Two years ago Sunday – the morning of Friday, March 13 – the first case of COVID-19 was diagnosed in Alabama, and by the end of the day the state had a total of six positive cases.

Schools that day announced they would be closing for what they thought would be 2½ weeks to let the virus pass us by. Nursing homes closed to all visitors and the first drive-thru testing location in the county opened in Vestavia Hills.

That was just two days after the World Health Organization declared that the spread of what then was called the novel coronavirus had reached pandemic levels, a declaration that came three months after the first cases were reported in the city of Wuhan, China. It would grow into a global health crisis on a scale not seen by the world in more than 100 years.

In other countries, people already were on mandatory shelter-in-place orders, but the change that would catch the attention of a broad swath of Americans wasn’t that. It was a change in a basketball game.

The National Basketball Association hastily called off a game after officials found out that Utah Jazz player Rudy Gobert had tested positive for the coronavirus, setting off a chain of events that resulted in the suspension of all NBA play.

As COVID spread in early 2020, health officials in Alabama had to move quickly to try to stop the outbreak.

Nursing homes were among the first institutions to close down, and for months no visitors were allowed as America’s elderly became the first sacrifices to the pandemic.

At first, health officials moved to limit public gatherings to fewer than 500 people, then days later the limit was reduced to 25. Gov. Kay Ivey put in place orders that shut down most nonessential businesses, and schools followed suit; classrooms via online broadcasts such as Zoom became the norm. Entire families stayed under the same roof day in and out as children attended class remotely and their parents either worked from home or had no job to go to.

High school sports were shut down for the rest of the 2020 spring sports season, and the football season was affected later in the year. Some schools opted out of play entirely, while weekly lists of scores regularly noted numerous games forfeited because of COVID outbreaks.

Places of worship were forced to cancel in-person services, and attending church via online video became the norm.

As of now, the U.S. has endured three distinct surges over the past two years. Vaccinations have helped curb cases, but the threat is not yet over.

COVID-19 is still a pandemic, and health officials haven’t predicted when it will enter an endemic phase, meaning cases would drop and the illness could mostly be managed by vaccinations and treatments, as the flu is.

Alabamians have seen many changes in their lives in the past two years because of COVID, some lasting and some temporary. But no one has seen more upheaval than the medical community.

Massive Effects for the Medical Community

Hospitals and health leaders had plans in place to deal with outbreaks of diseases, to be sure, many of them resulting from the Ebola virus outbreak in the middle of the 2010s. But when COVID hit, it was quickly apparent that the country was not prepared for how contagious the virus was, and stockpiles of needed medical supplies were either insufficient or had deteriorated in storage over time, or both.

“Some of the assumptions that we had just didn’t turn out to be true,” Jefferson County Health Officer Dr. Mark Wilson said Friday in a press conference marking the two-year anniversary of the pandemic. “One of them was simply not having material supplies of certain things we needed at the beginning. We did not have hand sanitizer; we didn’t have masks even for health care workers. The masks that were in our Strategic National Stockpile turned out to be out of date and deteriorating. Ventilators was another one we worried a lot about. … Having plenty of those things on hand for the next time and keeping those supplies in readiness to produce these things available (is important), and not depending on other countries for that supply chain.”

Authorities at all levels regularly perform simulations and “tabletop exercises” to prepare for the next big disaster, whether it be tornado or hurricane events, disease outbreaks, riots and the like. But some of those preparations before 2020 simply didn’t account for problems faced when the virus exploded onto the scene.

“One thing that was particularly challenging and that we need to think about a lot going forward is our workforce,” Wilson said.

“Our first responders and health care workers were being taken out of commission by the virus. … That really hamstrung us a great deal. We were talking about trying to set up a field hospital and open up an extra nursing home to spread people out to take care of more patients. We finally realized it didn’t matter, because we did not have the personnel.”

