Alabama is grappling with surging deaths as COVID-19 cases and hospitalizations remain high and intensive care unit capacity is stretched.
The state reported record numbers of new cases and hospitalizations following the holidays. At one point last week, only 39 ICU beds were available statewide.
This week has already been the deadliest of the pandemic in the state, according to an analysis by The COVID Tracking Project.
"I'm forever an optimist, it's going to get better. But I'm kind of tired of doing death certificates," Dr. Julia Boothe, a rural family medicine physician in Pickens County in western Alabama, told ABC News. "I've done a whole lot over the past few months. I do them in an online system, and unfortunately I have my password memorized because we've just had to do a lot."
The state's seven-day average for new daily COVID-19 cases was 2,666 as of Wednesday, officials said.
"That's far below the spike in cases recorded earlier this month following Christmas, but way above averages recorded two, three, even four months ago," Gov. Kay Ivey said during a press briefing Thursday announcing that the state's mask mandate will be extended through March 5 due to the latest trends.
Alabama has one of the highest COVID-19 hospitalization rates nationwide, according to The COVID Tracking Project, behind only Arizona, Nevada, Georgia and California.
Currently, the state has 4% of its ICU capacity available, down from 6% two weeks ago, according to Johns Hopkins University.
As case numbers and hospitalizations have recently started to decline, ICU capacity and ventilator use hasn't improved at the same rate, Dr. Donald Williamson, president of the Alabama Hospital Association, told ABC News.
"That tells me the people we're hospitalizing now are sicker than they were a week ago, 10 weeks ago," Williamson said. "That's very concerning."
Williamson believes an "aggressive" use of monoclonal antibodies has helped decrease the number of COVID-19 hospitalizations in the state. Though availability of the treatment -- meant for high-risk, non-hospitalized patients with mild to moderate symptoms -- can be limited. Hospitals have been receiving less than half of what they've requested, Williamson said.
Boothe told ABC News it could take up to 12 days for her patients to get scheduled for the treatment. By then, they may already be hospitalized and no longer eligible.
"It's really frustrating," Boothe said. "The thing with COVID is, if you can do something early, you actually can make a difference."
Another concern for Boothe throughout the pandemic has been COVID-19-positive patients delaying seeking treatment.
"Everyone's afraid of going to the hospital," Boothe said. "That's something we traditionally battle in rural areas, maybe a little bit more in Alabama."
Part of that is owed to the "Tuskegee Effect," Boothe said -- a distrust of the health care system among the African American community stemming from an infamous 1930s syphilis study in Tuskegee, Alabama. It's something front-line workers are used to addressing, she said, though the pandemic "complicates things to another level."
Another challenge: Pickens County has been without a hospital throughout the pandemic. The county's only hospital closed in early March, citing financial strain. It was a familiar story; most rural hospitals in the state operate in the red, and six shuttered from 2011 to 2017, according to the Alabama Hospital Association.
On top of that, Pickens County also had several primary care clinics recently close, Boothe said.
"The pressure of all that, with no local hospital backup, has been huge," she said.
Other health care workers are feeling the strain.
"The people who are on the front line who are providing care for these patients, they're tired, they're stretched," Jimmy Stout, director of quality and safety in the University of Alabama at Birmingham's special care unit, told ABC News.
The 12-bed unit, which works to wean patients off ventilator support, is currently full, Stout said, with typically nearly half of patients recovering from COVID-19 at any time.
"We are problem solvers, we're going to keep figuring it out. But it's taxing on your staff," said Boothe, who has had some employees quit during the pandemic. "It's just hard being in health care right now. At the end of the day, it's just hard."
With the Centers for Disease Control and Prevention warning that the more transmissible U.K. variant could become the predominant coronavirus strain in the U.S. by March, that puts more pressure on vaccinating people, Williamson said.
As of Thursday, Alabama had the lowest rate of administered doses in the country, according to CDC data.
State health officials said they were working to speed up vaccinations after residents complained about the slow rollout.
"People certainly have a right to expect that we can do things faster. I think we can also do things faster," Dr. Scott Harris, the state health officer, said during Thursday's briefing.
County health departments have been instructed to administer doses until they run out and suspend some clinical services to divert staff, Harris said. The state has also finalized a partnership with Walmart to administer the vaccine in its pharmacies and increased the number of providers eligible to receive it. Only a little over half of those 502 providers have actually received any doses due to limited supply, though, he said.
"We simply don't have enough to go around," Harris said.
In the meantime, the governor urged people to continue to take precautions.
"Quite frankly, we've run out of ways to underscore the importance of taking this virus seriously. And ironically, it's not very complicated," Ivey said. "Wear your mask, wash your hands, sanitize places where you are and if you're experiencing symptoms, please go get tested and wait until you received the results before you interact with others."
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