In states across the U.S., cases still on rise
When Gov. Doug Ducey allowed Arizona's stay-at-home order to expire on May 15, 340 patients were in intensive care units statewide due to the novel coronavirus - the largest number since the beginning of the pandemic. Public health experts at the University of Arizona spent the week before publicly pleading with Ducey to postpone reopening, suggesting cases in the state were still projected to grow.
About two weeks later, the maximum amount of time it takes the virus to incubate, Arizona began seeing a precipitous rise in cases and a flood of new hospitalizations, straining medical resources and forcing the state's top medical official to reissue a March order urging all hospitals to activate emergency plans.
What Arizona is experiencing could be an ominous sign. More than a dozen states are showing new highs in the number of positive coronavirus cases or hospitalizations, according to Washington Post data, a few weeks after lifting restrictions on most businesses and large gatherings.
The spikes provide disturbing data points for the ongoing tug-of-war between federal, state and local officials weighing the economic costs of restrictions meant to stop the spread of the virus with the human cost of lifting them.
"Worse times are ahead," said Joe Gerald, an associate professor and public health researcher at the University of Arizona who has been part of an academic team providing projections to the state health department. "The preponderance of evidence indicates community transmission is increasing."
Texas, Arkansas, South Carolina, Nevada, Arizona, North Carolina, Oregon, Florida and Utah all set new highs in seven-day rolling case averages Wednesday, according to Post data.
Montana, Arkansas, Utah, Arizona and Texas have all seen coronavirus hospitalizations rise by at least 35 percent in the weeks since Memorial Day.
Some states are pressing forward with reopening even as local officials point to data that suggests an increase, not a reduction, in the risk of transmission. The uptick may not directly correlate to reopenings in all states, as more robust testing or other localized factors could play a part.
Officials have also expressed concern that the virus could have spread among thousands of people protesting against police brutality, but experts said it is too early to determine the impact on case numbers.
Texas will begin allowing restaurants and businesses to operate at 75 percent of their normal capacity on June 12. The state set a new high in coronavirus hospitalizations for the third straight day on Wednesday and now has 2,153 patients hospitalized with the virus - more than at least 15 states have reported for the entire pandemic, according to The Post's data.
Gov. Greg Abbott, a Republican, let his state's stay-at-home order expire April 30. As he lifted restrictions, Abbott said he was keeping a close watch on hospitalizations and the rate of positive cases as the state rapidly expanded testing capacity.
"Every Texan who needs access to a hospital bed will have access to a hospital bed," vowed Abbott spokesman John Wittman.
Steve Love, president of the Dallas-Fort Worth Hospital Council, said the steady uptick in cases was likely linked to activities on Memorial Day.
"People need to be very careful and continue to social distance," he said.
Arkansas Gov. Asa Hutchinson, a Republican, announced Wednesday that despite rising case numbers, his state will be moving into Phase 2 of its reopening beginning Monday.
"Americans are on the move, and they can't be tied down, and they can't be restrained unless they make a voluntary decision that this is right for me and my health or my family," said Hutchinson, who added "there is no evidence of a correlation" between reopening of businesses and the rising case rates.
Appathurai Balamurugan, the state's deputy chief medical officer, said Arkansas is moving forward with reopening because the hospitalization rate had not dramatically spiked and the state is relying on contact tracers to determine the effect of reopening. He said only a small percentage of new cases were in people who visited restaurants, salons or other businesses.
Arkansas has established a new high in coronavirus cases nine times in the past 15 days, according to Post data.
In Arizona, Ducey, a Republican, has insisted he and his team expected a rise in cases to follow reopening, in part due to the doubling of testing statewide since mid-May. Leaders in Mississippi, Alabama, Florida, Texas and other states have also made similar statementsin recent weeks.
"We have anticipated increased cases in June," said Ducey spokesman Patrick Ptak. "We've spent the last few months working to increase capacity to ensure every Arizonan has access to care, should they need it."
South Carolina, which reopened most businesses by the end of May, has more daily cases than ever before, higher than a previous peak in April. Nearly 15 percent of all coronavirus tests statewide have come back positive. Hospital bed use is also increasing, although public health officials say that could be attributed in part to elective procedures put off earlier this year. The state set a new seven-day average for new cases Wednesday, the 14th time in 15 days it has done so, according to Post data.
