For months, the United States has been battling what has become the world’s largest and deadliest coronavirus outbreak.
And for months, the U.S. has been telling itself a relatively simple, optimistic story about its struggle with the pathogen.
The story goes like this:
Yes, things got bad. But mostly they got bad in big, crowded, blue states and cities: New York, Seattle, Boston, Los Angeles, Chicago, Detroit, New Orleans and so on. After seven weeks of lockdown and social distancing, the rest of the country — the rural areas, the inland areas, the heartland — seems to have been mostly spared. The virus never really took off there.
Now, the story continues, cases and deaths are going down nationally. COVID-19 is on the decline. It’s time to reopen the economy, especially in the least hard-hit states. And as long as we reopen the right way — carefully, in phases, with different timelines in different places — then the situation will continue to improve.
But what if this comforting tale isn’t true?
The latest data suggests it might not be. The future course of the epidemic is uncertain. But in recent days, new numbers from a variety of sources — including the Trump administration — have undercut each of the assumptions at the heart of this hopeful narrative, hinting that the trajectory of COVID-19 could still take a turn for the worse.
Infections and deaths are not declining. Red America has not necessarily been spared. And the worst may not be behind us.
Myth: Infections and deaths are declining.
Reality: Infections and deaths have been holding steady, even in lockdown.
Remember “flattening the curve”? It was the collective battle cry — the viral slogan, the epidemiological meme — of America’s initial engagement with the coronavirus. The idea was that a few weeks of distancing and enhanced hygiene would slow the spread of the pathogen enough to prevent deadly overloads at hospitals and give the public health system precious time to prepare.
For the most part, it worked. Some hospitals in New York City were overwhelmed with cases in March and April, but the flood never reached most other cities, and even in New York it has receded. Now the time it takes nationwide deaths to double has lengthened from every two or three days to every four weeks.
That’s good news. Or rather, it was good news. The bad news is that this national “flattening” stalled weeks ago. Despite a nearly universal slowdown in normal activities, which has devastated the U.S. economy, the spread of the virus has settled into a stubborn plateau rather than continuing to fall.
Consider the daily case and death counts. Day after day, the number of new reported infections has been roughly the same: about 25,000 to 30,000. On April 2, 28,058 new cases were logged; on May 2, that number was 30,038. This means that for at least the last month, with 95 percent of the U.S. population under some form of social distancing orders, the cumulative number of cases has been growing by an average of 2 to 4 percent each day.
Testing levels have increased over that period too, and it’s possible that more cases are popping up because more people are being tested. Yet death counts, which aren’t as dependent on testing levels, have been holding steady as well. After the first week of April, the number of daily deaths started to average about 2,000. That’s where they’ve been ever since. In fact, the U.S. has reported slightly more coronavirus deaths in the last week (12,782) than in the week before (12,039).
The point isn’t that the U.S. outbreak has stood still. The point is that it hasn’t. In mid-April, the New York metro area was routinely adding more than 10,000 cases per day by itself. Now it’s routinely adding half that number, and its seven-day average has been declining for weeks.
For the national daily case count to stay the same, other areas must be making up the difference. According to the New York Times, if you remove the epicenter of the U.S. outbreak (i.e., New York) from the equation, the number of new daily cases across the rest of the country is climbing — from about 15,000 in mid-April to more than 20,000 today.
In other words, the virus isn’t receding. It’s relocating.
Myth: Red America has been spared.
Reality: Coronavirus is coming for red America too.
It’s no secret that blue states, with their big, dense cities and heavily trafficked transportation hubs, have borne the brunt of this pandemic. According to a Kaiser Family Foundation report released in late April, the number of infections and deaths per capita in states with Democratic governors were (respectively) more than double and triple the corresponding rates in states with Republican governors.
But the same report told a different story when it came to the direction the virus was heading. While blue-state cases had increased 63 percent from April 13 to April 27, red-state cases had increased 91 percent; while blue-state deaths had increased 104 percent, red-state deaths had increased 170 percent.
That gap has likely widened since late April. According to the New York Times, the only states where daily cases are clearly declining are on the post-peak Eastern Seaboard (New York, New Jersey, Massachusetts, Connecticut, Rhode Island, Delaware), in the sparse Mountain West (Montana, Wyoming, Idaho, South Dakota, Colorado) or in the middle of the Pacific Ocean (Hawaii). With the exception of Arkansas, the rest of the country is either plateauing or climbing, and some of the sharpest upticks seem to be in places like Iowa, Nebraska, Kansas and Minnesota.
A site called Rt.live (which was developed by the co-founder of Instagram) confirms this development. By tracking Rt — the effective growth rate of the virus as expressed by the estimated number of people one infected person subsequently goes on to infect — Rt.live is able to gauge, roughly, how COVID-19 is spreading at the state level. Rt values over 1.0 mean we should expect more cases in that area; values under 1.0 mean we should expect fewer. (Rt is similar to the more-familiar R0, but the former measures real-time changes in the virus’s spread; R0 — or “R-naught” — is a fixed value inherent to a particular disease.)
The four states with the highest current Rt values are Nebraska (1.06), Minnesota (1.06), Wyoming (1.03) and Iowa (1.02). Wisconsin and Kansas are also at or above 1.0, and most other rural states show a possible range of Rt values that cross the 1.0 threshold.
