louisiana—since each state reached its sixth confirmed case.
Alabama now has 440 confirmed cases of COVID-19, as of Wednesday night, but the state reported its sixth case on Friday, March 13.
Wednesday was the 12th day since Alabama reported its sixth case. Our total nearly doubled in one day, from 242 cases on Tuesday night, to 440 by Wednesday night.
Alabama does have fewer cases than Louisiana did on its 12th day since its sixth case. Louisiana had 1,100 cases on its 12th day. But Alabama has far more cases than Florida and Georgia did at this point.
Florida reported 186 cases on its 12th day, according to data from the COVID Tracking Project, and Georgia reported 287. Alabama has more than twice the number of cases as Florida did at this point—and 150 more cases than Georgia did. Both states now have more than 1,000 cases.
Some of this could be chalked up to testing. Alabama could be testing way more than Louisiana, Georgia or Florida were at this point in their COVID-19 experience. But we can’t tell, because Alabama reports significantly less information about tests performed in this state than Florida, Georgia or Louisiana.
Either way, that is unlikely, because Louisiana has tested nearly 11,500 people. The Alabama Department of Public Health has reported less than 3,000 tests, though that includes only some negative results from commercial labs.
Because of that lack of data, all we can tell is that Alabama’s confirmed COVID-19 cases are growing significantly faster than Florida or Georgia, two states that have significantly larger populations than Alabama.
We’re not in as bad of shape as Louisiana is, but we are not that far off, either.
In Louisiana, there have been 65 deaths so far, and the president has declared a major disaster. The number of patients needing a ventilator in the state jumped from 94 on Tuesday to 163 on Wednesday.
For reference, there were already at least 60 patients with a confirmed COVID-19 diagnosis at UAB Medical Center in Birmingham Wednesday morning. Of those, 34 were on ventilators. There are surely more in other hospitals in the state.
Data show that Alabama and Louisiana have similar populations and demographics. Alabama has about 4.8 million people. Louisiana has 4.6 million. They also normally have a similar number of hospital beds. Alabama has about 14,800, and Louisiana has 14,500, according to the American Hospital Directory.
But Louisiana has far more ventilators than Alabama. According to Alabama Hospital Association President, Dr. Donald Williamson, the state’s hospitals have about 1,344 ventilators. On any given day, about 550 are in use on average, leaving a surge capacity of only about 800.
“We know that over the course of two or three weeks a situation can look a lot different than it does now,” state health officer Dr. Scott Harris said Tuesday.
Louisiana has nearly 2,750 ventilators, yet Gov. John Bell Edwards is warning that the state could run out of ventilators by the first week in April.
If our current rate of growth continues, nothing changes, and we don’t find more ventilators, Alabama could run out of by sometime in mid- to late April.
An analysis published by the Alabama Political Reporter Wednesday showed that more than 100 people are already hospitalized statewide with confirmed diagnoses of COVID-19 or illnesses the hospitals highly suspect as being COVID-19. That number has probably already increased.
Our analysis showed that, if you include hospitalized individuals in Alabama awaiting COVID-19 test results, the number is closer to 300.
In Louisiana, a total of 491 patients are currently in hospitals.
State Health Officer Dr. Scott Harris said Tuesday that some hospitals in Alabama are already nearing capacity. He did not name them.
It’s hard to know where we currently are in Alabama. Until recently, testing in the state was hard to come by. The numbers are now starting to tick up. We really don’t know how many people have been tested, so we can’t see the virus’s attack rate in Alabama.
We also don’t know exactly how many people are hospitalized in Alabama nor how many are on ventilators, despite APR‘s best efforts to get an estimate. The Alabama Department of Public Health has so far refused to publish these numbers.
New York has already reached the precarious point in its COVID-19 journey at which its hospitals are reaching capacity and it has to begin taking drastic measures to take care of its sick. New York City could run out of ICU beds by Friday. Louisiana is now nearing that point, too.
Alabama has so far been reluctant to issue a stay-at-home order or a shelter-in-place order, though Jefferson County and Birmingham have issued more intense restrictions than the state as a whole.
Ivey said Tuesday that she wasn’t considering one at this time.
“My priority is to keep the Alabama economy going as much as possible, while we take extraordinary measures to keep everyone healthy and safe,” Ivey said.”
Let’s hope that the situation in Alabama doesn’t get as bad as Louisiana, California or New York. But if it does, that we are prepared.
Judge hears testimony over temporary abortion ban during COVID crisis
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.
“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.
Alabama COVID-19 cases surpass 2,000; 53 deaths reported
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.
Cases jump in Alabama nursing homes, tests still scarce, association says
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.
Behind the model that projected 5,500 deaths in Alabama — and why it changed
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.
“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.”
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.
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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