Georgia's Reopening: Dinner, a Movie and a Virus?

Brenda Goodman, MA

April 30, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

In Atlanta, where Georgia's governor recently allowed businesses like restaurants, bowling alleys, nail salons, massage parlors, movie theaters, barbershops, and gyms to reopen, you can catch a movie at the Starlight Drive-In, but the snack bar is closed and you have to stay in your car. Other movie theaters, including the big chains, are keeping their doors closed for now. Some restaurants have announced plans to reopen their dining rooms, but most are sticking with takeout and delivery orders for the time being. Many nail salons have reopened, but a few say it's still not the right time.

There's a pandemic on, y'all.

Though the state won't officially lift its shelter-in-place order until May 1, Gov. Brian Kemp stunned local mayors and public health officials when he allowed some hands-on personal services to resume over the weekend, with restaurants and some entertainment venues getting the green light a few days later.

The move defied the guidance from some infectious disease forecasts, which had advised waiting for another 6 weeks or more to relax social distancing measures, and ignored national guidelines for reopening released by the White House and CDC that had advised states to wait until they had seen declining numbers of COVID-19 cases for at least 2 weeks. Georgia has not seen its cases decline steadily yet. It has turned the state into a national experiment.

"Georgia's governor is determined to open up first and fast. We'll see what happens," said William Schaffner, MD, an infectious disease expert at Vanderbilt University Medical Center in Nashville.

One Nail Salon's "New Normal"

On a recent Saturday in Atlanta's tony Westside Provisions District, Alayna Hoang, owner of Nouvelle Nail Spa, was getting ready to welcome her first clients in more than a month.

Hoang has been in business for 11 years. About a year ago, she moved her salon to this high-rent district and took out a loan to build out the space. She was about to pay off that loan when the pandemic hit. It was a "big, major setback."

She says she's been keeping the salon afloat by selling gift cards, adding a $10 bonus for customers who bought their services before they could reopen.

"That's pretty much what we've used to get by for the last month. It's not something that covers all expenses," she says.

She says she had been thinking through how she would come back for weeks, long before the governor's announcement.

Hoang is keeping her front door locked. Just two clients can be in the salon at any time. Her customers -- booked by appointment only -- wait on a bench outside the front door until she comes to get them.

She is keeping herself safe by wearing a fabric mask over a paper surgical mask, clear plastic goggles, and a double layer of gloves.

Before clients enter, she aims a touchless thermometer at their forehead and asks them how they're feeling. If they forget to bring a face mask, she's got some extras. At the door, she squirts soap into their hands and walks them over to a sink, where she helps them wash and dry. Her nail polishes have been sanitized and placed behind Plexiglas. For now, only the staff will touch them. Bottles of hand sanitizer are placed throughout the salon. Nails will now be shaped, smoothed, and intricately painted behind sneeze guards. Before her customers leave, their hands will get a spritz of alcohol-based sanitizer.

Her instruments are already sterilized with steam and alcohol. Now Hoang has added a new UV light box, which will help kill germs and also, she hopes, help her customers feel it's safe to come back. So far, it's working. Though appointments are limited, the slots are filled.

"It's very premature to have everyone opening back up. Not everyone is taking the precautions they should," she says, citing conversations with others in the industry.

"We're taking it seriously. We're doing everything we can. Every little thing, every little step. All the little details. I can only speak for myself, and not other people."

The new coronavirus has spread swiftly across the world, infecting more than 3 million people and killing nearly a quarter of a million.

Opening Too Soon?

In Georgia, limited testing of sick patients has revealed about 25,000 cases of COVID-19, and more than 1,000 people have died of the infection caused by the virus.

Even so, 3 weeks after closing nonessential businesses to slow the spread of the virus, Kemp, a Republican, issued an executive order that gives many high-contact businesses the choice to resume minimal operations. Restaurants and movie theaters were allowed to reopen a few days later. Businesses that reopen have to abide by certain social distancing and sanitation requirements or face warnings and, finally, closure.

A forecasting model for states, built by the University of Washington's Institute for Health Metrics and Evaluation, had advised the state to maintain strict social distancing until at least mid-June, to prevent a new spike in infections.

Kemp's move was widely criticized by public health officials and others, including President Donald Trump, who said last week he was opening too early.

Keisha Lance Bottoms, mayor of Atlanta, the state's most populous city, said she was blindsided. "I don't know what the reasoning and data that the governor used to make this decision was, because I have not spoken with him, but I did not know in advance," she said in an interview on WSB-TV.

