Why Arizona is suffering the worst Covid-19 outbreak in the US

The US is struggling with a resurgence of the coronavirus in the South and West. But the severity of Arizona’s Covid-19 outbreak is in a league of its own.

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Over the week of June 30, Arizona reported 55 new coronavirus cases per 100,000 people per day. That’s 34 percent more than the second-worst state, Florida. It’s more than double Texas, another hard-hit state. It’s more than triple the US average.

Arizona also maintained the highest rate of positive tests of any state at more than 25 percent over the week of June 30 — meaning more than a quarter of people who were tested for the coronavirus ultimately had it. That’s more than five times the recommended maximum of 5 percent. Such a high positive rate indicates Arizona doesn’t have enough testing to match its big Covid-19 outbreak.

To put it another way: As bad as Arizona’s coronavirus outbreak seems right now, the state is very likely still undercounting a lot of cases since it doesn’t have enough testing to pick up all the new infections.

The state also leads the country in coronavirus-related hospitalizations. According to the Centers for Disease Control and Prevention, more than one in five inpatient beds in Arizona are occupied by Covid-19 patients — about 42 percent more than Texas and 65 percent more than Florida, the states with the next-highest shares of Covid-19 patient-occupied beds. With hospitalizations rapidly climbing, Arizona became the first in the country to trigger “crisis care” standards to help doctors and nurses decide who gets treatment as the system deals with a surge of patients. Around 90 percent of the state’s intensive care unit beds are occupied, based on Arizona Department of Health Services data.

While reported deaths typically lag new coronavirus cases, the state has also seen its Covid-19 death toll increase over the past several weeks.

This is the result, experts say, of Arizona’s missteps at three crucial points in the pandemic. The state reacted too slowly to the coronavirus pandemic in March. As cases began to level off nationwide, officials moved too quickly to reopen in early and mid-May. As cases rose in the state in late May and then June, its leaders once again moved too slowly.

“What you’re seeing is not only a premature opening, but one done so rapidly there was no way to ensure the health care and public health systems didn’t get stressed in this process,” Saskia Popescu, an infectious disease epidemiologist based in Arizona, told me.

At the same time, recommended precautions against the coronavirus weren’t always taken seriously by the general public — with experts saying that, anecdotally, mask use in the state can be spotty. That could be partly a result of Republican Gov. Doug Ducey downplaying the threat of the virus: While he eventually told people to wear masks in mid-June, as of late May he claimed that “it’s safe out there,” adding, “I want to encourage people to get out and about, to take a loved one to dinner, to go retail shopping.”

Ducey’s actions and comments “gave the impression we were past Covid-19 and it was no longer an issue,” Popescu said, “which I believe encouraged people to become lax in their masking [and] social distancing.”

After weeks of increases in coronavirus cases and hospitalizations, Ducey pulled back Arizona’s reopening on June 29, closing downs bars, theaters, and gyms.

Experts say the move is a positive step forward, but also one that came too late: With coronavirus symptoms taking up to two weeks to develop, there are already infections out there that aren’t yet showing up in the data. The state can expect cases, hospitalizations, and, probably, deaths to continue to climb over the next few weeks.

Ducey acknowledged the sad reality: “It will take several weeks for the mitigations that we have put in place and are putting in place to take effect,” he said. “But they will take effect.”

Ducey’s office argued it took the action as was necessary at the time, based on the data it collected and its experts’ recommendations. “Our steps are in line with our facts on the ground that we’ve been tracking closely,” Patrick Ptak, a spokesperson for the governor’s office, told me.

Arizona now offers a warning to the rest of the world. The state’s caseload was for months far below the totals in New York, Michigan, and Louisiana, among the states that suffered the brunt of the virus in the US in the early months. But by letting its guard down, Arizona became a global hot spot for Covid-19 — a testament to the need for continued vigilance against the coronavirus until a vaccine or similarly effective treatment is developed.

Arizona was slow to close and quick to reopen

Arizona was initially slow to close down. While neighboring California instituted a stay-at-home order on March 19, Ducey didn’t issue a similar order for Arizona until March 31 — 12 days later.

