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

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
 ○ 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.

5
​https://www.covidexitstrategy.org/
6
​https://www.covidexitstrategy.org/
7

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/
 ○ 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.

13
​https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/
14

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
Leta Hice, MD, Internal Medicine/Hospitalist
Lee Ann Kelley, MD, Psychiatry
Amanda Kasem, MD, Pediatric Emergency Medicine
Lea Alhilali, MD, Radiology
Kristine Sellberg, MD, Cardiology
Sara Dhanani, MD, Neurology
Christina Kwasnica, MD, Physical Medicine, Rehabilitation
Carolyn Moats, MD, Family Medicine
Elizabeth Reynoso, MD, Obstetrics and Gynecology
Briana Wellington, MD, Obstetrics and Gynecology
Rashmi Halker Singh​, MD, Neurology
Dionne Mills, MD, FACOG Obstetrics and Gynecology
Julie Hastings, MD, Physical Medicine, Rehabilitation
Susan Zulke Hughes, MD, FAAFP Family Medicine
Sapna Amin, MD, Pathology
Himabindu Chaparala, MD, Nephrology
Charlene Shaughnessy​-​Volquardsen, MD, Emergency Medicine
Amaal Starling, MD, Neurology
Adrienne Kurland, MD, Internal Medicine/ Pediatrics
Ridhima Dabas, MD, Internal Medicine
Palak Patel, MD, Pediatric Anesthesiology
Amanda Rapp, MD, Family Medicine
Traci N. Fitzhugh, MD, FACOG Obstetrics and Gynecology
Nalini Tirumalasetty, MD, ECNU, FACE Endocrinology
Tiffany Lahr, MD, Pediatrics
Tiffany E. Hardaway, MD, Anesthesiology
Baharak Tabarsi, MD, Family Medicine
Juliana Kling, MD, MPH, Internal Medicine
Sheetal Chhaya DO, FACR, Rheumatology
Kari Evans, MD, Obstetrics and Gynecology
Christine Lovato MD, FACS, General and Bariatric Surgery
Mona Sodhi, DO, Internal Medicine/Obesity Medicine
Allison Peckumn, DO, FACE, Endocrinology
Christina Kang, DO, FACC, Cardiology
Reeti Chawla, MD, Pediatric Endocrinology
Hannah Lawther, MD, Radiology
Tiffany Nunnelley, DO, Family Medicine
Kimberly Chea, MD, Emergency Medicine
Lopa Misra Chhabra​,​ DO, Anesthesiology
Angela Valdez-Huizar, MD, Pediatrics
Carla Dormer, MD, Anesthesiology
Amy Schlaifer, MD, Urology
Lisa Buschmann, MD, Obstetrics and Gynecology
Christine Tymczyna, DO, Family Medicine
Erynne A. Faucett, MD, Pediatric Otolaryngology
Yarden Tahan, MD, Family Medicine
Dana Chase, MD, Gynecologic Oncology
Elizabeth L Wilson, DO, Emergency Medicine
Tina Byun, MD, Internal Medicine
Manisha Mehta, DO, Internal Medicine/Hospitalist/Nephrologist
Ashley Tian, MD, Pediatric Neurosurgery
Jacqueline Belen, DO, Gynecology
Maureen McCarthy, MD, Psychiatry
Shabana Pasha, MD, FACG, FASGE, Gastroenterology
Shana Wingo, MD, Gynecologic Oncology
Gailey Gonzales Ona, MD, Internal Medicine, Palliative Medicine
Jennifer O’Hea, MD, Critical Care/Pulmonary
Sandra Till DO, Pulmonary and Critical Care
Jennifer O’Hea, MD, Critical Care/Pulmonary
Michelle Ruha, MD, Medical Toxicology and Addiction Medicine
Julie Davis-Best, MD, Obstetrics and Gynecology
Rebecca Goldman, MD, Family Medicine
Amber Flaherty, MD, Hematology/Oncology
Sheetal Wadera, MD, Pediatric Gastroenterology
