By the time Florida's stay-at-home order kicks in on 2 April, two weeks after the arrival of thousands of spring breakers on the state's beaches, the number of identified coronavirus cases in the state climbed past 5,000.

Arizona's governor issued a stay-at-home order this week after banning cities from setting their own measure, tying the hands of mayors across the state against the advice of health officials.

Without a nationwide order to keep people indoors and close non-essential businesses in an effort to curb the viral spread through stringent "social distancing" measures, a staggered and patchwork response from state governments has made attempts to quarantine Americans essentially moot.

By April, 12 states have not issued statewide orders to stay at home, and 12 states have not closed so-called "nonessential" businesses.

But there remains a handful of states without either of those orders, on neither state or city levels, as health officials across the US continue to urge people to stay indoors and avoid going outside and risk interacting with infected people or unknowingly infecting others.

Republican governors in Arkansas, Iowa, Nebraska, North Dakota and South Dakota — the last states standing — said they're not considering virtual "lockdowns" in their respective states.

Asked why he hasn't considered a national order, Donald Trump said "because states are different" and that "some states don't have much of a problem."

At a White House briefing on 1 April, he said: "They don't have thousands of people that are positive or thousands of people that think they might have it, or hundreds of people in some cases." (This week, South Dakota became the last state to report more than 100 cases.)

Whether the White House or local governments put orders in place in coming days, experts say the damage is done. Harvard professor Juliette Kayyem, a former US Department of Homeland Security official in the Obama administration, said it's time for a national stay-at-home measure — at least three weeks ago.

She said: "The fat lady has sung, govs."

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Asked whether every state would have a stay at home order, US Surgeon General Jerome Adams told NBC that the White House suggestions ("30 days to slow the spread") are essentially a "national stay-at-home order."

He said that the administration wants "nationally people to understand the importance of social distancing" and is leaving those guidelines to states to determine their plans.

But virologist Joseph Fair told the network that those mitigation efforts only work "if all 50 states are doing the same thing."

He said: "Everybody gets on the same page as far as what they're going to do and everybody implements the same measures."

But even if that starts now, those "social distancing" rules would need to be in place for at least 10 weeks to be effective.

He said: "If everyone is not doing it, there are still going to be people spreading it. There are things we're going to have to do — we have to go to the grocery store, we have to go to the pharmacy. There are people working in hospitals. But we can all do our own part and everyone has to do it."

Arkansas is the last state in the south without any statewide measure. Neither Governor Asa Hutchinson nor any county or city in the state has told residents to stay at home.

She said: "I do not want to go to a shelter-in-place environment."

On 1 April, Nebraska Governor Pete Ricketts ordered schools to continue operating, without students, but he has refused a statewide stay-at-home order. There are no such orders in the rest of the state.

Words at the window: Social isolation and the Coronavirus Show all 12 1 /12 Words at the window: Social isolation and the Coronavirus Words at the window: Social isolation and the Coronavirus Agnetha Septimus, Matthew Septimus, and children Ezra and Nora Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Husband and wife filmmakers, Claire Ince and Ancil McKain pose for a portrait for the series by Shutterstock Staff Photographer, Stephen Lovekin, shot around the Ditmas Park neighborhood of Brooklyn, New York Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Khadijah Silver and son Eliot Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Anna Beth Rousakis and daughter Mary Rousakis Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Mike Pergola and Denise Pergola with children Henry, Jack, and Will Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Artist Shirley Fuerst Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Jean Davis and Danny Rosenthal, with children Simone, Naomi, and Leah Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Robert E Clark Jr Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Lisa Draho and Josh Zuckerman, with children Ruby and Ava Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Professor and activist Dr Kristin Lawler Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Tom Smith and Laura Ross, with daughters Caroline, Elizabeth, and Abigail Stephen Lovekin/REX/Shutterstock Words at the window: Social isolation and the Coronavirus Callie Lovekin and Lucas Lovekin Stephen Lovekin/REX/Shutterstock

Many Americans fear the consequences of relative martial law under the Trump administration, forcing people in their homes and out of their jobs without the assurance of any social safety nets and as a cover for the administration's more authoritarian impulses.