That might not seem like too much time, but experts say it really is: When the number of Covid-19 cases statewide can double within just 24 to 72 hours, days and weeks matter.

Arizona was also quick to reopen its economy. After states started to close down, experts and the White House recommended that states see a decline in coronavirus cases for two weeks before they reopen. Arizona never saw such a decline. In fact, it arguably never even saw a real plateau. The number of daily new cases rose slowly and steadily through April and into May, and then the exponential spike took off.

So it’s not quite right to say that Arizona is experiencing a “second wave” of the coronavirus. It arguably never controlled the first wave, and the current rise of cases is a result of continued inaction as the initial wave of the virus spread across the state. (The Navajo Nation, which is partly in Arizona, was an initial coronavirus hot spot. But its case count has declined since May, in part because it took strong measures against the virus.)

Arizona and other states experiencing a surge in Covid-19 now “never got to flat,” Pia MacDonald, an epidemiologist at the research institute RTI International, told me. “That means the states didn’t get to very good compliance with the public health interventions that we all need to take to make sure the outbreak doesn’t continue to grow.”

Despite no sustained decline in Covid-19 cases, Arizona moved forward with reopening anyway. Ptak, the governor’s spokesperson, acknowledged that the state didn’t meet the two-week decline in cases, but he said the state had met another federal gating criteria for reopening by seeing a decline in the test positivity rate “week after week” throughout May.

Once the state started to reopen, it moved quickly. Within weeks, Arizona not only let hospitals do elective surgeries but started to allow dining in at restaurants and bars, and gyms and salons, among other high-risk indoor spaces, to reopen. The short time frame prevented the state from seeing the full impact of each step of its reopening, even as it moved forward with additional steps.

Will Humble, executive director of the Arizona Public Health Association, argued it was this rate of reopening that really caused problems for the state. “It was a free-for-all by May 15,” Humble told me. Referencing federal guidelines for reopening in phases, he added, Arizona effectively “went from phase 0 to phase 3.”

It’s not just that Ducey aggressively reopened the state, but that he also prevented local governments from imposing their own stricter measures. That included requirements for masks, which Ducey didn’t allow municipalities to impose until mid-June — weeks after Covid-19 cases started to rapidly rise. (Ptak claimed the governor acted once he received requests from mayors along the southern border to do so.)

Some of that is likely political. As recommendations and requirements for masks have expanded, some conservatives have suggested wearing a mask is emblematic of an overreaction to the coronavirus pandemic that has eroded civil liberties. President Donald Trump has by and large refused to wear a mask in public, even saying that people wear masks to spite him and suggesting, contrary to the evidence, that masks do more harm than good. While some Republicans are breaking from Trump on this issue, his comments and actions have helped politicize mask-wearing and other measures.

For example, there was an anti-mask rally in Scottsdale, Arizona, on June 24. There, a local council member, Republican Guy Phillips, shouted George Floyd’s dying words — “I can’t breathe!” — before ripping his own mask off, according to the Washington Post. (Phillips later apologized “to anyone who became offended.”)

Evidence supports the use of masks: Several recent studies found masks reduce transmission. Some experts hypothesize — and early research suggests — that masks played a significant role in containing outbreaks in several Asian countries where their use is widespread, like South Korea and Japan.

But for a Republican governor like Ducey, the politicization of the issue means a large chunk of his political base is resistant to the kind of measures needed to get the coronavirus under control. And those same constituents are likelier to reject taking precautions against the coronavirus, even if they’re recommended by government officials or experts.

Ducey himself seemed to play into the politics: One day before Trump visited a plant in the state, and as the president urged states to reopen, Ducey announced an acceleration of the state’s reopening plans.

Other factors, beyond policy, likely played a role as well in the rise in cases. While summer in other parts of the country lets people go outside more often — where the coronavirus is less likely to spread — triple-digit temperatures in Arizona can actually push people inside, where poor ventilation and close contact is more likely to lead to transmission.

Some officials have argued Black Lives Matter protests played a role in the new outbreak. But the research and data so far suggest the demonstrations didn’t lead to a significant increase in Covid-19 cases, thanks to protests mostly taking place outside and participants embracing steps, such as wearing masks, that mitigate the risk of transmission. In Arizona, the surge in coronavirus cases also began before the protests took off in the state.

