Atlanta Serves as Test Case as First Major City to Relax Shelter-in-Place Orders

John Whyte, MD, MPH; Colleen S. Kraft, MD; Carlos del Rio, MD

Disclosures

June 16, 2020

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

  • Atlanta was the first major city — and Georgia among the first states — to relax shelter-in-place orders during the pandemic.

  • Atlanta has seen an uptick but not a large surge in COVID-19 cases as individuals are continuing to stay at home, wear masks, and practice social distancing.

  • Communities need to continue to protect vulnerable populations, such as those older than 65 and those with chronic health conditions.

  • The impact of COVID-19 is disproportionately higher among racial and ethnic minorities. Minority individuals are also disproportionately working as frontline and essential workers during the pandemic.

  • Individuals have the ability to protect others by wearing a mask in public, which can decrease COVID-19 transmission by about 40%.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today I'm joined by two guests: Dr Colleen Kraft, associate chief medical officer of Emory University Hospital; and Dr Carlos del Rio, executive associate dean of Emory University School of Medicine. Thanks for joining me today.

Colleen S. Kraft, MD: Thank you.

Carlos del Rio, MD: Good to meet with you, John.

Whyte: Atlanta was the first major city to reopen during the pandemic. I'd like to understand what you all are seeing. Dr Kraft, what are your impressions of what's been going on since the reopening?

Kraft: The city of Atlanta, and the state of Georgia, were the first to reopen. We have not seen a huge surge that we thought we were going to be seeing, mostly because many individuals, at least in the metro Atlanta area, are still really trying to focus on social distancing, wearing masks in public, and being very tentative about being in large crowds and being in public places such as restaurants. So even though there was a relaxing of the shelter-in-place statewide, I would say that it's been very slow. I mean, we're nowhere near what it was pre-COVID.

Whyte: Dr del Rio, has anything surprised you about that?

del Rio: No. I think Dr Kraft is absolutely right. One thing is policies and political decisions, and the other thing is individual decisions. What we need to understand is that it's really individual decisions that are going to impact what this pandemic does and what direction it takes. It's our own individual decisions, so if we continue practicing social distancing, wearing masks, doing the right things, not only are we not going to get infected, but we're going to prevent others from getting infected. So the reality is that we need to remember that this virus has not gone away and that we need to continue doing those things.

Having said that, there is clear evidence that we're seeing some impacts of that easing of restrictions. We're seeing some people thinking that the virus is gone and not wearing masks. And we are beginning to see an uptick in the number of patients being admitted and the number of new COVID cases. We need to be aware that cases are going to increase. We need to contain cases so they don't become big outbreaks.

Whyte: Dr Kraft, are we looking at the right data? We tend to look at total number of cases and the aggregate. We may not always focus as much on local communities. We don't hear as much about hospitalization and death rates. Do we have the right data points to really assess what's working and what's not?

Kraft: I think we do have the right data points. I tend to look at three main sources of truth. One of them is the Johns Hopkins Center for Health Security, and that gives you a real global perspective, which I think is important to think about. The number of global cases seems staggering compared with just a few months ago. That's a place to start. I look at the CDC website for our national data — what Dr del Rio was alluding to earlier, thinking about what's happening in other states. But then I spend a lot of time looking, and I know Dr del Rio does too, at our Georgia Department of Public Health website.

While you can see spikes in various counties, I really spend a lot of time looking at the top five counties in Georgia to see if there's a change — one county being higher than another in terms of cases. To me, it's all about looking at the microcosm that you may be living in, and then what area you're serving, either as a clinician, a hospital administrator, or a public health individual.

del Rio: I will just add to what Dr Kraft said. I think she's absolutely right in the source of data to look at. One additional one that I would add here in Atlanta is with the mayor's office, a website called ATLStrong.org. There's a dashboard there; looking at dashboards is very useful because the dashboard really tells you what the cases, deaths, and hospital admissions are doing, what the ICU capacity is, what testing is. There are a lot of data points that are helpful to know what you need to do.

