Epidemiologists are baffled by how the coronavirus pandemic has played out thus far in Florida but the state’s governor isn’t waiting to declare his response a win.
As Republican Gov. Ron DeSantis reopens much of his state Monday, he took a victory lap that began at the White House last week -- touting his “tailored” and “surgical” approach to stay-at-home orders as the central reason Florida has so far defied the dire predictions that it would become “way worse than Italy.”
With his self-congratulatory news conferences, DeSantis sparked new debate over the stay-at-home measures in more restrictive states -- framing those measures as "draconian" compared to what he views as his more targeted approach. But a number of epidemiologists warned it is too early to jump to conclusions about what kept case numbers lower than expected.
Ridiculing the scientific models that DeSantis says overstated the crisis and encouraged a climate of fear, the Republican governor has chided critics who faulted his slow and often hapless response to the coronavirus in March when spring break revelers thronged Florida's beaches.
DeSantis, however, isn't letting that lack of scientific certainty cloud his view of what the state's next steps should be.
"There's been a lot that's been done to try to promote fear, to promote worst-case scenarios, to drive hysteria," DeSantis said last week. "People should know that worst-case scenario thinking (in Florida) -- that has not proven to be true."
"The only thing we have to fear is letting fear overwhelm our sense of purpose and determination," he said as he explained his plans for reopening.
Florida remains an enigma, according to multiple epidemiologists who spoke to CNN -- a place where unique factors like "car culture," lower density in parts of the state outside of Miami, less frequent use of public transportation and possibly even heat and humidity may have slowed transmission of the coronavirus. They worry that the Sunshine State will see a second wave of coronavirus cases as restaurants and many businesses open their doors on Monday.
Scientists ‘puzzled by Florida’
Ali Mokdad, a professor of global health and health metrics sciences at the University of Washington's Institute for Health Metrics and Evaluation, noted that mobility data shows that many older Floridians started social distancing long before DeSantis issued his stay-at-home order on April 1. Mokdad also emphasized that the stringent measures that local officials enforced in places like Broward and Miami-Dade counties beginning in late March were critical in limiting the spread.
"We are really puzzled by Florida," said Mokdad, who has a home in Daytona Beach and has kept a close eye on the data. What is clear, he said, is that Floridians "took it seriously. They practiced social distancing, even when the governor didn't say practice social distancing" as they watched the virus ravage Italy and New York.
Paula Cannon, professor of microbiology and immunology for Keck School of Medicine at the University of Southern California, noted that researchers are also still investigating whether there is a humidity or heat effect on the virus in climates like Florida and Bangkok (where there were densely packed celebrations during the Chinese New Year but lower than expected cases afterward).
She explained that in humid or wetter environments, "the things that we breathe out and cough out -- that come out of our noses and mouths -- stay wet and heavy, and drop to the floor quickly. In a drier environment, they start to dry up as soon as they leave your mouth, and so they can float for longer."
"It's a reasonable hypothesis that humidity, by reducing the effective range that droplets can travel, could be a factor that helps reduce spread," said Cannon, who is a virologist. But some cities like New Orleans, where there was a spike of cases after Mardi Gras, don't fit the hypothesis, and there has not been enough testing in warmer climates like Africa and South and Central America yet.
“We don’t yet have enough information,” she said. “Clearly there is a lack of data. I think we all recognize the lack of comprehensive testing, the lack of uniform ways that states are reporting cases, even deaths... So it’s comparing apples to pears,” she said.
Cannon cautioned against making comparisons between states like Florida and California, where Democratic Gov. Gavin Newsom took a much stricter approach with his stay-at-home order and also managed to keep cases low.
Beyond that, two states can look very different in one moment in time, Cannon said, "and it's literally because one state is one week ahead of the other" in coronavirus cases.
Florida’s ‘surgical’ approach to closures
Outlining his reopening plan last week, DeSantis argued that the biggest obstacle for Florida in the days ahead is "fear sparked by constant doom and gloom and hysteria that has permeated our culture for the last six weeks."
"There have been wide-ranging and punitive orders issued in various regions of this country. People have rights, the government needs to protect health, but we should not go beyond what is necessary to do that," DeSantis said.
As of Sunday afternoon, Florida was reporting 36,078 COVID-19 cases and 1,379 deaths in a state of 21.5 million people. DeSantis continually pointed to the fact that Florida has 165 coronavirus cases per 100,000 residents, as evidence that the state can move on to the next phase. (By comparison, he noted the figures in New York, where there are 1,609 cases per 100,000 people).
