Years before I tasted a Viennese melange, I practiced ordering one in a high school language lab. Cafe culture occupied a small, luxuriant spread in one of my German textbooks, but the sheltering Atlanta suburbs where I grew up in the early 1990s gave no quarter to such mystique. I couldn’t wait to get the hell out of there—but in the meantime, there was Cafe Intermezzo.
Cafe Intermezzo had two branches in those days: the original in Dunwoody and the one I preferred, on a noisy strip of Peachtree Road near Brookwood Hills. I am told the parking at my favored location was terrible, which I do not remember because I did not drive until after high school. (Due to ill-advisedly skipping sixth grade, I was two years younger, and at least two years weirder, than most of my classmates.) Adulthood always seemed particularly far away to me, probably because it was.
Both the original cafe and its offshoots were designed in homage to Europe’s soigné coffeehouses, with high ceilings, walnut wainscoting, brass fixtures, and long uplit glass cases displaying pastries of infinite complexity. In my early teens, visits were a special occasion. I remember thronging to the Brookwood location for dessert—always something with manifold chocolate layers—after performing in high school musicals. Later on, home from college, I sipped cappuccinos in its front rooms with the doors opened to the street, brooding alone or with a friend.
To my untuned senses, Intermezzo’s hushed tones and lighting, dim even during the day, seemed engineered for maximal intrigue. In its surfaces, I saw glimmers of the life I would live when I finally grew up and got out. In that future, I promised myself, I would claim my own joy from the world when and how I wished to. Intermezzo was the first place where I smelled cigarettes and whiskey on another person’s breath and realized I did not hate it. Intermezzo was practice for adulthood.
I turned 21 a few months after graduating from college. My friends had scattered; I celebrated with a glass of wine at the Dunwoody Intermezzo with my mother. (The worse indignity: I did not get carded.) And then, I grew up. I moved to an exciting city. I traveled alone. I drank coffee in extraordinary rooms around the world—including, one Christmas, several of Vienna’s. I was gone for a long time.
While I was away, Cafe Intermezzo evolved too. Its Brookwood location shuttered in 2013—moody to the end, at least according to photos I found on an outdated review site—and moved to Midtown. The small chain now has four cafes, with one in Nashville. As they have for years, all of the locations play language-education recordings in their bathrooms and for customers holding the phone. (During a recent inquiry, I heard a woman ask in French where to pay a fine, or maybe where to buy almonds. I should have listened more carefully.) Now, though, you might hear Japanese or Arabic in addition to European tongues.
Atlanta may not have the kind of cafe culture that once seemed to me the purview of adults, but it does contain a creative ferment I never perceived as a kid—a magic and a serendipity and other things, grown-up things outside the margins of what I used to envision wanting. So, I’ve stayed. Sooner or later, I’ll make my way back to Intermezzo alone, just to be reminded of how different things are now—how different I am. Places can hurt but, with the right light, they can also heal.
When Amber Schmidtke was a medical school professor in Macon, she started a research project to better understand why so many of the state’s kids were behind on their childhood immunizations. In 2017, Georgia was the slowest state in the nation to get three-year-olds fully vaccinated against infections like measles and whooping cough. Schmidtke found that a major reason for the state’s poor performance was the Georgia Registry of Immunization Transactions and Services—abbreviated, obviously, as GRITS.
Created in 1996, GRITS was initially designed to ensure children statewide were benefiting from federal vaccination programs by tracking immunizations given mostly in pediatricians’ offices and by county health departments. It was built for “more of a trickle than a flood,” says Schmitdke, and was so infrequently used to track adult vaccinations that most internists had no clue how to use it.
Schmidtke wasn’t particularly surprised, then, to hear that during the state’s massive Covid-19 vaccination rollout effort, GRITS had become a particularly gluey cog in the public health machine, its crashes and delays leading to dramatically underreported levels of vaccine administration statewide. But she was stunned when, during a January 19 hearing before the Georgia legislature, health department director Kathleen Toomey requested only minimal additional funding for public health in the 2022 budget.
“It’s sort of a weird look to be asking for no real increase in expenditures when we know that there are so many areas where Georgia is deficient compared to other states,” says Schmidtke, who authors a daily newsletter on Georgia’s Covid-19 dynamics from her new home in Kansas City. Georgia has some of the country’s worst scores on maternal and child mortality, sexually transmitted infections, and HIV transmission. The state’s Covid-19 dashboard has been notoriously ineffective. And last August, mid-pandemic, the state’s Covid-19 data task force was dissembled due to a lack of funds.
But compared with other states, Georgia has spentrelativelylittle on public health in the past 10 years—and Governor Kemp’s proposed budget for the next fiscal year includes a $7 million cut to state public health funding compared to pre-pandemic levels, leaving county health departments to rely deeply on federal funds for their Covid-19 response, said Georgia Budget and Policy Institute analyst Laura Harker during a recent presentation. “The state has not been contributing to making sure that there’s some long-term stability for those health departments,” she said.
“Public health is drastically underfunded,” says Michelle Au, an anesthesiologist at Emory Saint Joseph’s Hospital in Atlanta and a state senator newly elected to represent North Atlanta’s 48th district. That’s why, she says, in the face of a national pandemic strategy until recently characterized largely by the punting of responsibility to state and local health departments, “we’re having this very fractured, Balkanized, under-sourced response.”
The messy vaccine rollout is not the fault of health departments whose resources have been stripped away over the past decade, says Au: “You never think you need to pay the money in until you need it.” And now, she says, we do.
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On January 11, a glitch led to the appearance of three times as many vaccine appointments in Fulton County’s registration system as its vaccination-site workers had planned for. The staff got all of the immunizations done anyway, tweeted Dr. David Holland, Chief Clinical Officer of Fulton County’s Board of Health, but at an enormous cost.
“The solution isn’t to work people to death. It’s to make sustainable investments in public health so that emergencies don’t crash the system,” he tweeted.
In early November, Georgia began working on a vaccine distribution plan that allocated vaccines to county health departments in each of Georgia’s 18 health districts according to the districts’ vaccination capacity and numbers of frontline workers and long-term care facilities. It wasn’t only local health departments that could request vaccine: large hospital systems, nonprofit organizations, private-sector physicians, and community health centers also placed orders.
While the decisions about where to allocate vaccines were made at the state level, each individual organization that requested vaccine had to create its own appointment system and website, and manage its own logistics for getting shots into arms. For local health departments already worn thin by months of testing and infection-tracking efforts, it was an enormous lift, especially when they were left with skeleton crews after years of public health cuts.
According to Holland, Fulton County’s health department employed 120 public health nurses at its peak—but over the past two decades, that number has shrunk to 30. “You can’t strangle public health and then expect to have a rapid, robust response to an emergency,” he tweeted.
Local health departments are also not Covid-only operations: “People don’t stop needing public health even though coronavirus happens,” says Au. “People still need regular childhood vaccinations, and WIC is still happening,” she says, referring to the federally funded program that provides supplemental nutrition to women, infants, and children. Public health workers at these departments also provide testing and treatment for HIV/AIDS, other sexually transmitted infections, tuberculosis, and other communicable diseases that, if not prevented with vigorous public health programs, can mushroom into entirely new public health emergencies.
“Money is important,” said Toomey in her testimony. “But even more than money, a thank you, and appreciation for what they’ve been through, and not the negativity that seems to come.”
Schmidtke noticed that statement with some dismay, and in a recent edition of her newsletter, struggled to square Toomey’s words with the accounts she’s been hearing from public health professionals who have been in overdrive for nearly a year. “Bringing in reinforcements would help a lot. Money would allow them to bring in more reinforcements,” she wrote. “I can imagine it is incredibly demoralizing to the public health workforce to know that help is not on the way.”
Indeed, there appears to be no rest in store for some of Georgia’s weariest public health workers: in early January, the state health department issued a three-month moratorium on vacation to its employees. And while lawmakers plan to give the state’s public school teachers and staff a $1,000 “hazard pay” bonus this year, no such support appears to be on the table for public health workers. “It is extremely disheartening to others of us who have been hard at it for nearly a year now too,” commented one district-level public health employee on a Facebook discussion about Georgia’s pandemic response.
In many parts of the state, including most of the metro Atlanta area, demand for the vaccine is greatly outpacing supply. When the state expanded vaccine eligibility to those 65 and older in late December, Georgians attempting to use the state health department’s vaccine portal encountered imploding websites and phone lines overwhelmed by callers desperately wanting vaccine appointments. People have been vocal about their frustration with the disorganized effort, says Rebecca Mitchell, a freshman representative in the Georgia House from Snellville and a veterinarian with a PhD in infectious disease epidemiology. “Everyone who reaches out to me is mad about the portal and not being able to get access,” she says.
In addition, while both brands of the vaccine available are quitesafe and well-tolerated, pockets of vaccine hesitancy among rural healthcare workers have been worrisome to Toomey and other public health authorities. While residents of long-term care facilities statewide have eagerly accepted the vaccine, Toomey noted in her January 26 testimony, only 25 to 30 percent of the facilities’ staff themselves agreed to be vaccinated—and the same was true in many rural hospitals both in North and South Georgia.
Pollingsuggests individual politics align with vaccine hesitancy, with willingness to get the vaccine generally higher among Democrats than Republicans, who make up the bulk of Georgia’s rural areas. Hesitancy is also more common among Black Americans than members of other ethnic groups. Amid inequities that have disadvantaged rural and Black people in so many other ways during the pandemic, these trends hint at future disparities in Covid infection unless serious investments are made in targeted community outreach and education, says Harry Heiman, an associate professor at Georgia State University’s School of Public Health.
