COVID-19 took more than 8,000 SC lives. What could officials have done differently?
A year ago, South Carolina entered a battle not only with an emerging, sometimes deadly virus, but also with human psychology and politics.
As the coronavirus raged in three major waves across the state, health officials, the governor and the Legislature engaged in a tough balancing act, South Carolina health experts said.
If the state focused too much on restrictions, it would have a negative impact on the economy. If enough restrictions were not imposed, they would not help slow down the progression of COVID-19.
And the longer the pandemic stretched, the more “COVID-19 fatigue” people would face, and they would stop strictly practicing safety measures like social distancing, staying home and avoiding crowds. And health officials had to consider all this while battling a wave of misinformation from the country’s highest levels.
“We made societal choices based on what we thought was the right thing,” said Danielle Scheurer, a professor with the Medical University of South Carolina’s school of medicine.
“If we really just wanted COVID (cases) to go down, there’s no question that we could have enacted a bunch of legislative policies to make it go down,” Scheurer added. “But the next question is at what cost.”
Statistics are one way of measuring the pandemic response.
More than 8,600 have died from COVID-19 in South Carolina, where nearly 500,000 cases have been reported as of Thursday, according to DHEC’s estimates for confirmed and probable cases and deaths resulting from the coronavirus.
South Carolina ranks 18th in the nation for death rate with 167 deaths per 100,000 residents, according to an analysis as of March 3 published in the Becker Hospital Review.
While some say the human cost could have been curbed, others say what the state avoided in terms of financial calamity may be a reasonable trade-off.
One of the biggest stalwarts of shielding the economy through the pandemic was S.C. Gov. Henry McMaster, who refused to issue a statewide mask rule, opting for a limited one focused mostly on restaurants, large gatherings and state government buildings.
“Political leaders in many states have gone too far. They have infringed on the Constitution and trampled personal freedoms,” McMaster said during his State of the State address in January.
“We took a road less traveled — a better road. We slowed down, but safely remained open. We never closed. Our reasonable steps of limited, measured and temporary actions allowed us to combat the virus without crippling our economy.”
Financially, the state has fared better than many other states that have had to make budget cuts to important programs like Medicaid and essential areas like education and transportation spending. Instead, South Carolina chose to operate on basically the same budget it used the fiscal year before COVID-19 struck, maintaining some sort of status quo.
The debate over how far to go to protect lives or the economy continues today.
On Feb. 26, McMaster lifted some of the last remaining COVID-19 restrictions: the “last call” rule preventing restaurants from serving alcohol after 11 p.m. and a rule preventing event gatherings of more than 250 people.
The rule change quickly garnered criticism from some members of the Legislature. On the Senate floor Tuesday, S.C. Sen. Marlon Kimpson, D-Charleston, pointed out that South Carolina still had very high rates of virus spread per capita.
During the week of Feb. 23 to March 1, South Carolina saw the 46th highest rate of spread of any U.S. state, U.S. territory or country with about 1,670 cases per million people, according to a State analysis of data from the CDC and the World Health Organization.
Kimpson cited CDC guidelines saying that several restrictions should still be in place in states with levels of spread like those in South Carolina.
“We’ve got people opining on meaningful restrictions that don’t have one iota or experience in health care,” Kimpson said. “Let’s listen to the CDC. They’re there for a reason.”
“We’ve got clear evidence that the governor is wrong.”
Legislative leadership is deeply divided on whether the governor and DHEC handled the pandemic the best they possibly could.
Senate Minority Leader Brad Hutto, D-Orangeburg, and Senate Majority Leader Shane Massey both expressed frustration with the lack of planning and preparation for the pandemic.
“I think it has not been handled nearly as well as it could have been handled or should have been handled,” said Massey, an Edgefield Republican who is considering a run for governor, challenging McMaster in the GOP primary. “I think most of South Carolina will tell you that the planning was poor, the implementation of the plan — whether we’re talking about the vaccine or testing rollout — has been poor.”
Hutto said while the governor’s work led to benefits for the economy and businesses, he hoped that the governor would have adhered more closely to Centers for Disease Control and Prevention guidelines. Specifically, Hutto also wanted the governor to issue a statewide mask mandate.
