UPDATED — As Gov. Kay Ivey eases her COVID-19 restrictions on businesses, stores, beaches and medical procedures, the question that remains for some is – is it time to reopen Alabama?

Ivey, who announced a “Safer At Home” strategy that will begin at 5 p.m. Thursday, has had advice from those who are primarily concerned about health outcomes of the coronavirus and those who consider economics – the loss of jobs, the shuttering of businesses – just as important, if not more. She was joined during her press conference Tuesday by members of her advisory team, including State Health Officer Dr. Scott Harris.

Ivey’s committee also includes lawmakers, Harris, infectious disease specialists and other health care officials, as well as law enforcement, the Alabama Department of Emergency Management, the state board of education, Alabama’s departments of commerce and human resources, and the Alabama Small Business Commission.

Although the team has reached the decision to begin reopening – while leaving some businesses, including restaurants and athletic facilities closed for later evaluation – not all in the state agree that it’s time to reopen.

“That is a very hard question to answer,” said Dr. Rachael Lee, an epidemiologist at UAB Hospital, speaking during a press conference the day before the governor’s new orders were announced. “If you look at Jefferson County, our rates have gone down significantly, but they’re not zero. We are still continuing to see new cases of COVID-19 every single day.

“So if we open up too soon — and there are still new cases circulating even when we have stay at home orders — then that could potentially go up. So if you don’t have enough testing, then you cannot keep that under control,” Lee said.

“What I think is potentially possible is we may be able to slowly open up certain areas where we can have people come in, as long as they’re big enough spaces. And that’s where we have to continue to have that social distancing. Bars and restaurants, they tend to have very close quarters so that’s where having restaurants look through their space and figure out, ‘Can we have this in a safe way to bring people back?’ I personally think that we still need more testing in other parts of Alabama to be able to truly say as a state that we can open up safely,” Lee said.

How should it be decided? Some authorities, including the White House and the Alabama Small Business Commission, faced with a chorus of complaints from businesses and individuals negatively impacted by the economic suspension, as well as the voices of health care advocates cautioning against a hasty return to normal, are recommending phased reopenings.

Some of the more conservative voices in Alabama are recommending a more liberal view of what’s safe to reopen. Back on April 17, the SBC, in conjunction with Lt. Gov. Will Ainsworth, who is a member of Ivey’s COVID-19 advisory group, recommended that, with some precautions, non-essential retail, jewelry stores, restaurants, body art and massage facilities and waxing salons, barbershops, hair salons, nail salons, tanning salons and child care centers, could open “immediately.”

The SBC does recommend that companies and customers continue social distancing and sanitizing measures. Restaurants, for instance, could resume table service but would limit the number of people per table, keep six feet between each table and clean high-contact areas regularly, in addition to monitoring employee health.

Ivey’s announcement essentially tabled the discussion regarding restaurants until meeting with a group representing their interests.

She went along with other SBC recommendations in allowing medical facilities to resume performing elective procedures. She did not reopen gaming facilities, exercise facilities, museums, planetariums, or youth sports, all of which SBC deemed safe to open in the near future.

The 158-page SBC report estimated that a 20% reduction in General Fund revenue sources would mean the loss of $400 million for the state budget, and the same decrease in income and sales tax would cost the Education Trust Fund $1.3 billion.

Those figures don’t include local and county budget losses and the individual financial struggles caused by business closures and unemployment.

SBC’s report justified focusing on the economic cost while calculating when to reopen. “It must be remembered that economics is not simply about dollars and cents,” the report notes. “There are, in fact, human consequences to a faltering economy. Job losses, lack of regular income, and other economic changes can increase rates of depression, suicide, and perhaps even social unrest. Examining the economic impact is not a cold, heartless thing to do, but an important factor to consider when determining the best way forward in a global pandemic.”

Health care advocates, by and large, are cautioning against reopening too soon.

On its website, the Centers for Disease Control and Prevention says that “in order to get and keep America open, states, tribes, localities and territories must be able to quickly identify new cases, break chains of transmission and protect first responders and health care workers from infection.”

But the agency at the front line of confronting disease outbreaks in the country — which happens to be based in Atlanta, the capital of a state whose governor started reopening last week — stops short of establishing a hard and fast rule about when opening is safe.

“CDC makes recommendations, shares information and provides guidance to help slow down the spread of COVID-19 in the U.S., including guidance for schools and businesses,” the website notes. “CDC regularly shares information and provides assistance to state, local, territorial and tribal health authorities. These local authorities are responsible for making decisions including ‘stay at home’ or ‘shelter in place.’ What is included in these orders and how they are implemented are also decided by local authorities. These decisions may also depend on many factors such as how the virus is spreading in a certain community.”