Vaccine education is another domain where resources would help, says Shanti Akers, a pulmonary and critical care doctor at Phoebe Putney Hospital in Albany, where 40 percent of the staff initially declined the vaccine. “One thing we suffer from as a rural-based health system is that we just don’t have the people,” she says. Without an infectious disease specialist or a vaccine coordinator on staff, there’s no one to plan “town hall” meetings like the ones large metro Atlanta hospital systems use to educate their staff about vaccine benefits and safety.
Georgia’s rural hospitals were already under extraordinary strain prior to the pandemic, largely as a consequence of elected officials’ refusal to expand the state’s Medicaid program. Over the past 10 years, eight have closed, and the ones that have survived are under enormous financial pressure due to high community rates of underinsurance.
A representative for the state health department wrote in an email that Toomey’s budget complied with Kemp’s August 2020 instructions to state agencies, which instructed them to submit budget requests equivalent to the past fiscal year’s, and that Kemp also directed agencies to prioritize spending federal Covid-19 response funds, which for the health department amounted to about $1.1 billion. But according to Laura Harker, the health policy analyst, doing so relies on short-term funding to keep both state and local health departments afloat when, in fact, they confront growing need every year. “When the federal funding goes away, the local departments will essentially face a cut because the state kept their grant funding flat,” she wrote in an email.
In a House Appropriations Subcommittee meeting on January 26, Representative Butch Parrish of Swainsboro said federal funds were not enough, adding that the pandemic had exposed critical public health staffing needs. “Federal funds have been used where we have been able to do that, but we still need to put in some state funds to help,” he said, shortly before proposing funding in support of several public health leadership positions, as well as $18 million to modernize systems to monitor disease trends—including GRITS—and $15.4 million to support the increased need for HIV/AIDS care during the pandemic.
Although the absolute number of vaccines Georgia receives is up to the federal government, several moves by Toomey’s agency and others may soon improve vaccine accessibility statewide. The health department has developed tech “strike teams” to help healthcare providers document vaccinations in GRITS in real time; a centralized appointment system is reportedly in the works; volunteers are being recruited to provide both administrative and clinical assistance at mass vaccination sites; and Toomey said in a January 21 press conference that she expects the locations of additional mass vaccination sites to be announced in the coming days.
Schmidtke says she understands that Toomey is in an uncomfortable spot. “I think she does want to advocate for her people, but she’s constrained by the politics of her position, too,” she says. The state health department’s budget shortfalls could easily be made up with just a crumb of the $1.7 billion in the state’s Revenue Shortfall Reserve, which it preserves as a rainy-day fund—but Kemp has not signaled that he intends to redirect those funds toward public health or any other of the state’s strained agencies.
“When you see what their budget request is,” says Schmidtke, “it doesn’t seem that public health is a priority compared to other issues, even in a pandemic. . . . It’s not so much an issue of staffing or funding, although those things would help. Perhaps it’s more of an issue of motivation.”
On Tuesday, April 28, eight days after Brian Kemp sent shock waves nationwide as the first governor to announce he would reopen his state during the pandemic, a quiet storm was brewing over another of Kemp’s decisions. State officials were sending flurries of emails about the previous day’s launch of Georgia’s new Covid-19–tracking dashboard—the primary tool that business owners would use to decide when or whether to reopen, now that they could. The launch was supposed to mark an improvement over the state’s preexisting Covid-19 webpage. But it was not going well.
Nancy Nydam, director of communications for the Georgia Department of Public Health, forwarded to two of her colleagues an email she’d received listing constituents’ complaints about the dashboard: deaths by county and demographic had disappeared; age and gender information had vanished; the color scheme was difficult to see for some readers; numbers on the page contradicted each other. At least one state agency reached out with an urgent need for data that were no longer on the page—an office manager from the Georgia Emergency Management and Homeland Security Agency (GEMA) wanted answers from the health department “like ASAP” to a list of questions about missing demographic information regarding hospitalizations and deaths, as well as some other metrics. “I wanted to see if you guys have the information listed below in an easy to share format?” she wrote.
That day’s hitches were not the first indication of the dashboard’s potential problems; as recently as the weekend before its launch, the state’s lead epidemiologists noted that Dougherty County, where the virus’s scorching arc through low-income Black communities had rendered Albany the city with the second-highest number of Covid-19 cases per capita in America, was absent from the as-yet-unpublished dashboard’s list of “top five” counties.
Nor would the dashboard operate smoothly in the weeks and months to come. That much would become clear both to state officials firing off frantic emails and to bewildered Georgians trying to interpret the dashboard’s data in an attempt to decide whether to visit a restaurant, attend religious services, or send their children to summer camp or daycare.
What remained unclear to the public, however, was who exactly was pulling the strings behind the state’s maligned Covid-19 dashboard. Although by all accounts it would appear that it was operated by the Georgia Department of Public Health, some skeptics felt that the fingerprints of the state’s public-health experts were conspicuously absent from the dashboard bearing the agency’s name.
“Who is making the call about what information the Department of Public Health is displaying on [its data dashboard] page?” reporter Sam Whitehead asked. “Is that being made within your agency?”
“Listen, I’m gonna have to run,” Dr. Toomey responded, in what came across as an almost comical attempt to avoid the question. “I actually can’t answer this right now because I’m getting called by the Governor’s office.”
Atlanta was able to obtain emails illuminating the inner workings of the state’s Covid-19 dashboard not from the state’s Department of Public Health but from the Governor’s Office of Planning and Budget. Why would the office that handles Kemp’s and the state’s budgetary affairs have been the custodian of emails about what ostensibly belongs in the state health department’s domain? Because that office had outsourced the dashboard to a private company—and had assumed what public-health experts describe as an unusually expansive role in overseeing the project.
A series of open records requests Atlanta filed to the Governor’s Office of Planning and Budget yielded thousands of emails concerning the state’s new Covid-19 dashboard, sent between employees of that office and those of the health department—as well as those of the third-party vendor tasked by that office with creating the dashboard. An examination of those emails revealed the health department had limited input into and no real oversight over the dashboard during its creation and in the months after its launch. Additionally, the sidelining of the health department allowed for errors in the analysis, interpretation, and visualization of the state’s Covid-19 data, while simultaneously costing the state tens of thousands of dollars—and time it did not have to spare.
Other open records requests for emails to and from a different state agency showed that at the same time the Covid-19 dashboard was suffering from very public problems, health department officials were working in collaboration with that agency to create a different dashboard—and that after its launch, they were unsuccessful in their attempts to make its existence widely known.
Furthermore, when the dashboard elicited public outrage, the health department shouldered the blame for errors over which it had no control, damaging the relationship between the agency and the community it serves.
“This is the type of information that you make informed decisions on—decisions that impact millions of people in a jurisdiction,” says Dr. Syra Madad, an infectious-disease epidemiologist and special pathogens preparedness expert in the New York City hospital system, in reference to state-run Covid dashboards. Because the impact of dashboards on those decisions is so outsized, authorities must take great care in determining who oversees them, according to Dr. Madad. “It’s okay to bring in outside individuals or contract with other entities as long as it’s in collaboration,” she says. “But if this [outsourcing of the dashboard] was based on a political decision and not in collaboration with public-health people that actually know what they’re doing, then that’s a recipe for disaster.”
In her April 28 email, Nydam, the health department’s communications director, particularly had been concerned about an inquiry from the AJC in relation to the one-day-old dashboard: “The most pressing is this email from the AJC,” she had written to two health department employees. “Someone must talk to them or we are going to get dragged through the dirt for something that we did not do.”
In response to Atlanta’s detailed questions about the contents of the emails—including why the health department didn’t have more control over the dashboard on its own site and whether its epidemiologists were given enough input into the dashboard—the governor’s press secretary, Cody Hall, only responded: “We are referring comment to DPH here.” When Atlanta pointed out that the questions concerned the actions and decisions of the Governor’s Office of Planning and Budget, Hall would only state: “As the media contact for the Governor’s Office my comment is: ‘I am referring this media request to the Department of Public Health.’”
Similarly detailed questions to the health department were met with this statement from Nydam: “Throughout the COVID-19 pandemic, the Georgia Department of Public Health has worked and continues to work closely with Governor Kemp’s office, the Georgia Department of Community Health and the Georgia Emergency Management and Homeland Security Agency to provide data that is accurate and transparent. We continually review and update features of the dashboard with our vendor . . . to ensure we are providing as complete a picture as possible of COVID-19 in Georgia.”
Several experts on American public-health infrastructure told Atlanta it’s not uncommon for health departments to have a contractual arrangement with a third party to help with certain aspects of data management or with special, time-limited projects like surveys. But it’s unusual to completely outsource a public-health data analysis that shows up on a health department’s site while failing to give the health department oversight of that analysis, says Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, a nonprofit organization representing public-health epidemiologists. She points out that a state’s team of epidemiologists is uniquely equipped to interpret, analyze, and visualize public-health data.
“That is the job of an epidemiologist, to not just produce a report—a biostatistician can do that—but [to carry out] the ‘ground truthing’ of it,” says Hamilton. That is, tethering the data to real events rather than the projections of policy experts. “It’s just so critical that you do have the right epidemiologists that are leading the efforts and able to see inside the work.”
