Florida now has more Covid-19 cases than any other state. Here’s what went wrong.

A health care worker administers a coronavirus test at a drive-up testing site in Tampa, Florida, on June 25, 2020.A health care worker administers a coronavirus test in Tampa, Florida, on June 25, 2020. | Octavio Jones/Getty Images

Florida’s governor took a victory lap on the coronavirus. Now his state has the most cases in the US.

Florida now has the worst ongoing coronavirus outbreak in the country.

Since the beginning of July, Covid-19 cases in the state have gone up nearly 60 percent, with hospitalizations and deaths rapidly rising as well. Florida now has 20 percent more daily new Covid-19 cases than Arizona, 70 percent more than Texas, and more than double California. Florida drew headlines on Sunday for surpassing the record for the highest number of new cases reported in one day, previously held by New York (though that was driven largely by Florida having much more testing than New York did at the peak of its outbreak).

The percentage of positive tests over the previous week hit nearly 19 percent, which is almost four times the recommended maximum of 5 percent. The high rate — an indicator of how widespread infection is, as well as whether an area is conducting enough testing — suggests Florida still doesn’t have enough testing to match its Covid-19 outbreak. As bad as things are in Florida, the state is likely undercounting the number of cases.

It wasn’t always going this way. Just weeks ago, Gov. Ron DeSantis made media rounds boasting about Florida’s response to the coronavirus pandemic, rebuking those who had criticized the state’s actions, and bragging that his state had managed to keep Covid-19 cases low despite a slower, less-aggressive lockdown and a quicker reopening than other places.

In a May article from the conservative National Review — titled “Where Does Ron DeSantis Go to Get His Apology?” — DeSantis said he “was doing a good job,” spending much of the article arguing that his critics were wrong and that he’d been purportedly driven by the data and science in his response.

DeSantis bragged about how quickly the state was able to reopen due to his great response to the pandemic, saying that “what we did in March and April is the equivalent of what New York will be or California, when they go to phase three” — in reference to California’s slower-moving phased plan for reopening.

Now, though, experts say it’s that rapid reopening — mixed with public complacency that the virus had been defeated and lackluster action in the previous months — that led Florida to its current crisis.

Florida “defiantly reopened in the name of rejuvenating their economy relatively early,” C. Brandon Ogbunu, a computational biologist at Yale, told me. “The prediction was quite clear that they would have a bad wave at some point.”

Florida was relatively late in closing down statewide, but it was also among the first to reopen. The state also reopened very quickly — letting restaurants, bars, and other businesses reopen, sometimes at high or full capacity, within weeks of ending its lockdown. That fast pace of reopening not only made it easier for people to infect each other with the coronavirus, but also made it much harder to evaluate, due to lags in coronavirus case reporting, if each phase of reopening was leading to uncontrollable growth in infections.

At the same time, the public didn’t follow precautions. Fueled by politics and complacency, people in Florida are, anecdotally, very inconsistent in physical distancing and wearing masks, experts said. Data also suggests that people in the state were much quicker to go out, once the lockdown ended, than most other states.

“I feel like we came out of the stay-at-home [order] and just thought, ‘Oh, it’s not a big deal anymore,’” Cindy Prins, an epidemiologist at the University of Florida, told me. People “went back to what they were doing before — those activities they were doing before — without modifying this time.”

Recognizing the surge in cases, the state suspended alcohol consumption at bars on June 26. But the state has resisted further action, with DeSantis declaring the state is “not going back” on reopening and moving ahead with reopening schools.

Even if Florida’s government and residents were to act now, though, the effects of the state’s quick reopening will likely linger for weeks as Covid-19 takes time to show symptoms and spread to others. That’s why, experts say, Florida should take more action sooner rather than later — as it’s now stuck with rising cases, hospitalizations, and deaths in the days or weeks to come. More targeted measures now, the thinking goes, could help the state avoid the worst and, potentially, another full stay-at-home order.

DeSantis’s office didn’t return requests for comment.

Like the surge in Arizona and California, Florida’s rising Covid-19 outbreak demonstrates the need for constant vigilance in the fight against the coronavirus. It’s now clear that as the governor and public grew complacent in their efforts, the virus slowly spread across the population. We’re now seeing the consequences — and the important lesson behind them.

“Don’t get comfortable,” Prins said. “Don’t think that just because you controlled it you can continue to control it.”

