States that imposed few restrictions now have the worst outbreaks

(Rick Bowmer | The Associated Press) University of Utah student Abigail Shull waits in line before taking a rapid COVID-19 test at the University of Utah student testing site Wednesday, Nov. 18, 2020, in Salt Lake City. Recently, Utah Gov. Gary Herbert imposed a mask mandate for the first time since the outbreak began.

Coronavirus cases are rising in almost every U.S. state. But the surge is worst now in places where leaders neglected to keep up forceful virus containment efforts or failed to implement basic measures like mask mandates in the first place, according to a New York Times analysis of data from the University of Oxford.

Outbreaks are comparatively smaller in states where efforts to contain the virus were stronger over the summer and fall — potential good news for leaders taking action now. States and cities are reinstating restrictions and implementing new ones; in recent days, the governors of Iowa, North Dakota and Utah imposed mask mandates for the first time since the outbreak began.

The index comes from Oxford’s Blavatnik School of Government, where researchers track the policies — or lack thereof — governments use to contain the virus and protect residents, such as contact tracing, mask mandates and restrictions on businesses and gatherings. Researchers aggregate those indicators and assign a number from 0 to 100 to each government’s total response.

At its highest level of containment efforts, New York state scored an 80 on the index. At the beginning of November, most states were scoring in the 40s and 50s. Although many have taken fresh steps to contain the virus since then, the Times analysis compares cases and hospitalizations for a given date to a state’s index score from two weeks before, since researchers say it is reasonable to expect a lag between a policy’s implementation and its outcome.

Most states imposed tight restrictions in the spring even if they did not have bad outbreaks then. After reopening early, some Sun Belt states, including Arizona and Texas, imposed restrictions again after case counts climbed. Now Midwestern states have among the worst outbreaks. Many have also done the least to contain the virus.

When cases first peaked in the United States in the spring, there was no clear correlation between containment strategies and case counts because most states enacted similar lockdown policies at the same time. And in New York and some other states, “those lockdowns came too late to prevent a big outbreak because that’s where the virus hit first,” said Thomas Hale, associate professor of global public policy at the Blavatnik School of Government, who leads the Oxford tracking effort.

A relationship between policies and the outbreak’s severity has become more clear as the pandemic has progressed.

“States that have kept more control policies in a more consistent way — New England states, for example — have avoided a summer surge and are now having a smaller fall surge, as opposed to states that rolled them back very quickly, like Florida or Texas,” Hale said. “I think timing really matters for the decisions.”

The worst outbreaks in the country now are in places where policymakers did the least to prevent transmission, according to the Oxford index. States with stronger policy responses over the long run are seeing comparatively smaller outbreaks.

Looking at one state at a time, it is possible to track the relationship between coronavirus policy and public health. When the outbreak slammed the New York City area in March and April, leaders locked down. Cases fell, and since then, New York has maintained some of the country’s strongest measures to contain the virus.

New infections have stayed among the lowest in the country, adjusted for population — though cases now are rising in New York as they are everywhere.

Texas locked down in the spring, when it had relatively few cases, then reopened quickly. When the state faced a surge of cases over the summer, the governor closed bars and placed limits on restaurant capacity. Many local leaders went further. Cases dropped in late July, but since then Texas has eased efforts to contain the virus, and cases are rising again.

Many states in the Upper Midwest and Mountain West resisted more stringent control measures, like limits on gatherings and mask mandates. North Dakota, for example, made few efforts to contain the virus. After briefly ramping up restrictions — closing bars, restaurants, gyms, theaters and schools — in March, when most other states did, Gov. Doug Burgum reopened the state nearly fully in May.

For a while, residents were spared. Now nearly 1 in 10 North Dakotans have tested positive — about one-third of those in the past two weeks — and 1 in 1,000 have died of the virus.

One of the biggest problems in the United States so far has been the lack of a coherent, cohesive national response, said Wafaa El-Sadr, a public health researcher at Columbia University. “It’s been piecemeal,” El-Sadr said. “It’s been largely delegated to a subnational level, to the states, for example, and municipalities to figure it out themselves.”

Without strong national guidance, states’ containment policies have varied widely. Since the spring, Maine mandated masks and had strict travel restrictions for out-of-state visitors; South Dakota, meanwhile, has never had a mask mandate and welcomed nearly a half-million people to the Sturgis motorcycle rally as well as its state fair, which attracted more than 100,000 visitors.

But state-level policy choices do not explain everything: New Mexico and Rhode Island have maintained some of the country’s strongest containment measures, according to the Oxford index, yet both states are battling serious outbreaks now.

The wave of new restrictions in the United States follows national and regional lockdowns in Europe, where outbreaks surged past their spring peaks but cases per capita remained lower than many Upper Midwest states. A couple weeks into those lockdowns, countries with new restrictions may be seeing results; the rate of new daily cases has begun to level off or drop in France, Spain, Germany and Italy, though it continues to rise in the United Kingdom.

Hale said the Oxford data makes it clear that acting quickly and forcefully is the best shot governments have to combat the virus. And the more swiftly they can act, the shorter any lockdown-style policies need to be.

Some countries that implemented fast, early restrictions and robust test-and-trace programs have seen the most success. New Zealand recently lifted all restrictions following 10 days with no new cases. New Zealand’s prime minister, Jacinda Ardern, called it a validation of the country’s “go hard, go early” strategy, in which the country reacts rapidly to signs of community spread.

Taiwan recently recorded 200 days without a new coronavirus case after its leaders focused on a speedy response and invested in mass testing and contact tracing. Despite an early outbreak, South Korea flattened the curve with aggressive testing and contact tracing as well as widespread mask-wearing.

“The question is — and I’m sure that’s the conversation now happening in the halls of power — what do we do next? Clearly you don’t want to wait too long because that’s the mistake we made last time, when things spun out of control. So there’s a need to make decisions and be decisive,” El-Sadr said. “Once you start thinking about acting, it probably is the time to act.”