How did North Dakota's COVID-19 outbreak become the worst in the country?
As of Friday, Nov. 13, more than 60,000 North Dakotans have tested positive for the coronavirus — about one of every 13 residents — enough to rank as the state’s third largest city.
MANDAN, N.D. — Jenn Kary watched nervously as the coronavirus spread across North Dakota. Her calculation of the infection rate convinced her the pandemic was worse than state officials made it out to be.
Kary has an autoimmune disease, so she took extra precautions and almost never ventured from her Mandan home. She even created a Facebook page to shed light on the severity of the state's outbreak.
Despite her best efforts, the stealthy virus infiltrated her household on Oct. 13, when she first noticed symptoms, including an irritated eye, runny nose, fever and chills.
By Oct. 28, all three members of her family were infected, with varying symptoms. Her husband, Jason, was hospitalized with dangerously low oxygen levels, after his third trip to the emergency room in as many days.
The next day he was transported to Sanford Broadway Medical Center in Fargo — one of two patients sharing an ambulance and one of eight Bismarck patients taken that day to Fargo because the capital city’s hospitals were full.
“He just keeps getting worse and worse,” Jenn Kary said the day her husband was taken to Fargo, experiencing the early stages of an inflammatory “cytokine storm,” in which the body’s immune system spirals out of control.
The Bismarck metro area stood at the epicenter of a stubborn coronavirus surge that has made North Dakota a nation-leading hot spot.
As of Friday, Nov. 13, more than 60,000 North Dakotans have tested positive — about one of every 13 residents — enough to rank as the state’s third largest city.
Jenn Kary was relieved that her husband was receiving hospital care. But it was difficult having Jason in a hospital bed 200 miles from home.
“It is a little bit stressful that I don’t really know what’s happening,” she said. All she could do was wait and hope.
A total collapse
Since the beginning of the COVID-19 pandemic, North Dakota, like other states, has relied on three core infection control concepts to guide its pandemic response: testing, contact tracing and isolation.
Testing identifies those infected, and therefore contagious, while contact tracing finds close contacts so they can be notified and begin quarantining. If sick residents and their potentially exposed close contacts are isolated from the rest of their community, it severs the chain of infection and slows the spread of the virus.
North Dakota has remained one of the nation’s leaders in testing per capita since March.
But as the pandemic wears on and the state’s outbreak has become increasingly unmanageable, the other two public health pillars have splintered under the pressure.
North Dakota’s strategy, headlined by massive testing capability and strong contact tracing operations, worked well in the beginning of the pandemic when case counts were low, said Dr. Paul Carson, an infectious disease physician who teaches public health at North Dakota State University and has advised Gov. Doug Burgum’s response.
Residents willingly listened to public health experts and followed recommendations when much about the virus was still unknown, said Renae Moch, director of Bismarck-Burleigh Public Health. North Dakotans refrained from large social gatherings and stayed home when contact tracers told them they may have been exposed, she said.
Back then, the state was fighting a one-front battle, in which the vast majority of COVID-19 cases were confined to the Fargo area.
Burgum ordered schools and certain public-facing businesses closed in mid-March, but with the spread seemingly contained across large swaths of the state, the governor gradually lifted the partial economic shutdown in May.
Spring gave way to summer, and North Dakota remained in good shape with the virus, but the cracks were forming at the base of the state’s response. Once cautious, many North Dakotans who hadn’t yet felt the negative effects of the pandemic developed lax attitudes toward public health measures.
As the warm weather hit, contact tracers began reporting more phone calls with infected or exposed North Dakotans who refused to isolate or quarantine at home, said state Disease Control Director Kirby Kruger. More residents with COVID-19 going to work and interacting with their communities meant the chain of infection could continue relatively unchecked.
When people diagnosed with the virus broke isolation, they could have been charged with a misdemeanor offense, though it was rarely enforced.
“That’s a pretty egregious thing,” placing one’s self-interest above protecting the community, Carson said.
Then the storm came.
Infections started spiking in late July, following Independence Day get-togethers. Officials traced at least 30 North Dakota cases to the Sturgis motorcycle rally in August, coinciding with students returning to schools and college campuses. At the same time, other states in the region, including South Dakota and Montana, began seeing climbing cases.
The Bismarck metro area felt the hurt first. Then, the western part of the state saw spikes in cases, and by early September, the virus had grabbed a hold of the whole state.
Nursing homes, widely identified as vulnerable to intense outbreaks, have been decimated by the illness in the last three months. About 60% of the state’s 707 COVID-19 deaths have been among residents of long-term care facilities, and the number rises each day. The state is averaging 12 deaths per day in November, and the high infection rate in nursing homes suggests relief is a long way off.
A growing strain on hospitals, rooted in a severe shortage of nurses and rising COVID-19 admissions, has endangered not just North Dakotans with the virus, but any residents in dire need of medical attention.
