On March 19, Dr. Aaron Milstone, a pulmonary and critical care specialist in Franklin, Tennessee, stayed up all night to share a link to an online petition with as many physicians in his contacts as he could.
"I've been here for two and a half decades," Milstone said. "So you can imagine that after 25 years of practicing medicine in Middle Tennessee, I know everybody from Chattanooga to the Tri Cities to Memphis."
The petition was a letter urging Tennessee Gov. Bill Lee to pass a mandatory shelter-in-place order for the state. Within 48 hours, 2,000 physicians across the Volunteer State had signed it.
With a unified voice from emergency room physicians, pediatricians, specialists, primary care physicians and the leaders of four major medical societies in Tennessee, Milstone thought Lee would have no choice but to act.
"To be honest with you, I thought that was going to be it," Milstone said. "I really thought when I woke up on the 21st, that was going to be the end."
On March 22, Tennessee had more than 300 confirmed cases of COVID-19.
In Georgia, the situation was worse. There were more than 600 cases and 25 coronavirus-related deaths. Public health experts urged Gov. Brian Kemp to issue a statewide shelter-in-place order.
At the time, nine other states, including Texas, Illinois and Louisiana, had issued statewide orders telling people to stay at home.
Four days later, 21 states were under a statewide mandate, including Kentucky.
The same weekend the petition was signed in Tennessee, Dr. Carlo Del Rio — an executive associate dean and chairman of the global health department for Emory University at Grady — said Georgia was at a critical time to make interventions.
"If we don't do them today, cases are going to continue to grow at a very rapid pace," he said during an online Q&A.
Meanwhile in Alabama, Jefferson County had nearly half of the state's 157 confirmed cases on March 22, with 71. The county's Department of Health closed down all non-essential businesses, but Gov. Kay Ivey decided not to take action from the top.
"Y'all, we are not California, we're not New York, we aren't even Louisiana," Ivey said on a March 24 conference call with reporters, according to AL.com.
Lee issued a handful of executive orders to help stop the spread of the coronavirus as the petition circulated, but none were as drastic as what Milstone and thousands of physicians wanted.
"That was probably the most frustrating 10 days of my entire life," Milstone said.
How to help flatten the curve
Dr. Aaron Milstone said there are three key ways the public can help flatten the curve.
1. Stay at home.
2. If you feel the need to wear anything in public, make sure that it is a cloth mask or a scarf. "Ideally a cloth mask," Milstone said. "I don't want the public using N95 or surgical masks because that greatly depletes, very quickly, what's available for health care workers."
3. If you have to go out, assess the situation and make sure that it is something you have to go out for. "Otherwise, follow the mandate and let's see where we are," Milstone said. "When the governor's mandate ends in mid-April and if we're not better in terms of our numbers for the state, then we need to continue the mandate until we win the war."
A lot has happened in all three states since then. Kemp announced a shelter-in-place order on Wednesday, Lee did the same the next day and Ivey issued one Friday night despite saying she didn't plan on one.
Public health officials and other experts have said the writing was on the wall for all three states, and the action — or inaction — along the way could play a large role in how each state handles the eventual spike of and recovery from this worldwide pandemic.
A turning point
For most people in the U.S., March 11 was a turning point.
That was the day the NBA suspended its season after a player tested positive for COVID-19, President Donald Trump suspended certain travel to and from Europe after the stock market took a dive and actor Tom Hanks announced he tested positive for the virus. That all happened within hours.
On March 16, Lee closed all schools until the end of the month after some districts around the state had already made the decision to close.
As the virus continued to spread in the Southeast, Lee resisted pleas from medical professionals to shut down the state. On March 30, he issued a statewide order "strongly urging" Tennesseans to stay inside. The main difference between that order and Thursday's was the word "require."
Lee said that he didn't require people to stay home as part of his first mandate to "protect personal liberties."
Meanwhile, mayors in Chattanooga, Nashville, Knoxville, Memphis and Atlanta all issued variations of shutdowns even though the governors of their states had held back from such a mandate.
Dr. David Aronoff, director of the Division of Infectious Diseases at Vanderbilt University Medical Center, said making policy changes for an entire state is difficult. Aronoff was one of the physicians who signed the petition but believed it would take time for things to unfold.
"Gov. Lee was hearing from a lot of different people and trying to really integrate a lot of data in unprecedented times," Aronoff said. "I think his approach was to leave it to the public to do the right thing. It seems, at least according to him [Thursday], the data wasn't convincing to him that we could do it without a mandate."
The first confirmed case in Georgia was March 2 but it wasn't until the events of March 11 when dominoes started to fall.
Communities in Northwest Georgia started closing schools, starting with Catoosa County, on March 12. Large events were canceled, public meetings in Ringgold and Walker County were postponed or moved online. Meanwhile, Kemp kept insisting the best way forward through the pandemic was to leave control up to local entities, despite pushback from medical professionals.
Last week, Kemp reversed course and issued the statewide shelter-in-place order, after telling reporters in March that he still had "arrows left in his quiver."
Dr. Gary Voccio, health director of the Georgia Department of Public Health Northwest Health District, said public health officials are feeling the knot in their stomach.
"We're going to have tough days ahead as we all have friends, neighbors or loved ones who will get sick and perhaps die from this virus," Voccio said in a news release. "We will limit the pain, but sadly, we will have lots of pain."
Birmingham issued a shelter-in-place order and, several other Alabama communities such as Tuscaloosa and Montgomery issued curfews to help slow the spread of coronavirus.
Milstone knows Lee had a tough decision to make. He had hoped he would make it sooner.
"My catchphrase during this time is, 'Be on the right side of history,'" Milstone said. "At the end of the day, I felt that no one would ever overly criticize Lee for being overreactive but that history would severely criticize him for being under reactive."
Knox County Mayor Glenn Jacobs, an ardent libertarian, said Thursday afternoon the county will comply with Lee's new order, but warned it will stress the limits of democracy, according to the Knoxville News Sentinel.
"I applaud the governor for following through with his convictions and fulfilling his duty to protect the people of Tennessee according to his best judgment," Jacobs said in a Facebook Live video. "I understand this is a crisis, but an economic crisis also looms with millions of people out of work and no way to earn a living, many of them due to mandated government shutdowns."
What happens now
Like anything involving the novel coronavirus, making predictions is difficult to do.
Aronoff and Milstone both said time will tell if Lee, Kemp and Ivey's decision making will have caused harm to residents in each state.
"I don't think we'll ever really know," Aronoff said. "During a pandemic, when a virus is spreading from person to person and the key ingredient to slowing its spread is getting people to separate from each other, the sooner you can do that, the better."
Aronoff is optimistic because the numbers he has seen show the health care system in Tennessee is not overwhelmed.
"Only time is going to answer that question," Milstone said. "We have to unite as citizens of our state and fight the war together and not look back over the past. We can only look forward."
Residents in Tennessee, Georgia and Alabama are now officially being told to stay inside.
"It sends a really important message to the citizens and population of a state when the governor mandates people stay at home," Aronoff said. "I'm very happy Gov. Lee did that, and it would make a lot of sense to me that every state should do that right now because this virus seems to be ignoring state lines."
Contact Patrick Filbin at email@example.com.