This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.
In Georgia, COVID-19 did something different.
It hit the densely populated areas first—this part is not new. But then it went into the countryside, popping up at church services, funerals, poultry processing plants.
Georgia’s Gov. Brian Kemp did something different, too. Georgia was the first state to reopen, on April 24. Relying on data that would later be questioned, he declared victory, or close enough, telling businesses they could reopen, which many did. The barbershops, the restaurants, the bars, the gyms, the tattoo parlors.
The doors at community events swung open for COVID-19. Close working quarters didn’t help, plus in rural Georgia you don’t get big-city resources. Testing is harder to find than it is in Atlanta, and a hospital bed can be several counties and hundreds of miles away.
Today, many of Georgia’s non-urban communities are reporting worse per-capita outcomes than the Atlanta metro area, home to seven million people. Public health experts worry about COVID’s rural hotspots, realizing also that the virus isn’t just sitting in the countryside. It’s bound to return to big cities—to spike again.
“I would think that urban areas would be more vulnerable to a second wave maybe than some of these rural communities,” Amelia A. Langston, professor and executive vice chair in the Department of Hematology and Medical Oncology at Emory University School of Medicine and director of the Bone Marrow and Stem Cell Transplant Program at Winship Cancer Institute of Emory University, said to The Cancer Letter.
“It may run its course in a place like Albany [in Dougherty County]—whereas in Atlanta, when everybody’s out at the bars and out at restaurants and getting their tattoos—I think that second wave phenomenon may actually hit the urban areas much more,” said Langston, who is also medical director of Winship Cancer Network.
COVID-19 in the community
Overall, cases in Georgia peaked around mid-to-late April.
Earlier cases in rural Georgia were linked to big social gatherings. Nursing homes were hit, too—the usual. Recent cases have spiked in Hispanic populations in the Gainesville area of Northeast Georgia. That one was about people working in close quarters at a poultry plant.
In northeast Hall County, where cases in Gainesville have been traced back to the poultry plant, there have been 2,262 confirmed cases and 41 deaths. The county reported 1,096 cases per 100,000 people, according to data from Georgia’s Department of Public Health.
Northeast Georgia Health System, part of the Georgia NCI Community Oncology Research Program, has reported an increase in COVID-19 cases.
“Gainesville is probably, in all areas of Georgia NCORP, the one that has been hit the worst—and while the state started to see a decline, they started to see an incline on the curve,” Guilherme Cantuaria, principal investigator of Georgia NCORP, and chair of the Gynecologic Oncology Steering Committee at Northside Hospital Cancer Program, said to The Cancer Letter. “It has to do with the poultry plant up there, and exposure that they’ve gotten through that contamination.”
While officials wait to see the full effects of Georgia’s controversial reopening strategy, medical experts have also looked to the conditions in Georgia prior to a phased reduction of quarantine restrictions as a case study in the spread of the virus.
“It’s a tale of two states. There’s the metropolitan area that responded well, and rural areas that were challenged, because of outbreaks that may have been event-related,” Len Lichtenfeld, deputy chief medical officer at American Cancer Society, which is based in Atlanta, said to The Cancer Letter. “There were some funerals in Southwest Georgia, but it went way beyond that and it spread into the community.”
The word “dramatic” is too bland to convey the differences in spread urban versus rural Georgia.
Northwest Fulton County—which includes Atlanta—has 3,893 confirmed cases within a total population of just over 1 million. In southwest Dougherty County, the rural area that saw a spike after the two funerals, there have been 1,715 confirmed cases within a total population of 89,905, according to Georgia’s Department of Public Health.
Fulton has 354 confirmed cases per 100,000 people, versus 1,908 in Dougherty—which has a majority black population of more than 70%.
“It seems to be more community-based and seems to spread outward after a small outbreak that might be related to, for example, the poultry processing plant,” Winship’s Langston said.
“In these smaller communities, they can’t do in-house testing, and so they’ve been really dependent upon the state, which has been very slow to stand up any high-throughput testing,” Langston said. “That’s part of why it’s been very difficult to manage these outbreaks in these smaller places, because without access to testing, you don’t know who has it. You’re forced into a situation where it’s very difficult to tell who should be quarantined and who should not.”
This was the case with public health before, and it’s only starker now. Georgia’s geography also makes it unique among southern states, where metropolitan areas are less common, Georgia NCORP’s Cantuaria said.
“Look at other southern states, they don’t have this massive metropolitan area of 6 million people in the middle of their state,” he said.
“It’s so absurd and so interesting. It’s not only within cancer risks and incidence, now it’s with coronavirus. You just drive your car outside—and like a painting, you’re in one painting, then a different painting, a different screen,” Cantuaria said. “Everything changes. People look different. It’s amazing, it’s two states in one.”
Second wave and manipulation of data
Several other states followed Georgia’s lead to reopen, but their rules vary.