Arizona is now stuck playing catch-up

Arizona saw its coronavirus cases start to increase by Memorial Day on May 25. The increase came hard — with the test positivity rate rising too, indicating early on that the increase was not merely the result of more testing in Arizona. Hospitalizations and deaths soon followed.

Yet Ducey didn’t begin to scale back the state’s reopening until more than a month later — on June 29. This left weeks for the coronavirus to spread throughout the community.

The sad reality is Arizona will suffer the consequences of the governor’s slow action for weeks. Because people can spread the virus without showing symptoms, can take up to weeks to show symptoms or get seriously ill, and there’s a delay in when new cases and deaths are reported, Arizona is bound to see weeks of new infections and deaths even after Ducey’s renewed restrictions.

“Even if I put in 100 percent face mask use and everybody complied with it in Arizona right now, there would still be weeks of pain,” Cyrus Shahpar, a director at the global health advocacy group Resolve to Save Lives, told me. “There are people out there spreading disease, and it takes time [to pick them up as cases], from exposure to symptom onset to testing to getting the testing results.”

Experts argue the state still needs to go even further. Humble advocated for more hospital staffing, a statewide mask requirement, more rigorous rules and better enforcement of the rules for reopening businesses, and improved testing capacity and contact tracing. He also pointed to the lack of timely testing in prisons as one area that hasn’t gotten enough attention and could lead to a blind spot for future Covid-19 outbreaks.

One potentially mitigating factor is the state’s infected have trended younger than they did in initial bouts of the US’s coronavirus outbreak, with people aged 20 to 44 making up roughly half of cases. That could keep the death toll down a bit — though Covid-19 deaths in Arizona have already risen, and experts warn of the risks of long-term complications from the coronavirus, including severe lung scarring, among young people as well.

Above all, experts say that the rise in cases was preventable and predictable.

The research suggests the lockdowns worked. One study in Health Affairs concluded:

Adoption of government-imposed social distancing measures reduced the daily growth rate by 5.4 percentage points after 1–5 days, 6.8 after 6–10 days, 8.2 after 11–15 days, and 9.1 after 16–20 days. Holding the amount of voluntary social distancing constant, these results imply 10 times greater spread by April 27 without SIPOs (10 million cases) and more than 35 times greater spread without any of the four measures (35 million).

The flipside, then, is likely true: Easing lockdowns likely led to more virus transmission.

This is what researchers saw in previous disease outbreaks.

Several studies of the 1918 flu pandemic found that quicker and more aggressive steps to enforce social distancing saved lives in those areas. But this research also shows the consequences of pulling back restrictions too early: A 2007 study in JAMA found that when St. Louis — widely praised for its response to the 1918 pandemic — eased its school closures, bans on public gatherings, and other restrictions, it saw a rise in deaths.

Here’s how that looks in chart form, with the dotted line representing excess flu deaths and the black and gray bars showing when social distancing measures were in place. The peak came after those measures were lifted, and the death rate fell only after they were reinstated.

This did not happen only in St. Louis. Analyzing data from 43 cities, the JAMA study found this pattern repeatedly across the country. Howard Markel, a co-author of the study and the director of the University of Michigan’s Center for the History of Medicine, described the results as a bunch of “double-humped epi curves” — officials instituted social distancing measures, saw flu cases fall, then pulled back the measures and saw flu cases rise again.

Arizona is now seeing that in real time: Social distancing worked at first. But as the state relaxed social distancing, it saw cases quickly rise.

This is why experts consistently cautioned not just Arizona but other states against reopening too quickly. It’s why they asked for some time — two weeks of falling cases — before states could start to reopen. It’s why they asked for states to take the reopening process slowly, ensuring that each relaxation didn’t lead to a surge in new Covid-19 cases.

Because Arizona and its leaders didn’t heed such warnings, it’s now suffering a predictable, preventable crisis — making it the state with the worst coronavirus epidemic in the country that’s suffered the most widespread coronavirus outbreak in the world.