An Open Letter to the Citizens of Arizona and our Governing Leaders, 06/14/2020 We, the undersigned, are physicians, spanning every medical specialty. We are conservatives, liberals, independents, and everything in between. We are mothers, daughters, and sisters. We are members of communities throughout the state of Arizona. And, as experts within the field of medicine, we are extremely concerned regarding the recent surge in Covid-19 cases throughout our state. Erroneous information bandied around social media, conspiracy theories, and rapidly changing and often contradicting information from government officials has left the public with the impression that this pandemic does not affect them and is nothing to fear. Sadly, this pandemic has become more about politics and “constitutional rights” than about the value of human life and science. This pandemic affects every human being regardless of political stance, education level, income, religious beliefs, or ethnicity. Unfortunately, in this situation, this virus will not only affect those who ignore the evidence; their actions will directly affect mothers, grandmothers, fathers, and children. It will affect our first responders and healthcare workers. It will take the lives of many innocent people, despite their own caution. As of June 6, 2020, nearly 600 healthcare workers in the U.S. have lost their lives to Covid-19, sacrificing their lives in an effort to save others. 1 That figure does nothing to quantify the toll this pandemic has taken on the mental health of those charged with saving our lives. We know of at least 2 suicides in healthcare workers fighting the pandemic in New York, 2 and we can share innumerable gut-wrenching personal accounts from physicians and other healthcare workers on the frontlines. It is important to note that our country has never experienced a pandemic of this kind, the severity worse than that of the Influenza pandemic of 1918. Given that fact and the rapidity with which this disease has spread globally, the science and medicine of this virus change as physicians and epidemiologists learn on their feet. ​These are the facts, as determined by current data and evidence: ● Arizona cases of Covid-19 have risen dramatically in the weeks since our re-opening. ○ In the last 14 days, Covid cases have risen by 187% 3 ○ This week on average, the number of new cases identified has been 1316 per day, up from 458 per day two weeks ago 4 1 https://khn.org/news/exclusive-investigation-nearly-600-and-counting-us-health-workers-have-died-of-covi d-19/ 2 ​https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/ 3 https://www.npr.org/sections/health-shots/2020/03/16/816707182/map-tracking-the-spread-of-the-coronav irus-in-the-u-s 4 https://www.npr.org/sections/health-shots/2020/03/16/816707182/map-tracking-the-spread-of-the-corona virus-in-the-u-s ○ ○ ○ ○ ○ 5 6 7 The percent of positive tests performed has risen to 15.9% 5; despite thoughts to the contrary, this is not because more testing is taking place. This rise is a direct reflection of the spread of Covid-19 throughout Arizona 6 Our ICU availability is low at 28% Our largest health system has gone on record stating they have reached the limit for their available life-saving ECMO machines, and they are nearing their ICU capacity; any additional would push into “emergency capacity” 7 The same health system reported that the number of patients requiring ventilators had quadrupled in roughly two weeks 8 A frequently overlooked fact is that we are not only limited by bed capacity and equipment, but perhaps more limited by insufficient staff skilled in operating ventilators and caring for critically ill patients, leading to pleas for nurses and physicians to come out of retirement and assist 9 ● A rapid surge of this nature can have grave consequences for our community and we must heed warnings and learn from other countries. ○ Italy’s health system is highly regarded and has 3.2 hospital beds per 1000 people (as compared with 2.8 in the United States); however, at the peak of their infection rate, it was impossible to meet the needs of so many critically ill patients simultaneously 10 ○ Due to their experience with prior respiratory diseases such as MERS and SARS, Asian countries overall have fared far better than the U.S. Hong Kong, with a population close to that of New York City and similar crowding, has only had 1,110 cases of Covid-19 and only 4 deaths 11 ○ South Korea has suffered only 277 deaths versus the 117,000 deaths in the U.S. In the month of April, the