In Georgia, those epidemiologists existed; they were employed by the Department of Public Health. But they were not leading the efforts.
On Monday, March 16, the novel coronavirus had begun to wreak havoc on Georgians’ lives. The night before, Atlanta mayor Keisha Lance Bottoms had declared a state of emergency, and it was the first day of remote learning for students in many school districts statewide. The Department of Public Health’s daily Covid-19 status report—at that time, a bare-bones page consisting of no more than a case density map of the state, a list of cases by county, and a couple of pie charts—counted 99 cases and one death due to the virus.
That morning, Chavis Paulk, the division director of analytics in Governor Kemp’s Office of Planning and Budget, sent an email introducing himself and his team to Theresa Do, a Washington, D.C.–based epidemiologist and manager at SAS, a data-analysis software and consulting company headquartered in North Carolina. The email mentioned an Excel file containing the details of each suspected Covid-19 infection in the state, which Paulk’s team had just uploaded to a secure server.
It was an innocuous enough introduction, but it opened the door to a protracted and consequential barrage of emails between SAS, the governor’s planning and budget office, and, eventually, the health department.
SAS has been around since the 1960s, when it was known as the Statistical Analysis System, a computer program for analyzing agricultural data. Later incorporated in Raleigh, the company has since evolved into a multinational software and data analysis consulting corporation with more than 14,000 employees. Its software is widely used in health-services research and in public health, including at the Centers for Disease Control and Prevention (CDC); the Morbidity and Mortality Weekly Report—the agency’s flagship publication—often notes use of the company’s software.
The relationship between the governor’s office and SAS was relatively new. In an annually renewable contract initially signed in August 2019, the company agreed to provide software and consulting services to the Governor’s Office of Planning and Budget at a total cost of nearly $3.7 million over five years. But OPB’s director since early 2019, Kelly Farr, who also had worked for Kemp back when the governor was the secretary of state, already knew SAS well: From 2017 to 2019, Farr had worked for the company as an account executive.
The data in the Excel file that the governor’s planning and budget office sent to SAS on March 16 were similar to the data the health department was using to make its own Covid-19 webpage, then only four days old. Over the next six weeks, as the health department continued to maintain its Covid page, the team at SAS would develop an entirely different one using its own software and analysts.
Well before the launch of the SAS dashboard, the Covid-19 webpage managed by the health department had its own problems. As the SAS team worked on its prototype—and as novel coronavirus infections surged in Georgia—the health department scrambled to keep its webpage updated with the flood of information coming its way. Its efforts were complicated by the massive influx of inaccurate and incomplete data pouring in via antiquated reporting processes managed by a decentralized and underfunded public-health system. The effects of these problems only would be amplified once the state’s public-health authorities no longer had control of how Covid-19 data was presented on its own website.
“I have no access to the site and no real awareness of who is responsible for the details behind this . . .”
The pressures of a public-health emergency can create intense demand for frequent, real-time reporting that may exceed a health department’s capacity, according to Hamilton, with the Council of State and Territorial Epidemiologists. But when outside data analysts responsible for quality control don’t see a dataset through a public-health lens, the high-pressure environment can lead to errors, she says. “I don’t necessarily want to say that [any errors are] malicious—I think that they’re being driven in part by unrealistic expectations that data is coming in in a way that is much cleaner” than it is, she says.
On April 11, Farr, director of the governor’s planning and budget office, sent an email to Lorri Smith, Governor Kemp’s chief operating officer, and Dr. Toomey, the health-department commissioner, with two links to the SAS team’s work in progress: one with “high level information that could be incorporated as [a] website” and another with “additional information and insights.”
Four days later, health-department epidemiologist Laura Edison responded to an email from Anand Balasubramanian, the governor’s technology advisor, in which he’d asked about “some concerns” she had with the dashboard prototype. “I think this is a great display,” she wrote back, “and just have some nuances to discuss.” In a conference call summarized in a subsequent email, Edison and her colleagues noted that in some places, the dashboard used inappropriate terminology and lacked sufficient explanatory text; in others, key metrics and tables were absent, or existed where they didn’t belong; the graph showing the daily case count did not use shading to indicate a 14-day “pending period” to account for the lag time between a person’s onset of symptoms and the confirmation of their positive test result by the state. SAS epidemiologist Do summarized health-department staffers’ recommendations in a table spanning three pages. (SAS would make nearly all the changes, she wrote.)
But Karl Soetebier, the director of the health department’s informatics office, later would make plain just how little input he’d had into the SAS dashboard.
“My only real involvement to date has been to provide the data to OPB [the governor’s planning and budget office] and a few discussions with the folks from SAS about the data itself,” he wrote to Balasubramanian. “I have no access to the site and no real awareness of who is responsible for the details behind this or what process is needed to have changes made.”
When Kemp announced on Monday, April 20, that he’d soon allow nail salons, hair salons, and bowling alleys—followed by restaurants and movie theaters—to resume serving customers, Georgia did not yet meet the criteria to reopen as set forth in White House guidelines (namely, a downward trajectory of documented cases within a 14-day period). President Trump himself criticized Kemp for reopening the state prematurely. The following weekend, the day after the first businesses reopened their doors, SAS’s Georgia team lead Albert Blackmon wrote to Aaron Cooper with the governor’s planning and budget office and several others, saying: “I know that there is a desire to go live with the site very soon.”
Blackmon acknowledged minor inconsistencies between SAS’s and the health department’s analyses of the state’s Covid-19 data and noted that, if there were still concerns about SAS’s numbers, his team would need to get on the phone with the health department immediately and attempt to reconcile any discrepancies before SAS’s new dashboard was unveiled.
Two days later, on the morning of Monday, April 27, Kemp’s technology advisor Balasubramanian wrote in an email to his colleagues and to SAS that the governor’s office wanted the SAS dashboard to go live that afternoon. The launch would come a day ahead of schedule—and an hour and 15 minutes in advance of a press conference at which Governor Kemp, with health-department commissioner Dr. Toomey at his side, discussed how restaurants would safely reopen for dine-in customers effective immediately. Kemp also took a few moments to introduce the new data dashboard: “We realized as a team that we can provide a more unified, user-friendly platform for Georgians in every corner of our state.”
The next day, the health department’s Soetebier vented to his higher-up, Dr. Toomey: “As you know we were given a new website for the public yesterday for which we have had little input on to date and for which we no longer have direct control.” He also made clear that SAS should take responsibility for any dashboard problems. “I have asked them to own the ongoing list of issues that are identified with the dashboard and to commit to reviewing their progress on them with us regularly,” he wrote.
The public reaction to the dashboard was negative and swift. An AJC article two days after the dashboard’s launch noted that it “confused ordinary Georgians as they decide whether Gov. Brian Kemp was right to begin reopening the state’s [businesses]” and was “making it difficult for the public to determine if Georgia is meeting a key White House criteria for reopening.”
“A lot of people are now accusing us of trying to hide data and/or misrepresenting . . .”
Three days after the dashboard’s launch, Megan Andrews, the health department’s director of government relations, forwarded a roundup of constituent complaints to SAS’s Blackmon, asking for assistance in responding to the concerns expressed in the constituents’ emails.
Blackmon replied, “We will get you answers ASAP.” Four days later, Andrews’s deputy, Emily Jones, sent a follow-up email: “We are really in need of some answers for constituents,” she wrote on May 4. “A lot of people are now accusing us of trying to hide data and/or misrepresenting, so getting them information quickly is important.”
Particularly worrying to Jones was the concern several constituents had raised about perceived manipulation of the data to artificially show a decrease in cases. They “believe that these graphs are intentionally designed to show a downward trend and are wondering if a better explanation of the methodology can be given,” she wrote.
SAS’s Blackmon seemed to think the existing explanation on the dashboard was enough: “There is a clear asterisk under the chart” explaining that the last 14 days in the chart may be missing cases, he wrote. “That is what I have been telling people,” replied Jones, “but I wanted to make you aware that we are getting several of these inquiries a day.”
The next Saturday, May 9, a Twitter user called out an egregious graphic on the dashboard. “I’m sorry but I have to curse your twitter feeds with this nightmare graph from @GaDPH,” she tweeted. “The X axis shows dates, BUT not in chronological order for some godforsaken reason.” In an attached image captured from the dashboard, cases descended from left to right, at first glance suggesting a downward trend as time progressed—but as the out-of-order dates indicated, time was not actually progressing but jumping all over the place.
Other Twitter users were quick to speculate about the explanation for the chart’s unusual configuration: “Oh, we know the reason. A clear attempt to make the data say what they want it to say, rather than just letting it speak,” wrote one. Journalists also were perplexed: “Only in Brian Kemp’s Georgia is the first Thursday in May followed immediately by the last Sunday in April,” a Washington Post columnist quipped. Pete Corson of the AJC tweeted that the graphic had been “the subject of much head scratching” at his publication.
In a response to Corson, Kemp’s director of communications, Candice Broce, implied the health department was to blame: “The graph was supposed to be helpful,” she tweeted, “but was met with such intense scorn that I, for one, will never encourage DPH to use anything but chronological order on the x axis moving forward.”
Over the next two weeks, a volley of errors emerged from the dashboard: A chart showing Covid-19 cases by race mistakenly included a diagnosis date in 1970, making it unreadable; the total case number inadvertently included—then abruptly expunged—231 serology test results, resulting in a confusing decrease in positive cases between reporting periods; and data points went missing from charts depicting individual counties’ daily case numbers.
