John Kitzhaber: “The Coronavirus in Oregon”

This is a true emergency. It is imperative that we move beyond a public health response (as important as that is) to an Emergency Response.

In addition to the important efforts to contain the spread of the coronavirus, Oregonians need to feel certain that the state’s health care system is prepared to deal with the medical consequences of those who become infected—and especially of those who require hospitalization.

 

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The coronavirus is now a full-blown pandemic. The steps being taken in an attempt to slow the spread of COVID 19 have disrupted the global economy with a direct impact on national, state and local economies. For example, the cancellation of large gatherings, conventions and sports events has had a disproportionate impact on lower wage workers in the hospitality and service industry, over forty percent of whom have no paid sick leave; school closures create significant child care issues for working parents; the list goes on.

However, the real problem is not the coronavirus itself. The real problem is:

• The fragility of global supply chains
• The lack of a true social safety net
• The regressive impact on low income people and those without health insurance
• The lack of capacity in our health care system
• The danger of panic, hoarding and blame, leading to community disintegration

While addressing the economic and social impacts of this pandemic will require a massive and effective intervention from the federal government, the responsibility for on-the-ground, day-to-day management of this challenge will fall to state and local jurisdictions.  At the state level we must start with a clear-eyed assessment of what we cannot control, and what we can control—and focus most of our time and energy to the latter.

What we cannot control

1. The fragility of global supply chains
2. The impact of the pandemic on the global and national economy
3. The wealth and income disparity that underlies the lack of a safety net
4. The availability of testing
5. The timing of the development of an effective vaccine

What we can control (or significantly influence)

1. The further spread of the virus in Oregon
2. The response to the social and economic disruption
3. The capacity in our health care system
4. The community response

In Oregon we are acting on the first two things we can control

The state, local jurisdictions and the private sector are taking actions to try to slow the spread of the virus including: public education on steps individuals can take, including “social distancing;” increased use of tele/video conferencing; universities going to online teaching; closure of primary and secondary schools; cancellation of large gatherings and events; cancellation of visitation to prisons. etc. The state is also taking steps (which should be facilitated by the president’s declaration of a National Emergency) to address some of the worst social and economic impacts of the steps taken to slow the spread of the virus—for example, making provisions for meals for those children who rely on the school free lunch program to fill a significant part of their daily nutritional needs.

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The areas where we appear to be far behind the curve are (1) expanding the capacity of our health care system; and, (2) helping Oregonians and Oregon communities in responding to the pandemic.

 

Capacity in our health care system

This is a true emergency and we need an Emergency Response Team, and Emergency Response Team Leader and the rapid development and execution of an Emergency Response Plan. Every day that goes by without an aggressive, coordinated Emergency Response Plan, undermines the likelihood that we will be able to successfully respond and manage the potential of a dramatic increase in hospital admissions.  Therefore, it is urgent that we move beyond a public health response (as important as that is) to an Emergency Response.

Our health care system is currently not prepared to deal with the potential magnitude of COVID 19. To illustrate this, let’s make some assumptions, based on experience in other countries where around 15% of those who contract the coronavirus require hospitalization and 5% require treatment in an ICU. Let’s assume, for argument sake, that 2.5% of Oregonians contract coronavirus (this could be high or low, but offers a benchmark for scenario planning). This would be 100,000 Oregonians. Furthermore, given the rate at which the virus has spread in other countries, we could reach this number by June.

Assuming that 15% will required hospitalization, we are looking at 15,000 admissions. Assuming that 5% will require intensive care, we are looking at the need for 5000 ICU beds. Currently, Oregon has 6,729 staffed hospital beds and 776 ICU beds. In short, currently we simply do not have the capacity to deal with this. Even assuming that only one percent of Oregonians contract the virus, we are still looking at 40,000 cases; 6,000 admissions, and the need for 2,000 ICU beds—far beyond our current capacity.

