Why North and South Dakota are suffering the worst Covid-19 epidemics in the US

Here’s why the coronavirus outbreaks in the Dakotas got so bad.

The third surge of Covid-19 cases is leading to worsening outbreaks across the United States. But two states — North Dakota and South Dakota — have coronavirus outbreaks that far surpass the rest of America.

While the Dakotas managed to avoid big outbreaks during the spring and for most of the summer, the current situation suggests that was more an element of luck and timing than anything else. With the coronavirus, it often seems like a matter of time before it hits your area to some extent. And if a country or state doesn’t have the proper precautions in place — and the Dakotas didn’t — the virus can and likely will spread through its population. It’s a lesson in the need for constant, continued vigilance.

North and South Dakota now have four to five times the weekly average for daily new coronavirus cases per 100,000 people. The US, overall, is seeing 22 cases per 100,000 people as of October 26. South Dakota, meanwhile, has 95 per 100,000, and North Dakota has 105 per 100,000 — making it the first state to surpass 100 per 100,000 at any time during this pandemic.

Greater testing capacity doesn’t fully explain the spikes in Covid-19 cases in either state. In North Dakota, the seven-day testing average actually fell by nearly 2 percent over the last week as the number of cases increased by more than 14 percent. In South Dakota, the testing average went up by 11 percent as cases increased by 20 percent over the previous week.

Both states have also seen their hospitalizations and deaths increase since September. North and South Dakota report the highest and second-highest, respectively, Covid-19 death rate over the previous week out of all states, Washington, DC, and US territories.

And the percent of tests coming back positive, which is used by experts to gauge testing capacity, is more than 11 percent for North Dakota. In South Dakota, it’s an astonishing 40 percent. The recommended maximum is 5 percent — which North Dakota surpasses and South Dakota completely demolishes. That suggests that, if anything, testing in the Dakotas is still missing a lot of cases, and each state’s outbreak is even worse than the official figures indicate.

Unlike other states, South and North Dakota never fully closed down, with the Republican governors in each state resisting ever issuing a stay-at-home order. So most of each state remained open — allowing the virus to spread freely through bars, restaurants, parties, celebrations, rodeos, rallies, and other large gatherings. Among those potential spreading events was a motorcycle rally in Sturgis, South Dakota, in early August, which some experts now blame for a Covid-19 surge that followed in the region, particularly in the Upper Midwest.

Neither state has adopted a mask mandate, which research shows can help suppress the coronavirus. Based on some national data, both Dakotas have some of the lowest rates of mask-wearing in the US.

Bonny Specker, an epidemiologist at South Dakota State University, was blunt in her assessment of the situation in the Dakotas. “Federal and many state leaders have not implemented mandates or reinforced [public health agencies’] recommendations to prevent the spread of the virus,” she told me. “In South Dakota, the governor had the information needed to minimize the impact of this virus on the health of South Dakotans, but she ignored that information as well as national recommendations from the CDC.”

Meanwhile, much of the public never saw the coronavirus as a major threat to the Dakotas. “Our low rates in the spring and summer built a sense of complacency, and that it was more of a problem for the rest of the country,” Paul Carson, an infectious disease expert at North Dakota State University, told me, speaking of his state’s experience in particular.

This follows the playbook set by President Donald Trump, who has pushed a false sense of normalcy and told his followers to not let the coronavirus “dominate your life” even after he himself got sick with Covid-19. North and South Dakota are led by Republican governors, and Trump won each state by 36 points and 30 points, respectively, in 2016. Trump also held a massive July Fourth rally in South Dakota at Mount Rushmore, attracting thousands of his supporters from around the region, despite public health experts’ advice against large gatherings.

All of this — a public rejection by state and national leadership of even the most basic precautions against Covid-19 — has allowed the coronavirus to spread out of control. With each new interaction, the virus has an opportunity to spread. While mostly rural states like the Dakotas managed to avoid big outbreaks during the early phases of the pandemic, experts say that it was only a matter of time — and perhaps a bit of bad luck — before the virus hit such places.

The only way this could turn around quickly is if the public and its leaders act. But there’s still a lot of resistance to stricter measures, including mask mandates and especially lockdowns.

So there’s another possibility: The coronavirus will continue spreading in North and South Dakota, fueling more serious illnesses, hospitalizations, and deaths.

“I fear we won’t see behavioral changes until people have been personally affected, or can’t get medical care because our hospitals are being overrun — which may not be too far off,” Carson warned.