A May 19 AJC article explored multiple explanations for the mistakes, quoting Broce as saying of the health department: “We are not selecting data and telling them how to portray it, although we do provide information about constituent complaints, check it for accuracy, and push them to provide more information if it is possible to do so.” Although the story noted a Kemp aide had blamed “a software vendor” for the widely ridiculed nonchronological graph, it did not give further detail on the extent or nature of the vendor’s responsibility.
The next morning, the Columbus Ledger-Enquirer reported that the dashboard’s misstep with the serology tests “artificially lowers the state’s percentage of positive tests.” (Emails indicate that the dashboard’s errors stemming from the tests were due to the health department misclassifying them. “This is not a technical issue per se with the website,” Soetebier wrote to his health-department colleagues and Kemp’s chief management officer, Caylee Noggle.)
Amid the fresh wave of public rancor in the wake of the story, the health department’s Edison warned in an email the next day to Noggle that “by rushing through data analyses, we run the risk of making errors.” Edison proposed that a clarifying footnote be added to the dashboard. “It takes time to work through these complicated and far from perfect data.”
Four hours later, Edison sent Noggle and several other Kemp staffers a four-page data FAQ of sorts to post to the site. Balasubramanian, the governor’s technology advisor, forwarded the document to the SAS team with a request to post it to the website—but two minutes later, he walked that request back: “Hold on, don’t POST,” he wrote. “Please review and let me know if you have any suggestions.” (Kemp staffers later stripped almost all of the explanatory content from the data FAQ the health department team had written.)
At a May 21 press conference, Kemp addressed some of the public derision related to the dashboard. Citing his administration’s commitment to transparency and honesty, he praised Dr. Toomey and the health department: “They are taking massive amounts of data from all sources, putting them into accessible format under a global spotlight, all at breakneck speed,” he said. “Please afford them some patience, and please steer clear of personal attacks.”
But Kemp did not mention his own team’s role in creating much of the pressure the health department was under, nor the fact that some of the highest-profile mistakes had not been the health department’s errors at all.
“It’s a fair point that it could look like we’re ‘moving the goalposts’ . . .”
Emails also show that when health-department staffers sought potential fixes with SAS, their requests were not treated with a sense of urgency. In early June, Leslie Onyewuenyi, a newly hired interim director of informatics who was brought on to work above Soetebier and improve data quality at the health department, asked SAS’s Blackmon for a 30-minute call to review SAS’s quality-control process.
“I don’t believe that there is a need for a call unless [the health department’s] Karl [Soetebier] would like for us to convene,” Blackmon responded.
“We need a high level overview of process flow on your end,” Onyewuenyi wrote back. “Are there any quality control checks on your end before the data is published? The aim of this exercise is to reduce the risk of publishing inaccurate data whether from DPH side or from your end.”
After Onyewuenyi appeared not to get a response to this email or to a follow-up one he sent three days later reiterating his request, the governor’s planning and budget office intervened to set up a call between Onyewuenyi and Blackmon, noting that Blackmon was on vacation.
“We’ll respond on email first,” a SAS project manager wrote. “We can then follow-up as needed.”
At around the same time, Balasubramanian forwarded to SAS a media question that had been sent to the health department about a county map: Why was the threshold for a county to be shaded red—indicating the highest case rates in the state—changing from day to day?
SAS responded by forwarding an explanation from one of its systems engineers: “It’s a fair point that it could look like we’re ‘moving the goalposts’, it might be something we could revisit.” But the method behind the color-coding would remain unchanged until, more than a month later, a viral tweet pointed to it as an example of how the health department “is violating data visualization best practices in a way that’s hiding the severity of the outbreak.”
Trent Smith, a senior external communications specialist with SAS, responded to a series of Atlanta’s questions about its work on Georgia’s Covid-19 dashboard by stating: “We can’t share customer names without their permission.” Smith also wrote: “SAS has been used for decades in public-health departments, from local to state to national governments and is currently in all U.S. state health departments.”
As the health department was publicly battered for mistakes over which it had little control, its leadership was well aware of the need to improve the dashboard and the magnitude of the fallout from its problems. On the Fourth of July, after reviewing examples of other states’ data dashboards, Dr. Toomey asked health-department staff to request that the SAS team add certain metrics to the dashboard and noted the negative public perception of her agency: “I am getting complaints from the public as well as other officials that we are deliberately not being transparent.”
Some of the state’s public-health experts felt Georgians deserved Covid-19 analysis and insight beyond what the SAS dashboard ultimately offered, and they tried— unsuccessfully—to offer that info on the health department’s site.
Back in March, at the same time SAS began what would be a six-week effort to build its dashboard, a team from another government agency was creating other Covid-19 dashboards for internal use.
Susan Miller, who leads the Georgia Geospatial Information Office (GIO), began working on maps to assist other state agencies in allocating pandemic-related resources in March. Her team used a product made by the California-based company Esri. No other mapping platform on the market is as “comprehensive, holistic, or stable,” as Esri, she says. (Miller worked for the company as a product engineer in the early 2000s.)
In mid-April, the health department’s Edison asked Miller’s team to create a report aimed at providing the governor—and, possibly, the general public—with the data Georgians would need to decide when it was safe to reopen for business. She asked if these could take the same form as one of the internal dashboards the team already had created.
Once Miller’s team got started on the project, it took less than a week for a prototype to come together. The GIO’s Esri dashboard, compared with the SAS dashboard, had “increased functionality, such as ZIP code level data, death demographics by county/zip, and downloadable data,” wrote the health department’s Edison in an email to Miller and colleagues at other agencies on April 28, one day after the SAS dashboard launched. “I do not think the SAS Dashboard has the functionality that the ESRI one has and I think they can be used in tandem to complement each other.”
Esri’s software and the use of its consulting services weren’t free: The contract Miller’s parent agency signed with Esri’s Disaster Response Program in May totaled $265,000. But those dollars went toward Esri’s work on multiple mapping projects for a variety of agencies.
Health-department officials were hopeful about sharing the Esri dashboard on their agency’s website. “My goal is at a minimum to make this accessible from a link on the page,” Soetebier wrote on April 29 to health-department colleague Edison and staffers at GIO and Esri, “though we should be able to get a new page put together to properly house it.”
On May 13, Edison forwarded to Miller an announcement about a CDC partnership with Esri aimed at enabling all states—at no cost to them—to build or enhance data dashboards using the software. The next day, Edison exclaimed in an email to Miller, Soetebier, and an Esri employee: “We have some traction!” She wrote that two people from the governor’s office “are going to pitch the dashboard!”
But the Esri dashboard would not end up being included or even noted anywhere on the health department’s site. It was published on the GIO’s Covid-19 website, but it wasn’t publicized until Miller’s office published a blog post about it three months later, in mid-August—and even then, the existence of the dashboard remained largely unheralded for several more weeks.
Eventually, one government agency would find value in the multiple Esri dashboards Miller’s team had produced and published on GIO’s Covid-19 website. In September, GEMA replaced its daily Covid-19 situation report with that website, calling it “a one-stop shop for all of the data in a format that is more easily accessible.”
At the most concrete level, the problems with the state’s Covid-19 dashboard made it unreliable as a tool for Georgians simply trying to figure out how to safely go about their lives. As Georgia planned to reopen its doors for business in late spring, the health department fielded an onslaught of questions and complaints from people confused about how to interpret what they were seeing on the dashboard. The lead pastor at a church in Cobb County wrote for assistance understanding how rampant the virus was locally in the hopes of helping his church determine when to reopen for in-person worship. The assistant superintendent of a school district south of Seattle requested an explanation of conflicting case numbers in the hopes of advocating to reopen his own state; “I would like my state open, and Georgia serves as a bellwether,” he wrote. “Please explain the data so that I can advocate correctly and not put my community at risk.”
In the next three months, Georgians celebrated Memorial Day and the Fourth of July, and Governor Kemp squashed mayors’ efforts to enact local mask mandates and other protective measures. Also in that time, more than 155,000 Georgians were infected with the novel coronavirus, of whom 2,551 died.
Beginning in late July, the dashboard stopped attracting as much negative attention as it had early on. Although two public-health experts recently told Atlanta they would like to see additional data on the dashboard, such as case information by zip code and information related to school outbreaks, public outrage over the dashboard’s appearance has largely ebbed.
But public-health experts say the damage to the health department’s reputation caused by the dashboard’s pattern of problems may have lasting effects. In a statewide survey the health department conducted in late July, only 55 percent of respondents perceived the agency as credible. Amber Schmidtke, a volunteer advisor to the state’s Covid-19 Data Task Force who until recently was an assistant professor of microbiology at Mercer University in Macon, recalled several fumbled efforts at transparency on the state’s Covid dashboard, concluding: “So, yeah, I think it does harm people’s trust.”
Melanie Thompson, an Atlanta doctor and researcher who coauthored two July letters protesting Kemp’s handling of the pandemic that were signed by thousands of healthcare workers, says the contents of her inbox made the public’s loss of faith plain: “The emails and things that I got from a variety of people made me feel that there is no trust in the governor to do the right thing scientifically,” she says, “and that extends to the Department of Public Health, because [its] commissioner basically serves at the pleasure of the governor and does not contradict him at all.”
When public trust in an institution is sufficiently eroded, it can be hard to recover, says Joseph Cappella, a specialist in health communication at the University of Pennsylvania’s Annenberg School for Communication. “It’s the old idea of poisoning the well,” he says. When public-health institutions lose credibility as a consequence of one misstep, he says, the resulting lack of trust can impact their ability to effectively carry out other public-health activities, like vaccine distribution.