Whyte: Dr del Rio, I wanted to follow up on your point about how in some ways there is this "quarantine fatigue" and people are out and about. They may not be hearing about the number of cases, and they see people in restaurants without masks and walking around. How do we keep people vigilant and recognize that the virus is still around and they need to still have these safeguards?

del Rio: The quarantine fatigue is true. But the reality is this is a pandemic. It is serious and unprecedented. The reality is that I've never lived through anything like this. Hospitals across the United States, primarily in the Northeast (New York and other places), got overwhelmed very rapidly. I remember a colleague at Cornell saying, "We have 500 people hospitalized with COVID, 170 who need ICU care, and we only have 100 ICU beds." It's scary. That level of overwhelming of hospitals, those images, should scare anybody. And if they don't scare somebody, we need to do a better job communicating this because the reality is this virus is still with us. We're learning a lot about it and we're learning how transmission occurs, how to avoid it. So as we learn these things, we need to communicate that to people, because we can in fact decrease transmission.

And we have to be particularly careful with our vulnerable populations. I think we really need to protect people over the age of 65, people who have chronic conditions. Those individuals are the ones who, if they happen to get sick, are going to get very sick. They're going to get admitted to the hospital, will need ICU care, and may die.

Whyte: I want to talk about the impact on different populations. What has been the disproportionate impact on minority populations? Are we seeing an even greater impact with reopening or has that leveled out?

Kraft: Especially in Atlanta, where we have a very wonderful, diverse community, we are seeing that the impact on persons of color and minorities is disproportionately higher. I think it's too early to tell if it's happening as a result of the release of shelter-in-place. We just know that it was happening already at baseline.

del Rio: Initially we saw a big number of cases among African Americans, among nursing home residents. I think we are continuing to see here at Grady Hospital a disproportionate impact on African Americans. But we're also seeing, across the city, an increase in the number of cases among Hispanics. What many of these people have in common is that they're frontline workers. They're the people serving; they're disproportionately in those positions and in jobs that require you to be in front of people. There's a lot of crowding. Think about meatpacking industries and so on.

Quite frankly, many of them live in crowded conditions. Shelter-in-place is a privilege. I've talked to many of our patients. I was talking to an infected 23-year-old man the other day who is Hispanic, and he said, "Well, I live with 15 other people in a two-bedroom apartment. I don't rent a room there; I rent a bed."

When people live in those kinds of conditions, transmission is going to happen. We need to remember that living conditions, poverty, being a frontline worker, and the need to take public transportation put minorities at a much greater risk than those of us who have the luxury of being able to shelter in place, telework, telecommute, and so on.

Whyte: Having been a month-plus in terms of reopening, what would each of you have done differently that other states and cities can learn from?

Kraft: In terms of the state, even though there was a lot of concern about us opening early, I think it is what Dr del Rio eloquently said earlier, which was even though there was a policy that was made and then revoked — meaning shelter-in-place — it's our personal responsibility to take care of ourselves. So while we can blame lots of other aspects of what's going on, we still have within our control the ability to protect ourselves. And I want to continue that message. Whether or not the state is open, the city is open, you don't have to return to work; you can telecommute or telework. I think we still need to realize that we have the ability — with hand sanitizer, masks, and good surface and face hygiene — to be able to protect ourselves against this virus, and we should be taking it seriously.

del Rio: We have the ability to protect ourselves, and we also have the ability to protect others. The reason I wear masks in public is not to protect me; it's to protect others. And if everybody in public wears a mask, you can decrease transmission at the population level by about 40%. So the reality is that we all have the responsibility to take care of ourselves; we all have the responsibility to take care of others. And if we do that, we can actually decrease transmission by not doing a bunch of things.

It's not like we need to stay inside and never go out again. But when we go out, we have to wear a mask. We have to do hand hygiene. There are certain things we have to do.

Whyte: That's very good advice, and I want to thank you both for joining us.

del Rio: Happy to be with you.

Kraft: Thank you for the opportunity.

Whyte: And I want to thank you for watching Coronavirus in Context.

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