The Florida governor explains a COVID-19 strategy that has gotten bad press and favorable results.
A couple of months ago, the media, almost as one, decided that Governor Ron DeSantis was a public menace who was going to get Floridians killed with his lax response to the coronavirus crisis.
In an interview with National Review, DeSantis says he was surprised at “how knee-jerk” the hostile coverage was, but he “also knew that none of these people knew anything about Florida at all, so I didn’t care what they were saying.”
The conventional wisdom has begun to change about Florida, as the disaster so widely predicted hasn’t materialized. It’s worth delving into the state’s response — as described by DeSantis and a couple of members of his team — because it is the opposite of the media narrative of a Trump-friendly governor disregarding the facts to pursue a reckless agenda. DeSantis and his team have followed the science closely from the beginning, which is why they forged a nuanced approach, but one that focused like a laser on the most vulnerable population, those in nursing homes.
An irony of the national coverage of the coronavirus crisis is that at the same time DeSantis was being made into a villain, New York governor Andrew Cuomo was being elevated as a hero, even though the DeSantis approach to nursing homes was obviously superior to that of Cuomo. Florida went out of its way to get COVID-19-positive people out of nursing homes, while New York went out of its way to get them in, a policy now widely acknowledged to have been a debacle.
The media didn’t exactly have their eyes on the ball. “The day that the media had their first big freakout about Florida was March 15th,” DeSantis recalls, “which was, there were people on Clearwater Beach, and it was this big deal. That same day is when we signed the executive order to, one, ban visitation in the nursing homes, and two, ban the reintroduction of a COVID-positive patient back into a nursing home.”
DeSantis is bemused by the obsession with Florida’s beaches. When they opened in Jacksonville, it was a big national story, usually relayed with a dire tone. “Jacksonville has almost no COVID activity outside of a nursing-home context,” he says. “Their hospitalizations are down, ICU down since the beaches opened a month ago. And yet, nobody talks about it. It’s just like, ‘Okay, we just move on to the next target.'”
Perhaps more understandably, The Villages, the iconic senior community, was a focus of media worries. According to DeSantis, as of last weekend there hadn’t been a single resident of The Villages in the hospital for COVID-19 for about a week. At one point, the infection rate in The Villages was so low that state officials were worried that they were missing something. “So I got the University of Florida to do a study,” he says. “They did 1,200 asymptomatic seniors at The Villages, and not one of them came back positive, which was really incredible.”
So how did DeSantis go about responding to the epidemic? It began with the data, and trying to learn the lessons of other countries.
Learn from the Evidence
At the outset, DeSantis looked at South Korea’s experience: “I just thought it was so dramatic, the extent to which this was concentrated in the older age groups. I think the first real fresh set of South Korea numbers I looked at, I think it had no fatalities under 30, and then 80 percent of them were 70 and above or something like that. It was really, really dramatic.”
Then there was Italy: “I think a lot of the policymakers in the U.S. acted like Italy would happen in the United States, but when you look under the hood of Italy, there were huge differences, and there were reasons why that part of Italy fared as poorly as it did. I think the median age of fatality was something like 82 in some of those areas in Northern Italy. So we looked at that, but that really helped inform the strategy to focus most of our efforts on the at-risk groups.”
He was hesitant about sweeping lockdowns, given that there wasn’t much of a precedent for them. “One of the things that bothered me throughout this whole time was, I researched the 1918 pandemic, ’57, ’68, and there were some mitigation efforts done in May 1918, but never just a national-shutdown type deal,” he says. “There was really no observed experience about what the negative impacts would be on that.”
“So I was very concerned about things on that side as well,” he continues, “and I think that’s why I had a more nuanced and balanced approach than some of the other governors. Because you have some of these health officials saying, ‘You’ve got to do this. This is science,’ or whatever. But really, these were unchartered territories.”
The DeSantis team also didn’t put much stock in dire projections. “We kind of lost confidence very early on in models,” a Florida health official says. “We look at them closely, but how can you rely on something when it says you’re peaking in a week and then the next day you’ve already peaked?” Instead, “we started really focusing on just what we saw.”