U.S. experienced an average of 85 deaths per hour due to Covid-19 12 ○ In addition to their prior experiences with highly contagious infections, widespread testing, and contact tracing, the success of containing the infection can surely be credited to the community-minded willingness of their citizens to don masks in public ● We will undoubtedly face further devastation in our country if more citizens do not limit interactions, abide by social distancing guidelines, and wear masks to limit the spread of disease. ​https://www.covidexitstrategy.org/ ​https://www.covidexitstrategy.org/ https://www.azcentral.com/story/news/local/arizona-health/2020/06/06/arizona-coronavirus-banner-health -reaches-capacity-ecmo-lung-machines/3163102001/ 8 ​https://www.medpagetoday.com/infectiousdisease/covid19/87004 9 https://www.vox.com/policy-and-politics/2020/3/31/21201281/coronavirus-staffing-shortage-governors-he alth-care-workers-help 10 ​https://www.nejm.org/doi/full/10.1056/NEJMp2005492 11 ​https://www.worldometers.info/coronavirus/country/china-hong-kong-sar/ 12 ​https://www.theatlantic.com/ideas/archive/2020/05/whats-south-koreas-secret/611215/ ○ ○ ○ ● 13 14 The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care published guidelines for physicians and nurses to follow in determining distribution of hospital resources to covid-19 patients. Statements from these guidelines included, “Informed by the principle of maximizing benefits for the largest number the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care” and “It may become necessary to establish an age limit for access to intensive care.” 13 In March, a group of doctors and academics from around the world established ​ e ​ thical guidelines​, which were published in the New England Journal of Medicine (NEJM); under these guidelines, patients do not receive treatment on a “first-come, first-served” basis. Instead, severely ill patients who are younger and who have fewer existing health conditions would receive top priority. 14 One must stop and ask themselves whether they would make “the cut” for treatment? Would your neighbor fighting cancer? What about your child with special needs? Or your mother with autoimmune disease? Would your pregnant sister? Such an algorithm could certainly be in our future if we don't curb the spread of the virus Covid-19 is NOT the same as the flu ○ Covid-19 is far more contagious than Influenza and even more contagious than Ebola; one person infected with Covid-19 can infect 2-2.5 people, with some reports from Wuhan of transmission to up to 5 people 15. Influenza is estimated to be half as contagious 16 ○ There is not yet a vaccine for Covid-19, so the only possibility of immunity might come from infection with the virus, but even immunity isn’t an established fact ○ The number of U.S deaths from the flu in one of our most severe Influenza seasons, 2017-2018, was 80,000 17 ○ To date, the death toll from Covid-19 in the U.S. is 117,847 18 ○ Individuals most likely to suffer significant effects of Influenza include the elderly and those with underlying health conditions such as asthma, heart disease, and diabetes; Covid-19 has demonstrated its ability to cause severe disease in otherwise healthy individuals, regardless of age ○ Covid-19 has led to blood clots, strokes, respiratory failure, long-term lung damage, multi-organ failure, and a systemic inflammatory condition in children, and this is only a partial list. While some groups are known to face a greater risk, ​no one​ is guaranteed a simple clinical course and quick recovery. ​https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/ https://www.bbc.com/future/article/20200428-coronavirus-how-doctors-choose-who-lives-and-dies?ocid=g lobal_future_rss 15 ​https://www.businessinsider.com/coronavirus-contagious-r-naught-average-patient-spread-2020-3 16 ​https://www.nytimes.com/article/coronavirus-vs-flu.html 17 ​https://www.healthline.com/health/influenza/facts-and-statistics#5 18 ​https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html Our recommendations as a large group of highly educated individuals with the best interests of our neighbors, our patients, and our families in mind would be the following: ● ● ● ● ● ● ● ● Put into place a state-wide mandate that every individual over the age of 2 must wear a mask when in public places, including offices, stores, schools, the gym, etc. (if, as was stated during a recent press conference, you are unable to wear a mask due to asthma or other underlying respiratory condition, you should stay home) We ask that