"I am more concerned about covid-19 in South Carolina than I have ever been before," said Linda Bell, the state epidemiologist, at a Wednesday afternoon news conference, referring to the disease the virus causes.
Gov. Henry McMaster, a Republican, said the state would not reimpose any restrictions.
"Shutting down is not the answer," he said. "People have to be able to go and work for a living." He said South Carolina slowed the spread enough to "arm ourselves with the knowledge of what we need to do to be safe . . . We now need to practice what we have learned."
Tom Frieden, former director of the Centers for Disease Control and Prevention, said drawing direct lines from reopening to increases in cases skips potential nuances that exist in each state. In Michigan, he said, a large influx of tests is contributing to a rise in cases. In other states, like Arizona, positive test rates are outpacing the increase in testing, suggesting testing is not behind the rise.
"It's not a question of opened versus closed. We were never fully closed and until there's a vaccine, we won't be fully open. It's a question of modulating," Frieden said.
Traditional public health strategies usually value the insight local authorities have and prioritize the decisions they make for those they serve. But as states like Arizona and Arkansas reopen, local officials have found their hands tied by state restrictions.
Ducey's executive order lifting restrictions includes language that prohibits mayors and county officials from imposing further restrictions to help limit the spread of the virus locally.
"I can no longer put in place restrictions, for example, on nightclubs. We can't do additional health restrictions on things such as masking," said Phoenix Mayor Kate Gallego, a Democrat, who is prioritizing messaging urging people to wear masks and social distance.
"But we do still have control over our city facilities. Our senior centers are still closed. Our libraries are curbside only. With our city services, we're trying to send a message that we can't go back to normal."
Little Rock Mayor Frank Scott Jr., a Democrat, has experienced similar challenges in Arkansas. As state officials resisted implementing a state-at-home order, Scott and his administration used executive orders to create what he called a "modified shelter-in-place policy" that included nighttime curfews, closing city parks, and limiting restaurants to delivery and takeout. But Scott said he eventually had to rein in curfews and other restrictions to comply with state law allowing bars and restaurants to open.
"That's the reason we've ramped up even more testing, data and mask distribution," Scott said. "And we're going to continue to find ways to get creative from a communications standpoint to try to continue to slow the community spread."
Different states have touted different metrics, making it difficult to assess local conditions.
Florida has not reported hospitalizations for influenza-like illness since the end of May, when the rise in cases began. In Utah, Republican Gov. Gary Herbert and members of his task force have emphasized the low fatality rate among those sickened with the virus, which is about 1 percent, according to Michael Good, CEO of University of Utah Health.
Health and emergency operations staff have pressed for further analysis about the impact of the rising case load on Utah hospital capacity, according to an official privy to the discussions who spoke on the condition of anonymity to reveal internal deliberations.
Herbert's office did not return a request for comment.
In Arizona, Gerald argues the spike is not due to increased testing. He says the statistical impact of a testing blitz toward the end of May has subsided, and two weeks of relatively stable levels of testing have still seen a surge in new infections. Mounting caseloads, combined with a corresponding increase in coronavirus-related hospitalizations and ICU care, he said, roughly correspond to the state's relaxation of distancing requirements.
"At the current pace of viral spread, we risk reaching or exceeding our hospital capacity sometime in July," he said.
Banner Health, Arizona's largest hospital system, sounded a similar alarm in a news briefing last week when Chief Medical Officer Marjorie Bessel showed data that the number of coronavirus patients in Banner hospitals had tripled in the past three weeks.
Banner Health told the state Tuesday it is unable to take any new patients requiring extracorporeal membrane oxygenation - a machine that helps patients whose lungs are so damaged that a ventilator is not enough. Bessel said her hospitals still have ventilator and ICU capacity for now.
Hospital capacity continues to be a concern in many states with spiking cases, according to local officials in the South and West who point to hospitals near nursing home outbreaks as most immediately at risk of becoming overwhelmed. Other at-risk facilities include those near rural areas without adequate health-care facilities of their own.
The White House has expressed concern about rising cases in North Carolina, where hospitalizations continue to rise and the state reported 1,011 new cases Wednesday. The state reopened restaurants, salons and swimming pools at half capacity on May 22.
"Our metrics have moved in the wrong direction," Mandy Cohen, the state's top health official, said Monday.