Why are COVID-19 cases soaring in the Midwest?

The United States does not have one coronavirus pandemic, it has 50.

Over the last three months, states have begun to display distinct local and regional outbreak patterns. New England, for example, has had relatively low caseloads, with Maine and Vermont recording zero deaths for days on end. The Northeast — New Jersey, New York and Massachusetts — took the bulk of the nation’s COVID-19 cases in April, then recovered and are now showing a steady rise in cases.

So far, the most distinct regional pattern as the virus enters its third wave is happening in the Midwest. On Wednesday, hospitalizations reached the highest levels yet in North Dakota, South Dakota, Nebraska, Minnesota, Wisconsin, Iowa, Missouri and Ohio.

Adjusted for population, the Midwest’s cases surpassed the peak New York and New Jersey saw in April. Of the 15 cities with the highest rate of new infections over the last two weeks, 11 are in North Dakota or Wisconsin.

The most alarming thing about the Midwestern outbreak is not its severity, but its grim predictability.

“Virus transmission dynamics are pretty clear at this point,” said Anne Rimoin, an epidemiology professor at the UCLA Fielding School of Public Health. “We know that indoor gatherings with individuals from multiple households where people are unable to social distance and are not wearing masks are risky.”

And despite having months to prepare, Midwestern governors have taken steps that exacerbate the spread of the coronavirus, with no impetus from national leaders to do otherwise.

Why The Midwest?

It’s tempting to blame the Midwest outbreak on factors outside of states’ control. Over the last three months, the coronavirus pandemic has generally moved from cities to suburban and rural areas. Many Midwestern states are sparsely populated and dotted with the kind of remote, midsize communities now emerging as a vulnerability for the virus.

Plus, it’s getting colder, and residents are abandoning outdoor gatherings and struggling to socially distance. The trend in the Midwest follows a nationwide rise in caseloads as Americans relax measures they’d taken earlier in the pandemic.

The problem with this explanation, though, is that it doesn’t account for the vast disparity between the Midwest and other regions with roughly similar conditions. Maine and Vermont are plenty cold and plenty rural, but they have roughly one-28th as many new daily cases as South Dakota. Wisconsin, with roughly 6 million inhabitants, has roughly the same number of new cases every day as California, with 40 million.

There are also noteworthy disparities within the Midwest. On Wednesday, Indiana had roughly 250 people hospitalized for every 1 million residents. Iowa had 600. New cases ranged from 1,469 per million residents in South Dakota to 224 per million in Ohio.

More testing can’t explain the increase either. North Dakota’s testing rate is roughly stagnant even as infections explode. If more testing was generating more cases, positivity rates would be falling. Instead, they are rising to troubling new heights.

On Wednesday, 27% of residents tested for COVID-19 in Wisconsin came back positive.

It’s The Policies, Stupid

One of the most consistent findings of the coronavirus pandemic is that policy differences matter. Across the country, COVID-19 cases are surging in states where political leaders have refused to implement the baseline guidance of local experts and the Centers for Disease Control and Prevention, like lockdown orders and restrictions on public gatherings.

Most Midwestern states have Republican governors who lifted lockdown orders early in the pandemic and have refused to reimpose restrictions even after caseloads surpassed their early-pandemic peaks. Missouri Gov. Mike Parson resisted imposing lockdown, then reopened businesses in early May — then tested positive for COVID-19 in September. South Dakota Gov. Kristi Noem never issued a lockdown order and even invited residents of lockdown states to visit her own.

Wisconsin Gov. Tony Evers, a Democrat, did impose a lockdown order in April, but the state Supreme Court struck it down a few weeks later. Evers tried imposing limits on public gatherings and capping bar and restaurant capacity, but a district court stayed the order after a challenge from business owners and pro-life groups.

Midwestern governors have also allowed large events, including the Sturgis Motorcycle Rally (which is now linked to a regional outbreak). Donald Trump has also organized campaign rallies in Wisconsin, Ohio, Michigan and Iowa. A Center for American Progress analysis found that roughly half of these rallies led to county-level COVID-19 outbreaks.

Pandemic Fatigue

The final reason for the Midwestern spike in COVID-19 cases could simply be that it has not happened there before.

Andreas Handel, an epidemiologist at the University of Georgia, said one of the reasons cases have stayed relatively low in the Northeast is the severe outbreak early in the pandemic. The sight of overflowing hospitals and triple-digit daily death counts could have made residents of New York, New Jersey and Massachusetts more willing to take precautions.

“People got scared enough to change their behavior, which led to less transmission and cases dropping — for a while,” Handel said. “Over the summer it hit the Southeast and we saw the same pattern: High case numbers left people sufficiently scared to do something, which led to cases dropping. Now it’s the Midwest’s turn.”

The third wave, however, won’t be like the first two. Local economies, already cratered by the pandemic, may not come back to life for months if outbreaks continue. Hospital staff, too, are exhausted and increasingly frustrated. On Thursday, the Milwaukee Journal Sentinel reported that the state would run out of ICU beds in as little as two weeks. Roughly 10% of health care workers in Wisconsin have contracted the virus.

“Our health system cannot be the unlimited backstop for COVID,” Eric Borgerding, the CEO of the Wisconsin Hospital Association, told the Milwaukee Journal Sentinel on Thursday. “We have to start taking this more seriously.”

Rimoin, who referred to this pattern as “pandemic fatigue,” also blamed national leaders for leaving so much of the management of the virus up to governors in the first place.

“The lack of a unified national plan including mask mandates, limits on social gatherings and the push to open the economy have all had an impact on the spread of the virus,” Rimoin said. “The mixed messaging coming from the White House has been confusing to the public and certainly resulted in the politicization of masks and other blunt public health measures.”

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