Alabama’s health care system is bracing for a tidal wave of COVID-19 cases that could overwhelm a hospital system already stretched thin, to the point physicians are limiting testing as they attempt to conserve precious supplies to protect their front-line workers.

In Alabama, a USA Today analysis found that the state's nearly 15,300 hospital beds will be filled unless the infection curve can be flattened to spread over a six-month period. Any faster spike in cases — a fast infection rate and a surge of need for hospitalized care — will overwhelm the system. And in a state that has failed to shore up its rural health care infrastructure over the past decade, entire counties are now facing down a global pandemic with limited hospital resources or, in many cases, no hospital at all.

Alabama’s best hope is to use social isolation and distancing to suppress the rate of infection long enough to give its doctors a fighting chance of testing, treating and discharging patients without having to ration life-saving equipment

"It would not bother me one iota if they came down and shut down the state,” said Dr. Ted Cox, a physician in rural Winfield, Alabama. “If it was my decision, we would come in and anything that was not essential would be shut down. Right now, we will be overwhelmed. We will not be able to take care of the number that are sick. I don't know if we can reverse out of that."

Just 11 days after the first coronavirus patient was confirmed in Montgomery County, the number of cases swelled to 242 statewide as of March 24. But Alabama was behind many states in ramping up its testing, and many health care workers say they’re rationing testing in an attempt to conserve critical protective equipment for nurses and doctors on the front lines.

Public health officials have continually cautioned that the worst is yet to come, and cases continue to rise.

But it’s hard to visualize something you’ve never experienced before, Cox admits. The rural doctor describes a scene in the disaster film "Twister," when winds start whipping at a drive-in movie theater. One character, reading the radar, yells that the twister is coming. But Bill Paxton, staring at the sky, knows otherwise.

"The tornado is already here," Cox said.

Cox doesn’t spook easily: “I’m not a real excitable guy.” But echoing the calls of others, he says Alabamians must take precautionary measures social distancing seriously, and they must take it seriously now.

“We're in unknown territory. Absolute unknown territory.”

Rural populations are at risk

USA TODAY’s analysis estimates 23.8 million Americans could contract COVID-19, the illness caused by the novel coronavirus that first appeared in Wuhan, China. That number is based on an infection rate of 7.4% — similar to a mild flu year. Experts say this infection rate is likely to be far higher.

USA TODAY gathered population figures from the Census and hospital bed data from the American Hospital Association, which counts figures from community hospitals – "all nonfederal, short-term general facilities. It also includes academic medical centers and other teaching hospitals if they are nonfederal. It doesn't include prison hospitals or college infirmaries."

Based on World Health Organization data, the analysis estimated 13.8% of diagnosed patients would develop severe symptoms and 6.1% with critical symptoms would need hospitalization.

"The World Health Organization defines a case of COVID-19 as severe if patients have shortness of breath, low blood oxygen, acute respiratory distress, and fluid buildup in their lungs. People in critical condition also experience respiratory failure, septic shock or multiple organ failure," USA Today noted.

More:US hospitals will run out of beds if coronavirus cases spike

Given these estimates, the analysis estimated nearly 360,000 Alabamians will contract the virus. Many of these people will recover, and some may experience zero symptoms.

Using WHO rates, the analysis estimates nearly 71,000 Alabamians will develop severe or critical illnesses.

Susie Shuford, 78, lives in Hayneville near Central High School with her 81-year-old husband, 40-year-old grandson and 3-year-old granddaughter.

Every adult member of her household is considered the most vulnerable to severe illness if they contract COVID-19. A data analysis by the Kaiser Family Foundation found Alabama ranks among the top six most at-risk states for its adult population. The analysis determined 46 percent of Alabama adults are considered “high-risk” adults, either aging or dealing with chronic health issues. Shuford’s son is on dialysis, making him extremely vulnerable to transmission, just as she and her husband are.

But if they were to get sick, or fear they’d been infected, they would have to drive at least 33 miles to Montgomery for testing or treatment. There’s no hospital in Lowndes County to treat them, and there never has been.

"It's all in the hands of the Lord," Shuford told the Advertiser by telephone.

As at least seven rural hospitals closed their doors and others limited services in Alabama over the past decade, physicians and hospital leadership made repeated pleas to expand Medicaid. A study group established by then-Gov. Robert Bentley recommended it.