One of the things medical personnel had practiced before COVID struck was drive-through vaccinations, which proved to be useful in the middle of the pandemic. But because the virus was extremely contagions, Alabama Health Officer Dr. Scott Harris said, “It wasn’t as simple as the flu shot.

“We had all the cold-storage issues, and the fact that we had to observe people for 15 minutes after vaccination. All of the recordkeeping and the administrative process for all of that was just on a higher scale and more complex than I think any of us anticipated.”

The personnel problem persists today in health care. Many workers have left the field since the initial surge of cases. Most of those losses were from workers who had simply had enough and quit.

“That’s going to be the long-term effect of COVID on the health care industry,” said Dr. Don Williamson, president of the Alabama Hospital Association. “We’ve had 20% of health care workers (leave) the industry, and it’s estimated that it will be 2025 before we get back up to the levels we need. Some of that shortage is a legacy of the pandemic, but some of it is because we were short-staffed before. A lot of people who were nearing retirement age decided it was a good time to get out.”

Williamson said that not only finding good people but learning how to keep them is something his industry has to work on in the next few years. “This pandemic has shown that health care is very rewarding but very stressful.”

One big thing hospitals learned during the pandemic was flexibility — the ability to reconfigure all sorts of spaces for patient care and even for intensive care.

“Hospitals were very creative in converting non-care space to care space, and non-critical care to critical care,” Williamson said. He said that at the height of the delta surge, more than 100 COVID patients were receiving intensive care in beds not officially considered part of ICUs.

Williamson said there was a great deal of planning for use of alternate care sites outside of hospitals, but ultimately that hasn’t been needed. For instance, UAB Hospital converted waiting rooms to emergency care and other spaces switched to COVID beds rather than moving patients off-site.

Three Surges

Since the beginning of the pandemic, three distinct surges have taken their toll on the public. The first, now called the alpha variant, built up over the remainder of 2020 until peaking around New Year’s Day 2021 with a 7-day average of more than new 3,500 cases per day and 154 deaths per day in January. The delta variant appeared just after the Independence Day holiday period, and over two months it reached a height of more than 5,500 new cases and 134 deaths per day.

Omicron’s surge began around Thanksgiving and peaked with more than 13,400 new cases on the 7-day moving average on Jan. 22, 2022. The peak number of omicron deaths is yet to be reached, as fatality rates continue to slowly increase. That’s typical of the surges in this pandemic; increases in deaths trails hikes in cases by four to eight weeks. Currently, the 7-day moving average is about 50 per day, roughly five times higher than the end-of-year holiday period about 11 weeks ago.

As the number of omicron-linked cases has rapidly declined, all mandates to wear face masks in public areas have been allowed to expire.

Businesses that survived the loss of revenue during the pandemic have reopened in full, though finding enough workers has become a major problem. Schools are back in their routine of learning in classrooms and full schedules for sports and other extracurricular activities.

Mass vaccination and testing sites mostly have closed, as vaccination rates have gradually climbed and home testing kits have become freely available. The latter also has meant that the reported rate of new cases has become less reliable, as people who test positive at home but have few or no symptoms will often self-quarantine and not report their positive test to health care agencies. That’s why recently the Centers for Disease Control and Prevention has changed the way it assess the level of COVID infection and whether residents should wear masks. The new measurements depend less on new case numbers and more on hospitalization numbers, Harris said.

The new CDC COVID-19 Community Levels measure takes into account new cases per 100,000 residents, new hospital admissions of COVID patients and the percentage of hospital beds with COVID patients. The first two criteria are measured over a 7-day rolling period.

Two years after the pandemic began, Jefferson County and Alabama both are rated as “moderate,” the middle of three risk levels. People in moderate counties are advised to check with their health care providers about wearing masks if they are at high risk for severe illnesses.

During those years, the state has had 1,288,999 cases of COVID reported, and 18,832 people have died of the disease. Just more than half of the state’s residents have gotten at least one dose of the vaccine.