Clarity about who’s doing the work on state websites is important, too, says Laura Harker, a senior policy analyst at the Georgia Budget and Policy Institute. When a consulting company’s work is presented on an agency’s website, “having that made clear somewhere—at least the name on the bottom of who the outside contractor is, or some type of contact information for the data managers—is always, I think, important to have for transparency purposes,” she says.
The state of Georgia slashed the health department’s epidemiology budget during the lean years of the recession—from $6 million annually in 2009 to less than $4 million in 2011—and that budget was never fully restored. Georgia’s public-health funding lags well below the national average.
“People are thinking that public health has failed society,” says Dr. Madad, the New York City–based epidemiologist and preparedness expert. “No. Society has failed public health because we didn’t invest and see the value of it. And we’re seeing the consequences today.”
The early chaos of the Covid-19 dashboard shows how Georgia squandered the chance to shine a light on the merits and necessity of a public-health department, says Thompson. “This was an opportunity for DPH to shine, . . . to come into its own, and to really teach the public what public health is all about, to really engender trust.”
On April 28, the day after the SAS dashboard launched, health-department epidemiologist Edison and GIO head Miller exchanged emails about the difficulty of getting the best Covid-19 data to the public and the need for a more collaborative effort among government agencies. “My head is spinning,” Edison wrote. “I just want to share the damn data.”
Miller responded: “We can either feed the real data to Georgians, the country and the world . . . or let them fend for themselves. . . . I will back you on getting the data out until the end of time!!!!”
TJ Muehleman is from Texas, but he has family in Louisiana, lived in Georgia for years, and now resides in Seattle. In the early days of the COVID-19 pandemic, he began to notice big differences in the ways data was presented by each of the states he’s called home. And he noticed something else about Georgia’s data in particular: it was a mess.
As co-founder of Standard Co, a company that builds public health data visualization platforms, it’s Muehleman’s job to find areas for improvement in charts and graphs. But the problems with the Georgia Department of Health’s data dashboard seemed particularly dangerous, he says, because of the life-and-death decisions business owners and others were making based on the data presented.
As a side project, Muehleman created the Covid Mapping Project, a website that displays simple charts describing the same key metrics from each state. And as he’s watched each of Georgia’s widely reported data fiascos play out, he has had increasing opportunity to reflect on the cause. “I don’t think anything nefarious is happening,” he says. “I just don’t think they know what they’re doing.”
That was his reaction last week, when a bewildering chart displaying county-level data in nonchronological order elicited widespreadjeering. The chart in question showed case totals arranged from highest to lowest; Muehleman speculates that “somebody, somewhere, said, I want to know what have been the worst days in the past month” and that graphic was the result. The chart was quickly revised to reflect chronological order, and a spokesperson for Governor Brian Kemp acknowledged the visual was problematic and apologized. But the state’s website was again pilloried on Wednesday after the Columbus Ledger-Enquirer reported the total testing numbers it displayed mixed tests for the virus and antibody tests, artificially lowering Georgia’s positive test rate. Combining these two tests in figures has been an issue in several states—even the CDC has followed the practice, although the agency also recently announced it would stop doing so.
Communicating clear, easy to read data to the public is perhaps one of the most pervasive problems during the COVID-19 pandemic. “You have a lot of very smart people producing really neat visualizations that other professionals might understand,” Muehleman says, “but the general public is like, What the hell am I looking at? I just want to know if it’s getting better or worse.”
But it’s not that easy to tell—at least, not in real time. As governments worldwide wrangle data in an effort to thoughtfully re-open economies, they all must reckon with an intrinsic quality of the COVID-19 outbreak: because it takes so long for a single person to go from getting infected to being counted by the state where they live, there’s no great way to know the pandemic’s immediate trajectory. But data scientists say there are good and bad ways to forecast the pandemic’s path, share the data they use—and, as that much-maligned chart demonstrated—clearly communicate how they use information to make critical decisions.
Not all of Georgia’s data problems are man-made; no matter who is making public health policy, a number of days will inevitably elapse between the time a person becomes infected with the coronavirus and the time their infection turns up on a health department’s website. To start, there’s the period between the moment a viral particle enters someone’s body and the moment they first start feeling sick, which usually takes around five days but can take as long as two weeks. Once a person starts feeling sick, it could take days before they are tested for COVID-19, then additional days for the test to actually be processed at a laboratory. The laboratory must then communicate the result to the state (more days) before the state can include that person’s infection in its counts.
When the state is finally notified about a COVID-19-infection, it adds the case to the numbers it displays on the dashboard using the date the infected person first felt sick. That means “new” cases usually show up as occurring several weeks in the past, before the state was notified. (There are exceptions: if the state receives a case report that’s missing the date of symptom onset, it instead substitutes the test date or the date they received the result.) So today’s case counts are the lowest point of a rolling wave that won’t crest until it’s well out of reach, which could give the public a false sense of security.
Georgia denotes this time lag is an unreliable basis for decisions by displaying newer data as dots rather than a line on its chart of daily case counts. But that’s probably not enough to prevent observers from becoming confused, says Muehleman: “until we shorten that time lag, onset is a problematic indicator to the general public,” even if it is a useful one for health officials, he says.
While the data will never be perfect and the data lag cannot be completely eliminated, there are better ways to communicate uncertainty, convey what we do know, and do most other things the cluttered and confusing Georgia dashboard attempts to do, Muehleman says. He points to Louisiana’s data dashboard, where a chart tracking new cases only displays data more than 12 days old. He also likes Alabama’s, which lists positive cases by the day their test result was confirmed, shortening its data lag.
J.C. Bradbury, an economist and data analyst at Kennesaw State University, sees additional problems with Georgia’s dashboard. Among his frustrations is that the most useful data isn’t all reported in the same place. “The governor keeps mentioning the number of people currently hospitalized” with COVID-19, he says, a metric that to him seems like a promising indicator of current disease prevalence. (That number recently went below 1,000 for the first time since the first surge of cases.) But that figure is published by the Georgia Emergency Management Agency (GEMA) in a PDF document under the “Situation Report” section of the agency’s coronavirus site—not on the health department’s dashboard. That metric should be front and center among the data the health department shares, says Bradbury.
Another key change both Bradbury and Muehleman would like to see on the state’s dashboard is more information on each case included in the downloadable raw data set that they and other scientists use to understand pandemic dynamics in Georgia, including the date each person who tested positive was suspected to have been exposed, the date each case sample was obtained, and the date each test was run. They also wish the state would prominently display the number of newly confirmed cases each day, much the way the Atlanta Journal-Constitution’s data dashboard does—they both calculate this figure independently using the state’s raw data because it is subject to less data lag than the existing metrics displayed.
In addition to running his own calculations, Muehleman also makes daily visits to the Covid Tracking Project, a volunteer-run website created by The Atlantic magazine.
There are other data sources that may emerge as useful indicators of real-time COVID-19 prevalence in the future—such as where fevers are reported (measured by smart thermometers) or flu-like symptoms (reported by doctors)—but none of these have yet been established as reliable indicators of whether the pandemic is getting better or worse at any given moment.
In the month since Carrollton was shut down to prevent the spread of COVID-19, the volume at Jerry’s Country Kitchen has shrunk to less than a quarter of its usual business. Brock Eady took over the breakfast-and-lunch place from his dad about 30 years ago. He’s still paying his five employees, but is just about broke. “I’m just trying to make payroll Friday,” he says. “But we may not be able to buy food to sell.”
A few days ago, he watched at home as Governor Brian Kemp announced his plan to reopen Georgia businesses. When the governor said, “I don’t give a damn about politics right now,” Eady rewound the video so he could post a recording to Facebook.
“I’m thankful that he wants us to go back to work,” he says. “I don’t have the answer if it’s safe or not.”
Others felt considerably more certain. The mayors of several Georgia cities, including Atlanta’s, expressedconcern about the order’s wisdom and encouraged their citizens to stay home. Throngs of Atlanta restaurateurs announced their intentions to stay closed. Publichealthcognoscenti and nationalmedia broadly condemned the decision.
Kemp said “favorable data, enhanced testing, and approval of our health care professionals” drove his decision to authorize the reopening of fitness centers, bowling alleys, body art studios, hairdressers, nail salons, massage therapists, and other personal service providers as early as Friday, April 24. (Dine-in restaurants and theaters will be allowed to reopen on Monday, April 27 under specific social distancing and sanitation conditions.)
But the existing data isn’t enough to ground such a critical decision, says Joshua Weitz, a quantitative biologist at Georgia Tech who specializes in disease dynamics. “It’s not just about looking at a number in a reported case count and saying, ‘Well, that looks flat enough that we can open up,’” he says; a better way is to consider whether current conditions allow a sustained downward curve—and if they don’t, to create better conditions.
There’s no playbook to guide leaders making the wrenching decisions they now must make: their choice is between subjecting their electorates to generational economic pain or to a plague of near-biblical proportions. Kemp’s decision suggests his priority is to salve financial wounds first—and with the kind of haste public health experts say will cost unnecessary lives.
To Kemp’s critics, the shape of Georgia’s epidemic curve is one of the greatest sources of concern. Each day, the state’s health department publishes a chart detailing the confirmed cases of COVID-19 by the date of illness onset. At first glance, the chart seems to show a downward trend in cases over the most recent week or so—but that trend doesn’t reflect reality.