"I don't know how you socially distance when someone is doing your hair or doing your nails, giving you a massage. These things are concerning to me," said Bottoms, who is a Democrat. "I do hope that I'm wrong and the governor is right. Because if he's wrong, more people can die."

Starting this week, Georgia began walking a tightrope, attempting to find a balance between public safety and economic security. The state, which was already grappling with a revenue shortfall and budget cuts, could face a $4 billion funding gap over the next 15 months in the wake of the pandemic's closures, according to a new report from the Georgia Budget and Policy Institute. Kemp acknowledged the economic pain the state was feeling in his decision to lift restrictions.

"These are tough moments in our state and nation," he said. "I see the terrible impact of COVID-19 on public health and the pocketbook."

Kemp has cited improved forecasts for the state, along with expanded capacity to care for patients in the state's hospitals, as his reason for reopening.

But other experts fear he has moved too quickly.

"Georgia's certainly jumping the gun, I think here, getting started too early relative to where they are in the epidemic," former FDA Commissioner Scott Gottlieb, MD, told CBS's Face the Nation.

Georgia has reopened many businesses before it has enough testing or contact tracing in place to effectively find and isolate people who are sick.

At a minimum, Gottlieb and his colleagues at the American Enterprise Institute have estimated that we should be testing 1% of the population each week to contain the spread of the virus. Other experts have recommended even more testing. With a population of roughly 10 million people, that means Georgia should be testing at least 100,000 people a week to meet that mark. So far, a total of 140,000 tests have been done in the state, according to the Georgia Department of Public Health. Though the state has partnered with Georgia universities to beef up its testing.

Georgia Public Health Commissioner Kathleen Toomey recently told The Associated Press that the state was working to retrain some employees to do contact tracing and plans to use a new mobile app. They are also counting on infected people to share cellphone data so the state can trace their recent contacts.

"That sounds like a great plan, but by their own words, it's being finalized and customized. It hasn't been tested," Harry J. Heiman, MD, a professor of public health at Georgia State University, told the AP. "The idea that we're going to start opening the doors before these things are in place I think is irresponsible."

Without enough surveillance, public health officials warn that COVID-19 cases could spike.

This happened on the Japanese island of Hokkaido. When the virus hit this mountainous prefecture of 5.3 million people, the governor asked people to stay home. Schools closed, and many restaurants and businesses did, too. The quick action, taken at the end of February, contained the outbreak but bankrupted the island's agriculture and tourism industries, according to Time . The governor lifted restrictions in mid-March, and 3 weeks later, COVID-19 cases surged. Hokkaido had to go back into hiding less than a month after reemerging.

"There are no right decisions, no wrong decisions, only difficult decisions," says Vanderbilt's Schaffner.

"I appreciate the need to open up economically. There are people who have gone without any income now for a prolonged period of time," he says. "That can't go on indefinitely."

Making the Choice

Simon Property Group, the largest owner of malls in the U.S., said it would open 49 shopping centers across the country, including seven properties in Georgia, starting this Friday, CNBC reported.

Despite the governor's green light, plenty of businesses are waiting. In a full-page ad in The Atlanta Journal-Constitution newspaper, more than 50 restaurant owners in Atlanta and Savannah said their collective 120 restaurants would remain closed, for now.

"We are struggling, there's no doubt. This is not an easy decision for us as we fight to survive," said Fred Castellucci of Castellucci Hospitality Group, owner of lauded dining rooms in Atlanta, including the Iberian Pig and Cooks & Soldiers.

"At the end of the day, we feel like if we want to be here for years to come and we want to get through this as quickly as possible, the best way to do that is to keep the dining rooms closed and do takeout and delivery for the time being," he said.

About 58% of Atlanta's restaurants have remained open for carryout and delivery service, says Karen Bremer, CEO of the Georgia Restaurant Association. She says restaurants are well-positioned to handle the detailed infection control measures needed during a disease outbreak.

"The restaurant industry is the original wash your hands' and 'sanitize everything' industry," she says.

And some restaurants say they are ready to welcome people back inside. Waffle House reopened its Georgia locations to in-house dining Monday morning, with to-go bags covering barstools to limit the number of people who could sit at counters. It was unclear if anyone would take them up on the offer. By mid-morning, there were no guests in at least one metro Atlanta location.

"We don't know what the guests want to do," said John Metz, who owns several Marlow's Tavern locations around Atlanta, as well as other eateries. Metz hasn't reopened any of his restaurants yet, but he plans to do so, soon.

In preparation, he says he's putting Plexiglas between booths and even between some tables. He's ordering new air filtration systems -- which cost between $2,000 and $4,000 -- for all his restaurants that he says will kill 99% of germs. There will be new hand sanitizing stations for guests.

