Some state and local leaders are softening their resistance to issuing public masking requirements as emerging research shows face coverings can slow the spread of COVID-19, even as others are doubling down on their opposition.
The debate over whether to require face coverings in public has become increasingly politicized in recent weeks, even as COVID-19 cases have increased in the Sun Belt and some other parts of the country as lockdowns across the country have greatly eased.
Governors in southern, conservative states have been reluctant to issue statewide mandates on public mask-wearing, and in some cases have prevented local governments from taking stronger actions.
“We want to make sure that individual liberty is not infringed upon by government and hence government cannot require individuals to wear a mask,” Texas Gov. Greg Abbott (R) said Wednesday in an interview with Waco television station KWTX.
Abbott, who frequently recommends mask-wearing, has resisted calls from local leaders to require it, and has also prohibited them from enforcing local orders with civil or criminal penalties on individuals.
However, two Texas counties on Wednesday announced businesses must impose a mask rule on staff and customers or face fines of up to $1,000, which Abbott said would be allowed under his executive order.
“Businesses … they’ve always had the opportunity and the ability, just like they can require people to wear shoes and shirts, these businesses can require people to wear face masks if they come into their businesses. Now local officials are just now realizing that that was authorized,” he said.
Texas has experienced a rapid increase in COVID-19 cases that experts say is likely related to the state’s decision to lift lockdown measures ahead of Memorial Day. The state reported 3,129 new COVID-19 cases Wednesday, its largest single-day increase. Nearly 2,800 people were hospitalized with COVID-19 as of Wednesday, a new high for the state.
In Arizona, which has also seen a surge in cases, Gov. Doug Ducey (R) on Wednesday again resisted calls to issue a statewide masking requirement, but in a reversal, said he would allow local governments to take their own actions. Larger cities including Phoenix and Tucson plan to do so.
“Every Arizonan should wear a face mask,” he said at a Wednesday press conference. “This is an issue of personal responsibility, and we’re asking Arizonans to make responsible decisions to protect the most vulnerable in our communities.”
While a number of coastal states and cities led by Democrats have strict mask requirements when in public settings such as grocery stores, where staying six feet away from others may not be possible, some Republicans appear to see it as a restriction on freedom and have emphasized individual responsibility.
Trump has almost exclusively declined to wear a mask, and has criticized his political rival Joe Biden, the Democratic candidate for president, for wearing one.
“I see Biden. It’s like his whole face is covered,” Trump said in an interview published Thursday in The Wall Street Journal. “It’s like he put a knapsack over his face. He probably likes it that way. He feels good that way because he does. He seems to feel good in a mask, you know, feels better than he does without the mask, which is a strange situation.”
The debate of whether to wear masks has sparked division on Capitol Hill, where two Republicans this week refused to follow a new directive from House Speaker Nancy Pelosi (D-Calif.)
“I consider masks much more effective at spreading panic and much less effective at stopping a virus,” said Rep. Tom McClintock (R-Calif.), during a hearing yesterday. He later put on a mask.
Polls have shown Democrats are more likely to wear masks in public than Republicans; a Gallup poll conducted in April found 75 percent of Democrats have worn a mask in public, compared to half of Republicans.
However, emerging evidence shows face coverings can slow the transmission of COVID-19. A study published in Health Affairs this week found that mandated use of face masks in public was associated with a reduction in the daily COVID-19 growth rate in 15 states and Washington, D.C., compared to states that did not have such requirements.
Governors of other states experiencing outbreaks, including Henry McMaster (R) of South Carolina, have recommended but don’t require people to wear face masks in public. City council members in Columbia, S.C., however, are reportedly considering a requirement for the state’s largest city.
Alabama Gov. Kay Ivey (R) hasn’t issued a statewide mask requirement for the public, but employees of certain businesses are required to wear them while working.
In Montgomery, Ala., which has the largest COVID-19 outbreak in the state, Mayor Steven Reed (D) issued an executive order Wednesday requiring face coverings be worn in public after a similar ordinance failed to pass the city’s council.
Florida Gov. Ron DeSantis (R) has also resisted a statewide mask requirement, though localities can require their use in public. On Tuesday, he encouraged people to wear masks when social distancing isn’t possible but said it would not be a requirement.
“In terms of forcing that under penalty of criminal law, we’re not going to be doing that. I think it would be applied unevenly and I just don’t think it would end up working,” DeSantis said at a press conference.
The state is also seeing an increase in cases, which DeSantis ties to increased testing. However, public health experts note that the percentage of tests coming back positive is also increasing, a sign of ongoing community transmission.
In Nebraska, where the rate of COVID-19 transmission has been declining, Gov. Pete Ricketts (R) encourages the use of masks in public but has threatened to withhold federal relief funding from localities that require their use in government buildings.
“The governor encourages people to wear a mask but does not believe that failure to wear a mask should be the basis for denying taxpayers’ services,” spokesman Taylor Gage told the Omaha World-Herald.
Not all Republican governors have resisted masking mandates. Maryland Gov. Larry Hogan and Massachusetts Gov. Charlie Baker were early to issue wide-ranging mask requirements in their states.
Meanwhile, Democratic governors are mandating mask requirements or say they are seriously considering it.
As cases continue to climb in North Carolina, Gov. Roy Cooper (D) said this state leaders are considering making mask-wearing in public settings mandatory but has not done so yet.
Oregon Gov. Kate Brown (D) announced Wednesday that people living in seven of the state’s counties will have to wear masks in public beginning June 24 as the state sees an increase in cases.
Democratic governors of states hit hard early in the pandemic including New York, Washington and New Jersey have required the use of face coverings in public for several weeks.
California Gov. Gavin Newsom (D) issued a statewide mask order Thursday amid an increase in COVID-19 cases in his state.
“Science shows that face coverings and masks work,” Newsom said Thursday. “They are critical to keeping those who are around you safe, keeping businesses open and restarting our economy.”
As coronavirus cases surge in states across the South and West of the United States, health experts in countries with falling case numbers are watching with a growing sense of alarm and disbelief, with many wondering why virus-stricken U.S. states continue to reopen and why the advice of scientists is often ignored.
“It really does feel like the U.S. has given up,” said Siouxsie Wiles, an infectious-diseases specialist at the University of Auckland in New Zealand — a country that has confirmed only three new cases over the last three weeks and where citizens have now largely returned to their pre-coronavirus routines.
“I can’t imagine what it must be like having to go to work knowing it’s unsafe,” Wiles said of the U.S.-wide economic reopening. “It’s hard to see how this ends. There are just going to be more and more people infected, and more and more deaths. It’s heartbreaking.”
China’s actions over the past week stand in stark contrast to those of the United States. In the wake of a new cluster of more than 150 new cases that emerged in Beijing, authorities sealed off neighborhoods, launched a mass testing campaign and imposed travel restrictions.
Meanwhile, President Trump maintains that the United States will not shut down a second time, although a surge in cases has convinced governors in some states, including Arizona, to walk back their opposition to mandatory face coverings in public.
Commentators and experts in Europe, where cases have continued to decline, voiced concerns over the state of the U.S. response. A headline on the website of Germany’s public broadcaster read: “Has the U.S. given up its fight against coronavirus?” Switzerland’s conservative Neue Zürcher Zeitung newspaper concluded, “U.S. increasingly accepts rising covid-19 numbers.”
“The only thing one can say with certainty: There’s nothing surprising about this development,” a journalist wrote in the paper, referring to crowded U.S. beaches and pools during Memorial Day weekend in May.
Some European health experts fear that the rising U.S. caseloads are rooted in a White House response that has at times deviated from the conclusions of leading scientists.
“Many scientists appeared to have reached an adequate assessment of the situation early on [in the United States], but this didn’t translate into a political action plan,” said Thomas Gerlinger, a professor of health sciences at the University of Bielefeld in Germany. For instance, it took a long time for the United States to ramp up testing capacity.
Whereas the U.S. response to the crisis has at times appeared disconnected from American scientists’ publicly available findings, U.S. researchers’ conclusions informed the actions of foreign governments.