House Majority Leader Gary Simrill, R-York, said the state waded into “uncharted waters” and leaders had to figure out what direction to take as they went. He said that, while the state’s response wasn’t seamless or perfect, it could have “absolutely” been worse.
“I think you can always play Monday morning quarterback looking back, but I think the governor, in everything he sought to do was to protect South Carolina health-wise, but also recognize that the economy needed to continue moving forward,” Simrill said.
Epidemiologists say that, at the beginning of the pandemic, it was difficult for officials to know the best course of action in response to the coronavirus. The last pandemic of this kind was the Spanish Flu in 1918.
“I think we were all pretty hopeful that this was not going to be a long term tragedy,” Scheurer said. “Once we discovered that it was not, we should have pivoted more quickly to learning the psychology of COVID.”
And a constant stream of misinformation from the nation’s highest official, former President Donald Trump, didn’t make navigating a global pandemic any easier, said Melissa Nolan, a professor at the University of South Carolina’s Epidemiology and Biostatistics department of the Arnold School of Public Health.
According to a study from Cornell University, Trump was the single largest source of misinformation on the pandemic, making up about 38% of “misinformation conversation” worldwide.
Complications arise “when you have federal executive branches saying completely inaccurate things and giving poor advice,” Nolan said.
For example, health officials struggled to get a “concise, believable, credible message,” around the efficacy of wearing masks, social distancing and washing hands in the early days, Scheurer said.
“If you think back to the early days of the pandemic, those were controversial and loosely enforced at best,” Scheurer said.
One can see the effects of that mixed messaging in “highly Republican areas,” where there tend to be more cases, Nolan said. Nolan pointed to Greenville County, a county that Trump won by nearly 20 percentage points in November, which has led the state in cases almost consistently since the summer. She also pointed to other conservative states like North Dakota and South Dakota, which saw severe outbreaks in early winter and Texas, which is seeing severe outbreaks now.
State Epidemiologist Linda Bell, the public face of the state Department of Health and Environmental Control throughout the pandemic, said the mixed messages certainly “had an impact on people’s choices and behavior.”
“At every level, I believe there was the creation of mixed messages, and people chose to believe who they trusted and at that time, created conflict with the more evidence-based communications,” Bell told The State Thursday.
DHEC struggled against those mixed messages by trying to employ consistent science-based and data-based recommendations, Bell said. But still, compliance and belief in the efficacy of disease prevention methods are still in question to this day.
“I don’t think there’s any doubt that that lead to more cases than was necessary,” Scheurer said.
Wave 1: Lockdown and testing struggles
Officials announced the first coronavirus cases in South Carolina on March 6, 2020.
For about a week, not much changed in the state. On March 11, with South Carolina recording 10 total cases, Gov. McMaster told reporters he still planned to attend the St. Patrick’s Day parade in Greenville, taking cues from state health officials who said there was no reason to change daily activities if there is no evidence of “community spread.”
McMaster told reporters the only action people needed to take was the following: “Cover your nose. Cover your mouth. Wash your hands all day long. If you’re sick, don’t leave home.”
His tone quickly changed.
On March 13, Trump, a major McMaster ally, issued a national state of emergency due to the virus, and the Palmetto State governor followed suit. On March 16, South Carolina saw its first coronavirus-related death and McMaster ordered schools across the state to close at least through the end of March.
The shut down led to schools losing contact with thousands of students. State officials spent months trying to track down students who never logged in to complete school work, but even by August, hundreds were still unaccounted for. To date, there are still districts across the state that have not returned for five-day a week in-person instruction, despite pressure from McMaster, Spearman and many lawmakers.
On March 17, with the state recording a total of 47 cases, McMaster ordered restaurants to close their dining rooms, and on March 24, Charleston became the first city in the state to issue a “stay at home” order for its residents. Columbia follows suit two days later.
“As we were responding to the virus and learning about the virus at the same time, we rapidly got more information and had to modify our practices as we learned more,” Bell said, reflecting on the early weeks of the pandemic.
By the end of March, McMaster had ordered all nonessential businesses to close as South Carolina surpassed 1,000 coronavirus cases. South Carolina entered a lockdown period, mirroring a national trend.
“We were in a containment mode,” Bell said.