Medicaid expansion under the Affordable Care Act would make anyone up to 138 percent of the poverty level — up to $23,336 for a family of two — eligible for health care benefits. For hospitals, this would bring much needed patients and revenue through their doors.

But the Republican-controlled Legislature has for years refused to take up the issue, citing fiscal concerns, as well as political concerns, tying Medicaid expansion to the Affordable Care Act, passed under President Barack Obama’s administration. But the fiscal concerns oft-cited by legislators don’t bear out: Though the state would have to put up around $168 million in its first year, the federal government matches the vast majority of state’s costs.

A 2019 UAB study estimated that Medicaid expansion would “reduce the state’s uninsured population by approximately 223,000 individuals while generating nearly $3 billion in new economic activity annually.”

Instead, hospitals closed and many of the remaining rural facilities are operating in the red or on razor-thin margins. A February report from health care analytics firm Chartis Group found that nearly 40 percent of the state’s remaining rural hospitals are considered “vulnerable” to closure, while 27 percent are designated “most vulnerable.”

In York, a town tucked in Sumter County on Alabama’s west border, its small hospital has 28 beds, none of which are ICU-designated. Hill Hospital has zero ventilators. Most patients who typically need that level of care must be transferred 30 miles to Meridian, Mississippi, a state with 249 of its own cases as of March 24, or 70 miles northeast to Tuscaloosa.

They had no COVID-19 patients as of last week, but are trying to prepare for the cases to come.

CEO Loretta Wilson said on March 18 they’re considering leaning on retired nurses, hospice workers and school nurses. They’ve converted the hospital’s front lobby to serve the general patient population — the every day emergencies and illnesses that will occur as coronavirus spreads — to reserve the ER for symptomatic COVID-19 cases. They're also considering converting a vacant building into a screening center.

Emerging research suggests COVID-19 can be highly infectious and easily spread by carriers who have it, but aren’t symptomatic. Countries such as South Korea have seen success in severely suppressing cases and infection rates by widespread testing, identifying and isolating asymptomatic carriers and treating those who need it.

But every health care professional in Alabama the Montgomery Advertiser spoke to said state health care facilities have so few resources, widespread testing is not a possibility, meaning asymptomatic COVID-19 carriers may be slipping through the cracks as workers strive to conserve precious equipment.

“We have very, very limited testing kits,” Wilson said. “We are not testing anybody who does not have the symptoms, because we just don’t have the testing kits to do so.”

The lack of personal protective equipment, or PPE, is a catch-22 for the state. Testing bias, or relatively low or stable confirmed case numbers due to low testing rates, may lull Alabamians into a complacency about where, how fast or in whom COVID-19 is spreading. But physicians and nurses must conserve PPE to treat the wave of patients they know is soon to break at their feet.

“I know we do not [have enough],” Wilson said. “What we’re using is some that we had here when we had other viruses we were preparing for like Ebola.”

Bullock County Hospital in Union Springs, Alabama, has no ICU rooms and a single portable ventilator used only when transporting patients elsewhere. They also foresee a PPE shortage and are hoping to lean on expired equipment

“Since an emergency has been declared there are some expired PPE that ADPH has said that they can release and we have applied to get some of that,” said CEO Sharon Lee, who did not yet know a timeline of when to expect those materials if approved. “We’ve reached out to everyone of our vendors, even vendors that we don’t normally use. We’re reaching out to anyone and everyone to get what we could possibly need.”

Rural hospitals around the state have surge plans in place to transport patients to larger, better equipped hospital systems.

Dr. Sarah Nafziger, the co-chair of UAB’s emergency management committee, acknowledged Tuesday the lack of PPE equipment around the state, which she said was due to issues outside of "local control."

"This is an unprecedented time, and we're making decisions based on what's best for everyone based on what we have in supplies today," Nafziger said.

'Everyone has a responsibility to save lives'

In Winfield, Cox said the city, which owns its hospital, began taking action more than two weeks ago when doctors saw "the handwriting on the wall." Cox, an OB/GYN with admitting privileges at the hospital, ended all elective procedures at his practice. The hospital shortly followed suit. Internists begin checking in patients for daily appointments in the parking lot, fearful of infection spread in waiting rooms.

