Delivery of Care

As the world churns

The world as we know it has been forever changed, disrupted by a pandemic, with U.S. mayors and governors forced to take dramatic action to protect residents from a virulent disease that does not recognize boundaries, borders or walls

Photo by Richard Asinof

Gov. Gina Raimondo speaks at the news briefing on Wednesday, March 11, as Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, and Stefan Pryor, secretary of Commerce RI, look on, while a sign interpreter translates for the benefit of the live Facebook streaming presentation.

By Richard Asinof
Posted 3/16/20
The world as we know it has been disrupted by the rapid spread of the coronavirus pandemic, forcing major changes in our culture and in our economy, underscoring the importance of investments in public health as a major determinant of future economic prosperity.
Does the state of Rhode Island have a preparedness plan in place for economic development in response to economic downturn and a national recession? How has the COVID-19 pandemic made the economic case for a single-payer government run health plan? How has stigma influenced the decisions around Rhode Islanders willing to seek testing for the coronavirus? How has the lack of testing made it difficult to measure the degree of community transmission of COVID-19 in Rhode Island? Why did Lifespan choose to lay off some 300 workers at the height of the coronavirus pandemic? What is the likelihood that public schools in Rhode Island will not reopen for at least a month?
The onslaught of the COVID-19 disease has turned almost everyone in the news media into a health care reporter, with a constant barrage of breaking news covering the rapidly changing front lines.
If and when a sense of normalcy returns to Rhode Island, the U.S. and the world in the aftermath of the COVID-19 pandemic, how much of the disruption in our lives will take on a kind of permanence in changed habits?
Like it or not, the public health emergency has demonstrated the important role that government, particularly public health, plays in our lives and in our economy. Further, as much as there has been heated debate about the costs of moving to a single-payer public health plan, the reality is that we have already done so in response to the COVID-19 pandemic – if anyone stops to consider the political ramifications.
Imagine what would happen if President Trump [his test was reportedly negative] or members of his family were to test positive for the coronavirus.

PROVIDENCE – A month ago, ConvergenceRI had asked, presciently, in rhetorical fashion: “What does public health have to do with future prosperity in Rhode Island?” in the headline to an in-depth story reporting on the “R.I. Innovates 2.0” future economic plan for the state, developed by CommerceRI, which had inexplicably left out any discussion of investments in public health infrastructure. [See link below to ConvergenceRI story, “What does public health have to do with future prosperity in RI?”]

That question is now front-and-center in the struggle to contain and to mitigate the spread of the novel coronavirus, renamed COVID-19, with our lives and our future economic survival hanging in the balance.

The world as we know it has come crashing down, as the rapid spread of COVID-19 continues its rampage across the globe, threatening to bring the U.S. economy to its knees and to push the country into a deep recession as travel has been restricted, large gatherings and concerts have been canceled, and all professional and collegiate sports have suspended play.

Beyond asking about investments in public health infrastructure in Rhode Island, perhaps the most important question that now needs to be asked is this: Does the state of Rhode Island have an economic preparedness plan in place to respond to a major national economic downturn and recession?

If the onset of new cases of COVID-19 follows the same epidemiological pattern found in China, in Italy and in Spain, Rhode Island and other states across the U.S. can expect to see an exponential escalation in the coming weeks, with its potential to overwhelm the existing public health infrastructure – with hospitals challenged by the lack of ICU beds, the lack of ventilators, the lack of nurses, and the lack of protective gear.

Indeed, the Centers for Disease Control and Prevention have been working with a team of epidemiologists that are experts in mathematical modeling to look at different scenarios for a potential influenza epidemic. That modeling work has now been retooled with the priority focused on the coronavirus, according to Ira Longini, co-director of the Center for Statistics and Quantitative Infections Diseases at the University of Florida, a member of the group convened by the CDC, as reported by The New York Times in the March 13 story, “Worst-Case Estimates for U.S. Coronavirus Deaths.”

The goal of the work is to develop a better understanding of how the virus might ravage the country, and what measures could slow it, and how far Americans will go in adopting or accepting socially disruptive steps that could avert deaths, according to Longini.

The modelers are working within four different ranges of assumptions, including: the rate of how many people would be infected by a person with the coronavirus [the rate of community transmission]; the hospitalization rate; and the mortality rate for those experiencing symptoms.

Other factors the modelers are looking at, according to the New York Times story, are calculating the impacts of community actions such as closing schools and the supply of respirators. “Those actions include testing for the virus, tracing contacts, and reducing human interactions by stopping mass gatherings, working from home and curbing travel,” according to the story.

What the numbers say in Rhode Island
The latest numbers released by the R.I. Department of Health appear to confirm the exponential growth curve of new cases. On Monday, March 9, there were 3 cases of residents who had tested positive for COVID-19, with 53 negative tests, and 6 people with results from tests pending, with approximately 290 people in self-quarantine.

Five days later, by Friday, March 13, there were 14 people who had tested positive for COVID-19, 142 people with negative test results, with 29 people with tests pending, and approximately 500 people in self-quarantine.