As McMaster locked down the state, some residents became confused about the reasoning behind some of the rules, Senate GOP leader Massey said. For example, when the governor locked down public boat ramps, constituents questioned what risk someone fishing on their own boat was taking. When the governor issued a limited mask order for inside of restaurants, people questioned why they needed to wear a mask from the door to the table, but once at the table, they were allowed to take it off.
When residents reached out to the governor’s office, they didn’t get answers, Massey said. And when their legislators tried to reach out on their behalf, they hit the same wall.
“In a situation like this, the leader has to be really clear about what he’s doing. He has to be very direct with people,” Massey said.
“I think the communications on those fronts was terrible.”
Massey also questioned how well McMaster understood what public health steps needed to be taken to slow the spread of the pandemic.
“I’ve come to believe that the problem wasn’t the communication,” Massey said. “The problem was the governor didn’t know what to communicate.”
The governor’s office was not immediately available for to comment.
Some of the governor’s lock down decisions had major consequences.
Concerned that hospitals would be overrun with COVID-19 patients, McMaster asked health systems to stop all elective surgeries in mid-March. Scheurer said this moment was an example of the state trying to strike a balance between providing routine care for residents and safeguarding the state’s hospital capacity.
“We just turned the faucet almost completely off in April,” Scheurer said.
“I think the hospital and health care suspension probably over did it, because at a minimum, we denied people care, which is not the right approach,” Scheurer said.
The suspension of elective procedures also caused a massive financial impact on health care systems across the state, Scheurer said.
The Lexington Medical Center, located just outside of Columbia, lost $18 million in March alone. In June, the S.C. Hospital Association released a report estimating that hospitals across the state saw a $2.3 billion impact from the pandemic.
The financial effect of the pandemic extended far beyond hospitals. South Carolina lost almost 300,000 jobs through April and hit an unemployment rate of 12.4%, McMaster said during his January State of the State address.
“During the worst week of the Great Recession in 2008 and 2009, we saw nearly 14,000 initial jobless claims filed,” McMaster said. “During the worst week of the COVID-19 pandemic, we saw more than 87,000.”
By April, the governor already launched a task force charged with coming up with recommendations on how schools and businesses could reopen safely.
As the economy suffered, the extent of the virus’ spread and how it works started to become more clear.
In the early stages of the pandemic, scientists realized that many people who contract COVID-19 are asymptomatic. This caused massive problems when it came to getting people to follow disease mitigation protocols, Scheurer said.
“For some diseases like Ebola, with a 70% mortality rate, you’re going to get people to conform,” Scheurer said. “There were so many people who got (COVID-19) and barely even know they have it. ... That makes it so much harder to get people to make sacrifices.”
Along with issues springing from asymptomatic cases, the state also struggled to perform tests early on, DHEC Director Dr. Edward Simmer said. Simmer was confirmed to lead the agency in February 2021.
South Carolina’s population was “naive and susceptible” when the virus was first introduced, and the lack of testing capacity is partially what caused the state to go into a lockdown, Nolan said. This was due in part in due to a poor federal response when it came to coordinating supplies, Nolan added.
On April 4, DHEC estimated that about 85% of South Carolinians with COVID-19 had not been tested for the virus. They release data on that figure for months — estimating in late August that more than 750,000 people actually had the virus while only about 111,000 had tested positive — but eventually stopped reporting it.
The data spoke to the enormity of the challenge facing public health officials tasked with tracking the virus’s spread.
“You can’t contain a pandemic if you don’t know who has it,” Scheurer said.
Lawmakers were unsatisfied with DHEC’s testing efforts even through August when state health officials set a goal of testing about 2.8% of the state’s population per month.
DHEC eventually increased its testing goal to 10%. Now, the state has reached a comfortable testing capacity.
As of Friday, more than six million tests have been performed across the state, whose population is about 5.1 million. During the final and most severe wave of COVID-19, state labs routinely completed between 20,000 and 40,000 tests a say without reporting backlogs.
Wave 2: Few restrictions hold South Carolinians, visitors back
Proclamations that the state was “flattening the curve” and seeing the end of the crisis came early from McMaster, who later would see daily case numbers and surges in deaths and case numbers eclipse the early weeks of the pandemic.
By mid-April, DHEC officials estimated that South Carolina rounded the coronavirus case curve and projected that the state would see decreases in cases starting in late April.