The Dakotas resisted basic policies to fight Covid-19

North and South Dakota have taken a laissez-faire approach to dealing with Covid-19 — never instituting stay-at-home orders or mask mandates as other states, including some of their neighbors, did.

South Dakota in particular took a very hands-off approach, with no restrictions even on large gatherings. The strongest action Republican Gov. Kristi Noem took was to push businesses to follow safety guidelines from the Centers for Disease Control and Prevention. Otherwise, Noem has boasted about her state’s loose strategy: She argued in an ad that businesses struggling with restrictions in other states should “come grow [their] company” in South Dakota.

“Here in South Dakota, we trust our people,” Noem said. “We respect their rights. We won’t shut them down.”

Noem still defends her approach, arguing in a recent op-ed that she’ll continue to resist stricter measures. “I’m going to continue to trust South Dakotans to make wise and well-informed decisions for themselves and their families,” she wrote.

North Dakota has done a little more. While avoiding statewide restrictions and lockdowns, Republican Gov. Doug Burgum in October called for reduced business capacity in some counties as cases spiked in his state. But these are mere recommendations — it’s hard to know if any businesses are following them — and, even then, he stopped short of recommending closures.

North Dakota also has one of the most expansive testing regimes in the US — consistently reporting one of the highest rates of coronavirus testing in the country. This may partially explain its high case count, although its positivity rate indicates that it still doesn’t have enough testing. And that testing-and-tracing system can only do so much once the virus is completely out of control, which growing hospitalizations and death rates are evidence of.

“Our contact tracers are overwhelmed with a backlog of cases,” Carson said. “We have further heard from many of our contact tracers that they are meeting increasing resistance from people to give up their contacts or abide by quarantine rules. People have become fatigued with the restrictions.”

Similar to South Dakota’s governor, North Dakota’s Burgum has pushed a message of personal responsibility. “It’s not a job for government,” he said. “This is a job for everybody.”

Social distancing and masking are effective for curtailing Covid-19. As a review of the research in The Lancet concluded, “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”

Government mandates seem to help, too. A study in Health Affairs found that “government-imposed social distancing measures reduced the daily growth rate of confirmed COVID-19 cases by 5.4 percentage points after one to five days, 6.8 percentage points after six to ten days, 8.2 percentage points after eleven to fifteen days, and 9.1 percentage points after sixteen to twenty days.”

And a study from the nonprofit research institute IZA found that Germany’s local and regional mask mandates “reduced the cumulative number of registered Covid-19 cases between 2.3% and 13% over a period of 10 days after they became compulsory” and “the daily growth rate of reported infections by around 40%.”

Carson acknowledged that such mandates “did not seem so necessary earlier in our epidemic.” But by not instituting government policies and allowing the public to act recklessly, North and South Dakota kept themselves vulnerable to the coronavirus. That vulnerability took a while to expose itself in two sparsely populated states with relatively little travel in and out — but once it appeared, Covid-19 has exploded, rapidly spreading across both of the Dakotas.

This wasn’t unpredictable. In the spring, a South Dakota meat plant became the US’s top coronavirus hot spot — showing Covid-19 could reach even mostly rural areas like South Dakota. But the outbreak didn’t change Noem’s approach.

Ian Fury, a spokesperson for Noem, defended her actions: “Since the start of the pandemic, Governor Noem has provided her citizens with up-to-date science, facts, and data, and then trusted them to make the best decisions for themselves and their loved ones.”

Burgum’s office didn’t respond to a request for comment.

The public, fueled by Trump, didn’t follow proper precautions

It wasn’t just the government that allowed Covid-19 to spread in the Dakotas. The public has played a role too, with large parts of each state acting as though everything is normal and refusing to embrace even the most basic precautions against the coronavirus.

COVIDcast, a project from Carnegie Mellon University that tracks real-time Covid-19 data, shows that North and South Dakota have some of the lowest levels of uptake in the US for both social distancing and masking. South Dakotans are the sixth most likely and North Dakotans are the eighth most likely, out of the 50 states plus Washington, DC, and Puerto Rico, to leave their homes for six or more hours a day. South Dakotans and North Dakotans are also among the least likely — 50th and 49th, respectively, out of all 50 states plus DC — to wear masks.

The most infamous example of this in either state is the Sturgis motorcycle rally. From August 7 to 16, bikers came from across the country, attending events and hitting up local bars and restaurants. Masks were uncommon — even shunned. Among the T-shirts sold at the events, one stated, “Screw Covid-19, I went to Sturgis.”

