Arizona has emerged as one of the country's newest coronavirus hot spots, with the weekly average of daily cases more than doubling from two weeks ago. The total number of people hospitalized is climbing, too.
Over the past week, Arizona has seen an average of more than 1,300 new COVID-19 cases each day.
After the state's largest hospital system warned about a shortage of ICU beds, Arizona Gov. Doug Ducey, a Republican, pushed back on claims that the health care system could soon be overwhelmed.
"The entire time we've been focused on a possible worst-case scenario with surge capacity for hospital beds, ICU beds and ventilators," Ducey told reporters on Thursday. "Those are not needed or necessary right now."
While he acknowledged a spike in positive cases, Ducey said a second stay-at-home order was "not under discussion."
"We put the stay-at-home order there so we could prepare for what we are going through," he said.
Some states have reopened more slowly with a set of specific benchmarks for different regions, but Arizona took a more aggressive approach.
The state began easing restrictions on businesses in early May and lifted its statewide lockdown order after May 15. Under Arizona's reopening plan, businesses are advised to follow federal guidance on social distancing.
There is also no requirement for everyone to wear masks in public.
Public health experts agree: The timing of this spike reflects the state's reopening.
"Perhaps, Arizona will be a warning sign to other areas," said Katherine Ellingson, an epidemiologist at the University of Arizona. "We never had that consistent downward trend that would signal it's time to reopen and we have everything in place to do it safely."
Before Arizona lifted its stay-at-home order, only about 5% of COVID-19 tests registered as positive. On Monday, that number was around 16%.
A slower reopening gives public health agencies time to identify whether cases are rising and then respond with contact tracing and isolating those who are infected.
"With a fast, rapid reopening, we don't have the time to mobilize those resources," said Ellingson.
Maricopa County, home to about 60% of the state's population, has ramped up contact tracing in recent weeks, but it may not have enough capacity if the surge in cases continues.
Dr. Peter Hotez said the spike in Arizona, as well as in parts of Texas such as Houston, Dallas and Austin, is the consequence of removing restrictions too quickly and without a public health system that can keep pace.
"It was just 'open it up' and then more or less business as usual, with a little bit of window dressing," said Hotez, the dean for the National School of Tropical Medicine at Baylor College of Medicine in Houston. "This is not an abstract number of cases. We're seeing people pile into intensive care units."
Arizona's governor has also faced criticism from the mayors of Arizona's two biggest cities for not putting in place more stringent requirements.
"There is a pandemic and it's spreading uncontrollably," said Tucson Mayor Regina Romero, a Democrat. Ducey, she said, "is just putting up his hands and saying 'the spread is happening and we just have to go about our business.'"
And the governor's executive order forbids local governments from implementing their own extra measures, which adds to Romero's frustration. Texas has a similar measure.
"What he did was pretty much tie the hands of mayors and public health officials," Romero said.
Arizona's hospital industry has tried to tamp down fears that it's on the verge of a crisis. Hospitals are still performing elective surgeries.
"It's very unfortunate because hospitals right now in Arizona are quite busy with elective procedures," said Saskia Popescu, a Phoenix-based epidemiologist with George Mason University. "You throw in increasing cases of COVID, and that's going to very much stress your hospital systems."
Phoenix's triple-digit summer temperatures actually may fuel the spread of the virus. People forgo outdoor activities and retreat to air-conditioned indoor spaces, where the risk of transmitting the virus goes up significantly.
"My concern is we're going to see a lot more people in close quarters for prolonged periods of time," Popescu said.
Since the stay-at-home order was lifted, Popescu and others say they've seen people returning to a pre-pandemic mindset, neglecting to wear masks or maintain social distance. Videos of crowded bars have only propelled these fears.
On Thursday, however, Arizona's top doctor stressed there were also dangers to keeping the state on lockdown, including the mental health effects of loneliness and isolation.
"We know that it's in the community. We are not going to be able to stop the spread. And so we can't stop living as well," said Dr. Cara Christ, health director for the Arizona Department of Health Services.
But Dr. Quinn Snyder, an emergency medicine physician in Mesa, Arizona, said there needs to be more consistent messaging on public health measures like wearing masks.
"Frankly, I just think a wholesale reevaluation of where we're at is critical right now, but I can tell you that we're not doing nearly enough," said Snyder, who has seen the uptick in seriously ill COVID-19 patients firsthand.
"If we continue to head down this path, the virus will press our health care facilities beyond capacity, where we're going to have to be making tough decisions like who gets a ventilator and who doesn't."
This story is part of a reporting partnership between NPR and Kaiser Health News.