The governor began to back off his restrictions, even as the state consistently saw more than 100 cases reported a day. On April 20, he began by allowing beaches and some retailers to open. A little more than a week later, he lifted his “home or work” order, and followed up by allowing restaurants to open outdoor seating.
By the end of May, with cases consistently alternating between the 100s and the 200s, McMaster allowed restaurant dining rooms, close-contact businesses and tourist attractions to reopen with some capacity restrictions, just in time for Memorial Day, the kick-off of tourist season.
McMaster has maintained that these early actions to keep the economy open have made South Carolina better situated today than many other states.
The State reached out to the governor’s office, and McMaster’s spokesman pointed to the governor’s comments in his January State of the State address.
“By freezing new spending and holding state government steady at last year’s spending levels, we have been able to avoid cutting services, raising taxes, or borrowing money,” McMaster said. “Today, South Carolina is in a stronger financial position than virtually every other state in the country. That’s because we were thinking ahead.”
While other states have had to make budget cuts and rely on federal assistance, South Carolina is expected to run a budget surplus yet again this year, though it is considerably smaller than pre-pandemic projections. While the state was projected to run an $800 million surplus, economists predicted in October that the state would still collect about $86 million more than the previous fiscal year.
The state’s health officials did not always agree with McMaster on his timeline for reopening the state.
In August, months after McMaster lifted major restrictions on business, The State in an exclusive report revealed that Bell believed that McMaster’s staff misled the public about her position on opening indoor dining and close-contact businesses. Bell called the staff “somewhat manipulative” in meetings and said she would not stand by the governor without speaking to the science.
Bell and DHEC recommended that McMaster hold off a week on reopening restaurants, though the governor did not ultimately follow that recommendation.
State health officials stressed the importance of personal responsibility when it comes to responding to the coronavirus. It’s a line that they and the governor continue to this day.
Bell said prolonging too many restrictions can lead to “coronavirus fatigue,” when people grow tired of social distancing and avoiding large group gatherings. After seeing the height of fatigue, the state sees a corresponding spike in cases.
Bell said that DHEC still needs to work with those who don’t follow preventative measures to make them understand their contribution is needed to help slow the spread of COVID-19.
“We know that many are concerned about their own health, concerned about their loved ones and those in the community,” Bell said. “But there are some that are not.”
But coronavirus fatigue was always expected to be a factor, legislative restrictions or not, Scheurer said. It’s caused by case numbers slowing down and people beginning to see their social distancing and isolation efforts paying off. Then, “you can’t help but crave normalcy and freedom, and people immediately slip back into old habits,” Scheurer said.
Despite the fatigue factor, policy does have an effect on behavior, Scheurer said. She said state officials could have done more on the policy end to slow the spread of COVID-19.
“We knew what the risks were, but despite that, we didn’t really have the appetite to legislate restrictions,” Scheurer said.
With most restrictions lifted by the end of May, the state saw a surge of cases following Memorial Day weekend.
Nolan said the worst of the second wave wasn’t directly caused by businesses reopening, but by the flood of tourists drawn to those now open businesses. Cases in major coastal counties like Horry, Charleston and Beaufort counties reached new heights over the summer.
While restrictions, such as closing the beaches, could have have impacted the summer wave of cases, “it would have impacted the local economy as well,” Nolan said.
By April, the S.C. Department of Parks, Recreation and Tourism was already reporting a $768 million drop in visitor spending due to the pandemic.
During this summer, McMaster continued to refuse to instate a statewide mask order, saying that it would be impossible for state officials to enforce. Instead, he left it up to local municipalities to create their own patchwork of mask requirements.
By the beginning of July, with cases beginning surpassing 1,000 a day, Greenville, Columbia and Charleston had instituted their own mask rules. Other local governments followed suit until about two million South Carolinians were living in a municipality with some sort of mask order.
By August, the state was already seeing positive effects of the local mask orders. DHEC released data showing that jurisdictions with mask requirements saw a 15.1% decrease in total coronavirus cases for four weeks after the rule was put into place. Areas without those requirements saw a 30.4% increase in total cases.
The message from DHEC was simple: “Masks work.”
