By Dustin Jayroe

Artwork on the Arkansas Heart Hospital building in Little Rock, featuring Rosie the Riveter wearing a protective facemask and eyewear.

The afternoon of March 11, 2020, formalized Arkansas’ annex in the fight against the novel coronavirus, as the state’s patient zero was announced in Pine Bluff. Our public health forces assembled alongside those in the rest of the country and the world as the attention of all persons set sight on the unseen, the unknown. However, the allied armies in this brigade have not locked arms in a literal sense — they prefer to maintain at least 6 feet between them.

 

The timing of Arkansas’ first positive case did provide us with an immediate advantage to others suffering from one of the most devastating pandemics in modern history, though. By that point, Arkansas was one of the last remaining states without a confirmed positive case of COVID-19, the disease caused by the virus SARS-CoV-2; it was only a matter of when, not if. Densely populated regions in the United States, like New York City and Los Angeles, were already on the offensive, shutting down commerce at virtually every level. The global epicenter at the time was Italy, a country that had also largely ceased the majority of its social activity to lessen its spread and attempt to flatten its curve of outbreak. Arkansas’ health and legislative leaders had observed what worked and how immediate inaction could create an out-of-control spiral of infection. On March 15, Gov. Asa Hutchinson announced that all schools should be shut down in the following days; they would not reopen during the spring term. The soft shutdown of the state followed shortly thereafter, in waves.

According to Dr. Nate Smith, the state’s secretary of health, such aggressive measures are not usually the way public health officials deal with communicable diseases, but unprecedented times call for unprecedented measures.

 

“Even during a bad influenza season, we don’t shut things down,” Smith tells AY About You. “What we try and do is identify where transmission is occurring and selectively take steps to block transmission there … It was sort of a blunt instrument that we used in the absence of testing capacity or understanding of the transmission, but not something that’s a normal tool.”

 

But it would be hard to argue that it wasn’t a useful tool, not just here in Arkansas, given the seriousness of the illness. By mid-June, the United States accumulated more than 2 million cases of COVID-19 and more than 120,000 related deaths (25 percent of the worldwide toll) in just three months. As a point of comparison, the Centers for Disease Control and Prevention (CDC) reports that during the 2009 H1N1 (swine flu) pandemic, there were 60.8 million cases of the strain in the United States and 12,500 deaths in one full year between April 2009 and April 2010. The case fatality rate pales in comparison.

 

So too do the numbers now versus the original COVID-19 projections, some of which forecasted double or more the total cases and deaths than we currently have. It’s hard to claim any semblance of victory when so many still have died, and our share of the worldwide totals are far greater than with previous pandemics, but it would be easy to purport that those early measures of mitigation had a dampening impact.

 

Many Arkansans remain in a coronavirus limbo, however, probably surprised that it continues to be such a large topic of discussion. At first, some asserted that the virus would deplete to the point of disappearance by the time the summer’s heat bore down. As of yet, that has not proven to be the case. And the preliminary information that, in hindsight, is contradictory to what we know now doesn’t stop at just projections and seasonal influences. Early on, some touted hydroxychloroquine, often used to treat malaria, as a “game-changing” prescription. Since, trials and studies have found less of a positive influence in that drug, and the U.S. Food and Drug Administration has revoked its original permission to use it. Originally, it appeared that children were relatively safe from the more detrimental effects of COVID-19, then, instances of multisystem inflammatory syndrome in children (MIS-C), with symptoms similar to Kawasaki disease, began to be reported at an unusual rate in some children who had been infected with the novel coronavirus.

 

Such fluidity in virtually every facet of a pandemic makes it difficult for health experts to make decisions, provide guidance, and has caused constant adaptation in how to handle the situation.

From April, a photo of UAMS’ drive-thru COVID-19 screening service. (Photo by Jamison Mosley).

