Restaurants in Texas are allowed to operate nearly at capacity, with three-quarters of their seats filled. North Carolinians could return to movie theaters and bowling alleys before the end of June. In Arizona, some bars and gyms opened their doors to patrons over a month ago.
Reopening shows no signs of slowing. Neither does the pandemic.
In these and at least 12 other states, COVID-19 cases are surging, in some cases to record levels. And though many governors left open the possibility that they would pause or reverse their reopening plans if the pandemic worsened, few have taken the exit ramp.
The dramatic uptick in new cases around the country could provide key lessons for Massachusetts, where cases continue to decline as the state steadily pursues a phased reopening plan. In states where leaders have failed to act when case numbers crept back up — either by reverting to tough lockdown measures or investing in meaningful alternative solutions — they have quickly lost control of the outbreak.
Massachusetts officials have identified six key indicators guiding the reopening process here, but are mum on what specific set of statistical conditions might trigger a halt. And any attempt to backtrack toward lockdown would surely be met with political opposition from business owners and others who have urged Governor Charlie Baker to move more quickly.
But other states are demonstrating that a spike in cases lurks behind every lifted lockdown.
Arizona’s shelter-in-place order ended on May 15. A month later, on Tuesday, the state reported 2,392 new cases of COVID-19, the highest single-day jump Arizona has seen since the pandemic began. Hospitalizations, ICU admissions, and ventilator use in the state are also at record highs.
A Globe analysis found that COVID-19 cases are rising in at least 15 states, primarily in the Sun Belt. Though some increase in confirmed cases is to be expected as states ramp up their testing efforts, more testing does not explain away the increased hospitalizations and deaths many of these states are also seeing. Nor does it explain why other states, including Virginia and Minnesota, have increased their testing capacity without finding significantly more cases.
Many of the states experiencing a surge in cases were spared the brunt of the pandemic’s early spread in the United States. On the other hand, several states that were hard hit in the winter and early spring, including Massachusetts, New York, and New Jersey, are seeing the daily count of new infections decline, even as they move forward with reopening.
Massachusetts officials reported Tuesday that the coronavirus death toll in Massachusetts had risen by 18 to 7,665 and that the number of people testing positive for the virus had climbed by 195, to 105,885. At its peak, the state was adding thousands of cases and hundreds of deaths per day.
A few factors could explain the divergent paths the country is on, said Dr. Jennifer Nuzzo, a Johns Hopkins epidemiologist.
“It has a lot to do with human behavior and how seriously people are taking it. Even in an open scenario, people still have the opportunity to pursue protective behaviors," she said.
Nuzzo added, “If you live in a place that’s hard hit, you less openly question the existence of the virus . . . so you may be more inclined to take protective measures.”
Leadership makes a difference, too.
Nuzzo said that states’ testing capacity, ability to track down infected people’s contacts, and resources for helping sick people quarantine all make a difference in slowing the pandemic’s spread, regardless of whether businesses are shut.
The additional interventions, Nuzzo said, paint a more complicated picture than whether a state is “open or not.” “I really think that that’s a false dichotomy. I think it’s a question about open but safer.”
Still, in states where cases are multiplying rapidly, it is difficult to say whether reopening can indeed remain safe.
Phased reopening plans were meant to be cautious. Change would be staggered, spread out over weeks and months, with plenty of time for public health officials to gauge whether the pandemic’s spread was accelerating too quickly. There would be options to pause between phases or move backward as necessary.
North Carolina’s reopening plan, for example, states, “If infections spike or benchmark trends begin to move in the wrong direction, the state may move to a previous phase to protect public health.”
In reality, the words of caution governors wrote into their plans often lack teeth. North Carolina, which has reported around 1,000 new cases daily for the past several days, could still move to the third and final phase of its reopening plan as early as next week.
Thus far, Utah and Oregon are among the only states to temporarily halt progress toward reopening. After Oregon saw an uptick in new cases last week, Governor Kate Brown said that reopening was partly to blame and that she would wait to further lift restrictions. After a similar increase in cases, Utah Governor Gary Herbert called for a weeklong pause.
Some cities have also delayed reopening plans, even as their states move forward.
Epidemiologists said part of the problem is that states never drew a line in the sand to mark the point at which additional lockdowns would be necessary.
“I don’t know how many states, if any, have developed specific criteria saying, ‘If we have a 40 percent increase in this measure, then we’re going to pull back to phase one,’ " said Dr. David Hamer, an infectious expert at Boston Medical Center and professor at Boston University.
Massachusetts is no exception. Though the state’s number of new cases is in a steady decline, the public has not been presented with a clear plan for what will happen if that trend reverses.
None of the six key indicators listed as part of the state’s reopening guidelines come with thresholds that would signal that the pandemic is too volatile for reopening to continue, or so severe that Baker would close businesses and advise people to stay home.
“I think that there should be some guidance," Hamer said. "And that needs to be communicated to citizens.”
When asked about his commitment to imposing new lockdown restrictions in the event of a resurgence, Baker emphasized the importance of other interventions.
“We’ve said all along that our goal here is to be cautious about the way we move forward, and to use our testing and tracing program to make, you know, sort of quick adjustments to deal with hot spots or issues of significance, either that involve particular populations or issues that involve particular geographies and communities," Baker said Monday. "And we would much prefer that strategy than some other.”
Governors and public health officials are correct to try other interventions before reverting to shelter-in-place orders, said Dr. Leana Wen, an emergency physician and public health professor at George Washington University.
“Lockdown should really be your last step,” said Wen, who previously served as Baltimore’s health commissioner. “Shelter-in place is a blunt instrument. Ideally, you’re able to use precision tools."
Those tools might include tracking and shutting the specific types of settings that are seeding community outbreaks. If infections seem to be spreading at bars, for example, a state could shut those businesses before closing others, Wen said. Testing and contact tracing also remain important.
Still, Wen said, public officials should be prepared to change course on reopening “if those precision tools are overwhelmed.”
Around the country, she said, officials’ poor communication with the public is partly to blame for the pressure governors feel to press forward with reopening no matter what.
“[Other countries] were very clear at the beginning that reopening was not an on and off switch, it was a dial," she said. “I do not believe that this has been done well in the US. The American people have gotten the message instead that this is a one way street."
“Even if we have an increased number of cases, it’s very hard to put the genie back in the bottle," Wen said.
Public health experts who spoke with the Globe agreed that publicly available, data-based standards would help bridge that gap in communication.
“Decisions should be based on science and evidence, and having those metrics in advance ensures that those are the reasons, as opposed to political considerations,” said Wen. “How well we do depends on what people do.”
Nuzzo agreed. “Public health interventions only work if the public is on your side."