Risk remains as South Carolina begins to reopen from coronavirus

As Gov. Henry McMaster announced the reopening of sectors of South Carolina's economy, health experts warned that the state isn't ready and doesn't have the proper capabilities to test for the novel coronavirus' spread — which could lead to a surge in new cases, more deaths and damage to the economy for months to come. 

Without widespread testing — in far greater rates than the state is currently testing — and without a widely available accurate antibody test to tell whether people have had the virus and recovered, South Carolina's flattened curve may rise again, putting the gains the state has made through social distancing at risk, multiple public health experts told The Greenville News. 

And even as businesses suffer under the constraints of the crisis, business leaders said they look to the public health experts for guidance. Businesses want customers to return with confidence, and that process may be gradual but would be helped by widespread testing, including for employees, to remove uncertainty, said Dean Hybl, an Upstate business leader and executive director of the business advocacy group Ten at the Top.

Coronavirus updates in SC:Here's what you need to know

“Until the public health issue is understood, the economic component is going to be kind of secondary,” Hybl said.

While the state's epidemiologist, Dr. Linda Bell, said South Carolina may have hit a plateau of new cases but hasn't yet seen a decline in disease activity, McMaster said he would rely on the "common sense" of South Carolinians to continue social distancing while shopping, calling it a gradual lifting of restrictions that he expected to continue to roll back in coming days. 

Asked if she felt comfortable in McMaster's decision to lift its restrictions on retail since the coronavirus hasn't yet dissipated, Bell said, "While I understand the importance of economic recovery, but public health practitioners, it's our job to do the disease monitoring, and as long as we continue to see a high level of disease activity in the community, we will continue to recommend the measures that we know are effective in preventing disease spread."

Even a limited reopening introduces risk and could hinder the state's effort to combat the virus, said Anthony Alberg, an epidemiologist at the Arnold School of Public Health at the University of South Carolina.

“It makes me uneasy for a number of reasons, and a big one is the testing situation and the limited capacity to test individuals both for active infection and for history of past infection," Alberg said.

If the state proceeds down this path toward reopening, Alberg said it needs to be done with caution and while continuing to study the patterns of infection in the state.

“Any evidence of that upward surge that I would predict, you’d want to be willing to clamp back down again," he said Monday.

In interviews with 11 public health experts over the past week, each said South Carolina isn't ready to reopen because the state doesn't have enough available testing. 

Dr. Marcus Blackstone, chief clinical officer at Bon Secours St. Francis Health System, said reopening now is “a mistake.”

SC coronavirus map:A look at COVID-19 cases by county and zip code

“We understand the economy and financial impact. We’re getting the same negative financial impact," he said. “Our big concern is if they decide to open the economy up because people are getting restless, and it all happens around the time we start getting the surge, it could significantly increase the number of people affected and the health care system could be overloaded.”

"South Carolina isn't even close to being ready," Michael Schmidt, a professor of immunology at the state’s leading medical training hospital, the Medical University of South Carolina in Charleston, said Monday.

To understand the public health component, the state “desperately” needs to do more testing, specifically antibody testing, in order to remove uncertainty that is holding the state hostage, Schmidt said.

“The thing that is driving everyone from the president of the United States down to you and me crazy is 'when,'” Schmidt said. “We just don’t have enough information.”

Knowing how many people have been infected, how many have developed antibodies to fight further infection and whether those antibodies do fight further infection will answer a lot of questions, he said.

Opening beaches is fine as long as people aren't congregating or throwing Frisbees or footballs, he said. But with no true understanding of who has been infected and no drugs to treat the virus or a vaccine, reopening retail stores, even on a limited basis, is perilous, he said.

“When will you feel safe to effectively decamp your family from your home where you’ve been safe and take a risk and go to the beach or go to a restaurant or go do things that you normally do?” Schmidt asked. “And it’s only in alleviating that uncertainty that we’re going to be able to get things back to normal.”

With people going broke, suffering cabin fever and growing more lonely as the coronavirus forces Americans to stay home, the pressure to reopen the economy is understandable, said Dr. Arthur Caplan, a nationally renowned medical ethicist from New York University School of Medicine, on Monday.

“But if you do it and don’t have adequate testing to monitor what’s going on, then you risk a rebound of the virus,” he said. “Really, you want to test people and say, 'You’re negative, you can go out,' or 'You’re positive, you shouldn’t go out because you might give it to others'... And it would be good to have serological testing to see if you had the disease and have immunity. Those would be the safest people to let out first.”

Countries that have seen their death rates decline and then reopened, including South Korea and Taiwan, did it with widespread testing, contact tracing and isolation of those who have the virus, Caplan said.

“Testing is the key,” he said. “And in South Carolina, it doesn’t look like you’re doing that.”