“We’re learning new things every day, every week,” Smith says. “It requires not just weighing the information we have carefully but also reevaluating the assumptions on which we made our initial decisions. So it’s not unexpected that our guidance and our directions will change; they’ll refine as we go along.

 

“But sometimes that’s very difficult to explain to the public or to other stakeholders. ‘Well, you said this two months ago, and you’re saying something different today.’ That is really what we should be doing. We should be adapting our guidance, adapting our direction to the information that we have and the new information that’s coming in.”

 

One of the most influential changes the state has made in recent weeks was the movement into Phase Two of the federally advised reopening plan, dubbed “Opening Up America Again.” The decision was met with revelry by some, most of which may have felt it a long-time-coming relief, but repudiated by others, arguing that the timing amid the state’s “second spike” was ill-advised.

 

According to Smith, a number of factors are weighed extensively before a decision is made to enter another phase of reopening, offering that what the state has done thus far — even in its movement to Phase One — has been done so incrementally and cautiously at every turn, differing from other states who utilize the same terminology of “phases.”

Concept art of SARS-CoV-2, the virus that causes COVID-19.

“We didn’t do that all in one jump,” Smith says. “Different things were expanded at slightly different times so that we could see the impact and that we could implement those successfully. And then by the time we went to Phase Two, we already had relaxed a number of the restrictions to where it was really a limited number of changes that had to be made.”

 

After moving into Phase One in May, Smith and the rest of the members on the governor’s COVID-19 team watched very carefully the sectors of the economy that had reopened, to identify if those same areas were associated with an influx of new cases. A new case surge did come in June, but they only found little association with Phase One — restaurants, salons, etc. — based on information gathered from the Department of Health’s contact-tracing initiative. Smith says this provided encouragement that the formal initiation into Phase Two was warranted in their eyes.

 

The health secretary also reminds that he and his colleagues continue to pore over information coming out of other states, some that have been more aggressive in reopening, to try and learn from those experiences in making decisions that reflect the best interest of Arkansans.

 

This decision-making process also involves a cost-benefit analysis, seeing how to most usefully and safely marry the relationship between physical and economic health.

 

“Some of the restrictions that we made had big economic impacts, but as time went on, maybe they weren’t having that big an impact on the transmission of the virus,” Smith explains. “There are other things that have a bigger impact on the transmission but don’t have much impact on the economy at all. For example, wearing face masks. We know from experience elsewhere and the data that are emerging, that if everyone wears a face mask in a setting where they can’t maintain that 6-foot distance, then it really does reduce transmission quite a bit, but it really doesn’t impact the economy in any way. It’s just getting people to change their behavior and to do it.”

 

In fact, the effects of face masks are proving to be more of an economic bolster than anything else. Around the world, countries with more successful masking campaigns have been able to plunge into a deeper valley of infection than in the United States, thus reopening more of their societal norms. A recent study by scientists at Britain’s Cambridge and Greenwich Universities found that if people wear face masks whenever in public, it reduces the transmission rate by up to 50 percent. In addition, regular face mask usage by 50 percent or more of the population reduces the reproduction rate of the disease to a level low enough to enact less rigid restrictions, in turn resulting in more steps toward normalcy until an eventual vaccine becomes available.

 

And since Smith does not project the state will move backward at any time — say, from Phase Two to Phase One — moving forward, especially amid the recent climbs to the highest daily rate of community spread the state has seen, may require the community to do its part.

 

But masking up has been a largely divisive issue, the activity being split into political factions countrywide, with no exception to that rule in Arkansas. Smith suggests that part of the aversion could be related to inconvenience, both due to the warmer weather and poor mask design making them uncomfortable for some. But he also desires more consistency in how the national leaders present themselves, something that he sees so far as providing more reason for doubt.

 

“We’ve not had very good leadership nationally on that,” Smith says plainly of mask-wearing. “Gov. Hutchinson has been very careful about wearing masks in public. I have tried to do the same when I’m not in a situation where there is a 6-foot distance between me and others. But you hardly see our national leaders wearing masks, even in settings where it’s expected and recommended.”