But several state officials say they delayed or refused to tell their residents to stay home to keep their fragile economies moving, echoing the president's claims to "re-open" the economy and weigh the loss of lives against the loss of business.

Iowa Governor Kim Reynolds has ordered many, but not all, nonessential businesses to close, but won't issue a statewide stay-at-home order, despite calls from lawmakers and other officials, as 946 cases of the virus were identified in the state this week.

She said: "I can't lock the state down, I can't lock everybody in their home ... We have to make sure the supply chain is up and going. We have an essential workforce that has to be available.

"What else are we doing" by ordering people to stay home "except for potentially disrupting the supply chain, putting additional pressure on the essential workforce, and making sure that we are considering how we bring that back up?" Reynolds said. "And, actually, what's the benefit of taking that additional step?"

She has called for "personal responsibility" instead, saying that limiting "the amount of times that we're going out, what we're going out for, where we're going, and minimising the number of people that we're around, we will start to accomplish, hopefully, what we're trying to do."

Fourteen counties in Missouri have mandate stay-at-home orders and nonessential business closures, but Governor Mike Parson won't issue a statewide order.

He said it's a matter of "personal responsibility."

"When you start talking about shutting the state down for 30 days, 60 days or 90 days, the effects that has on everyday people are dramatic," he said. "That means businesses will close, people will lose their jobs, the economy will be in worse shape than ever."