South Carolina is currently testing 28 people per day for every 100,000 residents in the state, but according to researchers at the Harvard Global Health Institute, the population should be tested at a rate of 152 tests per day for every 100,000 residents. 

The state is continuing to try to expand testing to make it more widely available, especially in under-served communities, Bell said.

Don't reopen, but if you're going to, do it carefully, experts say

South Carolina, and Greenville in particular, hasn't seen enough sustained days of declining cases to safely reopen, an important public health metric, said epidemiologist Elizabeth Holt, an associate professor in the department of health sciences at Furman University.

At the least, if South Carolina moves forward with reopening now, it should do so in a phased approach using social distancing measures at stores, the beach and elsewhere, Holt said Monday.

More:Greenville superintendent wants SC schools to remain closed. Decision is expected this week

Epidemiologist Kathleen Cartmell, associate professor of public health sciences at Clemson University, said leaders are looking to strike a delicate balance between health and the economy and it’s a tough job.

There are still a lot of active COVID-19 cases in the state and the disease “super-contagious,” with some getting only mild illness and spreading the disease while others get a deadly form of the virus, she said in an email. So the best way to avoid passing the virus around is to avoid being out and about in the community, she said.

“That's why we've seen such unprecedented measures being taken globally and in the U.S., such as school and business closures and stay at home guidance,” she said. “From an epidemiological standpoint, our best chance for defeating the virus is to stay home the best we can until we see a substantial decline in the number of cases."

When Vice President Mike Pence heralded on Thursday an improvement in the fight to control coronavirus across vast swaths of the country, he presented a series of Centers for Disease Control graphics that showed a decrease in many states of reports of influenza-like activity, a general indicator of the presence of COVID-19 symptoms.

Multiple states still indicated high levels of influenza-like illnesses, which Pence attributed mostly to the coronavirus. Among the worst in the latest figures for the week ending April 11 were New York, Massachusetts and Louisiana, all recognized hot spots for the coronavirus.

Also included was South Carolina. It's one of seven states that reported high numbers of influenza-like illness.

South Carolina was among the slowest states to ramp up testing for the coronavirus and has remained among the lower third of states conducting tests. And while tests are more readily available, including DHEC’s rollout of four rapid-response Abbott tests, the state has remained focused on testing only those showing symptoms.

By Monday, South Carolina reported 4,439 cases and 124 deaths due to complications from COVID-19, the illness caused by the coronavirus. It reported 64 new cases on Monday.

To fully reopen, the state's number of new cases should be "orders of magnitude" lower than the numbers of new cases announced this past week, Alberg said. 

“There’s so much infection taking place in the population despite these pretty extreme measures that have taken place, it shows just how infectious COVID-19 really is and how seriously we need to take it,” Alberg said.

South Carolinians need to be prepared to continue social distancing for the long haul, he said.

With as much as coronavirus has affected the state’s population, the vast majority of residents remain susceptible, he said. He likened it to a wildfire that could be under control but continue to smolder or inflame into an inferno again.

“If we eliminate the restrictions too soon, what we’re going to see is a big spike and regret that we didn’t eliminate that wildfire,” he said.

What then would the summer look like? Would movie theaters reopen, and if they did, would customers return? Would a night at the ballpark still be possible? What about trying on new clothes at a department store?

“In my view, the summer months would be very much the same as what they look like now,” Alberg said.

Crowded gatherings this summer, Alberg said, are his worst fear.

A new normal, reopening with social distancing

The White House task force issued some guidelines for states to consider for reopening economies but left the specific choices and time frame up to state leaders.

Among the guidelines was showing a downward trajectory of both coronavirus cases and influenza-like illness over a 14-day period; ensuring the state has proper capacity in its health-care facilities, which South Carolina currently does; ensuring a robust testing program for healthcare workers; ability to perform extensive contact tracing for positive coronavirus cases; and ensuring sentinel surveillance sites are testing for asymptomatic cases.

South Carolina hasn't had a downward trajectory for 14 days yet. Asked about how his reopening measures mesh with health guidelines when lives are at stake, McMaster said he was "comfortable taking this gradual step." 

More:SC governor announces change to allow some stores and businesses to reopen to customers

Even with lifting restrictions, employers should reopen in phases, with 25%-50% of staff and increasing slowly, while minimizing non-essential travel and providing accommodation for at-risk employees, said Dr. Deborah Birx, the U.S. Coronavirus Response Coordinator.

Bobby Hitt, South Carolina Secretary of Commerce, said that while manufacturing has continued to some extent during the crisis, for it to return in full, manufacturers want assurance that the state is on the right path.

“They’re also very cognizant that they can’t bring thousands of people into a facility and have it not work,” Hitt said. “Because if they do, they get set back, too.”

Companies want testing at the front door, either for temperatures or for the virus itself, Hitt said.

To get the state in position to reopen when ready, McMaster will launch Accelerate SC, which he announced Thursday. A task force would begin work this week with input from business and public health experts, he said.