How fast is coronavirus spreading in Alabama? It’s really hard to be sure. There are numbers of reported cases, including deaths, but Alabama is lagging far behind other states in the number of people tested for coronavirus infection — although that may be changing.

The Critical Factor: Testing

Ivey said in a press conference on April 21 that testing is one of the biggest influences in her decision on Alabama’s stay-at-home order. The state has not been able to get enough testing kits for a large-scale testing effort, like the rest of the nation, and Ivey said only about 1% of Alabama’s population has been tested.

“Before we can get fully open and fully operational, we’ve got to increase our testing capacity,” Ivey said at that press conference. “All the decisions I’m going to make are going to be based on data — not on a desired date.”

Up to now, CDC and state health department guidelines both say to use tests only for people showing symptoms to conserve resources.

The World Health Organization, by contrast, has recommended that an overall positive rate of 10% or fewer of tests is what states or countries should aim for, to show the scope of the disease’s spread through the entire population rather than simply testing obvious cases.

That standard has not been met nationwide, but Alabama has not been as hard-hit as some other states. Out of the 71,344 tests performed statewide so far, only about 8.7% have returned positive for COVID-19, meeting the WHO’s guidelines.

The White House’s guidelines for states is to look for 14 days of a downward trend in new cases before lifting stay-at-home orders or beginning to relax social distancing rules on businesses and individuals.

According to the ADPH’s online dashboard tracking coronavirus cases, Alabama has not met that standard yet. The daily case rate has fluctuated in the last two weeks of data, as high as 324 cases on April 12 and 297 on April 22 and as low as 83 cases on April 18. This past Friday, April 24, marked 200 new cases, and the number increased to 219 additional cases on Sunday. The seven-day moving average of new cases per day stood at 216.86 on Monday, increasing four out of the five previous days.

A BirminghamWatch story points out that Alabama had tested 1.07% of its population as of April 24 citing an analysis of health department data. A new Harvard study suggests the state would need to increase its testing more than threefold to get an adequate handle on the coronavirus outbreak.

Speaking of that Harvard study, Ashish Jha, director of the Harvard Global Health Institute told STAT, a health care news site, that to calculate the proper number of tests, “You have to base it on the size of the outbreak in a state.” STAT asked the institute to calculate the number of tests a given state would need to be doing as of May 1, then compared those numbers to that state’s daily testing totals — taken from data collected by the Covid Tracking Project — during an average week in mid-April.

Based on those calculations, Alabama would have to perform 2,750 tests each day to be prepared to reopen after May 1. As of Sunday, a total of 73,732 tests have been performed in the state, leaving a daily testing gap of 652 tests.

Also looking at the Harvard calculations, Dr. Rachael Lee of UAB said that testing is critical to contain the spread of coronavirus. “UAB has tested over 2,000 people for COVID-19. That’s an incredible feat for so short a period of time. But that’s not enough,” she said.

“What you want is the number of tests and the percentage that is positive is less than 10%. In March, our rates were close to 20% positive. Those have gone down to about 9% for those who are symptomatic and are given a test. So we’re getting there,” Lee said.

Another factor in determining how many are infected in Alabama is that there has been even less testing among the population in the state most likely to contract and most likely to die from COVID-19. Dr. Mona Fouad, director of the UAB Minority Health and Health Disparities Research Center told BirminghamWatch it is likely that we still don’t know the real number and spread of COVID-19 cases in Alabama because access to testing is limited for the poor and minority population most likely to be exposed.

Monday, UAB announced that it would begin rolling out mobile testing this week. ”What we know is we can only test what’s currently in our hospital, but there are many people who cannot get access to this test,” Lee said. “So being able to deliver this test platform to them is incredibly important for knowing what‘s going on in the community and containing the spread of COVID-19.”

Democratic Alabama Sen. Doug Jones applauded Ivey’s determination to take a measured approach to opening the state, but he also alluded to the testing shortfall.

“Everyone wants to get our economy rolling again and I understand the incredible pressure the Governor is facing to rush this process and follow our neighboring states,” Jones said in a press release. “Her remarks today about the importance of having more testing capacity than we currently have and putting our citizens’ health care needs first are spot-on….Even with all the success we’ve seen, we need to be mindful that we are by no means out of the woods yet.

“We must ensure we can sustain the good progress we have made on the health care crisis, but we can only do so if we have a strong testing regime in place, reduce cases for two consecutive weeks, and continue social distancing practices before we can responsibly and safely re-open our economy for business.”