all privately owned companies, stores, and restaurants require that all employees and customers wear a mask when on the premises, and that all maintain social distancing Make sanitizer and handwashing stations readily available at entrances to businesses Continue to provide coverage and broadened permissions for telehealth visits Guarantee private transportation to ahcccs beneficiaries with symptoms of illness so they can obtain necessary medical care; there are currently reports of patients being denied transportation and needing to take public transportation thereby potentially exposing many more individuals to Covid-19 Immediately make healthcare and associated resources more available to minority groups and underserved areas to conquer the disparity of care and the increased severity of this pandemic on those groups Institute contract tracing in every state across the country; contact tracing can save lives, greatly reduce the spread of disease, and preserve the economy. 19 In addition, we demand that priority be placed on obtaining and distributing adequate PPE to all of our frontline healthcare workers, not only to protect them, but also to protect those to whom they provide care; this includes those in nursing homes, hospitals, and outpatient clinics. Community providers report ongoing shortages. We understand: adhering to these guidelines means changing life as we have known it. It is not convenient, or fun, or easy. It means canceling or postponing celebrations with family and friends. It means keeping your distance from an elderly neighbor. It means staying home instead of going to the gym, meeting friends for happy hour, or participating in a basketball game at the park. ​ ​It means sacrificing some of your privacy through contact tracing apps and agencies so that others can live.​ ​Life as we once knew it has to change indefinitely to ensure the safety of fellow community members, to protect the most fragile of our population, and to reduce the strain on our healthcare system. Martin Luther King, Jr once said, ​“The ultimate measure of a man is not where he stands in moments of comfort, but where he stands at times of challenge and controversy.” This is a time of challenge for us all. It is time for us to step outside of ourselves, to put our individual desires aside, and do what is right for the greater good of our communities. 19 ​https://www.pbs.org/newshour/health/how-contact-tracing-can-help-the-u-s-get-control-over-coronavirus Christine S. Severance, DO, Family Medicine Caroline Geer, MD, Obstetric hospitalist Lori Bryant, MD, Pediatrics Molly F Walsh, DO, Plastic and Reconstructive Surgery Shauna Schroeder, MD, Pediatric Gastroenterology Deborah Rowan, MD, Obstetrics and Gynecology Lynn Lawrence, MD, Pediatric Emergency Medicine Michelle Cederburg, MD, Pediatric Anesthesiology Yasmine Kenani, MD, Hospitalist Nadia Day, MD, Pediatrics Gina Montion, MD, Pediatrics Leta Hice, MD, Internal Medicine/Hospitalist Molly Solorzano, MD, Anesthesiologist Lee Ann Kelley, MD, Psychiatry Amy Guzek, MD, Pediatrician Amanda Kasem, MD, Pediatric Emergency Medicine Iram Khan, MD. Internal Medicine Lea Alhilali, MD, Radiology Kimberly Winsor, MD, Diagnostic Radiology Kristine Sellberg, MD, Cardiology Mariah Scott, DO, FAAP, Pediatrics Sara Dhanani, MD, Neurology Heather Menzer, MD, Orthopaedic Surgery Christina Kwasnica, MD, Physical Medicine, Rehabilitation Lisa LeMond, MD, Advanced Heart Failure and Transplant Cardiology Carolyn Moats, MD, Family Medicine Aristea Karabinas, MD, FACOG, Obstetrics and Gynecology Elizabeth Reynoso, MD, Obstetrics and Gynecology Sarah Sharer, MD, IBCLC, FACOG, Obstetrics and Gynecology Briana Wellington, MD, Obstetrics and Gynecology Katayoun Baniriah, DO, Family Medicine Rashmi Halker Singh​, MD, Neurology Nicole C. Hoxworth, MD, Pathology Dionne Mills, MD, FACOG Obstetrics and Gynecology Sarah Bannister, DO, FAAP, Pediatric Hospitalist Julie Hastings, MD, Physical Medicine, Rehabilitation Karen Stern, MD, Urology Susan Zulke Hughes, MD, FAAFP Family Medicine Punal Patel, MD, Internal Medicine Sapna Amin, MD, Pathology Heather Holley, DO, FAAP, Pediatrics Himabindu Chaparala, MD, Nephrology Chhavi Manchanda, MD, FRCA, Pain Management/Anesthesiology Charlene Shaughnessy​-​Volquardsen, MD, Emergency Medicine Stephanie Fountain, MD, Pulmonary/Critical Care Amaal Starling, MD, Neurology Sara Hall, MD, Anesthesiology Adrienne Kurland, MD, Internal Medicine/ Pediatrics Nisha Bhatia, MD, Cardiology Ridhima Dabas, MD, Internal Medicine Judith Rosch Barnes Clark