 

COVID-19 is a complicated disease, to say the least; itself perhaps not so much as the effects from its rapid progression — from mere existence at the end of 2019 (by most accounts) to a plague-like cloak in a matter of months, covering virtually every place on this planet. And as much has been deciphered since its inception, plenty of unknowns still remain.

 

In June, many breathed a short sigh of relief when the World Health Organization stated that asymptomatic spread of the virus was “very rare,” especially considering that a significant portion of the known cases have lacked symptoms. Its walk-back of the statement added more confusion. Smith sees a lot of this perplexity as, at times, misnomers in terminology.

 

The term asymptomatic gets thrown around a lot, providing the perception that there are simply two classifications of infection: symptomatic and not. But that’s not necessarily the case, according to Smith. By many, asymptomatic refers to people who are infected but never show signs, but also can include people who don’t show significant symptoms while actually having some. It is also used initially to categorize people who are not visibly sick at the time of testing, but, as we know, symptoms can arise after a positive test, depending on the stage the virus is at within that individual.

 

“But sometimes they all get lumped into one basket,” Smith says, going on to suggest it would be better to be more specific in our labeling, such as presymptomatic or mildly symptomatic. “I think that it may be that those who never develop any symptoms at all probably don’t shed a lot of virus, and they may not be the main drivers of transmission. But clearly people who are presymptomatic — people who are either at the very beginning of their symptoms or a day or two before they have any symptoms at all — they can spread the infection.”

 

And as our case counts continue to billow higher and higher (even prior to the widely projected resurgence that may come in the fall) and the assuredness of an eventual movement into Phase Three, a lot of anxieties surround not just contracting COVID-19, but the potential aftermath of the virus in the bodies of those who have been infected — days, weeks or months after recovery. It is comforting that months have gone by and millions have tested positive without any obvious and widespread post symptoms, but saplings have emerged.

 

The aforementioned MIS-C, the Kawasaki-like syndrome that has reared its head in a portion of children who’ve been infected, is one of those curiosities — especially with the rollback of the probable in-person schooling schedule during the fall term. Symptoms of MIS-C, according to the CDC, include fever, abdominal pain, vomiting, diarrhea, neck pain, rash, bloodshot eyes and fatigue. The condition can be deadly and has already resulted in a number of deaths in the United States.

 

Smith sees the injurious after-effects of COVID-19 in three different ways.

 

Regarding MIS-C, the body’s immune response to infection is largely the cause of the inflammation and subsequent syndrome. This is why one of the more promising treatments for COVID-19 as of late is dexamethasone, a corticosteroid that decreases this inflammatory response and has shown progress in lowering the mortality rate in those who have been prescribed it — particularly in the most susceptible demographics, such as those 65 years of age and older.

The second is persistent infection.

 

“In some cases, we have seen people continue to shed virus for some time afterward, even weeks afterward,” Smith says. “And so the question is, is there some ongoing effect of that persistent viral replication, and that’s largely unknown.”

 

Finally, additional long term effects in recovered patients, which at present inhabit uncharted territory.

 

“Long-term or persistent problems seem to be at least very, very rare,” Smith notes. “But we haven’t had years of experience with this virus, so that’s something we’ll have to keep watching for as well.”

All of which, in Smith’s mind, makes even firmer the case for safe practices and behaviors.

 

“We know how explosively this virus can spread,” Smith says, including also that we have unfortunately had a large number of cases and deaths in this country, but not near as many as we might have had we not made the concerted effort to limit the spread. “I think that we know a lot about how to protect ourselves and our communities from this virus, in terms of physical distancing, hand washing and wearing masks. We’ve seen that we can do a lot of activities safely, but then we also have seen what happens when those things are not in place.

 

“As we’re learning more about the virus, let’s fully implement the stuff that we know works.”