Life seems to be coming to standstill. More bars are closing. Restaurants are moving to take-out only. You can’t visit your friends. You might be wondering, “Why is everything shutting down because of this coronavirus?” “What’s the point of social distancing?” “The hospitals can handle the flu, why can’t they handle this virus?” The answer doesn’t lie in the symptoms or severity of the illness itself but in the rate at which it spreads and, more importantly, whether our hospitals can handle the additional load.
Whether our hospitals and health care workers can handle the challenge of COVID-19 will depend entirely on how seriously we take social distancing and hygiene policies, like not eating out, not going to bars, staying six feet apart, working from home, not gathering in groups of more than 10 and washing our hands.
The charts below—created with data from the Harvard Global Health Institute—show how the rate at which the virus spreads over the next six to 18 months could make or break the ability of hospitals in Alabama to respond. Experts believe strict adherence to social distancing policies could spread the rate of infection out over 18 months, easing the burden on our hospitals, that’s what “flattening the curve means.” That’s why public health experts keep preaching it. And it’s why Alabama is starting to implement similar policies.
Even in the best case scenario, hospitals will be strained. Health care personnel will be reassigned to work COVID-19-related cases—in fact, these plans are already being put in place. Military doctors could be called in to help triage and treat patients. Retired doctors and nurses and medical techs could be called back in to face this pandemic. But, if social distancing measures aren’t followed and people go about their lives as usual, the curve could spike, meaning roughly the same proportion of the population could be infected over a shorter period of time—like over the course of six months instead of 12 or 18 months. That would send the sick into our hospitals faster than medical providers, who are already facing threats to their own health, can get them out. Such a scenario would likely be a terrible blow to the hospitals—or it would require a massive government intervention to build new facilities, re-open closed ones and recruit hundreds, if not thousands, of new health care workers. A response like that would be unprecedented in the history of our state.
Let’s look at some scenarios in Alabama to get a better understanding of how things could go.
About 80 percent of people who have COVID-19, the disease caused by the novel coronavirus, don’t need hospitalization. Many have mild symptoms and don’t need medical assistance at a hospital at all. But a lot of people—in fact, thousands of people—will need help and will fill hospitals in the coming months. About one out of every five people who are infected will require hospitalization. A smaller number will need ventilators and treatment in an intensive care unit. That’s about 5 percent of all cases. It’s smaller but it’s no less significant.
We’ll start with a pretty bad but still possible scenario: 60 percent of the adult population is infected.
The graph above shows the six hospital referral regions in Alabama: Birmingham, Dothan, Huntsville, Mobile, Montgomery and Tuscaloosa. For each region, it shows the number of available hospital beds on average, and the number of hospital beds that could potentially be made available if hospitals take drastic measures to clear out non-COVID patients.
The graph above shows the three most populous hospital referral regions in Alabama: Birmingham, Huntsville and Mobile. (There are six in total.) For each region, it shows the number of available hospital beds on average, and the number of hospital beds that could potentially be made available if hospitals take drastic measures to clear out non-COVID patients.
Available beds is a count of how many set up and staffed hospital beds are unoccupied at any given time, on average, within the hospital referral region. A majority of hospital beds are already occupied with people who are sick with something else other than COVID-19. This new pandemic doesn’t mean that people still aren’t being hospitalized with the flu or because of a heart attack
“Potentially available beds” is an estimation by the researchers of how many beds could be made available in a region if the number of non-COVID patients occupying beds was reduced by 50 percent. This would require canceling elective surgeries, which public health officials are already recommending, and delaying procedures that aren’t necessary to keep someone alive. In effect, it would be rationing of care to those most in need.
A Hospital Referral Region is an area within which people generally go to the same hospitals. For example, someone in Shelby county would go to hospitals in the Birmingham referral region. Someone in Pickens County, Alabama, would likely go to a hospital in the Tuscaloosa referral region. So, the numbers are an aggregate of the total number of beds within a region, not within a particular city.
