Marva Tsosie can see the world bustling from her window.
But for now, her only goal is to quarantine until she recovers from the fever, drowsiness and indigestion after testing positive for COVID-19.
“Everybody keep their mask on — hand sanitize,” Tsosie said. “I’m the one that washes my hands and I’m the one that got it.”
Tsosie was set up in the new hotel shelter last Monday after being moved from the now closed shelter at Hotel Aspen as part of a new partnership with Flagstaff Shelter Services. Tsosie is one of a few people who were transferred to the smaller hotel, which focuses on sheltering people who test positive for COVID-19 but do not have stable housing.
The county expects to pay the nightly room rate of people who have tested positive and are in stable condition. The shelter will continue to pay for the hotel rooms for clients to give them the space to social distance. Homeless shelters with bunk beds packed into one large room were deemed unsafe early on in the pandemic by the Centers for Disease Control and Prevention.
The new partnership is the result of a renewed attempt to create a response to COVID-19's impact on Flagstaff unsheltered population, including people who do not have stable housing, similar to a partnership that fell apart in May.
The Coconino County Board of Supervisors plans to release more information on the closing of the Hotel Aspen lease at the Oct. 6 board meeting.
In addition to the nightly room rate of quarantining patients, the county expects to support the shelter’s operations and staff costs at the new hotel. The official decision is pending board approval, according to Kim Musselman, county director of special initiatives.
“[The shelter] has been awesome to step into this space to work with us, knowing it was time to scale down the operation we had going at Hotel Aspen,” Musselman said.
Musselman and the shelter acknowledged that the census of Hotel Aspen was often low, saying that was in part because of the work the shelter had been doing to house unsheltered people.
“One of the biggest reasons [for the low census] is because of the work of Flagstaff Shelter Services, and other shelter partners as well, really limiting their congregate shelter operation,” Musselman said.
Ross Altenbaugh, director of Flagstaff Shelter Services, said the shelter often relied on the county’s health expertise, and described the partnership as a “win-win.”
“I feel great about it,” Altenbaugh said. “I think it makes sense for us to be working with this population. These are often our clients.”
The shelter is currently housing people out of three hotels, including the one being used as a result of the county partnership. The new hotel will continue to provide the same service as Hotel Aspen by providing a space for people who are housing insecure to quarantine if they are medically stable. More severe cases are managed by the Flagstaff Medical Center.
Since the shelter's clients were moved into hotel rooms after the COVID-19 outbreak in May among people at their congregate shelter, the other two hotels have had zero positive cases.
The county set up the hotel as an option for people who had insecure housing, and a way to help free up beds in the hospital. Musselman said the supervisors have been mindful of the public dollars being spent on the project, but were trying to find the best time to part ways with the hotel. Coconino County first tried to vacate the agreement with the hotel in May, but continued to use it when the state’s cases began to rise.
Both the county and shelter are looking for reimbursement from the Arizona Department of Emergency and Military Affairs and the Federal Emergency Management Agency. The county and shelter expect to be eligible for reimbursements on 75% of their separate costs so far. Musselman said the county hopes to find assistance with the remaining money.
The county spent $1.7 million on Hotel Aspen between March 19 and Sept. 4.
In total, the county has spent $3.5 million on its COVID-19 response and has only had $500,000 of its expenditures reimbursed.
The shelter has spent $2.5 million on housing 250 unsheltered people since moving their clients into hotels in May.
The shelter continues to be concerned about donations and income through grants and public assistance.
“We’re not talking about faceless people. We’re talking about people in our community who are our most vulnerable, sickest, and in the most need possible," Altenbaugh said. "But they’re also the people that take your credit card, drop off your Instacart or your takeout food. It’s a matter of my health is your health.”
After using biohazard-grade cleaners, the county handed Hotel Aspen back to the private property owner.
Musselman acknowledged there is a possibility that numbers could spike back up and more rooms could be necessary, but said the county would assist the shelter if that should happen.
“If there is a need to be increased, we will work hand in hand with Flagstaff Shelter Services to address other locations that may need to be utilized should numbers exceed current space that Flagstaff Shelter Services is operating in,” Musselman said. “We’re taking it one day at a time, and we can address that in the event it reaches capacity.”
When Northern Arizona Healthcare purchased Mountain Heart in April, the healthcare organization became the sole provider of cardiology services in Flagstaff until just this month, when Peak Heart & Vascular opened its Flagstaff office.
The idea for the Phoenix-based provider’s expansion to northern Arizona was prompted by an existing local practice, Flagstaff Family Care Clinic, whose primary care providers were struggling with the lack of nearby cardiology options.
“We have 14 providers and they came to me and said, ‘We can’t get our patients in. We’ve got three-month waits. We’re having to send our patients to Phoenix to see a cardiologist even for an office visit because we could not get them in in a timely manner,’” said Cindy Wade, practice administrator of Flagstaff Family Care Clinic. “So my mission was to go invite a cardiologist team that could come to Flagstaff.”