By Saturday, March 14, the number of people who had tested positive for COVID-19 had grown to 20, according to the R.I. Department of Health; with 198 negative tests, 57 people with tests pending, and approximately 600 in self-quarantine. By Sunday, March 15, the number of people in self-quarantine had reached 2,300.

Translated, in less than a week, the number of cases of COVID-19 in Rhode Island had jumped from 3 to 20, a 667 percent increase, with the number of people in self-quarantine escalating from 290 to 2,300, a 780 percent increase.

The relative small number of testing results to date here in Rhode Island appears to reflect the narrow protocols established initially by the federal Centers for Disease Control and Prevention as well as what appears to be a strategic decision made by state health authorities and by the Governor not to focus on testing.

“Don’t underestimate the importance of washing your hands,” Dr. Nicole Alexander-Scott said, lecturing the news media at the March 13 news briefing. “Testing is helping,” she said, “but social distancing” was the key strategy now in order to flatten the curve, she said.

All testing for the coronavirus in Rhode Island is being coordinated through the R.I. Department of Health, with requests being made through physicians calling a hotline, and then appointments being made for patients to be tested at a drive-through location, facilitated by the R.I. National Guard. Testing of samples is being conducted by the State Health Laboratories, with positive results considered presumptive until these results have been confirmed by the CDC.

Such a system assumes that a patient with symptoms has ready access to a primary care provider and to health insurance. [Plans to ramp up drive-through testing sites in Providence and Warwick have apparently stalled, despite Care New England President and CEO Dr. James Fanale announcing in an interview on the Dan Yorke Show on WPRO on Wednesday afternoon, March 11, that the opening of these two sites was imminent. The drive-through testing site on the campus of Kent Hospital in Warwick is slated to open on Monday, March 16, according to sources, with all appointments for testing scheduled by the R.I. Department of Health.]

How that will change with the new public-private partnerships regarding testing announced by the White House on March 13 remains an unknown factor. In Rhode Island, as of March 14, testing and screening for COV-19 can now be conducted without prior insurance authorization and without any cost to the patient.

Another big issue around testing for COVID-19 may prove to be stigma. For instance, an elected official canceled a meeting with ConvergenceRI two weeks ago, having had “a 103.5 fever for three straight days,” saying they had been sicker than the person could ever remember being – but said they never went to be tested for the coronavirus. Why not?

When ConvergenceRI asked that question, having bumped into the elected official at the R.I. Department of Administration building last week, the person shrugged their shoulders.

Testing failure

The “failure” to institute large-scale testing for the virus during the last two months has meant that federal, state and local governments are flying blind, without the ability to track and monitor the community spread of the COVID-19 disease. Further, the continued difficulty in accessing tests by patients exhibiting symptoms has hindered the public health response to contain the spread, according to numerous public health professionals, epidemiologists and elected officials.

“If you really wanted to quarantine and contain the situation, you would have wanted to know who was positive and quarantine them,” said Dr. Peter Beilenson, director of Sacramento County’s Department of Health Services, in a story reported by Kaiser Health News. “Because we never had the tests, it’s kind of a moot point, and the horse is out of the barn.” As of Friday, March 13, Sacramento County had 17 confirmed cases of COVID-19, including one death.

“The problem is, is that we really need to as leaders make decisions looking forward to where this is going, rather than where it is today,” Washington State Gov. Jay Inslee said in a recent interview, whose state has become an epicenter of community transmission of COVID-19, with 510 cases and 37 deaths as of Saturday, March 14. “We might have 1,000 people infected today in Washington but this doubles every week in an epidemic like this, and so seven weeks from now we may have 60,000 people plus infected.”

Dr. Marty Markary, a medical professor at Johns Hopkins University, warned against Americans believing in the low numbers of confirmed coronavirus cases in the U.S., claiming that the actual number of people walking around with the virus could be “between 50,000 and half a million.”

The horse may be out of the barn, so to speak, in terms of the lack of testing and community transmission, but testing provides a level of awareness enabling front-line health care workers, students and teachers to respond with greater caution. The identification of a member of the Brown University community as testing positive for COVID-19 has preciptated Brown to announce on Saturday, March 14, that it was going "to expedite the departure of students from campus and to take steps to limited the exposure of Brown employees to the virus."

Similarly, school offiicials in Barrington were notified by the R.I. Department of Health that a school support staff member has tested positive for the coronavirus, according to an email sent to parents on Saturday, March 14, as reported by WPRI. Barrington schools are already closed next week, but offiicials from the school district said tha tthey would be consulting with the Department of Health regarding future steps.

Life, interrupted
Nationally, all the major sports leagues have shut down competition, and collegiate basketball and hockey championships have been cancelled. Major concerts and conferences have been cancelled or postponed. Broadway in New York City has gone dark. St. Patrick’s Day parades have been canceled in Chicago, in New York, in Boston and in Newport, and the running of the Boston Marathon has been postponed until the fall. Many colleges and universities have suspended in-person classes, moving to remote learning platforms. Numerous states have shut down pubiic school systems. The U.S. financial markets have moved from a bull to a bear market in record time, in less than a month.

