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GRAND RAPIDS, Mich. - At Spectrum Health, a major health-care system here, officials spent part of last week debating whether to move to "red status" in a show of how strained hospitals had become.
A flood of mostly unvaccinated covid-19 patients was arriving at emergency departments already packed with people suffering other medical issues, sending capacity to unprecedented levels. The only hesitation for Spectrum's decision-makers? Data suggested the covid surge was not over.
"We don't have a darker color," said Darryl Elmouchi, president of Spectrum Health West Michigan. "So if we're red now, what are we in two weeks?"
He and other leaders ultimately decided Thursday to make the change, upgrading the health-care system to the most serious tier for the first time since the pandemic began. In recent days, the state had emerged as a new covid hot spot, leading the nation in new infections and hospitalizations. By the end of last week, its seven-day average of new cases had hit a pandemic high. State leaders asked the U.S. Department of Defense to provide emergency hospital staffing to handle the surge - a request granted Wednesday.
Coronavirus cases are on the rise nationally, an unwelcome trend after leveling off earlier this fall. On Monday, the United States reported a seven-day daily average of just under 93,000 cases - an 18% jump from a week earlier, according to figures from a briefing by the White House covid-19 response team. Hospitalizations were also up, increasing 6% to about 5,600 patients admitted per day.
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At least two dozen states have seen cases rise at least 5% in the past two weeks, with Michigan, Minnesota, New Mexico, New Hampshire and North Dakota each recording per capita jumps of more than 60%. Some highly vaccinated states, including Vermont and Massachusetts, were also seeing steep rises in cases.
The growing caseload across the country has raised the specter of another surge this winter - what would be the nation's fifth. Expert opinions vary, but Amber D'Souza, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, said a surge seems imminent. This one, though, could prove to be much milder than last winter's due to vaccines, boosters and therapeutics that were not available last year.
"We are absolutely heading into an additional wave this winter across the country that may hit at different times and it may be at different extents in different parts of the country," she said. "The good news is that we really do have hope that the toll from this wave this winter will be much less than last winter."
For now, Michigan appears to be experiencing the worst of it, with Minnesota following closely behind. The current surge is affecting "virtually every part of Michigan, both urban and rural," said Brian Peters, chief executive officer of the Michigan Health & Hospital Association, which represents all of the state's community hospitals.
In the two weeks between Nov. 8 and Nov. 22, cases in Michigan increased 86% and hospitalizations 37%, according to tracking by The Washington Post. The state on Monday reported 3,775 covid inpatients - more than anywhere else in the country.
Peters said current trends indicated the state could hit its peak of 4,640 hospitalizations, set in April 2020.
"Just doing the math, we are going to reach an all-time record high in hospitalizations in the not-too-distant future if this current surge does not reverse course," he said. "And we're not seeing anything that would tell us it's going to reverse course any time soon."
There were 4,090 covid patients in the state as of Wednesday.
In what feels like a flashback to an earlier phase of the pandemic, hospitals are now deferring nonessential procedures, adding beds, limiting visitors and warning of increased wait times. Some school districts canceled classes in the days leading up to Thanksgiving, pointing to increased cases and staffing shortages. The state Department of Health issued an advisory recommending everyone over 2 years old wear a mask, regardless of vaccination status.
The surge can be attributed to several factors. The baseline for cases was already high toward the end of the summer, said Spectrum Health's Elmouchi. Cold weather is driving more gatherings indoors, and a sizable portion of the public has stopped adhering to strict mitigation measures that were once common.
Hospitals in Michigan, like in other states with recent surges, are largely filled with people who have not gotten the coronavirus vaccine. The unvaccinated made up about three-quarters of cases, hospitalizations and deaths in the 30 days ending Nov. 5, according to the state health department. About 54% of Michiganders are fully vaccinated, trailing the national figure of 59%.
At this point in the pandemic, months after the shots became widely available, the state's health-care workers expected to see occasional ebbs and flows in case numbers. But not at this level.
"I think all of us had hoped that with relatively reasonable vaccination rates - and a year-plus under our belt - we would not get another surge like this," Elmouchi said.
Spectrum reported more than 370 people hospitalized with covid last week. The system has converted floors and tripled its intensive care unit space, yet there are still patients waiting for beds. Conference space and shared workspaces have been identified for conversion if the surge continues as expected. Elmouchi described the situation as "almost unmanageable."
The crisis echoes recent setbacks in other pockets of the country. Earlier this month, the number of covid-19 patients in parts of Colorado matched peaks from late last year at the same time previous southern state hot spots, like Florida and Texas, saw marked declines in cases.