After the available bed counts, the graph shows for each region how many beds would be needed if 60 percent of the adults in that region were infected over the course of six months, 12 months or 18 months. In most of the graphs, you’ll see the total needing care outpaces the number of available beds, especially if the pace of infection is faster and 60 percent are infected within 6 months instead of 12 or 18 months. You can begin to see how important it is to “flatten the curve” and spread out new infections over a longer period of time.
In the worst-case scenario, if 60 percent of people were infected over six months, an estimated 14,000 available hospital beds would be needed in the Birmingham area to handle the influx of patients. Only about 2,700 beds are available. Even if the hospitals reduced the number of non-COVID patients by 50 percent, which would be hard, only 5,000 beds would be available. Ten thousand people who would need to be hospitalized wouldn’t have a bed—and that is just in the Birmingham region.
In the Mobile region, the same scenario would leave 4,000 people who need hospital care without a hospital bed. In Huntsville, 3,000 people wouldn’t have a bed. Across the six regions of Alabama, hospitals would need about three-times the number of potentially available beds.
Now, to be clear, this isn’t just an issue in Alabama. It’s one that’s present across the United States. In New York, Gov. Andrew Cuomo has called for using the National Guard and Army Corps of Engineers to build new field hospitals or retrofit other facilities, including things like empty college dorms, to care for COVID-19 patients.
But let’s look at ICU beds in Alabama, which is potentially even more worrisome than a general hospital bed shortage.
ICU beds would also be in short supply, too. This is important because intensive care beds are used for the sickest and most vulnerable patients who need a ventilator to help them keep breathing. The need for a ventilator is a common occurrence, especially among older patients who are diagnosed with COVID-19.
In the same scenario I just mentioned above (60 percent infection over six months), more than 2,500 people in the Birmingham area would need ICU beds that simply wouldn’t be available.
The worst-case assumption is instructive, but even a more moderate scenario is worrisome. If 60 percent of the population is infected, but social distancing slows the rate of infection to about 18 months—which is about the time needed to develop a vaccine—Alabama’s hospitals, in aggregate, still would not have enough available ICU beds. Even if hospitals reduced the number of non-COVID patients in their ICU rooms by half, or the number of ICU beds increased by an equivalent amount, hospitals in the state would still need, on average, about twice the number of ICU beds.
This is why public health experts are pressing government officials to come up with a way to quickly manufacture more ventilators and why some are considering re-opening closed rural hospitals in the state or opening other kinds of temporary facilities. In Italy, where the pandemic has spread out of control and the country is on lockdown, patients are being treated in hospital hallways and some are being denied care.
It’s hard to know exactly what percentage of the population will get infected, the researchers say. It all depends on the rate of transmission and how serious we are about social distancing. This is truly in our hands—all of us. But 20 percent is considered by the experts who authored the report to be quite a conservative estimate based on the infection rate in other countries and in prior pandemics, according to ProPublica, and it would the result of the public strictly adhering to social distancing and hygiene guidelines.
Forty percent, according to the authors of the report, is the moderate scenario and in the middle of estimates that range from between 20 percent and 70 percent. For reference, COVID-19 appears to be more contagious than the novel H1N1 swine flu of 2009 that infected 60.8 million Americans over the course of a year and hospitalized more than 200,000 people across the country. The H1N1 was also less deadly.
How would the state fare if 40 percent or 20 percent of the adult population is infected? Again, it depends on how much we can flatten the curve.
Throughout Alabama, 131 cases of COVID-19 have been confirmed by laboratory tests, as of Saturday evening. Public health officials believe there’s community transmission of the virus in Alabama, and that far more cases exist than have been confirmed by testing. Nationally, more than 26,000 people have tested positive. At least 200 people have died so far. That does not mean that there are not more cases. In fact, we should assume that there are more cases that haven’t been confirmed yet because of the delay between testing and results, and because it’s been difficult to get tests for several weeks. It’s just now becoming easier to get a test with drive-thru centers popping up across the state, and that process has not been without its difficulties.
