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The group of academic family physicians that I have the honor of leading this year have found themselves in the midst of a Covid 19 outbreak. Representing all 50 states, these academic leaders are working in some of the largest, most modern academic health centers in the world. Academic health centers that, unfortunately, are not prepared for the challenge that is just now hitting the coasts but will soon spread across the country.

The preamble to this crisis goes back 30 years. As hospitals have tried to maximize their profits, they began using “just-in-time” inventory. Toyota, it turns out, does not have a warehouse for parts. Instead it gets the carburetor (or whatever parts cars have in them now) delivered at the exact moment the car rolls to that point on the assembly line. Hospitals began using the same, getting only the masks or other equipment they need for the next week from the plant (in China) rather that maintain a warehouse. Well, also only having enough hospital beds for people who need them. Toyota never needed to plan on all of America needing a car within the same 2 month period. Hospitals, turns out, also never planned for Americans to get sick all at once. Guess now we know.

We might have overcome the lack of protective gear except for one problem. If you are treating all of America for a virus that acts like 5 other viruses except it kills you, the only way to “not going to die” people from “just might die” people is by testing for the bad virus. If you know the patient has the bad virus, you can isolate him or her and protect the health care workers more accurately. America, with the best funded health systems in the world, botched the test.

If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

We have less protective equipment, fewer hospital beds, and more chronically ill people than Italy (7503 deaths to date, 743 last night) and Spain (3434 deaths to date, 514 last night). We did not spend the last year preparing for this surge and, by screwing up the testing, we probably have 200,000 infected people going around infecting others. If you look at the cities where things are bad, they are also cities where either lots of people live (New York, Los Angeles) or cities that had a lot of recent visitors from all over (Mardi Gras in New Orleans). It takes about 4 days to know if you are infected (with something….is it the flu? I just feel a little achy) and if you are going to get really sick it happens on about day 8. So now what?

  1. Sheltering in place. What we know is that if people who are infected limit themselves to limited contact with a small group people, the virus “dies out.” It takes enough time for the virus to finish with patient 0 (the first sick person) and the 2 other people who will likely get sick from that person as well. This virus is spread through coughing, sneezing, and otherwise having fluid spewed. 15 days is not nearly enough time to reduce the number of infected people. Even of only 5% of Americans get this virus (17,000,000) and 10% need intensive care we would need almost 1,000,000 ventilators. This is about 700,000 less than we have now. Without these ventilators people die, with them they live.
  2. Testing and contact tracing. Once we stop sheltering in place, the virus will still be with us. The countries that have successfully reopened have continued to test their populations and, once a positive is found, identified all of the folks they have come in contact with and placed them in “shelter in place” for 2 weeks as well. We not only have not invested in protective gear, we have not invested in this very basic public health workforce.
  3. Adequate personal protective equipment. 40% of those who became ill in China were associated with health care delivery, either as care providers or the families of care providers. Protecting health care workers is vital. Sending health care workers out to potentially die is unconscionable.

So, here we are. One choice is to shelter in place for the next month or three, put up with occasional outbreak which gets tamped down, and delay until a vaccine is developed. Another choice is to throw our hands in the air, declare this too hard, and sit back while 4,000,000 die a potentially preventable death. My colleagues and I believe the first choice is the only choice. Please discuss with the policymakers in your states.

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