How, not when

As new Covid 19 cases have spiked recently in states like Texas and Florida, it is not unusual to hear that the main reason for the spikes is that these states started opening their economies too soon. However, that claim ignores the fact that there are other states that started opening their economies at the same or even earlier time, and so far have accomplished gradual reopening while maintaining decent Covid experiences. Since there are legitimate public health issues from runaway Covid infections, non-Covid patients not getting the care they need, and also from forcing more and more people onto unemployment and poverty, it seems to us that rather than just wringing our hands over “states who started reopening too soon,” it would be more useful to see what might have allowed some states to start reopening successfully – thus better addressing the above public health issues.

Of the thirteen “rabbit” states that started reopening their economies early, we will look at four. Two have received much national publicity recently because new confirmed Covid cases and hospitalizations have increased significantly – Texas and Florida. Two have received hardly any national publicity, because they have been progressing relatively well with the pandemic – Indiana and Colorado. To us, it is very important to analyze what Indiana and Colorado have done. We should learn from our successes, as well as our failures.

All four states imposed a “Stay at Home” order by early April – IN on March 23; CO on March 25; FL on April 1; TX on April 2. By early May all four were starting to reopen their economies – CO on April 27; TX on April 30; IN on May 4; FL on May 4. 

We will focus on each state’s experience with new hospital admissions by day since their start of reopening. Because TX does not report new daily hospitalizations, but rather daily Covid hospital census, we are using the data from Texas Medical Center in Houston as a proxy – the Houston metro area accounts for >25% of all Covid hospitalizations in Texas and its daily hospitalization census trends parallel that of the state as a whole. We (and others, including the governor of Colorado) put a greater emphasis on hospital admissions, rather than cases, because case numbers can be skewed by the number of tests being conducted.

Public health experts watch hospitalizations closely because it can indicate how severe an outbreak is in an area. It’s considered a better measure than new cases because it’s not as reliant on the availability of testing.

Moreover, since PCR tests can detect live, dead or even fragments of the virus, there isn’t a clear correlation between a positive PCR test and clinical disease presentation or progression.

Colorado was the earliest to start reopening on April 27. While newly confirmed cases were still on the rise at the time the reopening was announced (April 20th), new Covid hospital admissions had already dropped significantly. Peak confirmed Covid cases happened on April 23 (just 4 days before reopening) at 969, while Covid hospital admissions had peaked two weeks before reopening, on April 14 at 282. By the first of July, new daily hospital admissions dropped to 30. 

Daily new Covid-19 hospitalizations and 7-day rolling average for the state of Colorado

Indiana, the other state that seems to have kept covid-19 under control, began re-opening on May 4th, and with a similar trajectory in hospitalizations as Colorado. Peak Covid hospital admissions occurred on March 31 at 181 and dropped to 38 by July 1, 2020. 

Daily new Covid-19 hospitalizations and 7-day rolling average for the state of Indiana

As for the two states that have seen a recent major surge in both cases and hospitalizations (Florida and Texas), it is of interest to note that in both locations, new daily hospitalizations were essentially flat prior to re-opening and for about a month following the initial re-opening date. 

Daily new Covid-19 hospitalizations and 7-day rolling average for the state of Florida
Daily new Covid-19 hospitalizations and 7-day rolling average for Texas Medical Center in Houston, TX

In our view, a major reason for the success in Colorado and Indiana is that each has made a serious effort to actually follow the four needed elements to control this virus. What are the four elements?  They were well pointed out in an article by Dr. Atul Gawande in a May article on reopening.  He comments on how his medical center had been doing it for its own employees. It is well stated in his own words, 

The Boston area has been a covid-19 hotspot. Yet the staff members of my hospital system here, Mass General Brigham, have been at work throughout the pandemic. We have seventy-five thousand employees—more people than in seventy-five per cent of U.S. counties. In April, two-thirds of us were working on site. Yet we’ve had few workplace transmissions. …in the face of enormous risks, American hospitals have learned how to avoid becoming sites of spread. …These lessons point toward an approach that we might think of as a combination therapy—like a drug cocktail. Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus.

To us, a key phrase in this quote is “when taken together, and taken seriously.” Both Colorado and Indiana have stressed repeatedly to wash hands, test, socially distance, and use face coverings/ masks.  In our view, Florida and Texas were both much more cavalier in their implementation of reopening – especially with regard to social distancing and face coverings/ masks.  

While it remains to be seen if Colorado and Indiana can maintain their success with keeping Covid in check, the two states have shown us that, it is possible to start reopening the economy and not have a Covid resurgence take over the efforts. While many claim that reopening the economy was the mistake of Florida and Texas, in our view it was not the reopening itself, but how it was carried out. We need to get our economy going again to help reduce the upcoming public health issues that are and will be coming from limiting healthcare access for non-Covid patients, as well as our massive unemployment and expansion of poverty – both of which will also increase social disparities of health. Let’s get our economy going again, but do so in steps and in keeping with what has been shown to work in some of our states.