If the Harvard Global Health Institute’s estimates pan out, all of Alabama’s major hospital regions will be at or near their bed capacity and exceeding their ICU bed capacity—even in the best case scenarios. If the worst case scenarios pan out, which could still happen if people decide to flout social-distancing guidance, thousands of Alabamians could die because there won’t be enough ICU beds, hospital beds and ventilators available. That’s why public health experts and hospital officials are sounding the alarm.
Alabama Hospital Association president, Dr. Donald Williamson, said Thursday that he fears the coronavirus outbreak could overwhelm Alabama’s health care system if the public doesn’t take social-distancing guidelines seriously. “My big, big concern is as this tsunami approaches us in the coming weeks, we are going to be challenged to have enough ventilators for the state at large,” he said.
“So I am very concerned about that over the long haul stressing our health care system and that’s why social distancing is so important,” Williamson said.
Dr. Jeanne Marrazzo from UAB told reporters Monday that the growth in the number of cases in the state and the potential for a ventilator or ICU bed shortage is “frightening.” She pointed to Italy, where some physicians are being forced to prioritize care for those they think can survive—in other words, younger people, who tend to fare better than the most elderly.
“In Italy, they don’t have enough” ventilators, 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.”
She said she believes we can avoid a similar crisis. “But again, my assurance is all based on my belief that we can deflect this curve and not be where Italy is right now,” she said.
We’ll know better where we are in a week or two. The U.S. — particularly the hardest hit states like New York and Washington — is not that far behind Italy.
President Donald Trump on Tuesday said that he was starting the process of deploying the Army Corps of Engineers to help New York, the state with the most confirmed cases, with its response to the Coronavirus. On a call with reporters earlier the same day, Sen. Doug Jones said all options “ought to be on the table,” including deployment of the national guard and Army reserves—and the re-opening of closed rural hospitals, which could be used to house and treat COVID-19 patients.
“We have got some of the greatest minds in the world,” Jones said. “We have got some of the greatest manufacturing facilities that are out there. We’ve got 3-D printing that is available. We have got to get American ingenuity thinking about this.”
“I don’t want to use the term war,” he said. “That’s not a term I use with this, but think about what we did when we had to ramp up our military in World War II. Think about all the manufacturing places, retooled a little bit to get things we needed. We need to start thinking in those terms right now. And, hopefully, if people do what they’re supposed to do, we never have to ramp those up to the extent necessary. But we need to be thinking ahead.”
There are 15,793 beds in Alabama’s six hospital referral areas and 1,903 ICU beds, according to the Harvard Global Health Institute report, which cites the American Hospital Association and the American Hospital Directory.
Alabama Hospital Association President Dr. Donald Williamson said Thursday that the state’s hospitals have about 1,344 ventilators on hand. On any given day, about 550 are in use on average. That means the state has a surge capacity of only 800 ventilators.
If 20 percent of the adult population is infected, according to the model, an estimated 759,191 people would be infected in the six hospital markets, which cover the vast majority of Alabama.
If 40 percent of the adult population is infected, an estimated 1,518,382 people would be infected.
If 60 percent of the adult population is infected, an estimated 2,277,573 people would be infected across the state’s six hospital referral regions.
If 20 percent of the adult population are infected, an estimated 158,906 people would need to be hospitalized, according to the Harvard model.
If 40 percent of the adult population are infected, an estimated 317,811 people would need hospital care.
If 60 percent are infected, an estimated 476,716 people would need hospital care.
But not all at once. The model assumes that the infections would happen over six, 12 or 18 months.
If 20 percent of the adults in Alabama are infected, an estimated 34,370 would need ICU care, according to the Harvard model.
If 40 percent of the adults in Alabama are infected, an estimated 68,741 people would need ICU care.
If 60 percent are infected, an estimated 103,111 people would need ICU care.
Again, not all at once. The model assumes that the infections and hospitalizations would happen over six, 12 or 18 months.