“A large portion of [Germany’s] measures that proved effective was based on studies by leading U.S. research institutes,” said Karl Lauterbach, a Harvard-educated epidemiologist who is a member of the German parliament for the Social Democrats, who are part of the coalition government. Lauterbach advised the German parliament and the government during the pandemic.
Despite its far older population, Germany has confirmed fewer than 9,000 coronavirus-linked deaths, compared to almost 120,000 in the United States. (Germany has about one-fourth of the United States’ population.)
Lauterbach cited in particular the work of Marc Lipsitch, a professor of epidemiology at Harvard University, whose research with colleagues recently suggested that forms of social distancing may have to remain in place into 2022. Lipsitch’s work, Lauterbach said, helped him to convince German Vice Chancellor Olaf Scholz that the pandemic will be “the new normal” for the time being, and it impacted German officials’ thinking on how long their strategy should be in place.
Regarding the effectiveness of face masks, Lauterbach added, “we almost entirely relied on U.S. studies.” Germany was among the first major European countries to make face masks mandatory on public transport and in supermarkets.
Lipsitch said Thursday that he was not previously aware of the impact of his research on German decision-making, but added that he has spoken to representatives of several other foreign governments in recent weeks, including Israeli Prime Minister Benjamin Netanyahu and officials or advisers from Canada, New Zealand and South Korea.
Even though Lipsitch cautioned it was impossible for him to say how or if his conversations influenced foreign governments’ thinking, he credited the overall European response as “science-based and a sincere effort to find out what experts in the field believe is a range of possible scenarios and consequences of decisions.”
Lipsitch said he presented some of his research to a White House group in the early stages of the U.S. outbreak but said the Trump administration’s response to the pandemic did not reflect his conclusions. “I think they have cherry-picked models that at each point looked the most rosy, and fundamentally not engaged with the magnitude of the problem,” he said.
The White House has defended its approach as science-based. After a study by Imperial College London predicted 510,000 deaths in Britain and 2.2 million in the United States if the pandemic remained fully uncontrolled, for instance, the Trump administration indicated that it was taking the research into account.
“If we didn’t act quickly and smartly, we would have had, in my opinion and in the opinion of others, anywhere from 10 to 20 and maybe even 25 times the number of deaths,” Trump said two months later,
But European researchers dispute that the U.S. government’s reliance on scientists to inform decision-making comes anywhere near the degree to which many European policymakers have relied on researchers.
After consulting U.S. research and German studies, for instance, German leaders agreed to make reopening dependent on case numbers, meaning restrictions snap back or reopening gets put on hold if the case numbers in a given region exceed a certain threshold.
Meanwhile, several U.S. states have reopened despite rising case numbers.
“I don’t understand that logic,” said Reinhard Busse, a health management professor a the Technical University of Berlin.
Lauterbach said that while most Germans disapproved of Trump before the pandemic, even his staunchest critics in Germany were surprised by how even respected U.S. institutions including the Centers for Disease Control and Prevention (CDC) struggled to respond to the crisis.
The CDC, for instance, initially botched the rollout of test kits in the early stages of the outbreak.
“Like many other aspects of our country, the CDC’s ability to function well is being severely handicapped by the interference coming from the White House,” said Harvard epidemiologist Lipsitch. “All of us in public health very much hope that this is not a permanent condition of the CDC.”
Some observers fear the damage will be difficult to reverse. “I’ve always thought of the CDC as a reliable and trusted source of information,” said Wiles, the New Zealand specialist. “Not anymore.”
ProPublica deputy managing editor Charles Ornstein wanted to know why experts were wrong when they said U.S. hospitals would be overwhelmed by COVID-19 patients. Here’s what he learned, including what hospitals can do before the next wave.
The prediction from New York Gov. Andrew Cuomo was grim.
In late March, as the number of COVID-19 cases was growing exponentially in the state, Cuomo said New York hospitals might need twice as many beds as they normally have. Otherwise there could be no space to treat patients seriously ill with the new coronavirus.
“We have 53,000 hospital beds available,” Cuomo, a Democrat, said at a briefing on March 22. “Right now, the curve suggests we could need 110,000 hospital beds, and that is an obvious problem and that’s what we’re dealing with.”
The governor required all hospitals to submit plans to increase their capacity by at least 50%, with a goal of doubling their bed count. Hospitals converted operating rooms into intensive care units, and at least one replaced the seats in a large auditorium with beds. The state worked with the federal government to open field hospitals around New York City, including a large one at the Jacob K. Javits Convention Center.
But when New York hit its peak in early April, fewer than 19,000 people were hospitalized with COVID-19. Some hospitals ran out of beds and were forced to transfer patients elsewhere. Other hospitals had to care for patients in rooms that had never been used for that purpose before. Supplies, medications and staff ran low. And, as The Wall Street Journal reported on Thursday, many New York hospitals were ill prepared and made a number of serious missteps.
All told, more than 30,000 New York state residents have died of COVID-19. It’s a toll worse than any scourge in recent memory and way worse than the flu, but, overall, the health care system didn’t run out of beds.
“All of those models were based on assumptions, then we were smacked in the face with reality,” said Robyn Gershon, a clinical professor of epidemiology at the NYU School of Global Public Health, who was not involved in the models New York used. “We were working without situational awareness, which is a tenet in disaster preparedness and response. We simply did not have that.”
Cuomo’s office did not return emails seeking comment, but at a press briefing on April 10, the governor defended the models and those who created them. “In fairness to the experts, nobody has been here before. Nobody. So everyone is trying to figure it out the best they can,” he said. “Second, the big variable was, what policies do you put in place? And the bigger variable was, does anybody listen to the policies you put in place?”
So, why were the projections so wrong? And how can political leaders and hospitals learn from the experience in the event there is a second wave of the coronavirus this year? Doctors, hospital officials and public health experts shared their perspectives.
The Models Overstated How Many People Would Need Hospital Care
The models used to calculate the number of people who would need hospitalization were based on assumptions that didn’t prove out.
Early data from the U.S. Centers for Disease Control and Prevention suggested that for every person who died of COVID-19, more than 11 would be hospitalized. But that ratio was far too high and decreased markedly over time, said Dr. Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington. IHME’s earliest models on hospitalizations were based on that CDC data and predicted that many states would quickly run out of hospital beds.
A subsequent model, released in early April, assumed about seven hospitalizations per death, reducing the predicted surge. Currently, Murray said, the ratio is about four hospital admissions per death.
“Initially what was happening and probably what we saw in the CDC data is doctors were admitting anybody they thought had COVID,” Murray said. “With time they started admitting only very sick people who needed oxygen or more aggressive care like mechanical ventilation.”
A patient with COVID-19 is taken into Mount Sinai Hospital in New York on May 3. (Alexi Rosenfeld/Getty Images)
A model created by the Harvard Global Health Institute made a different assumption that also turned out to be too high. Data from Wuhan, China, suggested that about 20% of those known to be infected with COVID-19 were hospitalized. Harvard’s model, which ProPublica used to build a data visualization, assumed a hospitalization rate in the United States of 19% for those under 65 who were infected and 28.5% for those older than 65.
But in the U.S., that percentage proved much too high. Official hospitalization rates vary dramatically among states, from as low as 6% to more than 20%, according to data gathered from states by The COVID Tracking Project. (States with higher rates may not have an accurate tally of those infected because testing was so limited in the early weeks of the pandemic.) As testing increases and doctors learn how to treat coronavirus patients out of the hospital, the average hospitalization rate continues to drop.
New York state’s testing showed that by mid-April, approximately 20% of the adult population in New York City had antibodies to COVID-19. Given the number hospitalized in the city and adjusting for the time needed for the body to produce antibodies, this means that the city’s hospitalization rate was closer to 2%, said Dr. Nathaniel Hupert, an associate professor at Weill Cornell Medicine and co-director of the Cornell Institute for Disease and Disaster Preparedness.
Dr. Ashish Jha, director of the Harvard Global Health Institute, and his team also assumed that between 20% and 60% of the population would be infected with COVID-19 over six to 18 months. That was before stay-at-home orders took effect nationwide, which slowed the virus’s spread. Outside of New York City, a far lower percentage of the population has been infected. Granted, we’re not even six months into the pandemic.