With the exception of Miami-Dade, Broward and Palm Beach counties -- areas where the highest number of cases are concentrated and the stay-at-home order remains in effect -- DeSantis will allow restaurants to resume operation with outdoor tables spaced six feet apart and 25% capacity indoors. Retail stores will also be allowed to open at 25% capacity, as long as customers maintain social distancing.
The Republican governor said one of the most important aspects of re-opening will be to convince Floridians that the state is taking "small, deliberate, methodical" steps "based on consultation with some of our greatest physicians."
But building that trust may be a tall order for DeSantis, who in March resisted the calls to put a stay-at-home order in place for Florida despite the enormous risk the virus posed to the state's huge elderly population. DeSantis' approval ratings thus far have been far lower than other governors handling the crisis.
Many Americans were shocked by the images in early March of spring breakers crowded into bars and congregating on beaches. A month later, an analysis by The New York Times traced how those spring break travelers brought the virus back to their states -- in some cases with deadly consequences.
DeSantis repeatedly foisted the decision about closures on local officials, creating a confusing maze of varying regulations in cities and counties across the state.
Two days before leaders in Broward and Miami-Dade counties issued stay-at-home measures on March 26, DeSantis insisted that "tailored approaches, surgical approaches" would work best in the differing regions of the state. (The local orders in Broward and Miami-Dade -- along with the city of Miami's curfew -- have been widely credited with keeping Florida's coronavirus numbers in check).
During that time, the governor continually suggested the threat was overblown -- disputing, for example, the assertion by Dr. Anthony Fauci, the nation's top infectious disease expert, in early March that there was evidence of community spread in Florida.
On April 1, when DeSantis finally announced his order limiting non-essential activity in Florida, he followed 33 other states. Though the first coronavirus cases in Florida were confirmed on March 2, DeSantis said he took his cue from President Donald Trump's decision to extend the White House's safer at home guidelines until April 30.
"When the president did the 30-day extension, to me that was -- people aren't just going to go back to work. That's a national pause button," DeSantis explained during his April 1 news conference in Tallahassee. "When you see the President up there -- if you've seen his demeanor the last couple of days -- that's not necessarily how he always is. I think that we all look at this and say this thing is really nasty."
Confusion persisted. DeSantis' initial order, which took effect April 3, said older Floridians as well as those with "a significant underlying medical condition" were required to stay at home. Several days later his office clarified that they were allowed to leave their homes for essential activities.
The Florida governor banned social gatherings of more than 10 people in public spaces, but created a loophole in his executive order by declaring that essential activities would encompass "attending religious services conducted in churches, synagogues and houses of worship."
When he pondered re-opening schools during an April 10 educators' meeting to discuss distance learning, DeSantis erroneously stated that the virus hadn't killed anyone under 25.
Like Trump, he vigorously touted the use of hydroxychloroquine as a treatment for coronavirus even though it was unproven and there were widespread concerns in the medical community about whether it was safe to use the anti-malarial drug.
In mid-April, the Miami Herald editorial board excoriated DeSantis for his handling of the crisis: "You know what Florida really needs right now? A governor," the editorial board opined. They encouraged him to listen more closely to health experts, follow "the lead of other governors who acted more decisively and earlier on behalf of their constituents" and do "his very best to do no further harm."
Praise from Trump
But DeSantis' loyalty to the President throughout this crisis has paid off in one way. During his Oval Office meeting with DeSantis last week, Trump lavished praise on the Florida governor for doing a "spectacular job" and told reporters DeSantis would soon be opening up large portions of Florida "because he's got great numbers."
DeSantis, who was elected in 2018 as a Trump acolyte, then gave an impromptu presentation to reporters that was styled as an explanation of Florida's "innovative" approach to the coronavirus. DeSantis described the state's "offensive" approach to testing the populations in nursing home and assisted living facilities.
He noted that the state deployed 120 "ambulatory assessment teams" to 3,800 long-term care facilities to do a needs assessment, "trying to figure out where they were deficient so we could try to get ahead of this." He also explained how a second set of teams from the Florida Department of Health went into long-term care facilities to train workers about infection control.
Federal resources allowed the state to create 50 mobile "strike teams," he said, staffed by the National Guard members who have been going into nursing homes to conduct tests. DeSantis said the state also distributed 7 million masks to nursing facilities in Florida.
During the meeting, Dr. Deborah Birx, the administration's coronavirus response coordinator, praised DeSantis for going "where the virus could cause the most damage to human beings."