Before and after photos show impact of coronavirus around the world Show all 20 1 /20 Before and after photos show impact of coronavirus around the world Before and after photos show impact of coronavirus around the world Top: Nabi Younes market, Mosul Bottom: Charles Bridge, Prague Reuters Before and after photos show impact of coronavirus around the world Grand Mosque, Mecca A combination photo shows Muslim pilgrims wearing protective face masks, following the outbreak of the coronavirus, as they pray at Kaaba in the Grand Mosque in the holy city of Mecca, Saudi Arabia March 3, 2020 (top) and general view of Kaaba at the Grand Mosque which is almost empty of worshippers, after Saudi authority suspended umrah (Islamic pilgrimage to Mecca) amid the fear of coronavirus outbreak, at Muslim holy city of Mecca, Saudi Arabia March 6, 2020. REUTERS/Ganoo Essa TPX IMAGES OF THE DAY GANOO ESSA Reuters Before and after photos show impact of coronavirus around the world Sagrada Familia, Barcelona A combination photo shows tourists gathering around Sagrada Familia basilica, before closing it and suspending its construction work as a precautionary measure due to the coronavirus outbreak in Barcelona, Spain March 11, 2020. Picture taken March 11, 2020 and an empty street of tourists as basilica stopped receiving visitors and suspend its construction work as a precautionary measure due to the coronavirus outbreak, in Barcelona, Spain March 13, 2020. REUTERS/Nacho Doce NACHO DOCE Reuters Before and after photos show impact of coronavirus around the world Nabi Younes market, Mosul A combination picture shows people shopping at the Nabi Younes market (top) March 11, 2020 and the empty market during a curfew imposed by Iraqi authorities, following the outbreak of coronavirus, in east Mosul, Iraq March 15, 2020. REUTERS/Abdullah Rashid ABDULLAH RASHID Reuters Before and after photos show impact of coronavirus around the world Basra Grand Mosque, Iraq A combination picture shows worshipers walking out after performing prayers at Basra Grand Mosque in Basra, Iraq March 12, 2020 and the mosque seen empty after a curfew was imposed to prevent the spread of coronavirus, March 17, 2020. REUTERS/Essam Al-Sudani ESSAM AL-SUDANI Reuters Before and after photos show impact of coronavirus around the world Charles Bridge, Prague A combination picture shows tourists walking across the medieval Charles Bridge in Prague, Czech Republic, November 7, 2019 and the bridge empty as the Czech government restricts movement of people to slow the spread of the new coronavirus disease (COVID-19), Czech Republic, March 16, 2020. REUTERS/David W Cerny DAVID W CERNY Reuters Before and after photos show impact of coronavirus around the world Taj Mahal hotel, India A combination picture shows the Taj Mahal hotel, November 25, 2018 and after the government tightened up measures for coronavirus prevention in Mumbai, India March 17, 2020. REUTERS/Francis Mascarenhas FRANCIS MASCARENHAS Reuters Before and after photos show impact of coronavirus around the world Dubai Mall, UAE A combination picture shows people at Dubai Mall (top), following the outbreak of coronavirus, in Dubai, United Arab Emirates, March 12, 2020 and the mall seen almost empty of customers, as precaution amid the outbreak of coronavirus, March 16, 2020. 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REUTERS/Danish Siddiqui/Francis Mascarenhas FRANCIS MASCARENHAS Reuters Before and after photos show impact of coronavirus around the world Cairo University, Egypt A combination picture shows students attending a lecture at Cairo University (top) in Cairo, Egypt, February 12, 2020 and seats seen empty at the lecture hall following government efforts to slow the spread of the coronavirus, March 15, 2020. REUTERS/Shokry Hussien TPX IMAGES OF THE DAY SHOKRY HUSSIEN Reuters Before and after photos show impact of coronavirus around the world Amman Citadel, Jordan A combination picture shows tourists posing for a picture at Amman Citadel, March 10, 2020, and the citadel seen empty after its closure to prevent the spread of the coronavirus in Jordan, in Amman, Jordan March 15, 2020. REUTERS/Muhammad Hamed MUHAMMAD HAMED Reuters Before and after photos show impact of coronavirus around the world Church of the Nativity, Bethlehem A combination picture shows visitors, wearing masks as a preventive measure against coronavirus, arriving at the Church of the Nativity in Bethlehem in the Israeli-occupied West Bank March 5, 2020, and the same area seen almost empty of people following the closure of the church to prevent the spread of the coronavirus March 6, 2020. REUTERS/Mussa Qawasma MUSSA ISSA QAWASMA Reuters Before and after photos show impact of coronavirus around the world Beirut March, Lebanon A combination picture shows people walking at Beirut's seaside Corniche March 15, 2020, and the corniche seen empty after Lebanon declared a medical state of emergency as part of the preventive measures against the spread of the coronavirus, in Beirut, Lebanon March 15, 2020. REUTERS/Mohamed Azakir MOHAMED AZAKIR Reuters Before and after photos show impact of coronavirus around the world Cairo, Egypt A combination picture shows school children leaving the primary school of Omar El Mokhtar in Cairo, Egypt March 11, 2020 and the school seen closed following government efforts to slow the spread of the coronavirus March 16, 2020. REUTERS/Rania Gomaa RANIA GOMAA Reuters Before and after photos show impact of coronavirus around the world Cairo University, Egypt A combination picture shows school children lining up at start of the day classes in Thamret Al Tawfiq School (top) in Cairo, Egypt March 8, 2020, and the school seen empty following government efforts to slow the spread of the coronavirus, March 15, 2020. REUTERS/Hanaa Habib STRINGER Reuters Before and after photos show impact of coronavirus around the world Victoria Memorial, India A combination picture shows the historic Victoria Memorial monument June 21, 2019 and after the government tightened up measures for coronavirus prevention, in Kolkata, India March 17, 2020. REUTERS/Rupak De Chowdhuri RUPAK DE CHOWDHURI Reuters Before and after photos show impact of coronavirus around the world Amman Citadel, Jordan A combination picture shows tourists visiting the Amman Citadel, March 10, 2020, and the citadel seen empty after its closure to prevent the spread of the coronavirus, in Amman, Jordan March 15, 2020. REUTERS/Muhammad Hamed MUHAMMAD HAMED Reuters Before and after photos show impact of coronavirus around the world Amman Citadel, Jordan A combination picture shows tourists visiting the pillars of the Roman Temple of Hercules at the Amman Citadel, March 10, 2020, and the citadel seen empty after its closure to prevent the spread of the coronavirus, in Amman, Jordan March 15, 2020. REUTERS/Muhammad Hamed MUHAMMAD HAMED Reuters Before and after photos show impact of coronavirus around the world Sidon, Lebanon A combination picture shows people playing cards inside a cafe, March 12, 2020, and the cafe seen closed after Lebanon declared a medical state of emergency as part of the preventive measures against the spread of the coronavirus, in Sidon, Lebanon March 16, 2020. REUTERS/Ali Hashisho ALI HASHISHO Reuters