It often takes days for new infections to be included in that chart, in part because people often have a fever or cough for days before getting tested for the virus causing COVID-19. Additionally, the way tests get reported to the health department can delay their inclusion in official case counts.
As a consequence of these reporting lags, what looks like a small number of cases today will grow substantially over the next week as new reports trickle in from around the state. These delays apply to COVID-19 death trends, too—a recent analysis suggested that on April 20, deaths attributed to COVID-19 were still being added to daily totals as far back as April 3.
So while Kemp said the virus is “on the downward trend,” daily case counts and fatalities have actually remained steady for the last few weeks, says Weitz. Even if there were clear evidence that Georgia had passed one peak, he says, “there’s no epidemiological rule that says there can only be one peak in an epidemic.” In diseases like COVID-19, cases can resurge or plateau after a peak—and human choices play an enormous role in the direction the curve takes.
“To those who see a trend, keep in mind that the trend is us,” says Weitz. “It’s our behavior that has led to the decrease, and if we change the behavior, there is a very high risk that there will be an increase.”
The way to avoid that increase is to build testing, tracing, and treatment infrastructure before changing our behavior. “In Georgia,” says Weitz, “almost all of us are susceptible to infection”—but survivors of COVID-19 may be less likely to become sick and contagious if they are re-exposed, potentially making them better candidates to re-enter the workforce sooner. Although scientists still have many unanswered questions about COVID-19 immunity, Weitz feels widespread testing for immunity should be a cornerstone of a successful reopening strategy.
Also important would be a strategy to identify, quarantine, and test contacts of known COVID-19 cases, known to public health authorities as “contact tracing.” This tool is critical for identifying the remaining disease hotspots once transmission rates trend downward, says Jeff Engel, executive director of the Council of State and Territorial Epidemiologists. But before attempting a contact tracing effort, states need to have “manageable” numbers of cases, says Engel—“maybe a hundred infected people for each person available to do the work. With Georgia lately averaging about 6,500 actively infected individuals on any given day, the workforce it would need to effectively trace contacts would be in the hundreds. It is unclear what progress the state has made toward this goal.
Weitz acknowledges the severe economic pressure created by the pandemic, and says the solution to those pressures is not to prematurely reopen businesses, but to provide financial aid directly to the people who are hardest hit—a process that has been delayed at the federal level. Furthermore, he said, businesses that do reopen need resources and information to help them keep employees and patrons safe. “Have they given that small business owner masks?” he asks. “Have they given the option to have at-will testing, especially for customer-facing staff? Have they given them advice on airflow?”
On Wednesday, Eady prepared to read a ten-page Georgia Chamber of Commerce document on the minimum basic operations needed to safely reopen a business; seven of its pages comprised the text of Kemp’s executive order. He’d bought his 83-year-old mother face masks at the Home Depot—she’s the “Jerry” in the restaurant’s name, and still works there almost every day. She hasn’t been wearing them.
He says he doesn’t know anyone who’s had severe health effects due to the virus, and isn’t sure what it would change if he did. “It would probably make me leery,” he says, “but the fact is, my doors have to be open.”
“My decision would still be, open this place up. Because it’s all I got.”
When area medical practices started to close down in early March due to COVID-19 concerns, Adrienne Clark, a registered nurse, got on the phone with her friends in the healthcare business. She asked if any of them had extra throat swabs and viral culture media, the nutrient-rich liquid needed to keep a virus alive during transport to a testing lab.
“They were like, ‘Oh yeah, we do—why?,’” she says. She explained those relatively common materials were all that was needed to test for COVID-19. But many providers were either unaware of the simplicity of sample collection or unwilling to do the testing in their office, and the supplies were languishing in supply closets unused. Now, many of them have been donated to Clark’s concierge medical practice, Qualified Quacks LLC. Clark sees between 10 and 15 people a day in the course of the house calls she makes on a fee-for-service basis; beginning this week, she has swabbed four to five symptomatic people a day for COVID-19, sending their samples to a Quest lab for testing. “Evaluating doesn’t mean you’re necessarily going to get swabbed, but we will evaluate anyone—and that’s one of the things that doing house calls allows us to do,” she says.
To avoid overwhelming labs, Clark and other Georgia providers are deploying the test carefully, using it only when it can guide treatment and quarantine precautions. That’s a different approach to testing than most Americans are used to—and a different approach than other states are taking—but really, everything in the last two weeks has been different than what most Americans are used to. As a result of our collective crash course in public health, most of us now know what “social distancing” means, and the conversational use of “contact tracing” may be at an all-time high. And a large number of people now understand that widespread testing for COVID-19 is something we don’t have—but should have had for a while.
Testing for the microbe at the heart of an infectious epidemic is a critical part of reducing that microbe’s damage. When public health officials know who’s infected and who isn’t, they don’t have to guess at who needs quarantining. Sure, they can just tell the entire population of a city or state to quarantine themselves—and in many cases, they have—but if you’ve seen the videos of spring breakers crowding Florida beaches, you know that’s often ineffective. Testing gives quarantine instructions weight and authority.
Testing also gives doctors and scientists a lot of information about how a germ behaves within a certain group of people. Imagine that a certain microbe makes 50 of a city’s residents pretty sick, but we know 100,000 residents have been infected—we’d worry a little bit, but we probably wouldn’t cancel life as we know it. However, if we knew that only 100 residents had been infected, we’d react with much greater concern. Without widespread testing, it’s hard to know how to react.
Based on data from countries where testing has been more robust, we know we need to worry about COVID-19. However, because differences between countries’ populations and health care systems might be related to how lethal the disease is, it would be extremely useful to know how lethal the disease has been in this country specifically.
Still, testing for COVID-19 remains unevenly distributed throughout the U.S. and relatively scarce in Georgia. The reasons are complicated: early on, there were problems with a test developed by the Centers for Disease Control and Prevention (CDC). Over the weeks it took to solve those problems, bureaucratic bottlenecks at the Food and Drug Administration caused delays in developing other versions of the test. And while many private companies are now developing several versions of a COVID-19 test and even deployingthem broadly within certain localities, the materials they need to scale up production and use of those tests have been in low supply due to high demand worldwide.
Emory University’s laboratory is among many nationwide that have a working COVID-19 test of their own. And while the state health department is reportedly working on a partnership with the university that could expand testing, there may be practical obstacles to overcome: on March 14th, an Emory scientist tweeted a list of supplies his lab would need to conduct COVID-19 testing. Message directly if you can help, he wrote, “and I’ll set you up with contact point.”
It is unclear why state and local public health officials are not scaling up distribution of these tests on a large scale, although the general lack of government resources to handle the scale of the current response probably has something to do with it. Lauren Bricks, COO of the Sandy Springs-based Ipsum Diagnostics, says her lab has developed the capacity to do 1,000 to 1,200 COVID-19 tests per day and on Friday applied for emergency use authorization from the FDA. However, calls to the state public health department, the mayor’s office, and the governor’s office to offer her lab’s capacity have gone unanswered. “I do want to believe that it’s because they’re so overwhelmed,” says Bricks.
In the case of COVID-19, testing does not actually guide treatment—and implementing widespread testing efforts consumes money and manpower while also increasing the risk of transmission to the healthcare workers performing the test and other people sharing the same space. The suspected density of cases in any area helps determine the testing strategy local public health officials design. Friday, for example, in New York City, where there are more than 5,000 confirmed COVID-19 cases, public health officials released guidance discouraging testing people unless they are sick and hospitalized, suggesting that in situations of wide local spread of the virus, public health authorities are pivoting away from testing. The same day, however, the Georgia Department of Health dispatched a team of epidemiologists to investigate a cluster of COVID-19 deaths in Albany, suggesting state and local public health officials think there is still potential to curtail local spread.
At press time for this article, about 170,000 COVID-19 tests had been conducted in the U.S. Other countries scaled up at a much higher clip: South Korea, for example, has tested more than 270,000 people since February, despite having a population one-seventh our size. More than 120 other countries have been testing thousands of people each day using a test developed for the World Health Organization, and while the U.S. could have saved weeks of dithering and delay by adopting this test up front—or even by switching to this test when the delays became evident—it did not. (Although the reasons for that are unclear, they may be largely political.)
Currently, between the CDC and state public health labs nationwide, about 3-5,000 tests are being done every day. Private, commercial labs are scaling up testing, too: LabCorp has announced it now has the capacity to perform 20,000 tests daily across three labs nationwide, and Quest expects to achieve this capacity, also spread across three labs, by next week. More than 3,000 tests have been done so far in Georgia, about 2,300 of them in a commercial lab.
In the meantime, Georgia’s public health officials have asked clinicians to reserve the test for those most vulnerable to severe illness in the event of an infection (such as elderly people and people with chronic underlying health conditions), those at risk of spreading the infection to vulnerable people (like healthcare workers and first responders), and hospitalized people.
Unlike many other tests healthcare providers order, the nasal swab needed to test for COVID-19 isn’t collected at an outpatient lab—it’s collected either in a clinic or, as of this week, at one of 18 drive-through specimen collection sites around the state, where people prioritized for testing could get swabbed for testing using one of hundreds of LabCorp and Quest kits reportedly purchased by the state. People will only be tested at these drive-through sites if they’ve been prescreened by a healthcare provider and have a referral.