A number of factors go into disease models, including the attack rate (the percentage of the entire population that eventually becomes infected), the symptomatic rate (how many people are going to show symptoms), the hospitalization rate for different age groups, the fraction of those hospitalized that will need intensive care and how much care they will need, as well as how the disease travels through the population over time (what is known as “the shape of the epidemic curve”), Hupert said.
Before mid-March, Hupert’s best estimate of the impact of COVID-19 in New York state was that it would lead to a peak hospital occupancy of between 13,800 to 61,000 patients in both regular medical wards and intensive care. He shared his work with state officials.
David Muhlestein, chief strategy and chief research officer at Leavitt Partners, a health care consulting firm, said one takeaway from COVID-19 is that models can’t try to predict too far into the future. His firm has created its own projection tool for hospital capacity that looks ahead three weeks, which Muhlestein said is most realistic given the available data.
“If we were held to our very initial projection of what was going to happen, everybody would be very wrong in every direction,” he said.
Hospitals Proved Surprisingly Adept at Adding Beds
When calculating whether hospitals would run out of beds, experts used as their baseline the number of beds in use in each hospital, region and state. That makes sense in normal times because hospitals have to meet stringent rules before they are able to add regular beds or intensive care units.
Workers prepare dozens of extra beds that were delivered to Mount Sinai on March 31. (Spencer Platt/Getty Images)
But in the early weeks of the pandemic, state health departments waived many rules and hospitals responded by increasing their capacity, sometimes dramatically. “Just because you only have six ICU beds doesn’t mean they will only have six ICU beds next week,” Muhlestein said. “They can really ramp that up. That’s one of the things we’re learning.”
Take Northwell Health, a chain of 17 acute-care hospitals in New York. Typically, the system has 4,000 beds, not including maternity beds, neonatal intensive care unit beds and psychiatric beds. The system grew to 6,000 beds within two weeks. At its peak, on April 7, the hospitals had about 5,500 patients, of which 3,425 had COVID-19.
The system erected tents, placed patients in lobbies and conference rooms, and its largest hospital, North Shore University Hospital, removed the chairs from its 300-seat auditorium and replaced them with a unit capable of treating about 50 patients. “We were pulling out all the stops at that point,” Senior Vice President Terence Lynam said. “It was unclear if the trend was going to go the other way. We did not end up needing them all.”
Northwell went from treating 49 COVID-19 inpatients on March 16 to 3,425 on April 7. “I don’t think anybody had a clear handle on what the ceiling was going to be,” Lynam said. As of Wednesday, the system was still caring for 367 COVID-19 patients in its hospitals.
As hospitals found ways to expand, government leaders worked with the Army Corps of Engineers to build dozens of field hospitals across the country, such as the one at the Javits Center. According to an analysis of federal spending by NPR, those efforts cost at least $660 million. “But nearly four months into the pandemic, most of these facilities haven’t treated a single patient,” NPR reported. As they began to come online, stay-at-home orders started producing results, with fewer positive cases and fewer hospitalizations.
Demand for Non-COVID-19 Care Plummeted More Than Expected
Hospitals across the country canceled elective surgeries, from hip replacements to kidney transplants. That greatly reduced the number of non-COVID-19 patients they had to treat. “We generated a lot more capacity by getting rid of elective procedures than any of us thought was possible,” Harvard’s Jha said.
Northwell canceled elective surgeries on March 16, and over the span of the next week and a half, its hospitals discharged several thousand patients in anticipation of the coming surge. “In retrospect, it was a wise move,” Lynam said. “It just ballooned after that. If we had not discharged those patients in time, there would have been a severe bottleneck.”
What’s more, experts say, it’s clear that some patients with true emergencies also stayed home. A recent report from the CDC said that emergency room visits dropped by 42% in the early weeks of the pandemic. In 2019, some 2.1 million people visited ERs each week from late March to late April. This year, that dropped to 1.2 million per week. That was especially true for children, women and people who live in the Northeast.
In New York City, emergency room visits for asthma practically ceased entirely at the peak, Cornell’s Hupert said. “You wouldn’t imagine that asthma would just disappear,” he said. “Why did it go away? … Nobody has seen anything like that.”
Undoubtedly some people experienced heart attacks and strokes and didn’t go to the hospital because they were fearful of getting COVID-19. “I didn’t expect that,” Jha said. A draft research paper available on a preprint server, before it is reviewed and published in an academic journal, found that heart disease deaths in Massachusetts were unchanged in the early weeks of the pandemic compared to the same period in 2019. What that may mean is that those people died at home.
The Coronavirus Attacked Every Region at a Different Pace
Some initial models forecast that COVID-19 would hit different regions in similar ways. That has not been the case. New York was hit hard early; California was not, at least initially.
In recent weeks, hospitals in Montgomery, Alabama, saw a lot of patients. Arizona’s health director has told hospitals in the state to “fully activate” their emergency plans in light of a spike in cases there. The Washington Post reported on Tuesday that hospitalizations in at least nine states have been rising since Memorial Day.
St. Luke’s, a closed hospital in Phoenix, is prepared to receive overflow patients on April 23. Arizona initially wasn’t hit hard, but cases are now spiking. (Ross D. Franklin/AP Photo)
Dr. Mark Rupp, medical director of the Department of Infection Control and Epidemiology at the University of Nebraska Medical Center in Omaha, said his region hasn’t seen a tidal wave like New York. “What we’ve seen is a rising tide, a steady increase in the number of cases.” Initially that was associated with outbreaks at specific locations like meatpacking and food processing plants and to some degree long-term care facilities.
But since then, “it has just plateaued,” he said. “That has me concerned. This is a time when I feel like we should be working as hard as we can to push these numbers as low as possible.”
Rupp’s hospital has been caring for 50 to 60 COVID-19 patients on any given day. The hospital has started to perform surgeries and procedures that had been on hold because “elective cases stay elective for only so long.”
The hospital’s general medical/surgical beds are 70% to 80% filled, and its ICU beds are 80% to 90% full. “We don’t have a big cushion.”
Even in New York City, the virus hit boroughs differently. Queens and the Bronx were hard hit; Manhattan, Brooklyn and Staten Island less so. “Maybe we can’t even model a city as big as New York,” Hupert said. “Each neighborhood seemed to have a different type of outbreak.”
That needs further study but could be attributable to both social and demographic conditions and the type of jobs residents of the neighborhoods had, among other factors.
What We Can Learn From Coronavirus “Round One”
While hospitals were able to add beds more quickly than experts realized they could, some other resources were harder to come by. Masks, gowns and other personal protective equipment were tough to get. So were ventilators. Anesthesia agents and dialysis medications were in short supply. And every additional bed meant the need for more doctors, nurses and respiratory therapists.
In early February, before any cases were discovered in New York, Northwell purchased $5 million in PPE, ventilators and lab supplies just in case, Lynam said. “It turned out to be a wise move,” he said. “What’s clear is that you can never have enough.”
Northwell has spent $42 million on PPE alone. “We were going through 10,000 N95 masks a day, just a crazy amount,” he said. “One of the lessons learned is you have to stockpile the PPE. There’s got to be a better procurement process in place.”
If there’s one thing the system could have done differently, Lynam said, it’s bringing in more temporary nurses earlier. Northwell brought in 500 nurses from staffing agencies. “They came in a week later than they should have.”
Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco, agreed. “I’ve helped run services in hospitals for 25 years,” he said. “I’ve probably given two minutes of thought to the notions of supply chains and PPE. You realize that is absolutely central to your preparedness. That’s a lesson.”
Experts and hospital leaders agree that everyone can do better if another wave hits. Here’s what that entails:
Having testing readily available, as it now is, to more quickly spot a resurgence of the virus.
Stocking up now on PPE and other supplies. “We definitely have to stockpile PPE by the fall,” Gershon of NYU said. “We have to. … [Hospitals and health departments] have to really get those contracts nailed down now. They should have been doing this, of course, all the time, but no one expected this kind of event.”
Being able to quickly move personnel and equipment from one hot spot to the next.