Wade researched various providers, considering references and the cost and availability to the clinic’s patients in northern Arizona, when reaching out to offer a partnership to increase local access to cardiovascular care, starting with Flagstaff Family Care’s patients.
“Whenever there is a specialty void in a community, it always affects the primary care providers as well as the patient,” Wade said.
The two practices are separate businesses and are each open to their own patients, but are working together to increase local access to cardiovascular care, a collaboration that extends to Flagstaff’s existing cardiologists.
Doctor of Nursing Practice Megan Engbring, who used to work at NAH, said she does not see the two cardiology practices as competitors, but instead as allies in the effort to improve the health of the entire northern Arizona community.
Engbring has worked in cardiology in Flagstaff for seven years and was one of the first patients at Flagstaff Family Care when it opened in 2006. She also worked there in primary care before transitioning to cardiology. This connection helped to spark Peak Heart & Vascular’s new office, which is located just two suites over from the clinic’s spot in the Yale Plaza.
“What I loved about Cindy’s idea to bring more cardiology here is just to increase the capacity for cardiology services. There is the demand for it, the patients feel it just in the volume. It’s hard for any one group to service all of northern Arizona,” Engbring said, explaining that, historically, there were cardiology outreach clinics throughout the region.
A benefit of the pandemic, she said, has been the ability to reach some of these more remote patients through the expansion of telemedicine, one of Peak Heart & Vascular’s specialties.
The practice, which has a total of 10 providers, allows same-day appointments and offers diagnostic and therapeutic cardiology services, vascular surgery and endovascular treatments as well as electrophysiology for patients with cardiac rhythm disorders. Physicians take turns working out of the new Flagstaff office every Friday, but those who are not in town are available via telehealth. The other two Peak Heart & Vascular offices are located in Surprise and Avondale.
“Most cardiac diseases need immediate attention,” said Dr. Kishlay Anand, who specializes in general cardiology and cardiac electrophysiology. “If you have to wait six months or so, that doesn’t help. A lot of these people need quick attention and improved access to care is critical. … Just imagine if somebody was having chest pain and they’re asked to wait to see a doctor.”
Anand said, despite the practice’s recent move to Flagstaff, patient volume has been increasing quickly.
“Our goal is to bring high quality cardiovascular care that’s easy access to the Flagstaff community,” he said, noting the physician-owned practice’s desire to serve “a full spectrum in the community.”
So far, this includes patients from areas including Flagstaff, Williams, Winslow, Kingman, Sedona, the Verde Valley, Kayenta and Tuba City.
Flagstaff Family Care previously partnered with Mountain Heart before its sale, which was prompted by the retirement of cardiologist Dr. Kent Winkler, who owned the practice since it opened in 2008. The clinic has a similar partnership with a provider in Sedona to offer neurology services, which Wade said are also limited in Flagstaff for the practice’s patients.
PITTSBURGH — President Donald Trump and Democrat Joe Biden kept up their debate-stage sniping from the road and the rails on Wednesday, fighting for working-class voters in the Midwest while both parties — and the debate commission, too — sought to deal with the most chaotic presidential faceoff in memory.
The debate raised fresh questions about Trump's continued reluctance to condemn white supremacy, his questioning the legitimacy of the election and his unwillingness to respect debate ground rules his campaign had agreed to. Some Democrats called on Biden to skip the next two debates.
Biden's campaign confirmed he would participate in the subsequent meetings, as did Trump's. But the Commission on Presidential Debates promised "additional structure ... to ensure a more orderly discussion of the issues."
One possibility being discussed is to give the moderator the ability to cut off the microphone of one of the debate participants while his opponent is talking, according to a person familiar with the deliberations who was not authorized to discuss the matter publicly and spoke on condition of anonymity.
Less than 12 hours after the wild debate concluded, Biden called Trump's behavior in the prime-time confrontation "a national embarrassment." The Democratic challenger launched his most intense day on the campaign trail all year, with eight stops planned for a train tour that began mid-morning in Cleveland and was ending 10 hours later in western Pennsylvania. Trump was to address voters and donors in Minnesota late in the day.
Biden balanced criticism of Trump with a call for national unity.
"If elected, I'm not going to be a Democratic president, I'm going to be an American president," Biden said at the Cleveland train station. As his tour moved into Pittsburgh, he accused Trump of never accepting responsibility for his mistakes, promising, "I'll always tell you the truth. And when I'm wrong, I'll say so."
While some Republicans feared that Trump's debate performance was too aggressive, he gave himself high marks as he left Washington. He had spent much of the morning assailing Biden and debate moderator Chris Wallace on social media.
"It was an exciting evening. I see the ratings were very high and it was good to be there," Trump said.
The first of three scheduled debates between Trump and Biden deteriorated into bitter taunts and chaos the night before as the Republican president repeatedly interrupted his Democratic rival with angry jabs that overshadowed any substantive discussion of the crises including the coronavirus threatening the nation.
Trump and Biden frequently talked over each other with Trump interrupting, nearly shouting, so often that Biden eventually snapped at him, "Will you shut up, man?"
Trump refused anew to say whether he would accept the results of the election, calling on his supporters to scrutinize voting procedures at the polls — something that critics warned could easily cross into voter intimidation.