Insufficient contact tracing makes it difficult to say with any certainty how much of the current epidemic originated at the Sturgis rally, but Covid-19 cases surged in the region, and particularly the Dakotas, in the weeks after the rally.

It’s not just Sturgis, though. On July Fourth, Trump held a large rally at Mount Rushmore, which is in South Dakota, that thousands of people attended, seldom wearing masks. Families and friends held their own parties and celebrations around the summer holidays, including Labor Day in September. There were rodeos and state fairs. Schools have reopened, with universities and colleges in particular fueling outbreaks nationwide.

“Those events, combined with the lack of leadership in encouraging the public to wear masks or practice social distancing, have contributed greatly to the current situation we are in,” Specker said.

Bars and restaurants are of special concern to experts: In these spaces, people are close together for long periods of time, they can’t wear masks as they eat or drink, the air can’t dilute the virus the way it can outdoors, and alcohol can lead them to drop their guards further.

Another problem is older teens and young adults may act more recklessly, believing they’re at lower risk of contracting Covid-19. But as a recent CDC study noted, younger people tend to spread the virus to their parents, grandparents, teachers, and so on. That, Carson said, appears to have happened in North Dakota: “We saw a surge of cases in our communities that had students coming back to start college. Those cases spiked in the young college-age population, then eventually spilled over into the broader community.”

Trump and Republican leaders have encouraged this. While touting their messages of personal responsibility, many Republicans have also downplayed the threat of Covid-19. Trump has deliberately done this — telling journalist Bob Woodward, “I wanted to always play [the coronavirus] down.” Even after his illness, Trump has tweeted, “Don’t be afraid of Covid. Don’t let it dominate your life.” He’s even mocked masks and claimed — falsely — that they’re ineffective. (In reality, the evidence for masks keeps getting stronger.)

For Trump, the goal here is obvious: If he manages to convince the public that things are okay and normal, it could boost his reelection chances. Republican lawmakers, in many ways beholden to Trump’s supporters, have by and large followed the president’s lead.

In North and South Dakota, that has seemingly translated to a predominantly Republican public going out, too often without masks, and spreading the coronavirus across the states.

North and South Dakota now have a serious and growing crisis

Experts often compare the spread of the coronavirus to a runaway freight train: The virus can take a while to build up, but once spread hits exponential growth, it takes an immense amount of work and time — up to weeks or months — to slow things down.

“Until the leaders of state and federal government support recommended public health policy, it is going to be difficult to slow the spread of this virus,” Specker said.

For the coronavirus, the solutions are the same things everyone has heard about for months now: More testing and contact tracing to isolate people who are infected, get their close contacts to quarantine, and deploy broader restrictions as necessary. More masking. More careful, phased reopenings. More social distancing.

This is what’s worked in other countries, from Germany to South Korea to New Zealand, to contain their respective outbreaks. It’s what’s worked in parts of the US, like New York and San Francisco.

But, crucially, this has to be sustained. Until a vaccine or similar treatment is available, the coronavirus will remain a constant threat in the US. Even less densely populated places — like the Dakotas — aren’t going to be safe for long without proper precautions in place.

Yet North and South Dakota leaders have continued resisting more hands-on approaches, calling for personal responsibility and limited, if any, role for government. Some local officials have stepped up to fill the vacuum, but they have more limited powers and reach than state leaders.

The fall and winter stand to hasten the spread of the coronavirus, too. Schools will continue to reopen. The cold will push people indoors, where, due to poor ventilation, the virus has an easier time spreading than it does outdoors. Families and friends will gather for the winter holidays, from Thanksgiving to Christmas to New Year’s. A looming flu season could strain hospitals further, inhibiting their ability to treat a surge of Covid-19 patients.

If it gets bad enough, the only possible solution to avert further spread could be a lockdown. Already, the mayor of Fargo, North Dakota, mentioned the possibility. “The concern is that if we don’t start turning this around and our numbers keep going up, it’ll be difficult to keep the businesses going and being open,” Democratic Mayor Tim Mahoney, a physician by training, said.

Given that the outbreaks are already so bad and state leaders have still refused tougher actions, another possibility is the Dakotas will continue tolerating a high number of cases and deaths, failing to take any serious action in response.

If so, the two worst outbreaks in one of the countries struggling the most with Covid-19 will remain bad and perhaps get even worse.

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