Planning for how to care for those with other medical ailments but who are scared of contracting COVID-19. “We have to have some sort of a mechanism by which we can offer people assurance that if they come in, they won’t get sick,” Jha said. “We can’t repeat in the fall what we just did in the spring. It’s terrible for hospitals. It’s terrible for patients.”
Providing mental health resources for front-line caregivers who have been deeply affected by their work. The intensity of the work, combined with watching patients suffer and die alone, was immensely taxing.
Coming up with ways to allow visitors in the hospital. Wachter said the visitor bans in place at many hospitals, though well intentioned, may have backfired. “When all hell was breaking loose and we were just doing the best we could in the face of a tsunami, it was reasonable to just keep everybody out,” he said. “We didn’t fully understand how important that was for patients, how much it might be contributing to some people not coming in for care when they really should have.”
Lynam of Northwell said he’s worried about what lies ahead. “You look back on the 1918 Spanish flu and the majority of victims from that died in the second wave. … We don’t know what’s coming on the second wave. There may be some folks who say you’re paranoid, but you’ve got to be prepared for the worst.”
Prison officials have been reluctant to do widespread virus testing even as infection rates are escalating.
Cases of the coronavirus in prisons and jails across the United States have soared in recent weeks, even as the overall daily infection rate in the nation has remained relatively flat.
The number of prison inmates known to be infected has doubled during the past month to more than 68,000. Prison deaths tied to the coronavirus have also risen, by 73 percent since mid-May. By now, the five largest known clusters of the virus in the United States are not at nursing homes or meatpacking plants, but inside correction institutions, according to data The New York Times has been collecting about confirmed coronavirus cases since the pandemic reached American shores.
And the risk of more cases appears imminent: The swift growth in virus cases behind bars comes as demonstrators arrested as part of large police brutality protests across the nation have often been placed in crowded holding cells in local jails.
A muddled, uneven response by corrections officials to testing and care for inmates and workers is complicating the spread of the coronavirus. In interviews, prison and jail officials acknowledged that their approach has largely been based on trial and error, and that an effective, consistent response for U.S. correctional facilities remains elusive.
“If there was clearly a right strategy, we all would have done it,” said Dr. Owen Murray, a University of Texas Medical Branch physician who oversees correctional health care at dozens of Texas prisons. “There is no clear-cut right strategy here. There are a lot of different choices that one could make that are going to be in-the-moment decisions.”
The inconsistent response to the spread of the coronavirus in correctional facilities is in contrast with efforts to halt its spread in other known incubators of the virus: Much of the cruise ship industry has been closed down. Staff members and residents of nursing homes in several states now face compulsory testing. Many meat processing plants have been shuttered for extensive cleaning.
As the toll in prisons has increased, so has fear among inmates who say the authorities have done too little to protect them. There have been riots and hunger strikes in correctional facilities from Washington State to New York. And even the known case numbers are likely a significant undercount because testing has been extremely limited inside prisons and because some places that test do not release the results to the public.
“It’s like a sword hanging over my head,” said Fred Roehler, 77, an inmate at a California prison who has chronic inflammatory lung disease and other respiratory ailments. “Any officer can bring it in.”
Public officials have long warned that the nation’s correctional facilities would likely become vectors in the pandemic because they are often overcrowded, unsanitary places where social distancing is impractical, bathrooms and day rooms are shared by hundreds of inmates, and access to cleaning supplies is tightly controlled. Many inmates are 60 or older, and many suffer from respiratory illnesses or heart conditions.
In response, local jails have discharged thousands of inmates since February, many of whom had been awaiting trials to have charges heard or serving time for nonviolent crimes. State prison systems, where people convicted of more serious crimes are housed, have been more reluctant to release inmates.
Testing for the virus within the nation’s penal institutions varies widely, and has become a matter of significant debate.
Republican-led states like Texas, Tennessee and Arkansas — which generally spend less on prisoners than the national average — have found themselves at the forefront of testing inmates.
In Texas, the number of prisoners and staff members known to be infected has more than quadrupled to 7,900 during the past three weeks after the state began to test every inmate.
Yet states that typically spend far more on prisons have carried out significantly less testing.
California, which spends $12 billion annually on its prison system, has tested fewer than 7 percent of inmates in several of its largest, most crowded facilities, according to the state’s data. Other Democratic-led states that also spend heavily on prisons, including New York, Oregon and Colorado, have also conducted limited testing despite large outbreaks in their facilities.
New York has tested about 3 percent of its 40,000 prison inmates; more than 40 percent of those tested were infected.
Critics say that the dearth of testing in some facilities has meant that prison and public health officials have only vague notions about the spread of the virus, which has allowed some elected officials to suggest that it is not present at all.
“We have really no true idea of how bad the problem is because most places are not yet testing the way they should,” said Dr. Homer Venters, who served as chief medical officer for the New York City jail system and now works for a group called Community Oriented Correctional Health Services, which works to improve health care services in local jails. “I think a lot of times some of the operational challenges of either not having adequate quarantine policies or adequate medical isolation policies are so vexing that places simply decide that they can just throw up their hands.”
Most state prison systems have conducted few tests. Systems in Illinois, Mississippi and Alabama have tested fewer than 2.5 percent of inmates. And in Louisiana, officials had tested several dozen of its 31,000 inmates in March when the warden and medical director at one of the state’s largest prisons died of the coronavirus. The state has since announced plans to test every inmate.
Prison officials in states where only a limited number of inmates have been tested say they are following federal guidelines. The Centers for Disease Control and Prevention recommend that only prisoners with symptoms be tested.
Prisons that have conducted mass testing have found that about one in seven tests of inmates have come back positive, the Times database shows. The vast majority of inmates who have tested positive have been asymptomatic.
Public health officials say that indicates the virus has been present in prison populations for far longer than had previously been understood.
“If you don’t do testing, you’re flying blind,” said Carlos Franco-Paredes, an infectious-disease specialist at the University of Colorado School of Medicine.
But in California, there continues to be reluctance to test each of the state’s 114,000 inmates, despite growing criticism to take a more aggressive approach. One in six inmates in the state’s prisons have been tested, and the state has released some inmates who were later found to have the virus, raising fears that prison systems could seed new infections outside penal institutions.
“Nothing significant had been done to protect those most vulnerable to the virus,” said Marie Waldron, the Republican minority leader of the California State Assembly.
But J. Clark Kelso, who oversees prison health care in California, said that mass testing would provide only a snapshot of the virus’s spread.
“Testing’s not a complete solution,” Mr. Kelso said. “It gives you better information, but you don’t want to get a false sense of security.”
California’s health department has recommended that a facility’s prison inmates and staff members be given priority for testing once an infection has been identified there.
But the state prison system has conducted mass testing at only a handful of institutions where infections have been found, according to state data. In one of those facilities, the California Institution for Men in Chino, nearly 875 people have tested positive and 13 inmates have died.
Instead, California has employed surveillance testing, which involves testing a limited number of inmates at each state prison regardless of the known infection rate.
That method, Mr. Kelso said, had led officials to conclude that the vast majority of its prisons are free of the virus.
“We’re not 100 percent confident because we’re not testing everyone,” he said. “As we learn every single day from what we’re doing, we may suddenly decide, ‘No, we actually have to test all of them.’ We’re not at that point yet.”
In interviews, California prison inmates say prison staff have sometimes refused to test them, even after they complained about symptoms similar to the coronavirus. Several prisoners said they had been too weak to move for weeks at a time, but were never permitted to see a nurse and had never been tested.
“I had chest pains. I couldn’t breathe,” said Althea Housley, 43, an inmate at Folsom State Prison, where no inmates have tested positive, according to state data. “They told us it was the flu going around, but I ain’t never had a flu like that.”
Mr. Kelso did not dispute the prisoners’ accounts.
In Texas, mass testing has found that nearly 8,000 inmates and guards have been infected. Sixty-two people have died, including some who had not exhibited symptoms.
Dr. Murray, the physician who oversees much of Texas’ prison health care system, said the disparate approaches taken by prison authorities might actually be beneficial as officials compare notes.
“I’m glad we’ve got 50 states and everyone is trying to do something a little different — whether that’s by intent or not — because it’s really the only basis that we’re going to have for comparison later on,” he said.
