For months, Arizona stood out as one of the world’s worst coronavirus hot spots, suffering through an outbreak that sickened hundreds of thousands of people. Hospitals were so overwhelmed that the state Department of Health enacted crisis standards of care, in preparation for surging capacity.
But now, cases have ebbed after major cities implemented new restrictions and lockdowns. Bars, theaters and gyms in Maricopa County, the state’s county, began reopening Thursday as the number of new confirmed cases dropped to less than one-sixth of its zenith in early July.
Arizona stands as an example of just how badly the coronavirus can devastate a region — and how aggressive action can bend the case curve down.
“Arizonans [are] really following the mitigation measures that we put in place,” said Cara Christ, director of the Arizona Department of Health Services.
As the virus spread out of control in New York City in late March and early April, Arizona confronted only a handful of cases. By the end of the month, only 24 people had died.
The state did not report more than 1,000 new cases on a single day until June 2.
That slow build gave some residents a false sense of security. Gov. Doug Ducey (R) allowed the first shuttered businesses to reopen May 8, and his stay-at-home order expired May 15, long before orders in many other states. Arizona also barred local governments from implementing orders that residents wear face masks.
“Everyone wanted to go back to normal, but it just wasn’t safe,” Phoenix Mayor Kate Gallego (D) said in an interview.
As summer temperatures soared into the triple digits, driving Arizonans indoors, the number of cases jumped sharply. Two weeks after the state’s first 1,000-case day, Arizona recorded 2,000 cases in one 24-hour span. Four days later, it hit 3,100 cases in a day. On the last day of June, almost 4,800 residents tested positive.
“What’s really different about Arizona is about the time we started seeing an increase in cases was about the time when it gets really hot,” Christ said. “In the summer, everyone is inside in the air conditioning, and in the winter we can go outside and be physically distant.”
The reproductive rate, the number of new infections caused by the average coronavirus case, peaked at a whopping 2.65 in May, according to estimates by the PolicyLab at Children’s Hospital of Philadelphia. By contrast, the reproductive rate in New York’s five boroughs never rose above an estimated 1.6.
The front-line nurses and doctors who had worked around the clock for months were stretched to breaking points. Hospitals had to prioritize who would get treatment, and personal protective gear ran low.
“July was scary. We were in the crisis standards of care,” said Will Humble, executive director of the Arizona Public Health Association. “If you got sick in July, quite honestly, you were probably not going to get the level of care that you expect.”
Much of the spread was driven by younger people, who incorrectly believed they were invulnerable to a virus that levies its worst tolls on the elderly and those with underlying conditions. About half of cases were being diagnosed among those aged 20 to 44, Christ said.
Gallego, who is 38, said she has spent much of her time addressing her peers.
“People in our 30s have a key role in slowing this spread. There was a narrative that only people who are older adults need to worry about this. That is not the case,” she said.
Under pressure from city and county governments, Ducey removed restrictions on local face mask requirements on June 17. Within a day, most of Arizona’s large cities had implemented mandates. A week later, Ducey ordered bars, nightclubs, gyms, theaters and tubing companies to close.
“Masks are not going to fix everything, but they really do save lives. It was frustrating for city councils and mayors to not have that tool, but I’m glad the governor changed his mind,” Gallego said. Masks are “a physical reminder that we are still fighting COVID, and you cannot go back to living the way you did in 2019.”
Ducey has not implemented a statewide mask mandate, like those in place in 25 states and the District of Columbia. But about 85 percent of Arizona residents live in a city or county that has one. Research from Arizona State University suggests masks can reduce transmission by about 35 percent.
“While a state-level mandate may have been more effective, I do sometimes wonder if the decentralization and ability to tailor the mandate to a specific community’s needs may have led to more buy-in and uptake of masks overall,” said Kacey Ernst, who directs the epidemiology program at the University of Arizona’s Zuckerman College of Public Health. “I have been impressed with the sharp increase in mask use that I personally witnessed.”
Daily case counts peaked on July 11, and the number of people in hospitals and intensive care units peaked a few days later.
All three indicators have have fallen steadily ever since. Arizona has reported fewer than 1,000 new cases on each of the last 15 days. Fewer than 900 Arizonans are in hospitals with confirmed COVID-19 cases, and only 311 are in the intensive care unit, according to state data analyzed by the COVID Tracking Project, an independent team of researchers.
“The face covering requirement takes some time to work. It’s not like it changes things overnight,” Humble said. “Once you get people over the hump and get them used to wearing a face covering in public, then it becomes a habit.”
The number of cases in eight counties has fallen sufficiently to allow shuttered businesses to reopen, albeit at reduced capacity.
“It could be that the steady decline that we’ve had levels out and it begins to plateau at a low level, or it could be that the cases begin ticking up,” Humble said. “That’s the grand experiment. And I’m OK with that. You can’t stay locked down forever.”
Public health experts and elected officials say they expect a slight increase in the number of cases as businesses reopen, as school returns and as flu season kicks off.
“I take very seriously warnings from public health officials that this fall could be a difficult time, with flu season on top of COVID-19. I know that everyone wants to get back to the way life used to be, but our economy will come back more quickly if we take public health seriously,” Gallego said. “Many people will not choose to participate in the economy the way that they used to until a vaccine is available.”
But if Arizonans continue using their masks, the state’s positive trajectory should keep improving. PolicyLab models estimate Maricopa County will suffer about 240 new infections a day over the next four weeks, about one-fifteenth the number of cases it experienced at the peak of the outbreak and a level sufficiently low to keep hospitals from being overrun.
“I would not make the recommendation now to lift the mask mandate,” Christ said. “We can’t let up. We have to continue wearing masks.”