The news from the heartland jibes with these numbers. Dakota County, Neb., had no known cases as recently as April 11. Now, driven by outbreaks at meat-processing plants, it has the third-most cases per capita in the country. Trousdale County, Tenn., another rural area, suddenly finds itself with the nation’s highest per capita infection rate by far. “A prison appears responsible for a huge spike in cases,” reports the New York Times. “In 10 days, this county of about 11,000 residents saw its known cases skyrocket to 1,344 from 27.”
Other hot-spot counties include Nobles, Minn. (home of the JBS pork plant); Cass, Ind. (a Tyson meatpacking plant); and Moore, Texas (a JBS Beef meatpacking plant), where the known infection rate of 19.91 per 1,000 residents far outpaces every other county in the state and is roughly 13 times higher than the rate in the Houston metro area.
Anyone tempted to dismiss these rural outbreaks as outliers confined to prisons and plants, where social distancing is all but impossible, should think again. That may be where they start. It isn’t necessarily where they end.
As the Texas Tribune recently reported, the “spread of the virus is not isolated to the meatpacking plant floors, reaching out into communities when workers wrap up their shifts and head home. Members of the community in Moore County, including church workers whose family members work at the plant, have also tested positive.” New outbreaks keep emerging in grocery stores, Walmarts, nursing homes and factories as well.
Instead, these new rural hot spots should probably be seen as harbingers of things to come — what happens when restrictions are relaxed and people resume assembling in the midst of a pandemic, long before the advent of a vaccine.
Which is happening a lot faster in red states than blue states — even in red states, like Nebraska, Iowa, Kansas, Indiana and so on, where the daily infection and death rates are still going up.
This isn’t to say Nebraska, with its much smaller and more dispersed population, is the next New York. But the risks remain. Twenty percent of nonmetro residents are older than 65, compared to 15 percent in metro areas, and rural residents under 65 are more likely to have preexisting health conditions (26 percent) compared to their urban counterparts (20 percent).
Meanwhile, as states reopen, their capacity to contain flare-ups will depend on their ability to test, trace and isolate infections. But rural states are less prepared for that complex public health challenge, and isolated hospitals lack the capacity to meet a surge of patients needing ICUs.
Assumption: The worst is behind us.
Reality: Who knows.
Two weeks ago, President Trump predicted that “we’re going toward 50 or 60,000” deaths from COVID-19. Then on April 27 he said the U.S. is “probably heading to 60,000, 70,000.” In both instances, Trump was contrasting those numbers with earlier models that estimated more than 100,000 deaths, claiming that if the count stayed below that threshold, “we all together have done a very good job.”
On Sunday, however — with the U.S. death toll nearing 70,000, which it has since exceeded — Trump again revised his estimate upward, admitting that deaths could reach 100,000, or twice as many as he had forecast in April.
“We’re going to lose anywhere from 75, 80 to 100,000 people,” Trump said in a virtual town hall on Fox News. “That’s a horrible thing. We shouldn’t lose one person over this.”
To point this out isn’t to play “gotcha” with the president. It’s to show how the steady pace of the virus’s growth, even in lockdown — along with its whack-a-mole geographical spread — is making it difficult for anyone to gauge whether we’re really past the peak.
Modeling the future course of the epidemic is fluid, but the estimates are trending upward. The Institute for Health Metrics and Evaluation at the University of Washington is now forecasting that there will be nearly 135,000 deaths in the U.S. through the beginning of August — more than double what it forecast on April 17, when it estimated 60,308 deaths by Aug. 4.
The institute wrote Monday that the revisions reflected “rising mobility in most U.S. states as well as the easing of social distancing measures expected in 31 states by May 11, indicating that growing contacts among people will promote transmission of the coronavirus.”
And even though Trump is publicly pushing for states to reopen, an internal document based on government modeling and obtained Monday by the New York Times shows that there could be “a steady rise in the number of coronavirus cases and deaths over the next several weeks” as a result, with the daily death toll potentially reaching about 3,000 on June 1, a 70 percent increase from the latest number, and as many 200,000 new cases each day by the end of the month, up from about 25,000 cases a day currently.
The administration has disavowed that document, calling it an unvetted draft report. Yet whatever the exact numbers turn out to be, almost no one is still claiming that reopening will bring them down — not even the Republican governor of Texas, Greg Abbott, who admitted during a private call Friday that “every scientific and medical report shows” state reopenings “ipso facto” lead to an increase in coronavirus cases, even as he publicly announced plans that same week to end an executive stay-at-home order in the state, according to the Daily Beast.
“Listen, the fact of the matter is pretty much every scientific and medical report shows that whenever you have a reopening — whether you want to call it a reopening of businesses or of just a reopening of society — in the aftermath of something like this, it actually will lead to an increase and spread,” Abbott said during a Friday afternoon phone call with members of the state Legislature and Congress. “It’s almost ipso facto.”
“The more that you have people out there, the greater the possibility is for transmission,” Abbott continued. “The goal never has been to get transmission down to zero.”
Abbott is likely correct on both counts — reopening will increase infections, and there was never a realistic hope we could end transmission entirely. But are Americans, especially Americans who believe they’ve dodged a bullet, prepared to accept the implications of those twinned truths?
Lockdown can’t continue forever. The economic repercussions are too dire. So perhaps the U.S. should start telling itself a new story — one that doesn’t involve defeating “the invisible enemy” but rather learning to live with it and mitigating its spread.
Click here for the latest coronavirus news and updates. According to experts, people over 60 and those who are immunocompromised continue to be the most at risk. If you have questions, please refer to the CDC’s and WHO’s resource guides.