Though Winfield does not yet have a confirmed case, Cox expects in the coming days to be called on to supplement hospital staff.

"There is no way that we can handle a huge rush of people," Cox said. "If we overrun the medical facilities because we have too many cases at one time, there's no way we can handle it. We have three ventilators in this hospital. What a horrible, horrible, horrible situation it will be. You can just look to the folks in Italy, who have to decide who gets these ventilators and who doesn't."

Health care practitioners and public officials are straddling a fine line of hammering home the importance of social distancing without causing panic.

"You don't want people to panic, but we must do anything and everything we can do to get the word out: Do not expose each other. Do not take the risk," Cox said.

Though hospital space is a major concern, the more pressing one surrounds ventilators, the respiratory machine that critical patients needs to help their bodies breathe as they fight the COVID-19 infection.

According to the Alabama Hospital Association, there are currently 1,344 ventilators statewide, about 40 percent already in use. Though some rural hospitals have a handful at their disposal, many of the devices are concentrated at large hospital systems.

But even the state's premier medical institutions are already feeling the strain. In Jefferson County, the state's epicenter for confirmed cases, 18 of UAB's 45 COVID-19 patients are currently on ventilators, about 15 percent of its total capacity.

In a sober statement on Tuesday, Nafziger said UAB is tracking "rapid community spread" of the illness. Hospitalizations of COVID-19 patients at UAB nearly tripled in a 24-hour period on Tuesday, far outpacing the hospitalization estimates given by public health officials.

"It is known to us as leaders in UAB Medicine that we will have to make some very difficult decisions in the coming days and weeks," Nafsizer said. "We ask for your cooperation, and we ask for your prayers for our health care workers as we face this unprecedented event."

The state developed a protocol in 2010 on how to ration ventilators in the case of shortages, which the Alabama Department of Public Health said Tuesday was not a "directive."

The protocol says that if a hospital exhausts all other resources to provide access to ventilators, it may shift their use away from individuals suffering end-stage organ failure, including neurological failure.

“Decision(s) for care remain those of the medical professional, as the treating provider, in discussion with the patient and the patient’s family,” ADPH said in a statement Tuesday. “Sometimes clinicians at the bedside will be faced with very difficult decisions, and in a true catastrophe, clinicians will be tasked with making the best possible decisions.”

Cox, speaking from his northwest Alabama farm late Sunday, said he's had just a "couple" of situations in his life where he's had to make similar decisions.

"It's a scary thing. You've got three patients laying there and you have to choose. It's a horrid, horrid, horrid experience. And we're fixing to have physicians who are going ...," Cox said, trailing off. "We're trying our best to have nobody in that position. As long as we can keep the number of cases manageable, and spread it out. In my opinion, it's going to come. We're going to have a whole lot of folks who are going to get this. We're going to be wrestling with this in May and June."

On Tuesday, Nafziger pleaded with the public to do their part and stay home.

"I want to be clear in what I'm saying about what this drastic and rapid increase means to our community," Nafziger said. "This is a dangerous situation that our community needs to take seriously. Everyone has an important responsibility right now to save lives."

But despite public health consensus and scientific evidence that social distancing is the strongest tool at our disposal to slow the spread of infection, widespread public shutdowns have morphed into a partisan football over competing economic concerns, resulting in piecemeal directives from city and state leaders.

As Birmingham on Tuesday issued a citywide "stay at home" directive on the heels of UAB's hospitalization numbers announcement, Gov. Kay Ivey appeared reluctant to discuss further orders to keep Alabamians at home.

"The safety and well-being of Alabamians is paramount," she said on a Tuesday conference call. "However, I agree with President (Donald) Trump that a healthy and vital economy is just as essential to our quality of life. ... It’s a balance, and we are trying to strike the appropriate balance as we move forward."

Cox on Sunday said he understands the social distancing and essential shutdown of public life is a bitter pill to swallow, as many may lose their jobs and watch their retirement savings dwindle. But the alternative would be an "astronomically high" death rate.

"We have got to do what it takes to keep the death rate down. The only thing that's been shown to help is to spread out the cases so the medical facilities can keep up," Cox said. "I hope it doesn't go this way, it would be an absolute blessing for it not to go this way. But we can't put a price on somebody's life."

Brian Lyman contributed to this report.