Elizabeth Carey, MD, FAASLD, AGAF, Transplant Hepatology
Rachel Deatherage, MD, Family Medicine
Judy Wu, MD, Family Medicine
Hospitalist
Krista Goulding, MD MPH, Orthopaedic surgery
Mariana Liu, DO, Internal Medicine/Pediatrics
Clari Borrero-Mejias, MD, Pediatric Neurologist
Yulia KoltzovaRang, MD, Internal Medicine
Gina Montion, MD, Pediatrics
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
Molly Solorzano, MD, Anesthesiologist
Amy Guzek, MD, Pediatrician
Iram Khan, MD. Internal Medicine
Kimberly Winsor, MD, Diagnostic Radiology
Mariah Scott, DO, FAAP, Pediatrics
Heather Menzer, MD, Orthopaedic Surgery
Lisa LeMond, MD, Advanced Heart Failure and Transplant Cardiology
Aristea Karabinas, MD, FACOG, Obstetrics and Gynecology
Sarah Sharer, MD, IBCLC, FACOG, Obstetrics and Gynecology
Katayoun Baniriah, DO, Family Medicine
Nicole C. Hoxworth, MD, Pathology
Sarah Bannister, DO, FAAP, Pediatric Hospitalist
Karen Stern, MD, Urology
Punal Patel, MD, Internal Medicine
Heather Holley, DO, FAAP, Pediatrics
Chhavi Manchanda, MD, FRCA, Pain Management/Anesthesiology
Stephanie Fountain, MD, Pulmonary/Critical Care
Sara Hall, MD, Anesthesiology
Nisha Bhatia, MD, Cardiology
Judith Rosch Barnes Clark MD, FAAP, Pediatrics
Sonya Mody, MD, Pediatrics
Jennifer Hill, MD, Allergy and Immunology
Cheryl A. MacKechnie, MD, Otolaryngology
Christine Brass Jones, DO, FACOOG, Obstetrics and Gynecology
Umaima Fatima, MD, Cardiology
Cindy Bauer, MD, Pediatric Allergy and Immunology
Annie Khurana, MD, Geriatrics and Palliative Medicine
Madhavi Boga​, ​MD, Internal Medicine, Hospitalist
Melissa Redleaf, MD, Pediatrics
Suzanne Sorof, MD, Cardiology
Harshita Paripati, MD, Hematology/Oncology
Jennifer Smith, MD, Internal Medicine
Susan S Pansing, MD, Adult Neurology
Amela Hozic, DO, Family Medicine
Kiranjit Khalsa MD, MPH, Allergy and Immunology
Dana I. Williams, MD, Pediatric Gastroenterology
Suganya Karuppana​,​ MD, CPE, CPHQ. Family Medicine
Leah Brown​,​ MD, Orthopedic Surgery
Patricia Drace, MD, Orthopaedic Surgery
Sandra Romero, MD, Pediatrics
Monica Viteri-Giordano, DO, Internal Medicine/Pediatrics
Nina Sukhrani, DO, Internal Medicine
Deepti Saini, MD, Ophthalmology
Aleta DaSilva, MD, FAAP, Pediatrics
Sara Kertz, DO, Pediatrics
Christina Martin, DO, Family Medicine
Ellen Giordano, MD, Pediatrics
Tabitha Moe, MD, Cardiology
Anupama Ramalingam, MD, Sleep Medicine
Gladys Martin, MD, Internal Medicine/Hospitalist
Sarah McKenna, DO, Family Medicine
Soyoung Park, MD, Hematology/Oncology
JulieAnn Heathcott, MD, Obstetrics and Gynecology
Jasgit Sachdev, MD, Medical Oncology
Nellie Farrington, MD Pediatric Critical Care
Amy Lee, MD, Internal Medicine
Cheryl Macy, MD, FACEP, Emergency Medicine
Jeanne Palmer, MD, Hematology, Blood and Marrow Transplantation
Tatyana Shekhel​, DO, Infectious Disease
Atsuko Koyama, MD, MPH, Pediatric Emergency Medicine
Amy Axberg​,​ MD, Emergency Medicine
Mary Kirkilas, DO, Pediatric Emergency Medicine
Ria Ghose Kundu, MD, Internal Medicine
Jacqueline May Carter, MD, Internal Medicine/Pediatrics
Laurie Jones MD, Pediatrics
Mary Atia, MD, Gastroenterology
Maya K Thosani, MD, Mohs Surgery
Punal Patel, MD, Internal Medicine
Taruna Ralhan, MD, Diagnostic Radiology