Even as the state reopens, it will likely do so unevenly and in “fits and starts,” said Hybl at Ten at the Top.

Restaurants will begin to think creatively, he said. Menus may be paper and disposable. Tables spaced apart. Some parts of the state may reopen sooner than others, Alberg said. The state’s beaches and tourism may be able to reopen with social distancing in mind, Hitt said.

After all, South Carolina is a drive-to tourism state and people will want to safely get away after the worst has past, Hitt said.

But despite the devastating hit on the state and local economy, business leaders remained confident South Carolina would rebound quickly.

Hitt said he’s been talking this week with companies looking to relocate to the state. Hybl said he’s heard the same from Upstate business recruiters.

In Greenville, Phillips said the interruption has been devastating to a thriving economy, but Greenville would bounce back. 

“We know how to win here,” he said. “We were winning. We’ll get that back. We’ll return to us winning.”

Once the decision is made to reopen, it would make sense to do it gradually and by sector, for instance, small businesses that can better control who’s in the store, said Caplan, the NYU ethicist. 

“Everybody doesn’t have to come out all at once,” he said. “(It) doesn’t mean we have to reopen bars so everyone can hang out together shoulder to shoulder from 8 until 2 a.m.”

From a medical perspective, the more contact people have with each other, the greater the likelihood of spreading the disease, said Dr. David Potts, a retired infectious disease specialist who works at AID Upstate.

“The more restaurants and movie theaters and bars that open, the greater risk that more people will catch coronavirus,” he said. “But you have to weigh that against the economic disparity.”

Potts added that even if businesses do open up, there will be some people who think it’s OK to go a restaurant and some who won’t.

“Probably those at highest risk will not and those at lower risk will go out,” he said. “And we’ll find out what happens.”

That’s why more testing is so crucial, he said.

“If you had lots and lots of testing readily available, and then open up, then if one person got it, you can test them and their immediate contacts, and isolate those who test positive,” he said. “But we don’t have the testing.”

And it would be beneficial to test not just people who are very sick, but those who are moderately sick and asymptomatic as well because they have been shown to spread the virus, Potts said.

“We say we have very few cases,” he said, “but we really don’t know that.”

City of Greenville, county, Chamber of Commerce form reopening task force

A business survey conducted by the Greenville Chamber of Commerce showed that while business owners need immediate cash from government assistance and a return of cash from customers, they want confidence that employees and customers are safe, and they’re seeking credible communication to know how to proceed, said Carlos Phillips, executive director of the chamber.

“Any time frame needs to be informed by public health professionals to assess our readiness to reopen,” Phillips said.

But, he said, it’s not too soon to plan for that. The Chamber, city of Greenville and Greenville County have formed a task force to determine a combined strategy to reopen, he said.

More:Greenville mayor 'comfortable' reopening retail stores; parks and restaurants uncertain

Key to that strategy will be to “protect our state and our community against a resurgence” of cases, he said.

Epidemiologists and other public health scientists need data to form and project models that inform decision-making, and right now, more data is needed to know what’s working and what’s not, a group of four Furman University professors said in a Zoom interview last week.

What shelter-in-place guidelines have bought in South Carolina is time, said Meghan Slining, a Furman University associate professor and trained epidemiologist.

“It’s not just buying time to create respirators and do everything we need to build capacity, but it’s also buying time for the science to catch up,” Slining said.

With so much unknown about a new virus, social distancing is allowing scientists to study and understand the virus in real time, to try new treatments and begin clinical trials — one at least of which Prisma Health is participating in — that will help determine a medical solution, Slining said.

And while McMaster said an end to the restrictions was in sight, he continued to urge South Carolinians to be patient because it's too early to celebrate.

“Keep the lid on yourselves,” McMaster said. “Contain your enthusiasm.”

The risk of opening too soon

St. Louis took great measures to socially distance its citizens during the flu pandemic that struck in 1918 and ravaged millions of lives across the globe. The city closed schools and churches, limited ridership on streetcars and staggered shifts at its factories. Its death toll from the pandemic was a fraction of that of other similar sized cities like Philadelphia, which enacted fewer restrictions, said Sharon DeWitte, a paleo epidemiologist at USC who researches past pandemics.

But St. Louis lifted its restrictions too soon, and flu deaths spiked a second time, forcing the city to shut down again, DeWitte said.

That’s what she fears South Carolina will do.

She urged the state’s residents, who she recognized are getting impatient, to continue to suffer through the short-term inconvenience and listen to public health officials who have the best interests of the community as their goal.

“If sheltering in place ends too soon, then the disease is going to spread and it’s going to kill vulnerable people — and quite frankly, they don’t have to die,” DeWitte said.

Nathaniel Cary is an investigative reporter at The Greenville News. He can be reached at ncary@greenvillenews.com or @nathanielcary on Twitter.