Florida was better able to do that than many states because of its routine experience dealing with natural disasters. “Many states simply did not have the data infrastructure that Florida has,” says Mary Mayhew, secretary of Florida’s Agency for Healthcare Administration. “We have an emergency status system that gets stood up, as I mentioned, in the case of a hurricane. Hospitals and nursing homes and other long-term-care providers are required to submit data on a daily basis, twice-daily basis, regarding their bed availability.”
The Florida Department of Health produces a report that DeSantis sees every morning: new cases, number of tests, positivity rates, etc. He also gets a rundown of the people who have gone into hospitals and of ICU usage. He can follow the key indicators down to the county level. This allows granular visibility into what’s happening. He cites the example of rural Hamilton County. It had 67 cases the other day. DeSantis was able to call the surgeon general of the state to find out what was going on, and learn it was an outbreak in a prison rather than a wider community spread.
His focus has been on “clinically significant cases,” or serious cases that might require hospitalizations, and that pointed to the nursing homes.
First, Protect the Nursing Homes
Here, Florida is indeed quite vulnerable. The state has roughly 350,000 residents and staff at more than 4,000 long-term-care facilities.
The state took precautions with its seniors generally. “We advised, before there was even mitigation,” DeSantis points out, “if you’re 65 and older, stay home as much as possible and avoid crowds. And that was just something that made sense.” The state talked to senior communities like The Villages about what they were doing to mitigate risk, and they took common-sense measures, such as stopping big indoor gatherings.
But the nursing homes represented a different level of risk. “It was clear to me,” says Mary Mayhew, “that there were much higher standards related to infection control being outlined by the federal CDC that well exceeded what our nursing homes traditionally have been expected to adhere to. So we never had false expectations.”
Inspectors and assessment teams visited nursing homes. The state homed in on facilities where, Mayhew says, “we had historically cited around infection control. We used that to prioritize our visits to those facilities, understanding that the guidance from CDC was changing frequently. So our initial focus was to be an effective resource education to provide guidance to these facilities to make sure they understood how to request personal protective equipment from the state.”
Florida, DeSantis notes, “required all staff and any worker that entered to be screened for COVID illness, temperature checks. Anybody that’s symptomatic would just simply not be allowed to go in.” And it required staff to wear PPE. “We put our money where our mouth is,” he continues. “We recognized that a lot of these facilities were just not prepared to deal with something like this. So we ended up sending a total of 10 million masks just to our long-term-care facilities, a million gloves, half a million face shields.”
Florida fortified the hospitals with PPE, too, but DeSantis realized that it wouldn’t do the hospitals any good if infection in the nursing homes ran out of control : “If I can send PPE to the nursing homes, and they can prevent an outbreak there, that’s going to do more to lower the burden on hospitals than me just sending them another 500,000 N95 masks.”
It’s impossible to overstate the importance of this insight, and how much it drove Florida’s approach, counter to the policies of New York and other states. (“I don’t want to cast aspersions on others, but it is incredible to me, it’s shocking,” says the Florida health official, “that Governor Cuomo [and others] are able to kind of just avoid real questions about their policies early on to actually send individuals into the nursing home, which is completely counter to the real data.”)
Mary Mayhew had daily calls with the hospitals, with people involved in discharge planning on the line. “Every day on these calls,” she says, “I would hear the same comments and questions around, we need to get these individuals returned back to the nursing home. We drew a hard line early on. I said repeatedly to the hospital, to the CEOs, to the discharge planners, to the chief medical officers, ‘I understand that for 20 years it’s been ingrained, especially through Medicare reimbursement policy, to get individuals in and out. That is not our focus today. I’m not going to send anyone back to a nursing home who has the slightest risk of being positive.'”
“What we said constantly is let’s not have two cases become 20 or five become 50,” she continues. “If you don’t manage this individual as you return them back, you will have far more being transferred back to the hospital.” Early on, when tests had a slow turnaround, there was a lot of pressure to give way, but Mayhew was unmovable on the question.
