The response to the COVID-19 crisis has varied from state to state depending on the perceived need for aggressive action and depending on political considerations in our divided nation. As a result, the United States offers 50 simultaneous experiments in epidemiological response, often with dramatically different initial conditions, such as the high population density and international travel hub characteristic of New York City, compared to West Virginia where half of the population lives in rural areas. New York had some of the very first COVID-19 cases, the epidemic has grown the fastest there, and has become the epicenter of the disease despite early efforts to impose social distancing to stem its spread. In contrast, West Virginia was the last state to have its first case of COVID-19, on March 17, 2020. Despite being last into the corona virus club, Gov. Jim Justice imposed stay-at-home orders just a week later, following on the heels of Governors in more hard-hit states around the nation.
But I don’t want to talk about New York and West Virginia. There, the demographics guarantee very different outcomes despite both states’ similar and prompt statewide orders to stem the spread of the disease. Rather, I want to compare my home state of Oregon with another largely rural state, South Dakota. South Dakota reported its first cases and first death on March 10. Oregon, a neighbor to the original hot-spot in the nation, Washington state, identified its first case on February 28, and recorded its first COVID-19 death on March 14. The Governors of these two states have taken very different paths. Oregon’s Gov. Kate Brown issued a series of recommendations culminating in a stay-at-home order on March 23. In contrast, Gov. Kristi Noem has yet to enact any mandatory restrictions on social distancing or congregating in South Dakota, declaring, “I’m just a big believer that the best person to make decisions for them and their family is the individual.”
South Dakota has a little less than 1 million residents, spread over a state about the same size as Oregon, which houses over 4 times as many people. The experience of New York City, with its explosive growth of the contagion, have made states with large population centers extremely cautious. On the other hand, rural states have not been totally spared, especially in the southeast. South Dakota, along with a handful of rural states have so far not imposed stay-at home orders, but they have closed schools for the rest of the year and made requests to their constituents to wash their hands, and to avoid large gatherings. South Dakota seems to be the least lucky of these states. COVID-19 hot-spots showed up at a meat packing plant, and on an Indian reservation. All seemed unexceptional in South Dakota until the middle of March when the infection began to take hold. Now the state has the fastest rate of growth of the virus in the nation.
The figure above shows that in South Dakota, the infection has continued to spread at a constant growth rate for the past month, while virtually every other state, and the nation as a whole, has seen the growth rate taper off. Distressing is the realization that even if much stronger measures were to be enacted today, before the curve would turn over, there would be many thousands more infections which are latent today. Every metric we have for this virus is behind the curve. Asymptomatic transmission, delayed onset of illness, and the slow progress of the disease mean that the number of cases and deaths lag by many weeks behind the actual occurrence of infections.
A group of computer modelers at Covid Act Now have looked at hospital data with granularity at the county level to be able to infer current trends. They use that data to extrapolate forward based on their infectious disease model, which is now back calibrated with the local trend data.
The figures above show what the Covid Act Now model predicts for South Dakota. The model expects that 69% of the population will become infected over the next 3 months and 7,000 will die based upon current trends. Lack of aggressive action results in significant loss of life.
In my home state things are somewhat better. Let’s look at these same data sets for the state of Oregon.
The growth rate of COVID-19 infection in Oregon was higher than in South Dakota in the middle of March. However, the pandemic was taken seriously, and shortly after the stay-at-home order was put in place on March 23, the growth rate began to decrease. Today, Oregon’s per capita infections are less than a third of those in South Dakota, and are unlikely to increase substantially. This becomes more apparent when looking at the Covid Act Now model predictions for Oregon.
Oregon has a larger population than South Dakota, so if restrictions were lifted in both states today, Oregon would suffer 41,000 deaths compared to 8,000 in South Dakota. However, if current trends continue in Oregon, then in three months time about 4% of us will have become infected and 2000 Oregonians may die, compared to 69% infected and 7000 dead in South Dakota (with only one-quarter Oregon’s population).
Wise leadership is enormously important when confronting an exponentially growing infection. Thousands of South Dakotans will die this spring because of irrational conviction that the rugged individual knows best. Beating back an exponentially growing infection requires reducing the growth rate to less than one. The measures South Dakota has taken have helped a little, if you compare the 4-5 day doubling time they are experiencing now with early infection rates in many places where the doubling was every two days. Listen here to Angela Merkel explaining to her constituents the nature of the critical moment we are facing and why we have to make some unpleasant sacrifices. Leadership that starts with the science, respects the intelligence of the people, engages in empathy with those affected, and strives for a common good through shared sacrifice will ultimately generate the best outcomes. My heart goes out to those with less capable leaders in this time of duress.