You didn’t need a crystal ball to see the explosion of cases and the swift overwhelming of hospitals and public health infrastructure. It was the entirely expected byproduct of leadership decisions and communication to the public that we were past the epidemic here. Currently, Arizona has been reporting over 4,000 cases a day consistently, while the availability of beds in intensive care units has hovered around 10 percent since late June. For every Arizonan tested, at least 1 in 4 is positive for the coronavirus. Recent efforts to increase testing indicate that there are probably many cases being missed. The same thing has been happening in other hot spots around the country, where reopening came too fast and too soon.
In a lifetime of studying pandemics and infectious diseases, one thing I never trained for is having to watch my city, state and country struggle through a broken response and economic recession. The coronavirus pandemic is a telling example of how investing in public health and health-care readiness is vital — but also how it can only be so effective with a fractured and indifferent national leadership. As a result, the state reopening efforts were pushed out to governors, which lays the success or failure of so many states in their hands.
The past few months have been so frustrating that it’s hard to describe. We’ve been working around-the-clock since February. My early hope that widespread community transmission wouldn’t happen has been dashed by the explosive rise in cases. The politicization of masks and public health data have shaken me to my core. I’m grateful every day for the masks and personal protective equipment that keep me safe while I support health-care workers and patients in infection prevention. Seeing people call basic public health and social responsibility efforts a violation of their rights has astounded me — especially as they kept at it while thousands protested safely for basic civil and human liberties.
The worst part, though, was knowing that no matter how much work we did to prepare, a wave of cases would hit us, and there was nothing we could do about it, because decision-makers weren’t paying attention to basic scientific and medical facts anymore.
Faced with an out-of-control epidemic, Arizona Gov. Doug Ducey (R) has ordered bars, gyms, theaters and water parks to close, but casinos are still open. Restaurants are set to operate at 50 percent capacity indoors. Testing capacity will be increased, but there are still no stay-at-home orders. Ducey’s news conferences have increasingly become bizarre, as the governor regales us with the news that he has a special ringtone for President Trump’s calls. As temperatures soar and many people move indoors, Arizonans will struggle to maintain social distancing while avoiding dangerous heat. The frequently given advice to “eat outside” is impractical and, frankly, impossible for central Arizona.
But like many places where case counts are rising rapidly, our descent into chaos really began with the delay in closures in late winter. The first case of covid-19 here was identified in late January, which triggered hospitals to start preparing for potential cases and working to acquire necessary personal protective equipment (PPE). Ducey declared a public health emergency on March 10, giving hospitals and health-care facilities more flexibility to enact safety measures and acquire resources. Stay-at-home orders were implemented for the state on March 31, elective surgeries were soon halted, and shortly after that, nonessential retailers and businesses were asked to close. Arizona cases were steadily rising from 200 a day and inching closer to 500 a day. It didn’t feel overwhelming yet: stressful, but manageable. The eeriness of increasingly empty hospitals began to set in. With elective surgeries canceled and many avoiding hospitals, health-care workers were furloughed.
In infection prevention and epidemiology, though, we were struggling to respond, with dozens of covid-19 patients in intensive care units, and dealing with the effects of national supply shortages. Many hospitals during this time were feeling the financial strain of canceled elective surgeries while trying to prepare for the pandemic. As May and the heat approached, many began to wonder if perhaps we were already dealing with Arizona’s “first wave” — could we be so lucky? From here, seeing what New York experienced felt like a warning, one that we thought we heeded.
So it wasn’t surprising that on April 22, an announcement came that elective surgeries were allowed to resume on May 1, as Arizona’s numbers looked like coronavirus cases would stay around 400 or 500 per day. That allowed hospitals to open their doors a bit more and patients to get the surgeries they needed, and with the state still under stay-at-home orders, it felt a logical way to test the waters without overwhelming the health-care systems. By then, about 5 percent of tests were positive, a sign that there was still much work to be done, but it was manageable.
Unfortunately, a few short days later, the cracks started to emerge.
In a surprising turn on May 4, Ducey announced plans to start reopening the state, with stay-at-home orders set to expire on May 15. Restaurants and retail operations were allowed to start reopening just four days after his announcement. What caused concern for so many of us in epidemiology and health care, though, was the first indicator that these decisions were not only hasty, but inherently political.
First, the state quietly, but quickly, disbanded a modeling team of experts from the University of Arizona and Arizona State University, whose data had been pointing to a need to continue the stay-at-home orders that Ducey clearly wanted to lift. As an epidemiologist working in health care and reliant on this data and dependent on the choices it guides, I felt betrayed. And I had a pit in my stomach that Arizona’s misguided plan to force reopening would bring more consequences soon.
Worse, cases were not declining consistently for two weeks, meaning that the state was opening up again even though it hadn’t met White House criteria for reopening. Arizona surpassed 1,000 cases on June 1, and the count has been increasing rapidly since then. During this time, the coronavirus was rippling through Navajo Nation, one of the largest indigenous reservations in the United States. With over 173,000 people living within the reservation across three states, case counts and deaths quickly soared, becoming one of the highest infection rates per capita. The severity of this outbreak was so devastating that Doctors Without Borders sent two teams to respond in mid-May.
While some states, like Washington, took their time reopening in incremental, phased approaches so they could closely monitor any spikes and not stress public health and health-care systems, Arizona took the opposite strategy: We reopened too early and too fast, and it’s no surprise that we’re at this point now. The same thing happened in other states, like Florida and Texas, which have booming case counts and stressed hospitals.
On June 8, Banner Health, the largest health system in the state, began to not-so-subtly hint at trouble on the horizon as ICU usage inched closer to 80 percent. Today, with 90 percent of ICU beds in use and over 40 percent of hospitalized patients there because of a covid-19 infection, Arizona is facing an increasingly dangerous situation.
The state is facing several other challenges on top of the virus. In a season with historical heat mortalities, adding an uncontrolled pandemic is stressing systems beyond health care — the Maricopa Office of the Medical Examiner reported 97 percent capacity in its morgue, requiring contracted refrigerator trucks. An overwhelmed testing capacity has also translated to delays in notification of results, which has widespread implications. Timely notifications ensure people isolate appropriately and contact tracing can begin to head off secondary cases.
Reopening too fast gave the impression that we were past the coronavirus, that life was back to normal. Coupled with the politicization of masks, this disjointed messaging created confusion in a situation where clarity and social responsibility are critical. As numbers began to climb, Ducey barred leaders from imposing stricter local rules on things such as requiring masks. Thankfully, that changed in mid-June, and municipalities were allowed to vote on mask ordinances, which Phoenix put in place on June 20, thanks to Mayor Kate Gallego’s decision to listen to public health experts. Three days later, though, Trump held a rally at an indoor church, dismissing concerns about the risk and calling the virus “the kung flu.”
The patchwork of America’s coronavirus epidemic makes this all much harder. Varying levels of transmission give some the impression that we’re past the pandemic, while other states struggle to stay above water. As cases surge in state after state, testing health care and public health systems, it’s infuriating to know we could have avoided it. As an epidemiologist and hospital infection preventionist, the front lines of Arizona have been my home during the pandemic, but I hope that the rest of the nation sees us a cautionary example. The virus doesn’t care how badly we want things to return to normal. If we go too fast, it will storm back everywhere.