The Georgia Department of Health has encouraged people with mild cold symptoms to isolate themselves at home until their symptoms go away. However, people with more severe symptoms should call their doctors or an urgent care center, where staff can determine whether the next steps should involve testing for COVID-19, the flu, or other common infections.
“The world is upside down right now,” said Keiran Neely, operator of the 175-person Music Room, speaking while on his way to a meeting with his landlord on Friday afternoon. “I’m not going to be able to pay the rent,” he said. “We’re in the business of creating large gatherings, and the messaging we’re receiving is that people should not be attending large gatherings.”
Over the next few days, Neely will be experimenting with live-streaming DJ sets. He’s not closing the venue yet, but he feels the pressure to shut its doors: this weekend is an experiment, he said, “to see whether people are brave enough to go out and dance.”
On Thursday and Friday, after a few days of what felt like an extended exercise in breath-holding, much of Atlanta got canceled.
It started with a trickle—Tuesday’s Fulton County public school closures following an employee’s positive test for infection with the COVID-19 virus; the NCAA’s Wednesday announcement it would play its much-anticipated men’s Final Four games, scheduled for early April at Mercedes-Benz Stadium, without fans (it later canceled the event altogether).
“It’s not an overreaction,” says Benjamin Lopman, an epidemiology professor at Emory’s Rollins School of Public Health. “As there’s more and more people who are infected in the community, the risk becomes higher,” he says, “so as things move along, it makes sense to be more aggressive.”
Canceling crowds is not a new public health trick, but it’s an effective one. During the 1918 Spanish Flu pandemic, cities that closed gathering places like schools, churches, and theaters had about half the peak death rates of cities that didn’t. “Proactive approaches are going to be more effective at slowing transmission,” says Lopman.
Upon reaching the point where there are thousands of infections circulating in the community, the chance that someone at a 10,000-person event will be infected increases sharply. Josh Weitz, a Georgia Tech biology professor who models viral dynamics in populations, recently tweeted a chart demonstrating the risk of encountering a COVID-19-infected person at an event as crowd size and the virus’ prevalence increase. “Take-away point: serious questions should be asked soon about policies for holding large-scale events,” he wrote.
Take-away point: serious questions should be asked soon about policies for holding large-scale events (and even certain small-scale events depending on locality) that minimize risk for all and preserve public health resources for those who need it most.
Georgia’s numbers of confirmed COVID-19 infections might seem so low as to be negligible: 45 people out of the state’s 10.5 million doesn’t sound like many. But because access to testing is so profoundly limited in the U.S., the number of cases we know about is probably just the tip of a very large iceberg. In Washington state, where 457 cases have been reported, viral dynamic modeling has suggested the actual number of cases is at least twice as high and will double every 6 days.
To date, neither the Centers for Disease Control and Prevention nor the Georgia Department of Public Health have recommended canceling mass gatherings. Georgia’s elected officials have not made formal statements on the subject, although the Atlanta Journal-Constitution reports city mayor Keisha Lance Bottoms is in discussions with Governor Kemp about issuing a ban on large events. [Editor’s Note: On March 15, the CDC recommended postponing and canceling gatherings of more than 50 people for the next 8 weeks. Bottoms signed an order to prohibit gatherings of more than 250 people, but noted on Twitter that in light of the CDC’s recommendation, her administration would “continue toevaluate and adjust our policies accordingly.“)
Georgia currently has 45 confirmed cases of COVID-19 infection. States with fewer cases have been more proactive about crowd control: In a press conference Thursday, Florida Governor Ron DeSantis recommended postponing large-scale events, according to local reports; 31 cases have been reported in that state. Governor Mike DeWine of Ohio, where five cases of COVID-19 infection have been confirmed, announced Thursday that gatherings of more than 100 people would be prohibited.
The goal of canceling large events isn’t to stop transmission entirely—most public health officials agree that’s impossible—but to slow it down to reduce the chance a surge in infections will overwhelm an already-strained healthcare system.
“We’re at a turning point in the response to this epidemic,” said Lopman. He’s been following the accounts of healthcare workers in Northern Italy, where more than 100 deaths each day are being reported from COVID-19 infection, and where hospital intensive care units and healthcare workers have been overwhelmed.
The infection is highly transmissible, likely to be severe in many adults, and likely to be new to almost everyone’s immune system, he said. “Public health is not overplaying its hand.”
Right now, Dr. Carlos del Rio is more worried about driving in this city than he is about getting COVID-19. “Accidents on the Connector are more common than any coronavirus I know at this point in time in Atlanta,” said the Emory University infectious disease doctor during a recent morning rush hour. Currently, a handful of COVID-19 cases have been identified in the metro area, most linked to recent travel—but it’s likely Georgia will see more cases. Below, we’ve gathered some information, including top tips from Dr. del Rio, on how to prepare yourself and your family. [Editor’s note: This story was initially published on March 6; the amount of cases in Georgia has since grown to more than 100.]
Should I wear a mask? Seeing healthcare personnel suit up in personal protective equipment to transport patients with COVID-19 makes people wonder if they, too, need full-body Tyvek to avoid infection. They do not. People providing direct care to infected and seriously ill patients get exposed to large amounts of virus-loaded respiratory droplets and then have close contact with other uninfected but vulnerable patients, so they need a much higher level of protection than people who might pick up the virus through casual contact.
“We need to do a lot of handwashing,” says del Rio, to protect from this and most other respiratory illnesses. Wash your hands when you think they’re dirty or when you’ve been in public places, around children, in bathrooms, or anywhere else your hands may have touched surfaces others have touched. Twenty seconds with warm water, soap, and a catchy tune does the job, and you can use any soap—it doesn’t have to be branded as “antibacterial.”
Alcohol-based hand sanitizers are great for convenience, but are not otherwise superior to handwashing. If you haven’t stocked up and shelves near you are empty, you can make your own at home using other widely available ingredients and the World Health Organization’s recipe. And remember that if your hands are visibly soiled or very greasy, sanitizer won’t work—you’ll need to wash with soap and water.
As for face masks, healthcare personnel use two types: surgical masks to prevent their own germs from reaching patients, and N95 masks to prevent themselves from catching patients’ germs. If you are sick but need to go to the store for milk, says del Rio, a surgical mask is a public kindness; but N95 masks are a different story. To work at all, they need to be individually fit-tested to the user’s face to ensure no air flows around the sides of the mask. Because of that fit, they’re stifling to have on and cannot be worn for long periods of time.
Additionally, N95 masks are critically important for people providing direct care to patients. If healthcare providers get infected with a COVID-19 patient’s germs, not only could they infect other patients, but they would have to stay out of work for at least two weeks, further straining an already-overburdened healthcare system. So don’t hoard masks, especially N95s.
Do I need to stay home even if I’m not sick? Because older adults and people with chronic medical conditions are at higher risk for more serious illness with COVID-19 infection, the CDC has now recommended people in these risk groups stay home as much as possible and avoid crowds. [Editor’s Note: Since the publication of this story, many large gatherings including the NCAA tournament, MLS, MLB, and NBA games have been canceled or postponed, schools and universities closed, and some offices have implemented work-from-home polities. Social distancing is strongly encouraged and Mayor Keisha Lance Bottoms has prohibited gatherings of more than 50 people. Follow local guidelines and stay home if you feel ill—see below for more on what to do if you feel sick.]
How is COVID-19 transmitted? The virus that causes COVID-19 is part of the family of coronaviruses, which cause 10 to 30 percent of common colds. Like other coronaviruses, it’s spread by breathing in droplets from an infected person’s cough or sneeze. But it’s also transmitted when those droplets land on surfaces; if an infected person sneezes into their hand then touches a doorknob, the person who touches that doorknob next could easily get viral particles on their hands, making it easy to introduce into their respiratory tract by rubbing their eyes or touching their nose or mouth.
One of the best ways to protect yourself is to avoid touching your face. “It’s not going to go in through your skin,” says del Rio. “After you touch that doorknob, if you don’t touch your face, you’re not going to get contaminated.”
Can the coronavirus live on surfaces? We don’t yet know exactly how long this particular virus hangs around on surfaces, so it’s also a good idea to clean that doorknob on a regular basis. Research on other coronaviruses suggests that while they can stay on metal, glass, or plastic for over a week, they usually persist for closer to half a day. The good news is that the COVID-19 virus is a relatively delicate organism, making it easy to remove from surfaces with common household cleaners such as diluted household bleach solutions, alcohol solutions with at least 70 percent alcohol, and most common EPA-registered household disinfectants. If you’re cleaning after sharing space with someone who might be sick, focus on high-touch surfaces, including tables, hard-backed chairs, doorknobs, light switches, remotes, handles, desks, toilets, and sinks.
What should I do if I might be infected? If you develop fever and a dry cough after recent travel or contact with a sick person who traveled recently to a place where COVID-19 is spreading, call your doctor. If you don’t have a doctor, reach out to an urgent care center. Either way, call in advance rather than appearing unannounced at the clinic, where you might infect other patients and staff. You might not need testing; but if you do, the samples will need to be gathered at a healthcare provider’s office and sent to CDC.
Will testing be expensive? In Georgia, COVID-19 tests are currently being done at CDC and the Georgia Public Health Laboratory, and they do not cost anything to the people who are tested. However, testing should soon be more widely available, as several commerciallaboratories have also developed COVID-19 tests.