Florida reopened too quickly

DeSantis initially saw it as a bragging point, but Florida’s quick reopening is one of the big reasons, experts said, that the state is now experiencing a huge outbreak.

Florida was slow to close in the beginning of the pandemic. While California, for example, closed on March 19 and New York on March 22, Florida took until April to issue a stay-at-home order. Those few weeks can really matter with Covid-19: When the number of cases can double within just 24 to 72 hours, days and weeks matter.

But at least in Florida, cases did stay relatively low through March and April — with the caveat that low testing capacity back then meant many cases were very likely missed.

Then, Florida was one of the first states to reopen. Its stay-at-home order expired on May 4, a little more than a month after it went into effect.

Unlike other states that have seen a surge in cases, like Arizona, Florida actually did see its reported Covid-19 cases drop during its full lockdown before it moved to reopen. That put it in line with what experts and the White House recommended: a two-week decline in cases before reopening. The drop happened as Florida’s Covid-19 testing numbers increased and the positive rate fell, indicating the decline in cases was genuine.

But after the state reopened, cases began to surge in June.

A chart of Florida’s coronavirus cases, which started to surge in June.German Lopez/Vox

Where Florida went wrong, experts say, is it let its guard down. The state reopened very quickly. Between early May and early June, the state went from a full lockdown to letting gyms, salons, bars, and indoor dining at restaurants to reopen. This made it difficult to track the full effects of each phase of reopening — a process experts say requires weeks or even more than a month to fully gauge.

“When you have a low level of cases in a state, and you have a virus that takes two weeks to replicate, and people are going to transmit to each other, you have to give it time to see the number of cases come up to know that maybe we have an issue,” Prins said, arguing that six weeks are necessary to see the full effects of each phase of reopening.

But many people in Florida seemed to embrace the state’s reopening. Based on restaurant data from OpenTable, Florida was among a handful of states — most of which are now experiencing major outbreaks — to see people start trickling back out to restaurants in the first full week of May. By June, dine-in was down around 60 to 70 percent compared to the same period last year in Florida; in comparison, it was down by more than 80 percent in California and 90 percent to 100 percent in New York and New Jersey.

The result: People in Florida were increasingly out and about, interacting and infecting each other with the coronavirus. Friends and families began gathering again, especially as they celebrated Memorial Day and the summer kicked off. Tourists came into the state for the summer, too. As they came together — in poorly ventilated homes, restaurants, and bars, in close proximity to people they don’t live with, often for hours at a time — people spread the virus more frequently.

The research backs this up. 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 also 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, Missouri — 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.

A chart showing deaths in St. Louis during social distancing measures amid the 1918 flu pandemic.Courtesy of JAMA

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.

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

“We know what has worked,” Ogbunu said. “It’s very, very clear now that states that were defiant with regard to their social distancing policies are suffering the consequences for it.”

People didn’t always follow public health advice

On top of the policy response, experts worry that people in Florida never really got the message that precautions against Covid-19 would be needed for months and possibly years to come (until a vaccine or effective treatment is available). In some ways, it seems the public came under the impression that drastic action was only needed during the one-month lockdown — hence the rush back to restaurants, bars, and other indoor venues when Florida reopened, with at best spotty adherence to physical distancing and wearing a mask.

Studies suggest that, for the general public, physical distancing and masking really do work. A review of the research published in The Lancet found that “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”

But, experts said, it’s on them and public officials to get the word out about what the public needs to do. To this end, Florida hasn’t done a good job — especially to the extent DeSantis and local, state, and federal officials played into the politicization of such measures.

“We didn’t have a population that knew and believed that this virus is dangerous,” Aileen Maria Marty, an infectious diseases specialist at Florida International University, told me. “They took the virus for granted.”

One factor is the recommended precautions, including physical distancing but especially masks, became politicized. 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. DeSantis, a Trump ally, joined the president in the Oval Office in April to boast about Florida’s response to Covid-19, claim that the state’s light touch was correct, and that, relative to other states, “Florida’s done better.”

This kind of politicization created pockets of resistance, particularly among conservatives who see social distancing, masks, and other steps as an overreaction to Covid-19 and the policies requiring such measures as government overreach. Most recently, this was seen in an anti-mask “freedom rally” in a Florida restaurant, which organizers advertised as a “mask free zone.” One organizer compared the enforcement of state restrictions on restaurants to “tyranny,” the “Gestapo,” and “Nazi Germany.”