But Baleegh Brown, 31, an inmate at a California prison, said he was displeased about being part of what he considered a science experiment. His prison has had more than 170 infections.
He said that he and his cellmate are confined to a 6-by-9-foot space for about 22 hours each day as the prison tries to prevent the virus from spreading further. Mr. Brown said he had a weakened immune system after a case of non-Hodgkin’s lymphoma, making him particularly vulnerable to illness.
“We need more testing here so everyone knows for sure,” he said. “And for me, my body has been compromised, so I don’t know how it is going to react. That makes all you don’t know even scarier.”
Despite a raft of data suggesting that wearing face masks (in conjunction with hand washing and social distancing) is effective in preventing person-to-person transmission of the coronavirus, the practice is still a partisan political issue in some places even as new cases continue to rise.
KEY FACTS
A new review published in The Lancet looked at 172 observational studies and found that masks are effective in many settings in preventing the spread of the coronavirus (though the results cannot be treated with absolute certainty since they were not obtained through randomized trials, the Washington Postnotes).
Another recent study found that wearing a mask was the most effective way to reduce the transmission of the virus.
90% of Americans now say they’re wearing a mask in compliance with the CDC’s recommendations, up from 78% in April, according to a new poll conducted by NORC at the University of Chicago for the Data Foundation.
But despite the conclusive research and what seems to be a public consensus, masks remain a divisive subject.
As new coronavirus cases surge in Arizona, where cases have jumped 300% since the beginning of May, for instance, Governor Doug Ducey has not made it mandatory to wear masks in public, and in Orange County, California, officials on Friday rescinded a mask mandate after public backlash, even as cases rise; when cases peaked in April, on the other hand, New York made wearing a mask mandatory when people could not socially distance from others, and other states passed similar restrictions.
Part of the politicization of masks may have to do with resistance to heavy-handed government mandates, which in this case could cause people who are already skeptical of wearing face coverings to dig in their heels.
CRUCIAL QUOTE
Lindsay Wiley, an American University Washington College of Law professor specializing in public health law and ethics, told NPR last month that stringent mask requirements “can actually cause people who are skeptical of wearing masks to double down.” And in turn, that “reinforce[s] what they perceive to be a positive association with refusing to wear a mask … that they love freedom, that they’re smart and skeptical of public health recommendations.”
KEY BACKGROUND
Masks have also become a heavily politicized issue in recent weeks: Senate Majority Leader Mitch McConnell (R-Ky.) last month voiced his support of mask wearing in public, for instance, in contrast to President Trump and other GOP leaders who have portrayed masks as a sign of weakness. Trump infamously refused to wear a face mask as he toured a Ford facility in Michigan last month. When asked about the mask, he said that he wore one in private but “didn’t want to give the press the pleasure of seeing it.” House Speaker Nancy Pelosi has voiced her support for the practice: “real men wear masks,” she said earlier this month.
TANGENT
A video posted to Twitter on Friday showed a street in New York City’s East Village that was packed with people ignoring social distancing guidelines, most of whom were not wearing masks, drew widespread criticism. “When there’s a new spike people will blame the (masked) protests, but it’s really gonna be maskless crap like this,” one Twitter user wrote.
New York Governor Andrew Cuomo even weighed in on the scene. “Don’t make me come down there,” he tweeted.
The director of the Center for Infectious Disease Research and Prevention said the US is in an “unsure moment” regarding the effects of states reopening and protests during the novel coronavirus pandemic.
Dr. Michael Osterholm told “Fox News Sunday” that it’s too early to tell if protests have been a source of widespread infections, but early data suggests the demonstrations aren’t responsible for rises in 22 states.
The Centers for Disease Control and Prevention predicted on June 12 that the US coronavirus death toll could increase to 130,000 by July 4.
Dr. Michael Osterholm, the director of the Center for Infectious Disease Research and Prevention, said Sunday that the US is in an “unsure moment” as states reopen and new cases emerge.
“We have to be humble and say we’re in an unsure moment,” Osterholm said on “Fox News Sunday,” adding that states across the country are in varied stages of the pandemic as 22 have recorded an increase in coronavirus cases, eight in plateaus, and 21 with decreasing cases.
Osterholm was speaking as states have been reopening businesses for weeks, Americans flocked to warm weather, and widespread protests drew people to the streets in cities across the country. The first few weeks of June have seen sharp rises in new cases and hospitalizations.
The US hit a grim milestone two weeks into June as it marked more than 2 million infected and 115,000 dead from the virus. Centers for Disease Control and Prevention predicted on June 12 that the US coronavirus death toll could increase to 130,000 by July 4.
“About 5% of the US population has been infected to date with the virus, this virus is not going to rest until it gets to about 60% or 70%,” Osterholm said. “When I say rest, I mean just slow down, so one way or another we’re going to see a lot of additional cases.”
The expert told host Chris Wallace that the increase cannot only be attributed to increasingly available testing, and it’s too early to tell if protests have been a source of widespread infections, but early data suggests not.
“These next weeks, the two weeks are going to be the telling time, we just don’t know,” he said. “We’re not driving this tiger, we’re riding it.”
“My biggest concern is if cases start to disappear across the country, suggesting we are in a trough” that would lead to a second wave of the virus, Osterholm said.
Though Fauci told CNN on June 12 that indicators like hospitalizations could still spell concern for officials, increased testing and CDC capabilities could counter a possible resurgence in cases.
Emily Brown was director of the Rio Grande County Public Health Department in Colorado until May 22, when the county commissioners fired her after battling with her over coronavirus restrictions. “They finally were tired of me not going along the line they wanted me to go along,” she says.
Emily Brown was stretched thin.
As the director of the Rio Grande County Public Health Department in rural Colorado, she was working 12- and 14-hour days, struggling to respond to the pandemic with only five full-time employees for more than 11,000 residents. Case counts were rising.
She was already at odds with county commissioners, who were pushing to loosen public health restrictions in late May, against her advice. She had previously clashed with them over data releases and had haggled over a variance regarding reopening businesses.
But she reasoned that standing up for public health principles was worth it, even if she risked losing the job that allowed her to live close to her hometown and help her parents with their farm.
Then came the Facebook post: a photo of her and other health officials with comments about their weight and references to “armed citizens” and “bodies swinging from trees.”
The commissioners had asked her to meet with them the next day. She intended to ask them for more support. Instead, she was fired.
“They finally were tired of me not going along the line they wanted me to go along,” she said.
In the battle against COVID-19, public health workers spread across states, cities and small towns make up an invisible army on the front lines. But that army, which has suffered neglect for decades, is under assault when it’s needed most.
Officials who usually work behind the scenes managing everything from immunizations to water quality inspections have found themselves center stage. Elected officials and members of the public who are frustrated with the lockdowns and safety restrictions have at times turned public health workers into politicized punching bags, battering them with countless angry calls and even physical threats.
On Thursday, Ohio’s state health director, who had armed protesters come to her house, resigned. The health officer for Orange County, California, quit Monday after weeks of criticism and personal threats from residents and other public officials over an order requiring face coverings in public.
As the pressure and scrutiny rise, many more health officials have chosen to leave or been pushed out of their jobs. A review by KHN and The Associated Press finds at least 27 state and local health leaders have resigned, retired or been fired since April across 13 states.
In California, senior health officials from seven counties, including the Orange County officer, have resigned or retired since March 15. Dr. Charity Dean, the second in command at the state Department of Public Health, submitted her resignation June 4.
These officials have left their posts due to a mix of backlash and stressful, nonstop working conditions, all while dealing with chronic staffing and funding shortages.
Some health officials have not been up to the job during the biggest health crisis in a century. Others previously had plans to leave or cited their own health issues.
But Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials, said the majority of what she calls an “alarming” exodus resulted from increasing pressure as states reopen. Three of those 27 were members of her board and well known in the public health community — Rio Grande County’s Brown; Detroit’s senior public health adviser, Dr. Kanzoni Asabigi; and the head of North Carolina’s Gaston County Department of Health and Human Services, Chris Dobbins.
Asabigi’s sudden retirement, considering his stature in the public health community, shocked Freeman. She also was upset to hear about the departure of Dobbins, who was chosen as health director of the year for North Carolina in 2017. Asabigi and Dobbins did not reply to requests for comment.