This means that unless we rapidly increase our capacity (and probably, even if we do) we will be forced to triage care—sometimes lifesaving care— for very sick people both among those with COVID 19, and between those with COVID 19 and those with other unrelated, serious medical problems. This will take place at a time when we are already boarding people in our ER’s because of the weaknesses in our behavioral health system. Of even greater concern is the reality that this potential wave of admissions for treating coronavirus will take place in an environment of deepening scarcity caused by the impact that the intersection of demand and the disruption of global supply chains will have on the availability of key supplies including, but not limited to: pharmaceuticals, saline and other fluids, oxygen, ventilators and protective gear. The lack of protective gear could easily lead to health care workforce shortages as some frontline workers begin to contract the disease.

Actions

1. Immediate appointment of an Emergency Response Team with the authority to develop an Emergency Response Plan and to manage and coordinate all resource allocation decisions related to the pandemic. State agencies would be partners in the execution of this plan. The plan must include, among other things:

• • Bed management and coordination, allocation of limited resources and patient triage, if necessary. The latter should be planned for in advance with deep involvement of the OHSU Center of Ethics in Health Care and other like resources.
  • Immediate development of statewide inventories of key supplies and resources. This needs to go beyond just counting masks. We need to be proactive and creative—for example, how many people in Oregon who have been diagnosed with sleep apnea have a CPAP (continuous positive airway pressure) machine sitting unused in their home?
  • First responders and front-line workers should be given initial priority on protective gear to ensure an adequate health workforce.

2. Immediate steps to expand “quarantine” hospital bed capacity

Currently we have 36 cases of COVID 19 in Oregon (up from 1 case on February 28). Because of the lead time required, we need to start addressing the bed capacity issue now, not when we have 3,000 cases and rising. At the very least, this effort must include:

• The identification of facilities/beds that could be ready in the shortest period of time to be used for the COVID 19 admissions (e.g. Peace Health facility in Eugene—104 beds; Tuality Hospital in Hillsboro—215 beds). Obstacles and issues that would have to be overcome must be identified as well as strategies to address them. This would require a high degree of collaboration and coordination among all hospitals in Oregon.
• The identification of facilities/beds that will take longer to bring online. For example, fundraising efforts are underway to open three of the nine wings at the Wapato Jail facility for people experiencing homelessness. What would it take to use these wings to expand capacity for managing those with coronavirus who need inpatient care, but not ICU care? There is no reason why this capacity could not still be used for the original purpose once the pandemic is over and, indeed, some of the investments in the facility that would be needed in the short term, might be an asset to the long-term goal around homelessness.

 

Community response

This is an extremely important aspect of managing the pandemic. Anyone who’s been to the grocery store recently will see empty shelves and long lines of worried people stocking up on food, household cleaners and everything in between. Some of this may be due to the expectation that they might be quarantined or that they will self-isolate to reduce the chances of exposure.  Much of it however is due to the uncertainty that has been created by the pandemic – hoarding behavior— which reflects an “every person for themselves” response rather than a “we’re all in this together” response.

We need to do everything we can to foster and build up the second response because a central aspect of managing through this challenge is engaging and supporting our communities. It is also critical that our communities be aware of and understand the stress that the pandemic can potentially place on our health care system and what steps are being taken to get ahead of and manage that challenge. It is critical, therefore, that we actively and proactively work to prevent panic, hoarding and blame.

The best bulwark against these things is close communications with communities through trusted messengers—ensuring people that they are not alone, keeping them apprised of what is going on and, especially, how they can help and support one another. Oregon already has a network of community-based problem-solving and delivery structures, including: watershed councils, regional solutions teams, early learning hubs and coordinated care organizations. We should be activating these groups to participate in a coordinated, well-thought out message of reassurance, of what to be concerned about; what not to be concerned about; and of the steps being taken and progress being made to address the virus itself, as well as its economic and social consequences.

Notwithstanding these divisive and difficult times, there is an opportunity here —and I think an imperative—for us to pull together as Oregonians. We can respond to this pandemic by retreating into fear and blame and suspicion toward one another; or we can do what we have done so many times before. We can remember that we are truly all in this together, that the coronavirus does not respect income, partisanship or political ideology; and that by facing this challenge together, as a caring and compassionate Oregon community, we can emerge stronger and more united than when we began.