America’s Health Insurance Plans, a lobbying organization that represents some of the nation’s biggest insurers—including Georgia’s largest, Anthem Blue Cross Blue Shield—today released a statement indicating it would provide coverage for coronavirus tests ordered by physicians, and that insurers may waive out-of-pocket costs for testing. Check with your insurance plan to determine what your individual policy will cover.
What are state officials doing to prepare now that the virus is here? The Georgia Department of Public Health is adapting its pandemic flu plan to prepare in case of COVID-19 spread and has epidemiologists on call to help health care providers evaluate people with symptoms. Passenger screening is underway at Hartsfield-Jackson Atlanta International Airport. If needed, the health department may recommend measures to reduce community spread, like school and child care closures and postponement or cancellation of mass gatherings. But in Atlanta, we’re not there yet. Keep an eye on the state’s COVID-19 website for updates. [Editor’s note: Many metro Atlanta schools have since announced closures, including Cobb, Fulton, DeKalb, Decatur, and APS. Please check with your local school system for updates.]
If the health department does recommend reduced social contact, it will be much less painful if you’ve done some prep work. That means having three days’ worth of shelf-stable food and water in the house: “You don’t need to go to Costco and buy the entire store,” says del Rio. “This is not nuclear catastrophe.” It is also worth having a month’s supply of medications you or your pets take regularly at home. The CDC maintains a robust disaster preparedness checklist that works well for epidemic preparation. [Editor’s note: Since publication of this story, the CDC is strongly encouraging social distancing. Based on CDC recommendations, the mayor has prohibited gatherings of more than 50 people.]
And an important note: One more thing, says del Rio: Take care not to hold entire ethnicities and nationalities responsible for infections like COVID-19. He loves something CDC director Robert Redfield recently said: “Stigma is the enemy of public health.” Although COVID-19 might have originated in China, Chinese food and products cannot transmit the virus, says del Rio. Unfortunately, the AJC reported recently that business at local Chinese restaurants has been depressed, likely due to coronavirus anxiety.
Hell yeah, he’d go eat on Buford Highway, del Rio says. “My biggest concern,” he noted, “would be trying to get there and driving and having an accident.”
In southeast Atlanta, a newly designated city park is set to become the nation’s largest food forest—a place where volunteers tend crops of fruits, vegetables, nuts, and herbs, much of which is available to the public for free. The Urban Food Forest at Browns Mill occupies a seven-acre plot where husband and wife Willie and Ruby Morgan once kept a farm; the couple often left surplus produce in bags on neighbors’ fence posts.
In the mid-2000s, developers bought the Morgan property—but the planned townhouses never materialized. Instead, the Conservation Fund purchased the plot in 2016 to preserve the greenspace and pass it on to the city’s parks department, which will help with the group effort to transform the land into a space to feed, educate, and engage the community.
The surrounding Browns Mill Park and Lakewood neighborhoods are U.S. Department of Agriculture–designated food deserts (places with limited access to affordable and nutritious food), and southeast Atlanta as a whole has seen little of the recent investment in the city’s urban core, says Soisette Lumpkin, who leads the Friends of the Forest community group. “The Food Forest not only brings food but brings life to the area,” Lumpkin says.
Below is a glimpse of the crops, plants, and people who form the crux of the forest and its mission.
Mullein and cardoon
. . . or how to heal with herbs
Celeste Lomax, the park’s community organizer, oversees the forest’s medicinal herb garden. “There’s healing in herbs,” she says; her favorite is mullein, thought by herbalists to ease respiratory conditions like asthma, which disproportionately affects south Atlanta residents. Lumpkin says that offering access to the plants used in ancestral healing practices sends a message to the community about the park’s purpose: “The Food Forest is not just a garden,” she says. “It’s a holistic approach to health.”
Figs, nectarines, plums, and pawpaws
. . . or how to teach others to grow
Some of the Food Forest’s hundreds of fruit trees were planted in the past year by students from nearby elementary schools. It will be several years before the trees bear fruit, but eventually, they will yield thousands of pounds of figs, nectarines, plums, apples, pears, pomegranates, cherries, and native pawpaws, which taste like banana custard with hints of mango and cantaloupe. The forest also houses beehives and newly sown mushroom beds, which provide additional educational opportunities. “For many of these kids, it’s their first time interacting with a fruit or vegetable in the ground,” says Michael McCord, the food forest’s ranger and a staff member at Trees Atlanta.
Corn and collards
. . . or how to feed the neighbors
Corn, collard greens, and other vegetables are already growing in the community garden, where Doug Hardeman and Rosemary Griffin, who live nearby, volunteer nearly every day. For now, the harvest is distributed among volunteers and neighbors. Later, produce may be distributed to neighborhood food pantries.
Pecans and black walnuts
. . . or how to honor the original farmers
“The piece of the Morgans we’re trying to replicate is that willingness to share with your neighbor,” says Shannon Lee, the Conservation Fund’s urban conservation manager. The family’s legacy lives on in more than one way; there are dozens of mature pecan, black walnut, and mulberry trees across the property that date back at least to the Morgans’ ownership, including four giant pecan trees near what’s now the picnic table area.
Butterfly milkweed and echinacea
. . . or how to engage the community
Designing the greenspace was a group effort driven largely by the Browns Mill Community Association. Lead designer Lindsey Mann’s job, she says, was to “distill what it was the community wanted and then draw it up into a plan.” Among the community’s desires was a garden to memorialize ancestors, to be planted near the park’s East Rhinehill Road border. It will bloom with wildflowers and pollinators, including milkweed, echinacea, and other flowers, that attract insects such as bees and butterflies, which help propagate future generations of plants. “Flowers are good medicine for the emotional heart,” Mann says.
Worn by anyone else, white cotton flour sacks printed with the “Fulton Seamless” logo might not have been particularly clever costumes. But when Jake Elsas’s parents wore them to a party sometime in the early 1970s, they were a hit: his great-great-grandfather, the original Jacob Elsas, was the founder of the Fulton Bag and Cotton Mill—which produced the sacks—and built the neat shotgun houses of Cabbagetown to accommodate his workers nearby. Although the Elsas family sold the mill in the late 1950s, both it and the neighborhood remained a strong part of the family’s identity—and, at least as late as Jake’s childhood, an occasional source of self-referential fashion.
Flour sacks weren’t the only mill relics the family held on to. Now, photos and artifacts from the Elsas family’s collective archives, along with art made by and about Cabbagetown, are on display at the Patch Works, a neighborhood art and history center opened by Jake and his wife, Nina, who has a degree in art history.
Growing up in a variety of well-heeled Atlanta neighborhoods, Jake knew Cabbagetown as a tightly knit community where people took care of each other with a irrepressible and noisy pride. He says he drank lemonade at annual reunions while displaced old-timers made music on porches of their former neighbors, who themselves tried to negotiate neighborhood revitalization projects with the City of Atlanta. The mill’s gradual closure between 1974 and 1981 greatly depressed the neighborhood and the mostly white, Appalachian mill workers who had lived there, and Cabbagetown began to gentrify in the 1980s. Jake’s father chaired the board of the Patch, a socioeconomic assistance organization founded by Esther Lefever that provided arts programs and other education for laid-off mill workers and functioned as a drop-in center for neighborhood kids.
After spending most of his adulthood outside of Atlanta, Jake returned in 2012 to care for his ailing father. When he visited Cabbagetown, he hardly recognized the neighborhood: “It suddenly dawned on me that a lot of what I understood Cabbagetown to be was in danger of being lost forever with these waves of outsiders and gentrification,” he says. What worried him most was how little new residents knew about the neighborhood’s history.
He bought one of the lofts in the Stacks, the residential development built on the mill’s ruins at the turn of the 21st century. When his home was featured on a 2013 loft tour, he used the space to showcase mill-related ephemera from his father’s archives. Family members caught wind of the exhibit and offered to empty their attics into his collection. For a while his loft was “basically an art museum,” he says.
The mushrooming assemblage needed more space. In 2015, he and Nina moved it to a space on Carroll Street previously occupied by a tattoo parlor and named it the Patch Works in homage to the organization his father had helped lead. It was a trial run, Jake says, for a more permanent location, which opened in December 2017 in a blue house on the corner of Gaskill and Carroll Streets. Next door is the lot where the Patch once stood, now the Agave restaurant. Jake and Nina have been self-funding the museum and launched a GoFundMe in January that has since raised a little over $3,000. They hope to eventually secure 501(c)(3) nonprofit status, which would make them more eligible for grants.
The museum has three distinct spaces: the entry room contains mill-related displays, including a table of cogs, bobbins, and scale models of mill buildings. Two other rooms showcase Cabbagetown art, including works by street artist Donna Howells (aka 70dot) and the late photographer and artist Panorama Ray, along with rotating exhibits, such as one featuring the music of Cabbagetown folk singer and activist Joyce Brookshire, who died in 2017. The space also hosts monthly acoustic concerts and bagel pop-ups several Sundays a month with Emerald City Bagels.
When people leave the museum, Jake hopes they will have a better understanding of the neighborhood’s contribution to Atlanta’s economic development after the Civil War, and the ferocious pride its residents once took in their unwavering support for each other. 593 Gaskill Street; Open Tuesday and Thursday 12-6 p.m., Friday and Saturday 1-7 p.m., Sunday 9 a.m.-3 p.m.
Since 1961, Atlanta magazine, the city’s premier general interest publication, has served as the authority on Atlanta, providing its readers with a mix of long-form nonfiction, lively lifestyle coverage, in-depth service journalism, and literary essays, columns, and profiles.