“They just don’t leave like that,” Freeman said.
Public health officials are “really getting tired of the ongoing pressures and the blame game,” Freeman said. She warned that more departures could be expected in the coming days and weeks as political pressure trickles down from the federal to the state to the local level.
From the beginning of the coronavirus pandemic, federal public health officials have complained of being sidelined or politicized. The Centers for Disease Control and Prevention has been marginalized; a government whistleblower said he faced retaliation because he opposed a White House directive to allow widespread access to the malaria drug hydroxychloroquine as a COVID-19 treatment.
In Hawaii, U.S. Rep. Tulsi Gabbard called on the governor to fire his top public health officials, saying she believed they were too slow on testing, contact tracing and travel restrictions. In Wisconsin, several Republican lawmakers have repeatedly demanded that the state’s health services secretary resign, and the state’s conservative Supreme Court ruled 4-3 that she had exceeded her authority by extending a stay-at-home order.
With the increased public scrutiny, security details — like those seen on a federal level for Dr. Anthony Fauci, the top infectious disease expert — have been assigned to state health leaders, including Georgia’s Dr. Kathleen Toomey after she was threatened. Ohio’s Dr. Amy Acton, who also had a security detail assigned after armed protesters showed up at her home, resigned Thursday.
In Orange County, in late May, nearly a hundred people attended a county supervisors meeting, waiting hours to speak against an order requiring face coverings. One person suggested that the order might make it necessary to invoke Second Amendment rights to bear arms, while another read aloud the home address of the order’s author — the county’s chief health officer, Dr. Nichole Quick — as well as the name of her boyfriend.
Quick, attending by phone, left the meeting. In a statement, the sheriff’s office later said Quick had expressed concern for her safety following “several threatening statements both in public comment and online.” She was given personal protection by the sheriff.
But Monday, after yet another public meeting that included criticism from members of the board of supervisors, Quick resigned. She could not be reached for comment. Earlier, the county’s deputy director of public health services, David Souleles, retired abruptly.
An official in another California county also has been given a security detail, said Kat DeBurgh, the executive director of the Health Officers Association of California, declining to name the county or official because the threats have not been made public.
DeBurgh is worried about the impact these events will have on recruiting people into public health leadership.
“It’s disheartening to see people who disagree with the order go from attacking the order to attacking the officer to questioning their motivation, expertise and patriotism,” said DeBurgh. “That’s not something that should ever happen.”
Many local health leaders, accustomed to relative anonymity as they work to protect the public’s health, have been shocked by the growing threats, said Theresa Anselmo, the executive director of the Colorado Association of Local Public Health Officials.
After polling local health directors across the state at a meeting last month, Anselmo found about 80% said they or their personal property had been threatened since the pandemic began. About 80% also said they’d encountered threats to pull funding from their department or other forms of political pressure.
To Anselmo, the ugly politics and threats are a result of the politicization of the pandemic from the start. So far in Colorado, six top local health officials have retired, resigned or been fired. A handful of state and local health department staff members have left as well, she said.
“It’s just appalling that in this country that spends as much as we do on health care that we’re facing these really difficult ethical dilemmas: Do I stay in my job and risk threats, or do I leave because it’s not worth it?” Anselmo asked.
Some of the online abuse has been going on for years, said Bill Snook, a spokesperson for the health department in Kansas City, Missouri. He has seen instances in which people took a health inspector’s name and made a meme out of it, or said a health worker should be strung up or killed. He said opponents of vaccinations, known as anti-vaxxers, have called staffers “baby killers.”
The pandemic, though, has brought such behavior to another level.
In Ohio, the Delaware General Health District has had two lockdowns since the pandemic began — one after an angry individual came to the health department. Fortunately, the doors were locked, said Dustin Kent, program manager for the department’s residential services unit.
Angry calls over contact tracing continue to pour in, Kent said.
In Colorado, the Tri-County Health Department, which serves Adams, Arapahoe and Douglas counties near Denver, has also been getting hundreds of calls and emails from frustrated citizens, deputy director Jennifer Ludwig said.
Some have been angry their businesses could not open and blamed the health department for depriving them of their livelihood. Others were furious with neighbors who were not wearing masks outside. It’s a constant wave of “confusion and angst and anxiety and anger,” she said.
Then in April and May, rocks were thrown at one of their office’s windows — three separate times. The office was tagged with obscene graffiti. The department also received an email calling members of the department “tyrants,” adding “you’re about to start a hot-shooting … civil war.” Health department workers decamped to another office.
Although the police determined there was no imminent threat, Ludwig stressed how proud she was of her staff, who weathered the pressure while working round-the-clock.
“It does wear on you, but at the same time we know what we need to do to keep moving to keep our community safe,” she said. “Despite the complaints, the grievances, the threats, the vandalism — the staff have really excelled and stood up.”
The threats didn’t end there, however: Someone asked on the health department’s Facebook page how many people would like to know the home addresses of the Tri-County Health Department leadership. “You want to make this a war??? No problem,” the poster wrote.
Back in Colorado’s Rio Grande County, some members of the community have rallied in support of Brown with public comments and a letter to the editor of a local paper. Meanwhile, COVID-19 case counts have jumped from 14 to 49 as of Wednesday.
Brown is grappling with what she should do next: dive back into another strenuous public health job in a pandemic, or take a moment to recoup?
When she told her 6-year-old son she no longer had a job, he responded: “Good — now you can spend more time with us.”
In Maryland, drive-through coronavirus testing sites are now open to all residents, whether or not they show signs of illness.
In Oregon, by contrast, officials have said that generally only people with symptoms of covid-19, the illness associated with the coronavirus, should be tested — even in the case of front-line health-care workers.
In Rhode Island, officials have proactively tested all of the state’s 7,500 nursing home residents, including those with no symptoms, and are developing plans to test more people in high-risk workplaces, such as restaurants and grocery stores.
The wide range of approaches across the country comes as the federal government has offered little guidance on the best way to test a broad swath of the population, leaving state public health officials to wrestle on their own with difficult questions about how to measure the spread of the virus and make decisions about reopening their economies.
Faced with conflicting advice from experts in the field, states are using different tests that vary in reliability and have adopted a variety of policies about who else should get tested and when — particularly when it comes to asymptomatic people who are considered low-risk for the illness.
“The states are on their own,” said Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories, noting that the kind of guidance the federal government routinely gives in screening for flu and other outbreaks “has been absent” in the covid-19 pandemic. “There has been no coordination.”
That means that while tests are available to anyone who wants them in states such as Kentucky and Georgia and some large cities such as Detroit and Los Angeles, state officials in Idaho and Louisiana continue to recommend that only sick people get tested.
The lack of a unified national strategy has left Americans uncertain about whether and how to be tested and is hampering reopening plans, experts warn.
Many officials now worry that protests in more than 100 U.S. cities in recent days after the death of George Floyd in police custody, which have drawn thousands of people packed closely together, could spark new infections.
So far, about 460,000 Americans are being tested a day — 0.15 percent of the population, and still shy of the 900,000 to 30 million that experts say need to be tested daily to capture the extent of the virus’s spread.
“The case numbers we’re seeing are probably massively undercounted,” said Divya Siddarth, a researcher who helped devise a testing strategy for Harvard University’s Safra Center that emphasizes finding and suppressing the disease in areas with fewer cases. “These [lower prevalence] regions are likely to reopen, and they’ve barely done any tests.”
The lack of clear information is forcing businesses large and small, schools, universities and professional sports organizations to make their own decisions about how much testing they need to be safe.
Some institutions have announced their own plans for universal testing. The National Hockey League, for example, has said it plans to test all players daily as part of a plan to resume play in June. The University of Arizona has developed its own antibody test that’s available to all students and local health-care workers.
Under a law passed earlier this year, the Trump administration is required to develop a national testing strategy. But an 81-page document submitted to Congress by the Department of Health and Human Services late last month was not released publicly and offered few detailed recommendations.
The Washington Post obtained a copy of the plan, which set a goal for states of testing at least 2 percent of their residents in May and June. But how to meet that benchmark and whether to go further was left up to state leaders who were required to submit plans this month to HHS for review.