Epidemiologists said that McMaster’s reluctance to issue a statewide mask order, a step that several other states had taken, would have been much more effective that a smattering of local rules.
“It just makes it cleaner,” Nolan said.
Later, restaurant owners, including a member of the governor’s task force that advised how South Carolina should reopen during the coronavirus pandemic, said the governor should have issues a statewide mask requirement.
“From the latest information at that time, we didn’t even think about (pushing for a statewide mask requirement),” said Bobby Williams, a member of S.C. Gov. Henry McMaster’s task force on reopening. Williams’ association encouraged the governor to reopen businesses in May. “But now, in hindsight, I think it would have made a difference.”
Wave 3: Winter weather drives increases
South Carolina entered a brief phase where seeing fewer than 1,000 coronavirus cases each day became normal. But that phase ended in mid-November as colder weather pushed residents indoors and the holidays rolled around.
DHEC officials began warning of a possible cool-weather surge on Nov. 5, saying they already saw cases in the Upstate rising at a steady rate.
“We understand that ‘COVID-19 fatigue’ is occurring and we’re all wishing for a return to normalcy,” DHEC interim Director of Public Health Brannon Traxler said in a statement. “But think of our first responders, doctors and nurses, law enforcement officers and essential workers who, although exhausted, keep working to keep us safe. We can’t give up.”
Still, cases and hospitalizations crept higher through the month of November.
The third wave was largely associated with “respiratory season,” when viruses like the flu are more commonplace, Nolan said. On top of medical changes that happen in the winter and cause people to be more susceptible to diseases like the flu or COVID-19, South Carolinians also experienced another period of COVID-19 fatigue, she added. This was likely aggravated by the holidays.
“We started really seeing with this third wave was more associated with friendship and close family groups,” Nolan said.
McMaster and DHEC officials warned residents to “get tested before turkey,” in an effort to clamp down on spread caused by the holidays. But by early December, the state began reporting more than 2,000 coronavirus cases a day almost every day, reaching new record highs.
Unsatisfied with DHEC’s performance and the revolving door of leaders throughout the COVID-19 crisis, S.C. Senate President Harvey Peeler called for the agency to be broken up.
“No one is in control at DHEC and hasn’t been for quite some time,’’ Peeler, R-Cherokee, said in a news release.
During his State of the State request, McMaster said the department “needs attention.”
“It is a massive agency with thousands of talented, experienced employees but two different and equally complex missions — health and the environment,” McMaster said. “A jack of all trades is the master of none. The pandemic — against the backdrop of our expanding economy — has highlighted the agency’s need to move and act in a more nimble and responsive fashion.”
Just as cases skyrocketed and records were broken, some good news came. On Dec. 14, South Carolina received its first allotments of the coronavirus vaccine and began vaccinating frontline workers.
The holiday cheer brought by the vaccines quickly faded as McMaster expressed frustration with the speed at which they were being distributed. At the time, DHEC had distributed 31% of vaccine doses it had received.
During a Jan. 5 press conference, the governor, who had recently recovered from his own bout of COVID-19, threatened to issue executive orders to speed up the process if DHEC didn’t act.
The governor announced a new plan to set a deadline for people in the first phase to get the vaccine appointment. The next day, DHEC announced it would be reversing its vaccine policy in favor of McMaster’s plan.
As of Tuesday, South Carolina had distributed more than one million doses of COVID-19 vaccine.
The future of vaccination
With three vaccines approved for emergency use, DHEC is working to vaccinate as much of the population as possible. Starting Monday, South Carolina enters a new vaccine phase that includes about half of the state’s population.
But it’s important to understand that COVID is never going to go away, Nolan said. The virus will likely continue to be in circulation, like the H1N1 or “swine” flu, and it will cause small, isolated flare ups.
For South Carolina to achieve some sort of herd immunity to the virus, about 70-80% of the population will need to be vaccinated, DHEC Director Simmer said. That means about 3.5 to 4 million people have to receive the vaccine. To date, about 14% of the state has received the vaccine, according to DHEC data.
Bell predicted that a large percentage of those who want to get vaccinated will be able to do so by the spring.
Until then, Simmer and Bell said people should continue to practice the tried and true methods of disease prevention like social distancing and wearing a mask.
“We’re not out of the woods yet,” Simmer said.