 Open in Birmingham?

Birmingham has been operating under a shelter-in-place order, but that will expire Thursday in favor of Ivey’s new rules. The City Council did pass an ordinance Tuesday that requires people in the city to wear face masks in public settings.

Birmingham Mayor Randall Woodfin said during a telephone town hall call with a group of neighborhood and faith leaders on April 23 that he had been seeing indicators that compliance with the shelter-in-place order and social distancing helped keep infection rates manageable in the city. He has spoken with Birmingham hospitals and heard rates of patients admitted and ventilators needed have stayed mostly steady in recent days.

“The one I’m most encouraged about is our hospitals,” he said.

There have been 822 cases in Jefferson County so far, second only to Mobile County with 885.

But Woodfin said that, while he is encouraged by the hospitals’ capacity to treat patients, testing levels are not sufficient to give the amount of information he would like to have.

“We don’t have the necessary information we need today around symptoms and cases to adequately assess should we extend or not extend,” he said.

Dr. David Hicks of the Jefferson County Department of Health spoke of the limited testing kits and protective equipment during the same town hall. Hicks said about 1.4% of the county has been tested so far, “which is definitely wholly inadequate.” The ADPH’s April 25 report stated that 12,476 people have been tested in Jefferson County, more than any other county.

“We definitely need a lot more testing in the community,” Hicks said.

The county health department is taking steps this week to expand its testing efforts, Hicks said, now that the Centers for Disease Control and Prevention has approved a method of self-testing that reduces the need to interact with health workers. The county and UAB are also starting a mobile testing program this week, he said, which will first be sent to Center Point, which is a “hot spot” according to UAB testing data, and later to other underserved parts of the county.

On the economic front, Woodfin said Birmingham’s sales, lodging, use and occupational tax revenue are “being hit pretty hard” due to the decrease in consumer spending. Those make up “about 80 cents of every dollar that comes into Birmingham,” and he’s not sure what next year’s budget, starting July 1, will look like at this point.

“We’ve probably taken a significant hit in the month of April. And we won’t know the numbers of how hard we were hit in April until the end of May,” Woodfin said.

Other Views

As states grapple with the question of when to go back to normal, other organizations are weighing in. For instance, the Institute for Health Metrics and Evaluation has reviewed coronavirus protection efforts state by state and given its own recommendations for reopening. The IHME’s current recommendation, updated April 22, is that Alabama delay reopening until May 19 and continue to use social distancing, testing, contact tracing and isolation after that date to prevent a resurgence in cases.

By contrast, the IHME says Georgia — which has already begun reopening despite a higher number of cases — should not have started relaxing its restrictions until June 22.

The American Enterprise Institute’s March 28 “Road Map to Reopening” report, which is included in the Alabama Small Business Commission’s report on the coronavirus situation, recommends a phased approach. The AEI recommends states begin to reopen businesses and activities when hospitals can safely handle treating patients at current infection rates. Social distancing, use of face masks, limited gatherings and isolation for high-risk individuals should be continued until more effective treatments or a vaccine are available to the public.

The White House also has a phased plan for states to reopen. Once states can show a 14-day decline in positive COVID-19 tests and COVID-like cases, as well as the ability for hospitals to provide testing for its workers and treat all patients without crisis measures, they can start to reopen businesses and public areas, under the White House guidelines.

As with the SBC and AEI reports, the White House “Opening Up America” plan recommends social distancing and limits on group gatherings in this first phase. Employers should still encourage remote work or limited staff, and facilities such as nursing homes and schools would be closed to the public.

If there’s no sign of a resurgence in cases and states meet the criteria a second time, they could begin allowing some larger gatherings, non-essential travel, reopening of school and youth activities, and reopening of venues such as bars and entertainment sites with limited capacity.

After meeting the criteria a third time, businesses could operate mostly without limitations, though sanitation protocols are still recommended.

Alabama’s governor while announcing a measured reopening also said acknowledged that the virus is a continuing threat.

“Let me be abundantly clear,” she said in Tuesday’s press conference. “The threat of COVID-19 is not over. We’re still seeing the virus spread, and all of our people are susceptible to the infection. The greatest disservice for the people who might be watching me here today is to think that by lifting the comprehensive health restrictions, this might be a sign that there’s no longer a threat of COVID-19. Folks, we must continue to be vigilant in our social distancing both today and for the foreseeable future,” Ivey said.

Robert Carter and Hank Black also contributed to this report.