The Centers for Disease Control and Prevention has recommended universal testing for residents of nursing homes, which have been especially hit hard by the coronavirus. But the HHS document said the CDC was still working on guidelines for other large populations of mostly asymptomatic people — including at universities, prisons and “critical infrastructure worksites” — as well as those for integrating testing into reopening work places.
Mia Palmieri Heck, a spokeswoman for HHS, said the federal government “has provided prescriptive criteria about testing asymptomatic individuals when they affect highly vulnerable populations such as individuals who live in nursing homes, working in or visiting health-care clinics or communal dining spaces.” She added that federal experts have also been advising states on developing plans to more broadly test people without symptoms to determine community spread.
The question of asymptomatic testing is particularly tricky given that the CDC late last month said that its researchers now believe as many as 35 percent of people infected with the coronavirus never show symptoms of disease.
Typifying the kind of conflicting information facing states, a World Health Organization official sparked global confusion on Monday when she said it is “very rare” for people with no symptoms to transmit the disease. After significant pushback from researchers, the official said Tuesday that scientists continue to believe that people without symptoms do in fact spread the virus — but more research is needed to understand by how much.
She noted that some modeling shows as much as 41 percent of transmission may be due to asymptomatic people.
“In some ways, this may be the Achilles’ heel of the entire testing challenge for this virus,” said Ashish Jha, director of the Harvard Global Health Institute, who has advocated for increasing the number of people getting tested.
Local and state health officials worry that the lack of coherent strategy could result in tests becoming widely available for the affluent, while remaining limited for those with fewer resources, including minority communities that have already been disproportionately affected by the virus.
At the University of Arizona, officials plan to reserve molecular swab tests, which determine if a person is currently infected, for symptomatic students and their contacts. Each test is about $50 to $75 dollars; there are 60,000 students, staff and faculty and each would have to be tested repeatedly.
“Maybe the NFL can afford that; we can’t, and I don’t know any university that can,” said Robert C. Robbins, the university’s president.
‘Box the virus in’
When coronavirus cases began to mount in March, a severe shortage of test kits and supplies meant tests were sharply rationed. Even after it was clear that the virus was spreading in the United States, the CDC at first recommend only testing people who had visited China or been in contact with someone who had.
Later, federal officials suggested that younger, healthy people did not necessarily need testing even if they were experiencing coronavirus symptoms, reasoning that the tests should be reserved for hospitalized patients for whom a positive result might make a difference in treatment plan.
As tests have become more available, officials have begun to recommend that anyone who is experiencing signs of illness, even a mild cough or sore throat, get one.
The goal is to identify and quarantine people with the disease, and then use contact tracers to track down people who have interacted with that person and quarantine them as well.
“Testing is just part of a comprehensive strategy,” former CDC director Tom Frieden said. “As you emerge from that sheltering situation, you box the virus in.”
But when it comes to testing people without symptoms, state recommendations vary.
About at least half of states aim to test people identified as contacts of known positive cases, according to a Post tally, as was recommended in new guidance from the CDC this week. But many others tell those people to self-isolate for 14 days.
“Every state is figuring this out on its own, little bit by little bit,” said Philip Chan, medical director for the Rhode Island Department of Health.
Nearly all states have set aside thousands of tests for people in congregate settings — residential settings where large numbers of people live in proximity, especially nursing homes and prisons.
But only a handful of states have so far satisfied the CDC goal to test everyone living in a nursing home, where the age and underlying medical conditions of residents make them especially vulnerable to covid-19 outbreaks.
Some states have also prioritized testing front-line health-care workers and other people working elbow-to-elbow in manufacturing facilities, particularly meatpacking plants, which have been hit hard by the virus.
Even states that have conducted widespread testing in such facilities face difficult questions about whether a single round of testing is sufficient, given that people could easily contract the virus at any time, including after testing negative.
“There’s not a lot of communication between the states and there’s not a lot of specifics, so everybody’s kind of going on their own,” Wroblewski said.
A tricky disease
A number of states and large cities, such as Detroit and Los Angeles, have opened drive-through testing sites like those offered in Maryland, a mode of mass testing used effectively overseas in South Korea and elsewhere.
Experts have warned that drive-through sites often fail to collect enough information from those tested to follow up effectively. They also prioritize people who choose to show up, tending to mean tests go to better educated and informed residents and not necessarily those most likely to have been exposed to the virus.
In Macon, Ga., the Moonhanger Group set up drive-through testing for employees returning to work at their four restaurants. But they did not wait for the results, or for all employees to get tested, before reopening on May 26.
“We were confident, based on the low number of positive results reported in Bibb county, that none of our employees would test positive and we hoped to share that news with the public,” owner Wes Griffith wrote on Facebook. “Unfortunately and surprisingly, we have employees who have tested positive. All of them were a-symptomatic.” Griffith did not respond to a request for comment.
Three of the four restaurants had to quickly close again, pending further testing.
In Georgia, public officials are advertising on radio and social media to encourage anyone to get tested at drive-through sites.
Those tested have included political leaders, who got tested largely to encourage others to do so too, only to find themselves “shocked” when their results came back positive, said Phillip Coule, chief medical officer of the Augusta University Health System, which is partnering with the state on testing.
“It’s a great demonstration of how tricky this disease is,” he said.
Other states have downplayed asymptomatic testing as unreliable or a poor use of resources.
Coule noted that the message, “If you want a test, you can get a test,” puts the onus for deciding who should get tested on individuals, rather than prioritizing the highest-risk or the most vulnerable. One of his patients, he noted, sought a test because he wanted to honeymoon in St. Lucia and needed a negative result to enter the country.
Oregon only opened testing to front-line workers and long-term care residents without symptoms in April and continues not to recommend asymptomatic testing, saying on the state website that it is “not useful” because the false negative rate is high. Viral tests have been estimated to have up to a 20 percent false negative rate.
At a recent news conference, Oregon Health Authority Chief Medical Officer Dana Hargunani said people without symptoms are “unlikely or certainly less likely to cause transmission of the virus.”
‘It’s like a war’
For states looking to figure out who to test and when, advice from national experts has been abundant — but not always consistent.
Proposals from academics and other experts vary widely in their recommendations of the numbers of tests that should be performed each day, and many do not offer guidance about who should be tested.
Some researchers have recommended focusing on parts of the country that have few cases in hopes of stamping out the disease.
“We should quickly get resources to places where the disease can be suppressed, then backfill tests in the places currently overwhelmed,” said Glen Weyl, an economist at Microsoft, who worked on the Harvard University proposal. “It’s like a war — you have to more troops than the enemy in order to win a battle.”
Other researchers have proposed blanketing the country with tests, with a focus on places experiencing clear outbreaks.
Paul Romer, an economist at New York University, said there should be mass testing in hot spots that is quickly expanded to near-universal, constant testing for everyone — 23 million tests a day, noting that the cost of tests have dropped.
“It would be feasible if we just invested and made it happen,” he said.
Other countries have used aggressive and organized testing to help stop the spread of the virus. South Korea — where the first case of the coronavirus was diagnosed on the same day as in the United States — quickly started mass testing at drive-through sites to spot and isolate cases.
The government has also instituted a sophisticated and aggressive effort to trace contacts of any known case, to squelch outbreaks. After several people who visited nightclubs in Seoul tested positive in early May, the government within two weeks tracked down 46,000 people who might have been exposed and tested them all.
In Wuhan, China, the site of the world’s first major coronavirus outbreak, government officials said theytested nearly 10 million of the city’s 11 million residents since mid-May, part of an effort to test universally and ensure the city doesn’t experience a new wave of infections.
Still, many experts agree that completely random asymptomatic testing is not an effective strategy.
A report issued late last month by the Center for Infectious Disease Research and Policy at the University of Minnesota called for ramping up testing nationwide, including in some congregate settings and as part of public health research. But the report found that widespread testing of people without symptoms was not advisable in most workplaces, in schools or in the broader community.
Researchers at the center found such testing could waste precious resources and could cause problems for communities, given that the tests are not fully reliable.