Beyond politicization, there has been complacency and fatigue toward stricter Covid-19 measures. Surveys from Gallup found that just 39 percent of people were “always” social distancing in late June, compared with 65 percent in early April; the number of people who “sometimes,” “rarely,” or “never” practice social distancing increased from 7 to 27 percent in the same time frame.

A chart showing Americans’ declining embrace of social distancing, based on Gallup’s surveys.Gallup

This may be particularly true for younger people, many of whom perhaps feel that they’re less vulnerable to Covid-19 than older populations. It’s no coincidence, then, that coronavirus cases in Florida disproportionately rose at first among younger people. But the problem is that young people can still get sick, suffer long-term complications, and die from Covid-19. They can also spread the virus to older populations that are more vulnerable — which in Florida increasingly seems to be happening.

When recommendations were followed, experts worried that the measures were sometimes carried out incorrectly. Anecdotally, it’s common for people to wear masks inappropriately — to the point they’re not covering their nose or even mouth. That, experts argued, comes down to an education problem.

Other factors, beyond policy and the public response to Covid-19, 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 Florida can actually push people inside, where poor ventilation and close contact is more likely to lead to transmission.

Some officials in Florida have argued that 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.

Florida now has to deal with the consequences

In response to the surge in cases, DeSantis on June 26 effectively closed bars across the state.

He argued the move was needed due to people disobeying social distancing guidance, forcing further action. “People weren’t following it,” he claimed. “There was widespread noncompliance, and that led to issues. If folks just follow the guidelines, we’re going to be in good shape. When you depart from that, then it becomes problematic.”

DeSantis, however, has so far resisted going further. He hasn’t moved to close down the state more widely, as California’s governor did, and instead pushed forward with schools reopening as soon as possible. And he’s rejected a statewide mask mandate — which could reduce transmission, based on studies of states and of Germany.

“We need to immediately have a civil order about wearing masks in the same way we have civil penalties for running a stop sign,” Marty said. “It is a reasonable request that we do to protect ourselves and others.”

It’s probably too late to completely reverse the outbreak. 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, Florida is bound to see days or weeks of new infections and deaths even if DeSantis suddenly closes the state back down.

That gets to a point that experts often make about disease outbreaks: It’s important to act before it’s obviously a problem.

“One of the things I’ve learned in any outbreak is that if it seems you overreacted, you’ve done a good job,” Krutika Kuppalli, an infectious disease specialist and a fellow in the Emerging Leaders in Biosecurity Initiative at the Johns Hopkins Center for Health Security, told me. What looks like overreaction, she added, means that “we prevented things from becoming a catastrophe. We don’t want to wait until things are a catastrophe and then react, because that’s too late.”

In that sense, any action Florida takes would help, but those results could take weeks to really reverse trends. So anything Florida does at this point isn’t too little, but it is likely too late.

But to make sure things don’t get much worse, experts have called for more aggressive steps. Some have asked for more targeted restrictions, particularly on indoor venues. They support statewide mask mandates. They want more aggressive education, along with more testing, tracing, and isolation of the sick, all of which is currently held back by big delays in testing results.

If the state government doesn’t act, experts said local officials could — and some cities and counties are already imposing stricter standards, including mask mandates.

Short of government action, experts urged the public to take precautions against Covid-19 more seriously. People should wear masks, prioritize outdoor venues over indoor spaces, keep 6 feet from each other, avoid touching their faces, and wash their hands. How well a community as a whole does all of that could dictate how bad things get — and could help make up, at least partially, for government inaction.

The goal now is to avoid things getting so out of control that another stay-at-home order is necessary. Everyone wants to avoid this, but the reality is that it may be the only way to stop an outbreak if it gets too bad — which is damaging not just for public health but for other parts of American life, too.

“Dead people don’t shop. They don’t spend money. They don’t invest in things,” Jade Pagkas-Bather, an infectious diseases expert and doctor at the University of Chicago, told me. “When you fail to invest in the health of your population, then there are longitudinal downstream effects.”

But as Florida gets worse by the day, it gets closer to requiring drastic measures to reclaim control of the pandemic. If Florida’s leaders had acted sooner or more cautiously, maybe much of this could have been prevented. Instead, they bragged about how great the state was doing, and now Floridians are suffering a predictable, preventable crisis.


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Source: Vox.com