At the other end of the equation at the nursing homes, the state made it clear, according to Mayhew, “if you are unable to adhere to these infection-control standards, if you are unable to safely isolate and dedicate staff to an isolation wing or unit, you need to transfer that individual to a hospital.”
As the health officials put it, succinctly, “We wanted people out, not in.”
When the state was seeing infections at nursing homes presumably caused by staff, DeSantis deployed what he calls “an expeditionary testing force,” 50 National Guard teams of four guardsmen together with Department of Health personnel that tested staff and residents.
Most facilities haven’t had confirmed cases. “But the ones that have,” he says, “the majority of them have had between one and five infections. So the infections are identified, but then, you’re isolating either the individual or the small cluster before you have an outbreak.”
The state has just deployed a mobile testing lab in an RV that has a rapid test with results in an hour or two. It goes to a community and the staff goes to different long-term-care facilities. “If you’re talking about an asymptomatic carrier, if you can identify that person instead of waiting 48 hours for lab results to come back, I mean, that could be the difference between saving a lot of infections,” according to DeSantis.
The state has also started a sentinel surveillance program for long-term-care facilities, routinely taking representative samples to monitor for flare-ups.
Finally, it has established several COVID-19-only nursing homes, with a couple more in the pipeline. The idea, again, is to get COVID-19-positive residents out of the regular nursing homes to the maximum extent possible.
Diverse State, Diverse Approaches
At the same time Florida was devoting enormous attention to nursing homes and establishing highly restrictive policies to protect them, it was giving its counties latitude in how they reacted to the crisis.
“I said from the beginning,” DeSantis explains, “we’re a big, diverse state. The epidemic is not going to affect this state uniformly, and what’s appropriate in Miami and Broward may not be appropriate for Jacksonville or the Panhandle. And that’s pretty much the way we did it.”
“We worked with the locals in Southeast Florida,” he continues. “They had more restrictive measures than the rest of the state.”
And understandably so: “Even at this point, 60 percent of our cases have come from just those three counties. I mean, they represent 29 percent of the population, but 60 percent of the cases, and certainly a majority of the fatalities and hospitalizations.”
DeSantis eventually did issue his own statewide order, but he argues that it was more flexible and less prescriptive than those of other states. “We had a broad essential-business definition,” he says. “So we basically had businesses operating. We had the daycares open, we had recreation open, and my order never actually closed any businesses. We allowed them to operate within the context of just limiting contact between people outside the household.”
He was relaxed from the beginning about outdoor activities, even as critics sounded the alarm about the beaches: “I always believed that respiratory viruses were less likely to be transmitted in a hot outdoor environment, and then you started to see the studies come in, in March, saying that that’s what it was.”
He thinks that the relatively short, relatively capacious shutdown order has allowed Florida to be ahead of the curve of reopening of the more restrictive states. DeSantis maintains that “what we did in March and April is the equivalent of what New York will be or California, when they go to phase three.”
Looking ahead, he says, “being measured and being thoughtful and just following data is important.” He’s not following the advice of some people to, as he puts it, “just rip off the Band-Aid and just go whole hog.” In looking at the cases every day, there are cases in prisons and nursing homes, but “outside of southeast Florida, we’re not seeing a huge amount of community transmission, which is a good sign.” Of course, testing will continue to be a priority, as it has been all along.
“Our 13 drive-through sites in the state of Florida, we can do about 10,000 tests a day, just on those sites,” he says. “And we obviously have so much more testing going on in hospitals, doctor’s offices. But we can do 10,000 tests a day, and we average about 5,000 people that actually come to test. So we have a surplus of availability.”
Perhaps things will still go wrong in Florida, perhaps its relative good fortune can be chalked up to weather, perhaps county-level lockdowns made a big difference, but no one can say that the state hasn’t taken a thoughtful approach to the crisis. Or, no one can reasonably say that — which, of course, hasn’t stopped many journalists.
“I view it more as a badge of honor that I was doing a good job,” DeSantis says, “and that they viewed me as a target, because if I wasn’t, they probably would just ignore me.”
(C) 2020 National Review