Maryland, a state with more strict reopening guidelines, recently lifted its active stay-at-home orders. Maryland still doesn’t allow dining in at restaurants. Nor does it allow complete reopening of salons, which Georgia permits.
The so-called second wave that health officials feared would come as a result of the controversial reopening hasn’t materialized, not yet, at least, but health experts told The Cancer Letter it’s too soon to tell. Cases of COVID-19 have fallen in most counties in Georgia, though the doubling time of infections remains rapid in Echols and Monroe Counties, at 3 and 8 days, respectively, according to The New York Times.
“It’s still too early to tell to determine the impact of our early opening,” Lichtenfeld said. “As always, time will tell what the impact is. And it may well be possible that, for whatever reason, all this may be unwarranted concern. However, we still have several weeks to go before we know whether we’re going to see a significant increase in cases or not.”
Gov. Kemp’s reopening of the state—the first in the country—was only the beginning of the controversy. The state’s response to COVID-19 has been further complicated by news reports that state health officials had manipulated data on which the reopening was based.
In the first instance, a chart from the website of Georgia’s Department of Health showed that confirmed cases of COVID-19 had dropped each day for two weeks in counties with a high infection rate. In reality, there was not a clear drop, The Atlanta Journal-Constitution reported.
Above: Georgia’s Department of Public Health initial chart misrepresented data that showed a decline in cases of COVID-19.
Below: the corrected chart. – Source: Georgia Department of Public Health
“It’s one thing to make an honest mistake and fess up. It is quite another to rearrange dates to produce a false sense of security,” Lichtenfeld said. “That was no honest mistake with respect to the trend lines. The person responsible should be held accountable. They violated the public trust and the public health in a material and intentional way.”
Second, published test counts in Georgia were inflated in official reports by 57,000, or about 14% of total tests in the state, The Atlanta Journal-Constitution reported May 20. The Department of Public Health included antibody tests in the count of total tests given in the state—403,000.
In a webinar with other public health officials, Lichtenfeld recalled the riddle of the day: the data presented in state graphs appeared to show a decrease in cases by placing the dates out of order.
“Where does May 2 come before April 26? The answer was on the Department of Public Health COVID reports,” Lichtenfeld said. “People were just shaking their heads that the information could be manipulated. Why it was manipulated in a bizarre way—I have no idea, but it was manipulated.”
“There are people who read that information as an honest representation of the current situation. They want informed personal freedom and believe we are doing better in our fight against the virus—which by some measures we are, at least for today. They may not have made the same decisions had the data been correctly counted and displayed,” Lichtenfeld said.
Manipulation of the data builds further distrust of public health officials and the government, Lichtenfeld said.
“What does it mean? Number one, the attempt to manipulate data, to make it appear better than it actually is, is one more step to increase distrust of how this situation has been handled in Georgia,” Lichtenfeld said. “The second question is trust in government, which is key to having a successful response to any public health emergency, let alone one that’s responsible for a number of fatalities—and a circumstance where we remain, as a state, at increased risk of recurrence.”
In Albany, a city in predominantly rural southwest Dougherty County, two funerals in March sparked a sharp increase in cases. In Rome, located in northwest Floyd county—about 70 miles outside of Atlanta—a high number of cases were linked to a church service in Atlanta.
A spike of cases in Hall County was traced back to workers at a poultry plant—where there’s hardly any room to allow for social distancing. Other areas, in rural McDuffie County and then the Atlanta metropolitan region, haven’t been hit as hard.
Jose Tongol, a hematologist/oncologist at Phoebe Putney Memorial Hospital in Albany, said at least two of his cancer patients contracted COVID-19 from the funerals.
“There was a person who attended the funeral here. There were two funerals—and a lot of those people got sick,” Jose Tongol, a hematologist/oncologist at Phoebe Putney Memorial Hospital in Albany, said to The Cancer Letter. “A lot of people were affected by that. It precipitated a lot of deaths—a lot of patients.”
Dougherty County, where Albany is located, has reported 1,715 confirmed cases and 138 deaths.
The National Guard was called in to establish makeshift hospitals and testing centers at rural areas across Georgia. Still, there was overflow—some patients admitted to the hospital for reasons unrelated to COVID-19 were sent to the seventh floor of Phoebe Putney Memorial, which had been reserved for cancer patients.
During the COVID-19 peak, Phoebe Putney Memorial Hospital was taking care of 180 patients with the disease. Now, that number stands at about 60 to 70 patients, Tongol said. Some of Tongol’s cancer patients were among those infected with COVID-19 and admitted to the hospital.
Health officials suspect that patients with hematologic malignancies who are under active treatment would be most vulnerable to COVID-19. Data from Wuhan, China, presented at the first virtual meeting of the American Association for Cancer Research, showed that cancer patients under active treatment were more likely to die from COVID-19 than those who have completed treatment, while data from Europe did not show that cancer is necessarily an adverse prognostic factor (The Cancer Letter, May 1, 2020).