"Part of that is just how our behavior changes as things get colder and we are in more places inside and in close proximity to people where infection spreads," D'Souza said. "The underlying issue is the same nationwide: The pandemic is not over."
In Michigan and Minnesota, members of the medical community said the current surge is in some ways more challenging than what they experienced late last year. Hospitals are filled not just with covid-related cases but also with everyone else. A high volume of non-covid patients are seriously ill, after many delayed medical care in the earlier months of the pandemic, officials said.
Staffing shortages that have worsened during the pandemic also mean hospitals don't always have enough people to handle the surge of patients.
A health-care coalition representing 13 counties in West Michigan warned last week of the possibility for lengthier emergency room wait times, delayed ambulance transfers and deferred surgeries. In a Nov. 17 letter to the public, the Region 6 Healthcare Coalition said hospitals and EMS systems were operating at extremely high capacity, describing the situation as being at "a tipping point."
One hospital has been putting adult patients in a pediatric hospital due to space constraints, while smaller hospitals have been unable to transfer patients to larger ones, said Jerry Evans, the coalition's medical director and author of the letter.
"We're in a pretty serious condition right now," Evans said. "Our hospitals can handle it at the moment, but they're handling it by doing extraordinary measures."
In Minnesota, hospitalizations were also approaching levels not seen in nearly a year. As of Monday, the state had the nation's third-highest number of total new cases per capita and 1,518 covid-related hospitalizations, according to data tracked by The Post. There have not been more than 1,500 covid patients hospitalized statewide since December 2020.
"This surge for us felt a little more like a slow burn as opposed to a rampant forest fire," said George Morris, incident commander for covid-19 response at CentraCare, a central Minnesota health-care system. "During this fall, it's just been a steady incline. However, over the past two weeks, it is a forest fire - we really saw that rate of rise go up rapidly."
Morris said the strain at St. Cloud Hospital, the system's main large hospital, has had a domino effect across the region.
"At times we've had to divert people or defer them, and that means patients are having to stay and be cared for in place at small rural hospitals, many of whom are associated with us, or other regional facilities where they can't send them to us for needed care," Morris said. "So patients stay in their small facility, and people do the best they can."
Ulrika Wigert, a family practice physician who has worked at CentraCare - Sauk Centre for 19 years, said the last six weeks have been "just unprecedented from anything we've had to deal with in medicine before this point."
The small hospital usually treats five to six patients a day and is now routinely seeing nine to 13. The current crisis point, she said, "doesn't compare at all" to earlier pandemic surges. Covid patients are now younger and require more oxygen than last year, she said. People were also staying home in 2020 and the system saw few, if any, cases of flu or other respiratory illnesses - unlike this year, when they are widely circulating.
The University of Michigan said earlier this month it was dealing with more than 500 flu cases, an outbreak that prompted the Centers for Disease Control and Prevention to deploy a team to the Ann Arbor campus.
"Our biggest fear has always been a double surge - influenza and covid," Evans said.
Michigan residents expressed varying levels of concern about the state's covid status.
Claire Goodman wore a mask Monday while heading to an appointment in the Grand Rapids suburb of Ada. She said that although she and her husband are vaccinated, she still worried: Her parents are in their 70s, one of her children is too young for the vaccine and the other has a condition that makes her susceptible to the virus.
Her family was still mostly staying home. They had recently looked at photographs of life before covid, marveling at memories of swimming lessons and dance recitals they now haven't experienced in almost two years.
Before her appointment, she had called ahead to ask whether her doctor would be wearing a mask, she said, and if the answer was no, "I was going to cancel and find somebody who would."
At Woodland Mall in Grand Rapids, a handful of shoppers wore masks, and some stores had hand sanitizer stands or signs announcing capacity limits set up outside. Gabi Labioda, a health-care worker shopping with her younger sister, said Michigan's emergence as a covid hot spot had her family rethinking holiday plans.
"We think we're putting the kibosh on Thanksgiving," she said.
But Gordy Fransen, who was strolling the mall with plans of catching a movie later, said he thought the risks were being overstated. He had worn a mask when it was mandated but had mostly returned to normal life.
"I like being able to go to the mall, go to a movie, go out to eat, go to the casino and not have to wear a mask," he said.
D'Souza, of Johns Hopkins, said it's hard to pinpoint one reason the virus is still spreading because "there are multiple factors and they vary by place and time." At this point, she said, "we're not working toward eradication, we're working toward containment. ... Right now we have to try to suppress, but live with it."
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The Washington Post's Jacqueline Dupree contributed to this report.