But he knows that people will feel cautious about coming back. "You can't eat with a mask on," he says.

Metz says he's told his normally friendly and solicitous servers to limit their trips to tables.

"We're going to tell the guests, we're not going to come as often as you did before this," he says.
"We're going to give you a little more space so you can enjoy your meals."

He is limiting his menu so he won't need as many prep stations in the kitchen. That way, his back-of-house staff can be appropriately spread out. Everyone will wear masks.

Dining will be by appointment only. Managers will stand in front of the store to limit the number of people inside at any time. Takeout orders will enter and exit through a completely separate door.

"We have a huge responsibility to help show the rest of the country that this can be done safely," Metz says. "I'm taking it very seriously. I know my fellow restauranteurs are taking this very seriously."

Other businesses tried to reopen but found their customers weren't ready to come back. Bad Axe Throwing tried to entice customers to come into its entertainment venue for "quarantine anger and stress relief," but only had two customers all weekend. "The reopening this weekend was a disaster," Mario Zelaya, president and CEO, told What Now Atlanta.

"Bars, bowling alleys, movie theatres, axe throwing, and any other entertainment concepts are going to have the most difficult time reaching normalcy after the closures. This past weekend showed us that," he said.

Another Salon: "No Dismount Advice"

On a recent sunny morning in Atlanta's Grant Park neighborhood, the door to Lark & Sparrow was open wide to catch fresh air.

Normally, by mid-morning on a Saturday, the couch and manicure stations would be bustling with clients lining up to get their feet scrubbed with a paste of lemon juice and baking soda, and their nails painted with nontoxic polishes.

But co-owner Linda Sharp says they are holding off on reopening. Part of the reason, she says, is that they can't get the supplies they need to safely open back up.

"Our normal supplier that we go through, they're completely out of gloves, completely out of masks, out of the alcohol that we usually purchase, and they don't have a date when those will be available," she says.

She could maybe order limited quantities of those needed items on Amazon, but even those orders are backed up for at least 2 weeks.

"We didn't stockpile because the last thing we wanted to do when this was going on was say, 'Well, we better order all the masks, we better order all the gloves.' We were leaving it to the people who really needed it. As far as I know, they still need it. It feels weird for me to buy it," Sharp says.

She says they have a litany of questions that they can't get answered. They aren't sure, for example, what will happen to their staff's unemployment checks if they reopen. They've waited on hold for hours trying to talk to someone at the Georgia Department of Labor.

"There's no dismount advice, you know?" says Jody Hill, who's also a co-owner.

If they reopen, they'll have to maintain social distancing, which will limit the number of clients they can see.

"It's going to cut our revenue down at least 50%," Sharp says. "As business owners, that means that we'll be able to provide jobs, but we won't have any money for ourselves."

For now, they're selling gift bags of pumice stones and scrubs to bring in some money.

Infectious disease experts agree that slow and steady is the right approach.

"We're not going back to normal," Schaffner says. "We're going forward -- slowly -- to a new normal. We're all trying to figure out what that new normal is."

He says as we go back into businesses, everyone should wear masks and keep hand sanitizer close.

And people who are older or who have chronic health conditions should continue to limit their contact with public places.

"If you're 70 years old and you've been cooped up, if you go to the movies, wear the mask. Sit as far from other people as possible. Take some hand sanitizer with you. Use it as you sit down. When you get home, go straight to the sink," to wash your hands, Schaffner says.

He says we'll know whether Georgia and other states have pulled this off by watching some key numbers.

"The single most important metric to watch will be patients admitted to the hospital with diagnosed COVID," he says. "How many really sick patients are showing up. If we can keep that flat, or get it to go down, then we'll all smile."


Alayna Hoang, owner, Nouvelle Nail Spa, Atlanta.

William Schaffner, MD, infectious disease expert, Vanderbilt University Medical Center, Nashville.

Keisha Lance Bottoms, mayor, Atlanta.

Karen Bremer, CEO, Georgia Restaurant Association, Atlanta.

Mario Zelaya, president and CEO, Bad Axe Throwing, Atlanta.

Jody Hill, co-owner, Lark & Sparrow, Atlanta.

Linda Sharp, co-owner, Lark & Sparrow, Atlanta.

John Metz, executive chef and co-owner, Marlow's Tavern, Aqua Blue, and Hi Life Kitchen and Cocktails, Atlanta.

Fred Castellucci, Castellucci Hospitality Group, Atlanta.

Scott Gottlieb, MD, American Enterprise Institute.