Secretaries and nurses at the hospital, and even a neighbor of Tongol’s contracted the virus—likely from one of the funerals, he said.
“Some of our patients were in the hospital,” Tongol said. “I’m also a hematologist. I have a few sickle cell patients who developed it. Fortunately, they survived the illness. Based on my leukemia and myeloma patients, we had one or two here that developed it—and we had to delay treatment.”
In Rome, the largest city in Floyd County, with a population of nearly 40,000, the majority of COVID-19 cases can be linked back to a church service in Cartersville, a town in neighboring rural Bartow County, said Melissa Dillmon, hematologist/oncologist at Harbin Clinic Cancer Center, and chair of the Government Relations Committee of the Association for Clinical Oncology.
“Our first index case in our county was caused by the neighboring county—that church service. Most of our deaths were then related to that church service,” Dillmon said to The Cancer Letter. “It was an of-out-of town person who went to the church service, and then a lot of their choir members got sick.”
Floyd County had 220 confirmed cases and 13 deaths. This translates into 220 cases per 100,000 people, according to data from Georgia’s Department of Public Health.
Two of Dillmon’s patients died from the disease—one of whom had attended the church service. She suspects that another of her patients had the disease when the outbreak began, in early March.
“One was on a chronic immunosuppressive therapy, and also he had low ability to fight infection and was also receiving high intravenous immunoglobulin,” Dillmon said. “He had not had any treatment in several months, but acquired it.”
Dillmon’s other patient who died was not under active treatment, but died as a result of COVID-19 that spread in a nursing home. Dillmon suspects another patient with chronic leukemia, who is under active treatment, developed COVID-19 in early March and recovered.
“I have another patient who I feel pretty sure had coronavirus the first week as well—her son-in-law came back from China two weeks before,” Dillmon said. “It’s kind of classic, but that was in that first week, when we really didn’t have adequate testing—and she was in the hospital and very ill for a week, but they never tested her.”
“There’s some things you just can’t do over the phone, even over a video”
The Atlanta Metropolitan Area—where Winship’s Langston treats patients with hematologic malignancies, has not seen spread at the same scale.
“We have certainly seen a steady stream of COVID in the Atlanta Metro area, but it’s not the Atlanta Metro area that’s actually been the most stressed within our region,” Langston said. “We’ve been resourced appropriately to deal with the cases we’ve seen, but some of these other areas have not—and so they’ve had to have little pop-up tent hospitals and other kinds of resources brought to bear in order to care for patients.”
Then, there are rural communities that haven’t felt the same reverberations of SARS-CoV-2. At the peak of COVID-19 in Thomson this April, about 12 patients would come to the Monday clinic for patients with COVID-19 at the Center for Primary Care.
Usually, Monday is the busiest clinic day, Jacqueline W. Fincher, an internal medicine physician and partner at Center for Primary Care, said to The Cancer Letter.
There have been 63 confirmed cases and five deaths in McDuffie County, an eastern part of Georgia where Thomson is located. The county has 292 cases per 100,000 people.
“The numbers dropped enough over the last 10 days that we actually have gone now to Monday, Wednesdays and Fridays starting this week, as opposed to every day,” Fincher, who is also president of the American College of Physicians, said.
The makeup of patients at Fincher’s practice include some of the most vulnerable to COVID-19, with about 70% of her patients over age 65. Still, at the start of testing at the beginning of March, Fincher’s practice only received two testing kits.
“My concern is my diabetic, my hypertensive patients with chronic kidney disease—or who is on dialysis, or my patient with congestive heart failure,” Fincher said. “We don’t want them to end up in the hospital. And the way you do that is you see them on a regular basis, before they get into trouble, so that you can cut these things off at the path, and be able to treat them more vigorously or aggressively as an outpatient.”
Before widespread testing became available in Georgia, the majority of Fincher’s patients who are older and have less access to resources, would have had to travel to Augusta—about 45 miles out from her practice—for testing of COVID-19.
“A drive-through clinic for a nose swab was very difficult,” Fincher said.
As in other states where COVID-19 has hit hard, the pandemic has exacerbated existing disparities. Older populations can have a harder time navigating phone apps and video platforms that are inherent to telehealth. There are also those who don’t have access to the internet to begin with because cost is a barrier. Other times, internet isn’t up-to-speed in more rural areas.
Cancer, too, is still around.
On a recent day, Fincher evaluated two patients. She did so the old-fashioned way, in person. One came in with severe jaundice and was ultimately diagnosed with pancreatic cancer. The other had a cyst that was found to be benign.
“There’s some things you just can’t do over the phone, even over a video,” Fincher said. “Ideally, we’d like to have everything done on time, but we’re in an unprecedented time, so we have to do unprecedented things that are the safest for patients, for hospital and clinic staff,” Fincher said.
“As many who have said in the economic realm, we have to go on living. And that’s true. But it doesn’t have to be the Wild West. We can do that in safe, risk-controlled, phased-in approaches.”