Trump also refused at the debate to condemn white supremacists who have supported him, telling one such group known as Proud Boys to "stand back and stand by." Asked directly on Wednesday if he welcomed white supremacist support, he first said only that he favored law enforcement but when the questioner persisted he said he had always denounced "any form of any of that."
On Capitol Hill, Republicans showed signs of debate hangover with few willing to defend Trump's performance.
Utah Sen. Mitt Romney called the debate "an embarrassment" and said Trump "of course" should have condemned white supremacists.
"I think he misspoke," said South Carolina Sen. Tim Scott, the only Black Republican senator. "I think he should correct it. If he doesn't correct it, I guess he didn't misspeak."
Trump did not say he misspoke when asked on Wednesday but claimed he did not know who the Proud Boys were.
"They have to stand down — everybody. Whatever group you're talking about, let law enforcement do the work," he said.
The president's brash debate posture may have appealed to his most passionate supporters, but it was unclear whether the embattled incumbent helped expand his coalition or won over any persuadable voters, particularly white, educated women and independents who have been turned off in part by the same tone and tenor the president displayed on the debate stage.
With just five weeks until Election Day and voting already underway in several key states, Biden holds a lead in national polls and in many battlegrounds. Polling has been remarkably stable for months, despite the historic crises that have battered the country this year, including the pandemic that has killed more than 200,000 Americans and a reckoning over race and police.
Public health officials in the U.S. could take heart at the end of the summer. Even as the new coronavirus continued to spread, fewer people were winding up in the hospital because of COVID-19, and fewer were dying.
Now, as the seasons turn, there are signs suggesting there will be more deaths and serious illness ahead.
Data collected by the COVID Tracking Project shows that the number of people hospitalized has plateaued at about 30,000 in the past week, after a decline from nearly 60,000 that began in late July. Deaths, meanwhile, averaged about 750 over the seven days through Sunday, higher than the roughly 600 deaths a day in the first week of July.
Scientists had hoped that a warm-weather reprieve could soften an expected reemergence of the coronavirus in the colder months. Instead, the contagion continued to spread across the country after Memorial Day, with early-summer outbreaks in Sun Belt states followed by the recent surge of new infections in the Upper Midwest and on college campuses nationwide.
Any indication hospitals are attending to more coronavirus patients is likely to reignite concerns that the health care system could be overwhelmed by new cases as the weather cools and more activities, including school and holiday socializing, move indoors.
History and science suggest the second winter with coronavirus is likely to be worse than the first. The pathogen is more entrenched and most respiratory viruses circulate primarily in the winter months.
"We haven't had exposure to COVID throughout an entire winter, when more people are indoors and close together for prolonged periods," said William Schaffner, an infectious disease professor at Vanderbilt University in Nashville, Tennessee. "We are certainly concerned that COVID could spread even more readily in the winter than it has so far."
The Trump administration has pointed to the increasing availability of coronavirus tests as the reason the number of new cases in the U.S. remains high. Diagnostics manufacturers are now shipping more than 1.2 million tests nationwide each day, up from 600,000 at the start of May, according to AdvaMed, a trade group for the medical-technology industry.
Increased testing has also made it possible to catch coronavirus cases earlier. That, combined with improved hospital care and medicines such as Gilead Sciences Inc.'s remdesivir and generic steroid dexamethasone, allowed more patients to survive their infections this summer.
However, a weeklong plateau in new cases, hospitalizations and deaths are an early warning that things could be about to get worse. Along with the resumption of school, more states are easing curbs on restaurants and bars, giving the virus more chances to find vulnerable people to infect. Last week, Florida Gov. Ron DeSantis lifted capacity limits on restaurants and other businesses.
"It's not complicated to explain. All of that opening up, so many people taking off their masks, gathering together in bars and parties, going back to the old normal," Schaffner said. "We should not be surprised that we are seeing an increase in COVID again. COVID loves that environment."
States that had been doing well, including New York, which was wracked early on by the virus, are seeing a new surge. New York Gov. Andrew Cuomo said there were 868 new cases in the state on Sunday, an 18% increase from two weeks earlier. A higher percentage of those getting tested are now coming back positive, suggesting the amount of virus in the community is on the rise.
Similar increases are happening among the nation's children, as more than 56 million returned to school this month. More than a quarter of a million children were infected with coronavirus from March through Sept. 19, according to the U.S. Centers for Disease Control and Prevention.
While those hardest hit were more likely to have other conditions, about three of every four who were hospitalized, needed intensive care or died had no other health concerns, the CDC said.
The number of cases among children has increased dramatically since the start of September, when many went back to school in person at least part time.
Coronavirus cases in those 19 and younger have increased threefold since May, according to the CDC, suggesting they may play an increasingly important role in community transmission even if their individual risk of serious illness is low.
"School studies suggest that in-person learning can be safe in communities with low SARS-CoV-2 transmission rates, but might increase transmission risk in communities where transmission is already high," the agency said in its Morbidity and Mortality Weekly Report.