“There’s been far too much of this group think around, ‘test, test, test,’ without understanding what it’s accomplishing,” said Michael Osterholm, the director of the center. “You need the right test, at the right time, for the right reasons.”
The report’s central recommendation: that HHS form a blue-ribbon commission with national experts to formulate advice for states.
Evidence is mounting that widespread mask-wearing can significantly slow the spread of coronavirus and help reduce the need for future lockdowns.
Public health authorities did not initially put an emphasis on masks, but that’s changed and there is now increasing consensus that they play an important role in hindering transmission of the virus at a time when wearing one has become politicized as some states and businesses have made them a requirement for certain activities.
Wearing a mask is also seen by experts as a relatively easy action that could help avoid much costlier responses like stay at home orders and closing businesses.
“It’s a lot less economically disruptive to wear a mask than to shut society, so I can’t understand some of the resistance to mask wearing,” Tom Frieden, the former director of the Centers for Disease Control and Prevention (CDC), said on a call with reporters on Thursday.
Experts say mask-wearing is not the only response needed to slow the spread of the virus. Avoiding crowds and staying six feet apart from others is also important, as is an effective system of testing and contact tracing so people can quarantine and prevent further spread.
A study from University of Cambridge researchers this week found that widespread mask-wearing can help prevent a resurgence of the virus with less reliance on lockdowns that have proven economically devastating.
The modeling in the study found that if 50 percent or more of the population routinely wore masks, each infected person would on average spread the virus to less than one additional person, causing the outbreak to decline, the university said.
“We have little to lose from the widespread adoption of facemasks, but the gains could be significant,” Renata Retkute, one of the authors of the study, said in a statement.
Scott Gottlieb, the former FDA Commissioner for President Trump, pointed to the study on Twitter this week and wrote: “More widespread masking with higher quality masks could help mitigate a second wave.”
It cannot be ruled out that further lockdowns will be needed, but wearing a mask is one part of a strategy to help avoid them, according to Joshua Sharfstein, vice dean at the Johns Hopkins Bloomberg School of Public Health.
“I think it could substantially help open workplaces, but I’d still want to maximize distancing,” he said.
The emphasis on masks has been slow to develop in some places. The World Health Organization did not issue a recommendation for the general public to wear masks until last week, previously only saying people who are sick and those caring for them should use masks.
In the early days of the outbreak in the United States, there was also concern about the general public using up masks that were in short supply for health workers.
“Seriously people- STOP BUYING MASKS!” Surgeon General Jerome Adams tweeted at the end of February. “They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!”
That has changed, though, and the general public is now recommended to wear a simple cloth covering that could even be homemade, while leaving more advanced N95 masks for health care workers. The CDC now recommends wearing a mask in public when it is hard to stay six feet away from others, such as in grocery stores and pharmacies. Experts add that wearing a mask is mostly to protect others, not oneself.
“I don’t think it was so obvious from the beginning,” Sharfstein said, pushing back on critics who say authorities were slow to issue mask recommendations. “But it’s become more obvious,” he added.
Public health experts are lamenting, though, that mask-wearing has become politicized as opponents call requirements they wear one an infringement on their personal freedoms.
President Trump did not publicly wear a mask during a May visit to a Ford factory despite the company policy requiring one. He also called it “unusual” that presumptive Democratic presidential nominee Joe Biden wore a mask during a Memorial Day ceremony, though he said he “wasn’t criticizing.”
In Arizona, which has seen a surge in coronavirus cases recently, Gov. Doug Ducey (R) was pressed at a news conference on Thursday by a reporter who asked, “When was the last time you wore a face mask, governor?”
“I’ve got my face masks with me today,” Ducey said, taking some out of his pocket. “And when I’m not physically distancing, I wear them and wash them often.”
Some states, like Massachusetts and New York, have mandated masks when people are in public and cannot stay six feet apart. Asked if he would mandate masks in Arizona, Ducey did not answer directly, but said, “I want people to wear masks when they can’t socially distance.”
Carlos del Rio, a professor of epidemiology at Emory University, compared the situation with mask-wearing to the early days of seatbelts.
“Imagine if today was the ‘60s and we were starting to use seatbelts and you would have some politicians say, ‘Oh, seatbelts don’t make a difference; I like my freedom; I don’t like to be tied down when I’m driving,’” he said.
But, he added: “Over and over the evidence is showing masks work; masks make a difference.”
“I didn’t jump on masks immediately,” he said. “But after a while, I said, ‘Yeah this is what we all need to be doing,’ but I think it took some time.”
When throngs of tourists and revelers left their homes over Memorial Day weekend, public health experts braced for a surge in coronavirus infections that could force a second round of painful shutdowns.
Two weeks later, that surge has hit places like Houston, Phoenix, South Carolina and Missouri. Week-over-week case counts are on the rise in half of all states. Only 16 states and the District of Columbia have seen their total case counts decline for two consecutive weeks.
But instead of new lockdowns to stop a second spike in cases, states are moving ahead with plans to allow most businesses to reopen, lifting stay-at-home orders and returning to something that resembles normal life.
“There is no — zero — discussion of re-tightening any measures to combat this trend. Instead, states are treating this as a one-way trip. That sets us up for a very dangerous fall, but potentially even for a dangerous summer,” said Jeremy Konyndyk, a senior fellow at the Center for Global Development who oversaw the U.S. Agency for International Development’s Office of Foreign Disaster Assistance during the Obama administration.
The moves suggest that many Americans — anxious to end two-plus months of lockdowns, smarting from the devastating economic toll they have already suffered and focused on the social justice protests that have roiled the nation — are ready to put the coronavirus behind them.
Even as case curves bend upward again, little action has been taken to counter the reversal.
“There are places that I suspect a lot of people are shrugging their shoulders and just rushing forward,” said David Rubin, who runs the PolicyLab at Children’s Hospital of Philadelphia. “I just worry that they might lose control of their epidemic, and that’s what you have to worry about these days.”
The statistics are startling. The average number of confirmed cases over a two-week period has doubled or more in Arizona, Arkansas, Oregon and Utah. Fewer than a quarter of intensive care unit beds in Alabama, Georgia and Rhode Island are available.
In Texas, the number of people admitted to the hospital has grown 42 percent since Memorial Day. Arizona’s top health official has urged hospitals to activate their emergency plans.
North Carolina, California, Mississippi and Arkansas are all reporting record levels of hospitalizations.
Some experts worry Americans have begun to accept the drumbeat of death, numbed by the nearly 2 million cases already confirmed across the country and the 112,000 who have died.
A virus once dismissed as not a serious threat to the nation and later acknowledged as a public health emergency is now becoming just another daily worry to be absorbed.
“One fear is that the U.S. will accept tens of thousands of deaths, as from gun violence, unlike other countries,” said Tom Frieden, director of the Centers for Disease Control and Prevention during the Obama administration.
“It’s not just lives. Unless we protect lives, we won’t get livelihoods back,” said Frieden, who now runs Resolve to Save Lives, a global health nonprofit.
The race to reopen comes even as new research shows the lockdowns were working. The dramatic steps Americans took to stop the virus saved an estimated 5 million infections through April 6, according to research by the Global Policy Lab at the University of California-Berkeley.
President Trump has been perhaps the loudest proponent of reopening, at times putting pressure on states to lift coronavirus restrictions even if the data is flashing warning signs.
World Health Organization (WHO) officials have practically begged nations to be slow and considerate as they move to reopen their economies.
“We need to focus on the now. This is far from over,” Maria Van Kerkhove, the WHO’s technical lead on the coronavirus, told reporters at a virtual press conference Monday. “I know many of us would like this to be over and I know many situations are seeing positive signs. But it is far from over.”
On Wednesday, WHO’s director of emergency programs acknowledged the challenges of lockdown life.
“We fully understand that governments are very reticent to go back into lockdowns that can be damaging to social and economic life,” said Mike Ryan.
“There has to be a balance between lives and livelihoods and the public health control of COVID-19,” Ryan added.
There are few signs that Americans are heeding the warnings.
“We’re just at the beginning of the Memorial Day story, not at the end,” Rubin said. “We are seeing the sea levels rise.”
HENRY KOTULA 