MD, FAAP, Pediatrics Palak Patel, MD, Pediatric Anesthesiology Sonya Mody, MD, Pediatrics Amanda Rapp, MD, Family Medicine Jennifer Hill, MD, Allergy and Immunology Traci N. Fitzhugh, MD, FACOG Obstetrics and Gynecology Cheryl A. MacKechnie, MD, Otolaryngology Nalini Tirumalasetty, MD, ECNU, FACE Endocrinology Christine Brass Jones, DO, FACOOG, Obstetrics and Gynecology Tiffany Lahr, MD, Pediatrics Umaima Fatima, MD, Cardiology Tiffany E. Hardaway, MD, Anesthesiology Cindy Bauer, MD, Pediatric Allergy and Immunology Baharak Tabarsi, MD, Family Medicine Annie Khurana, MD, Geriatrics and Palliative Medicine Juliana Kling, MD, MPH, Internal Medicine Madhavi Boga​, ​MD, Internal Medicine, Hospitalist Sheetal Chhaya DO, FACR, Rheumatology Shazia A Malik, MD, FACOG, Female Pelvic Medicine and Reconstructive Surgery Mary C. Harrel, MD, Family and Community Medicine Indu Srinivasan, MD, Gastroenterology Felicia McCreary, MD, Pediatric Anesthesiology Reena Gogia Rastogi, MD, Pediatric Neurology Joyce Lee-Iannotti​,​ MD, Neurology/Sleep Medicine Rashi Agarwal, MD, FACP, Endocrinology Shaghayegh Abdollahi, MD, FACP, FAAP, Internal Medicine/Pediatrics Melissa Redleaf, MD, Pediatrics Kari Evans, MD, Obstetrics and Gynecology Suzanne Sorof, MD, Cardiology Christine Lovato MD, FACS, General and Bariatric Surgery Harshita Paripati, MD, Hematology/Oncology Mona Sodhi, DO, Internal Medicine/Obesity Medicine Jennifer Smith, MD, Internal Medicine Allison Peckumn, DO, FACE, Endocrinology Susan S Pansing, MD, Adult Neurology Christina Kang, DO, FACC, Cardiology Amela Hozic, DO, Family Medicine Reeti Chawla, MD, Pediatric Endocrinology Kiranjit Khalsa MD, MPH, Allergy and Immunology Hannah Lawther, MD, Radiology Dana I. Williams, MD, Pediatric Gastroenterology Tiffany Nunnelley, DO, Family Medicine Suganya Karuppana​,​ MD, CPE, CPHQ. Family Medicine Kimberly Chea, MD, Emergency Medicine Lopa Misra Chhabra​,​ DO, Anesthesiology Leah Brown​,​ MD, Orthopedic Surgery Patricia Drace, MD, Orthopaedic Surgery Angela Valdez-Huizar, MD, Pediatrics Sandra Romero, MD, Pediatrics Carla Dormer, MD, Anesthesiology Monica Viteri-Giordano, DO, Internal Medicine/Pediatrics Amy Schlaifer, MD, Urology Nina Sukhrani, DO, Internal Medicine Lisa Buschmann, MD, Obstetrics and Gynecology Deepti Saini, MD, Ophthalmology Christine Tymczyna, DO, Family Medicine Aleta DaSilva, MD, FAAP, Pediatrics Erynne A. Faucett, MD, Pediatric Otolaryngology Sara Kertz, DO, Pediatrics Yarden Tahan, MD, Family Medicine Christina Martin, DO, Family Medicine Dana Chase, MD, Gynecologic Oncology Ellen Giordano, MD, Pediatrics Elizabeth L Wilson, DO, Emergency Medicine Tabitha Moe, MD, Cardiology Tina Byun, MD, Internal Medicine Anupama Ramalingam, MD, Sleep Medicine Manisha Mehta, DO, Internal Medicine/Hospitalist/Nephrologist Gladys Martin, MD, Internal Medicine/Hospitalist Ashley Tian, MD, Pediatric Neurosurgery Sarah McKenna, DO, Family Medicine Jacqueline Belen, DO, Gynecology Soyoung Park, MD, Hematology/Oncology Maureen McCarthy, MD, Psychiatry JulieAnn Heathcott, MD, Obstetrics and Gynecology Shabana Pasha, MD, FACG, FASGE, Gastroenterology Jasgit Sachdev, MD, Medical Oncology Shana Wingo, MD, Gynecologic Oncology Nellie Farrington, MD Pediatric Critical Care Gailey Gonzales Ona, MD, Internal Medicine, Palliative Medicine Amy Lee, MD, Internal Medicine Jennifer O’Hea, MD, Critical Care/Pulmonary Cheryl Macy, MD, FACEP, Emergency Medicine Sandra Till DO, Pulmonary and Critical Care Jeanne Palmer, MD, Hematology, Blood and Marrow Transplantation Jennifer O’Hea, MD, Critical Care/Pulmonary Tatyana Shekhel​, DO, Infectious Disease Michelle Ruha, MD, Medical Toxicology and Addiction Medicine Atsuko Koyama, MD, MPH, Pediatric Emergency Medicine Julie Davis-Best, MD, Obstetrics and Gynecology Amy Axberg​,​ MD, Emergency Medicine Rebecca Goldman, MD, Family Medicine Mary Kirkilas, DO, Pediatric Emergency Medicine Amber Flaherty, MD, Hematology/Oncology Ria Ghose Kundu, MD, Internal Medicine Sheetal Wadera, MD, Pediatric Gastroenterology Jacqueline May Carter, MD, Internal Medicine/Pediatrics Elizabeth Carey, MD, FAASLD, AGAF, Transplant Hepatology Laurie Jones MD, Pediatrics Rachel Deatherage, MD, Family Medicine Mary Atia, MD, Gastroenterology Judy Wu, MD, Family Medicine Maya K Thosani, MD, Mohs Surgery Hospitalist Punal Patel, MD, Internal Medicine Krista Goulding, MD MPH, Orthopaedic surgery Taruna Ralhan, MD, Diagnostic Radiology Mariana Liu, DO, Internal Medicine/Pediatrics Clari Borrero-Mejias, MD, Pediatric Neurologist Yulia KoltzovaRang, MD, Internal Medicine