"He went into the nursing homes to proactively test," she said, noting that the White House task force has emphasized the importance of both symptomatic and asymptomatic testing to protect the most vulnerable individuals.
"You can see what it did with the nursing home fatality rates. I mean, it's remarkable," Birx said. (In Florida, more than a third of deaths are linked to nursing homes, according to state data).
During his Oval Office visit, DeSantis raised eyebrows by saying, Florida's "ability to test exceeds the current demand." State labs, DeSantis said, should be able to conduct 18,000 tests per day by the end of May. As of Saturday, the state had conducted 416,012 coronavirus tests.
Some advocates for Florida's older population have argued that the level of testing is still not sufficient. More than 80% of the deaths so far in Florida have occurred in people who are 65 and older, according to Florida Department of Health statistics.
During a press conference with DeSantis last Monday, the dean of the University of South Florida's Morsani College of Medicine, Charles Lockwood, said Florida should be testing 150 people per 100,000 residents daily -- which would be about 33,000 tests a day. Currently, Florida is testing about half that many people, though the numbers fluctuate.
DeSantis said the state is rapidly ramping up testing capacity and adding more drive-up and walk-up testing sites. During a Saturday event in Florida's Orange County, DeSantis noted there is a lag in test results and said he expects to have 500,000 test results by Monday -- predicting the state will report between 10,000 and 20,000 test results each day for the next few days.
Questions about data
Amid Florida's grand reopening, questions remain about how the coronavirus pandemic is playing out in the state. Central to that is renewed scrutiny of Florida's coronavirus data -- from the number of coronavirus deaths reported by the state to the tally of tests conducted each day -- because "people tested on multiple days" are included "for each day a new result was received," according to fine print in the Florida Department of Health's comprehensive report.
In mid-April, the Tampa Bay Times discovered that some Florida snowbirds who died from coronavirus were being excluded from the Florida Department of Health's count. The newspaper found the discrepancy by comparing the state's list to a separate tally that was kept by the state's medical examiners, which did not include non-residents who died in Florida.
The Florida Department of Health explained that it was not including "non-resident" deaths in its tally, so they would not be inadvertently listed twice in multiple states. The Florida Department of Health ultimately began posting resident and non-resident deaths on its Covid-19 dashboard.
Additionally, the Miami Herald threatened to sue the state to force DeSantis to divulge the names of all of the elder-care facilities where residents have tested positive. The newspaper subsequently reported that a DeSantis aide called the law firm that initially represented the newspaper in an effort to quash the lawsuit.
Recently, the state began posting a weekly report detailing coronavirus related deaths in long-term care facilities.
The latest development in questions over coronavirus data came this past week. In what appeared to be another effort to limit the release of data, The Tampa Bay Times reported that the Florida Department of Health asked the Florida Medical Examiners Commission, which sets minimum and uniform standards for statewide medical examiner services, to stop releasing its own comprehensive list of Covid-19 deaths.
The medical examiners' death tally was 10% higher than that of the Florida Health Department, the Times reported. For example, when the Tampa Bay Times discovered the discrepancy on April 10, the Florida Department of Health was reporting 419 coronavirus deaths, while the medical examiners tally showed only 461 deaths. (The discrepancy stemmed in part from the fact that the state department of health was only reporting the deaths of people who claimed residency in Florida).
The Florida Department of Health told CNN this week that it had concerns about the disclosure of "personal" information through the medical examiners list. But commission chairman Dr. Stephen Nelson told CNN that concern was odd because the examiners' comprehensive list does not include the names of the deceased. It only includes age, sex, date of death, cause of death and a summary of what happened.
The Florida health department's central concern, he said, was the information on the list that details cause of death and a summary of what happened. Of the list, he said the commission was told: "Don't send it out."
The concerns about data, insufficient testing and the ongoing study of whether heat and humidity affect transmission of the virus all suggest to epidemiologists that the coronavirus picture in Florida is still unclear, and certainly not yet a vindication of any one containment strategy.
"There are too many possibilities here," said Jeffrey Shaman, a leading epidemiologist at Columbia University.
Cannon, the virologist from USC, said political leaders must be careful not to lean too heavily into the "element of wishful thinking that gets overlaid over all of this" as they try to explain why one state has done better than others in their handling of the pandemic.
“We all wish so fervently that there is going to be some mitigating factor -- that we just get lucky in some way,” Cannon said. “So far, humankind has been very unlucky with this virus. It has some extraordinary superpowers. What we can’t do right now -- it’s just too soon and we don’t have the correct comparisons -- is rule out other explanations that are just pure chance.”