March 13, 2020

*FOR URGENT CONSIDERATION*

To: Governor Greg Abbott
Re: The COVID-19 Outbreak in Texas - Medical Recommendations for Immediate Action

Dear Governor Abbott:

We appreciate the impossible situation you are in. You must balance people’s physical lives and people’s economic lives. You must balance your reputation, and our state’s place in history. You are surrounded by experts with vastly different opinions, because no one is an expert in a once-in-a-hundred-year event.

On a much smaller level, we see ourselves making decisions in the next two weeks on who will live and who will die because we don’t have resources sufficient to care for them. We have heard the stories second- and farther-hand from China and Italy and have no reason to think Texas won’t suffer the same fate. We truly must flatten the curve of impact on our healthcare system.

There are those who will judge you as being embarrassingly over-prepared or tragically under-prepared. We know which side we want you to be on - in this pandemic we cannot be over-prepared. Our citizens will step up in the face of the crisis. We will see the best in people come out. Be the voice that calls our citizens to action - donating salaries to those who make less at the local employer level, sharing childcare, neighborhood watches on our elderly, etc.

Here are the recommendations by health care professionals in Texas, following the lead of our colleagues in Oregon:

1. Establish and empower, with true autonomy to act on medical decisions, a full-time, multidisciplinary team of public health and medical experts (ID, ER, Critical Care, emergency response needed) who staff a central state-wide command center to direct a coordinated statewide response. This must include
a. A call center where front-line care providers across the state can call to coordinate transfers.
b. There should be an ethics team writing recommended guidelines for how to allocate resources when they become limited that is made public. First-come, first-served cannot be the answer. It will need to be utilitarian in nature.
c. A healthcare information line for front-line care providers with written, recorded and video updates that are meticulously kept up to date.
d. Ensure that all major metroplexes have up to date recommendations for Texans across the state with translational services keeping all information immediately updated when changes are made. Urban centers should be partitioned to service suburban and rural communities within specific catchment areas. This is the information people need to know how to stay safe and where to go as things get worse.
e. Coordination with physicians who can provide telemedicine consultations per CDC and state and local guidelines in order to reduce exposures. Texans with mild symptoms should not be advised to further expose our communities by showing up in crowded ERs and clinics. They should, however, be educated about symptom vigilance and social distancing practices.
f. Coordination with health professionals performing elective procedures or care that can otherwise be postponed to minimize transmission.
2. Liberate state resources now to support families who will miss work and school. We will need our community to step up and staff childcare centers in schools that aren’t necessarily licensed. People should have ways to collaborate on childcare sharing in their homes where no old people are. This is an important call to action for the community that will help keep low-income families supported. This will NOT be perfect and it will be better than if we don’t do anything. Priority needs to be given in school-based care centers to children of essential workers including healthcare workers, environmental service workers, essential service providers and first-responders).
3. Close all schools after tomorrow. Across the state. You will need to have #2’s plan figured out with food and childcare services by then to avoid panic. The school districts can close them but not without significant harm unless you assure them that food and childcare services will be coming as much as possible.
4. Eliminate all evictions and mortgage foreclosures until this passes.
5. Establish paid leave support for all vulnerable families.
6. Establish shelters that house people with and without COVID-19. You will likely need to take over hotels to get everyone off the streets immediately.
7. At least temporarily suspend SB4 and ALL 287(g) agreements that Texas counties have with Immigration and Customs Enforcement to ensure that undocumented people do not hesitate in engaging (public) health resources.
8. Work with county and municipal law enforcement to at least temporarily release all non-violent offenders from incarceration in order to mitigate certain disaster for those in congregant care facilities.
9. Demand of all Office of Refugee Resettlement shelters in the state of Texas that release to family of all incarcerated unaccompanied minors be expedited.
10. Social isolation recommendations go into effect - No one should leave their homes except for medical care, essential supplies, essential work services and compelling other reasons you designate. Virtual work options encouraged.
11. Hand sanitizer and masks should be available at the entrance to all businesses. In Thailand there are workers at malls who check temperatures on everyone entering the mall, put hand sanitizer and masks on the people entering. It is mandatory going inside any public spaces.
12. Expansive, safely executed, reliable testing is needed immediately however we currently do not have sufficient reagents and an allocation plan for these should be instituted as soon as possible. We must be able to identify infected individuals to care for them and take steps to decrease risk to others. Mobile, drive through testing must be instituted and preferably self-testing at home kits (similar to kits in Seattle supported by The Gates Foundation). Testing needs to happen outside of the ER and hospitals as much as possible. We support expedited roll out of the drive-through model.
13. Hospitals must be able to test outpatients, inpatients, and emergency room patients commercially.
14. A tracking method at the state level for people self quarantined must be instituted for public health tracking and follow up.
15. We will need COVID-19 positive and negative nursing homes. They cannot stay in the same facilities without severe risks.
16. Healthcare workers, including first-responders, are at high risk for infection and even death according to China’s experience. We immediately need sufficient and appropriate protective attire and comprehensive testing availability for all at-risk healthcare workers.
17. Ask that Praxair start stockpiling/making oxygen. They have time to start stock-piling it if they make it now.
18. The state should have a record of all available ventilators in the state and will be able to shift them to the areas with the greatest need. Anesthesia ventilators can be used in the ICUs if the ORs aren’t being used. Firefighter transfer vents may also be used.
19. There will not be enough masks, mechanical ventilators and potentially other medical supplies (intravenous fluids, antibiotics, resuscitation medications) to treat this infection. We need tactical and massive increased production of these resources.
20. Temporary ventilators will be needed in the near future - we should contract with innovators to create these now.
21. Medical workforce expansion plans need to be created and implemented.
22. The Texas Medical Board must work towards emergent and free licensing for medical personal so medical providers can cross states lines for patient care.

We ask you to take action now. Only you have this power. Our country and state have overcome adversity before. We need the tools to do it again.

In solidarity and gratitude,