North Dakota and South Dakota, with largely rural and spread-out populations, also don't have orders anywhere in their state telling people to stay at home or close nonessential businesses.

South Dakota — the last state to hit more than 100 cases — only has a ban on gatherings of more than 10 people.

Rural Americans live an average of 10.5 miles from the nearest hospital, while people in urban and suburban neighbourhoods live, on average, five miles away from a hospital, according to Pew Research Center.

But more than 1 million Americans live in rural areas at least 20 miles from the nearest hospital, and a majority of those residents are 60 and older and more prone to chronic illness, putting them in a more acutely at-risk population if exposed to Covid-19.

They largely live in states that do not have any stay-at-home orders in place.

More than 400 rural hospitals across the US are at risk of closing, as Republican-led governments have refused to expand Medicaid in their states leaving health systems to rely on negative margins, according to the Chartis Center for Rural Health.

Since 2016, 41 rural hospitals across the US have closed, mostly in the southeast and Great Plains.

More than 40 per cent of rural hospitals in Florida, Missouri, Mississippi, Tennessee and Texas are considered "vulnerable" to closure. Of that group, only Florida and Tennessee have ordered statewide stay-at-home measures.

Those hospitals could be bolstered by $100bn from Congress aimed at hospitals and health providers, though it's unclear how that will be allocated.

Texas, a large and rural state with several massive metropolitan areas, has stay-at-home orders in more than two dozen cities and counties, putting roughly 82 per cent of the state under shelter-in-place orders

Echoing the president's support for "reopening the US" by Easter, a timetable he has since withdrawn, Texas Lt Gov Dan Patrick was slammed for his Fox New appearance in which he suggested that senior citizens should be willing "take a chance on your survival in exchange for keeping the America that all America loves" by putting Americans back to work in the middle of the pandemic.

In a letter to Governor Greg Abbot, Democrats in the state have urged the governor to act: "Despite the hardship, the best science we have is clear that this is the best way forward for our state and our country."

He recently announced that religious services in Texas are considered "essential" after police arrested pastors in Louisiana and Florida for holding large Sunday ceremonies.

After Arizona Governor Doug Ducey barred cities in his state from setting their own orders, Tucson Mayor Regina Romero's office told The Independent that the city was exploring "all options" to set an order at the local level.

The state's emergency management director resigned last month citing a "lack of communication and transparency" through the coronavirus response.

The governor ultimately issued a stay-at-home order this week, but has left in place a broad list of businesses considered "essential" that can remain open.

Several other Democratic mayors in Republican states have issued citywide measures in the absence of statewide orders.

Mississippi Governor Tate Reeves has urged people to stay at home but has not made that an order. Oxford mayor Robyn Tannehill did.

Alabama Governor Kay Ivey has advised residents to "consider" staying home "now and for the foreseeable future" but has not issued a statewide order. Birmingham mayor Randall Woodfin did.

This week, Wyoming Governor Mark Gordon said the state still has no plans for an order. Jackson mayor Pete Muldoon's order went into effect "immediately" last week.

White House officials have praised stringent measures in hard-hit states and cities, but insist on respecting "statehood" in the face of the crisis.

Mike Pence told CNN: "At the present moment, we truly do believe that the strong actions taken in places like California and Washington and New York and New Jersey are appropriate ... We fully support those efforts."

The vice president said the administration is "going to continue to bring the president the best recommendations based on real-time data and science for what every state, what every community should be doing" but is aiming to "reopen" the country by early June and "put America back to work."

He said: "We could well have the coronavirus largely behind us."