From containment to mitigation strategies

Here in Rhode Island, the government’s response has been mostly focused on shoring up the public health infrastructure to contain the threat of the pandemic. The past week has seen a daily escalation of strategic interventions – first declaring a state of emergency, then banning public gatherings larger than 250 people, followed by the closing public schools for a week [and possibly longer], shutting down visitations at nursing homes, and finally closing down casinos, all the while stressing the importance of good social distancing habits such not shaking hands, avoiding crowded venues, and washing your hands with soap and water. All prudent measures.

Three times last week, Gov. Gina Raimondo held a news conference around the growing spread of the novel coronavirus, the event being live-streamed on Facebook, replete with sign language interpreters. After the first two news conferences, the Governor, as if by magic orchestrated by her communications handlers, appeared on MSNBC to tout her actions.

• On Monday, March 9, the messaging was targeted to businesses to “do the right thing,” as the Governor declared a state of emergency because it was a “tool in the toolbox” to leverage more federal aid. At the time, attending the session, ConvergenceRI imagined a scene where the Governor and Spike Lee shared the podium, sharing the same message. [See link below to YouTube trailer to the 1989 film, “Do the right thing.”] The risk for most Rhode Islanders remained low, both she and Alexander-Scott maintained.

• On Wednesday, March 11, the messaging changed to “we’ve got one chance” to get this right, to contain the rampaging virus, as the Governor urged everyone in the state to consider canceling any public gatherings involving 250 or more people and to avoid large public gatherings.

This time, ConvergenceRI imagined a scene with Eminem singing, “Lose yourself,” the theme song of Eminem’s semi-biographical movie, “8 Mile,” as a duet with the Governor.

“The moment, you own it, you better never let it go/ You only get one shot, do not miss your chance to blow/ This opportunity comes once in a lifetime.” [See link below to YouTube video of “Lose Yourself.”]

Once again, the Governor and Alexander-Scott stressed that while the risk remained low for most Rhode Islanders, the renewed focus was on social distancing, in order to “flatten the curve” of the coming pandemic, so as not to overwhelm the public health infrastructure in Rhode Island. [The news media, as the Governor remarked at the March 11 gathering, did not seem willing to follow her suggestion about social distancing, refusing to stay six feet apart from one another.]

• On Friday, March 13, the messaging was “Shut them down!” when it came to public gatherings, with a new urgency in her voice. She appealed to all residents, saying: “Every single Rhode Islander is on the front lines containing it. Every single one of us has to do your part.”

The Governor continued: “Avoid large crowds. Stay local. Stay here. Don’t panic. Don’t spread rumors. Don’t make it worse than it is.” The state, Raimondo said, was in the containment and mitigation stages. “We will get to the recovery stage.”

ConvergenceRI imagined a scene with Raimondo and Alexander-Scott sharing the podium with the Staples Singers, singing together the song: “Respect yourself.”

“Respect yourself/ Respect yourself/
If you don’t respect yourself/ Ain’t nobody gonna give a good cahoots…”

[On Saturday, March 14, the Governor and her team also held what has become a daily briefing update on the coronavirus in Rhode Island. The messaging around social distancing was expanded to include religious services. On Sunday, March 15, the Governor announced tha tall daycare and child care facilities were being asked to close as of Monday, March 16.]

The spread of lies, distortions and disease
Soon after the Governor’s news availability, President Trump held a news conference at the White House in the Rose Garden on Friday afternoon, March 13, to declare a national emergency. The event, however, was filled with distortions, lies and mixed messaging.

• In a time of social distancing, Trump kept shaking hands with the CEOs lined up behind him, sending the wrong message.

• Trump refused to take any responsibility for the problems related to the botched rollout of testing for the coronavirus, falsely attempting to blame it on the Obama administration.

• Trump then falsely claimed that Google was preparing a national screening website to help anyone who wanted to get tested, with Dr. Deborah Blix holding up a flow chart, allegedly depicting the screening website as a national effort. The website is being built by Verily as a pilot project in San Francisco.

• When asked by reporter Yamiche Alcindor about why his administration had eliminated preparedness planning for a pandemic in 2018, Trump called the question “nasty” and falsely denied he had done so.

• When pressed about whether he himself would be tested for coronavirus, having been in close personal contact with a number of people at Mar-a-Lago who have since tested positive foro COVID-19, Trump resisted saying whether he would agree to be tested. [On Saturday, March 14, Trump acknowledged publicly that he had been tested the previous evening. The test reportedly came back as negative.]

On the good news front, the U.S. House of Representatives passed bipartisan legislation early on the morning of March 14 that puts supports in place for American workers and makes coronavirus testing free. The measure would mandate paid medical and family leave, expand food security programs, and inject funding into state Medicaid programs. The legislation could direct some $150 million to Rhode Island’s Medicaid program, according to an estimate cited by Sen. Sheldon Whitehouse.

If nothing else, the legislative effort, led by House Speaker Nancy Pelosi, in negotiations with Treasurer Secretary Steven Mnuchin, has demonstrated how bipartisan efforts can succeed, even in a highly polarized political environment.

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