Gigantic waves of new cases — often more than 1,000 per day — overwhelmed contact tracers, and on Oct. 20, the state and local public health units announced they were suspending most contact tracing operations. Some residents who tested positive were waiting three days or more to hear their results from case investigators who were busy tracing others' contacts, and abandoning most contact tracing was the only way to clear the backlog, state officials determined.
Kruger admits contact tracing for COVID-19 was a tall task from the beginning given the nature of the virus, but it became apparent that spending hours calling potentially exposed residents would have to take a back seat with the high case counts persisting.
The increasing harshness of the state’s outbreak also rendered contact tracing much less useful. Testing and tracing can work well with a seven-day average of about 10 new cases per 100,000 population, Carson said. North Dakota’s rate is about 170 per 100,000.
Case investigators now tell residents who test positive to inform their own close contacts of their diagnosis. Kruger said he wouldn’t rule anything out, but there’s no plan to bring back the kind of contact tracing operation the state used to run.
Burgum touts North Dakota’s testing operation as a success of his administration, but with the state’s public health foundation otherwise compromised, it hasn’t been enough.
“We can’t test our way out of this,” Carson said. “Now we find ourselves in the exponential growth phase of the epidemic in the Upper Midwest.”
Even among other states in the region with acute outbreaks, North Dakota stands apart. The Peace Garden State leads the nation in COVID-19 cases and deaths per capita over the last week — an unwanted title it has held for most of the last two months.
An underestimated enemy
Dr. Stephen McDonough looked on in despair as the state’s positivity rate soared nearly six times higher than the national average. He was alarmed by a projection that Burleigh County, which includes Bismarck and had more than 80 deaths — a number that now stands at almost 100 — could see another 115 deaths in three months.
The pandemic never had to get this bad, in the view of McDonough, a Bismarck pediatrician and former senior official at the North Dakota Department of Health.
He calls the uncurbed outbreak the “greatest public health disaster in the state’s 131-year history.”
The spread of COVID-19, smoldering at first and then igniting like dry tinder, erupted because North Dakotans underestimated the virus, McDonough and other experts say.
Due to its rural and isolated nature, North Dakota was insulated from the initial outbreaks in spring that devastated coastal states and big cities. As such, residents didn’t get the wake-up call New Yorkers and Californians did, leading them to feel a false sense of security from the virus, said Dr. Joshua Wynne, dean of the School of Medicine at the University of North Dakota and a COVID-19 adviser to the state’s university system and health department.
“I think partly, quite frankly, we let our guard down,” Wynne said. “We thought we were immune.”
In McDonough’s eyes, much of that complacency stems from the Burgum administration’s failure to accurately depict the scope of the spread. The governor faced criticism from health experts and political opponents in July and August for refusing to adjust an official COVID-19 risk dial out of the low risk, “or green,” category even as cases continued to climb. By the time Burgum began altering individual counties’ risk levels in early September, the state’s active case count had already started on a steep climb that continues to reach new peaks almost daily.
Burgum spokesman Mike Nowatzki said at the time “we want to confirm a longer-term trend before changing the risk level.”
Nowatzki noted more recently that “Gov. Burgum set the tone right from (the) beginning about the serious risk associated with the coronavirus – for example closing schools to in-person instruction within 4 days of North Dakota’s first case being identified – and has continued through roughly 80 press briefings and hundreds of other communications to advocate for physical distancing, mask wearing, hand washing and avoiding large gatherings, while repeatedly stressing the need to protect the most vulnerable who are at much higher risk from COVID-19.”
The governor also downplayed the state’s lack of hospital capacity as recently as early October. Nowatzki said Burgum’s remarks then reflected survey responses from hospitals.
The increasingly dire scarcity of available staffed hospital beds came to a head earlier this week when Burgum said the state’s medical centers were at full capacity. The sobering announcement came with several extraordinary measures to address the shortage of health care workers, including allowing health care workers with asymptomatic cases of the virus to work in COVID-19 units at hospitals and nursing homes. The move has been criticized by nurses , who say the state should exhaust all other virus mitigation tools, including mandating masks, before allowing infected health care workers back into the workplace. Neither Essentia Health nor Sanford Health in Fargo say they plan to exercise that option.
McDonough and other doctors say the worst implications of having hospitals at full capacity are likely yet to come as more vulnerable residents come down with the virus.
“A tsunami of ill patients is coming,” McDonough said. “There have been long waits of over a dozen patients in the ERs awaiting hospital beds with patients being transferred to Billings, Aberdeen and Fargo.”
Despite the immediate threat a worsening COVID-19 outbreak poses to their lives, many North Dakotans continue to brush off the virus.
Carson speculated that this careless attitude might only change as the human toll grows and everyone eventually knows someone who has become sick or died.
“I think when it hits us all personally, then people will take it personally,” Carson said. “It will be a shame if that’s what it takes.”
Eight months into North Dakota's pandemic, Burgum announced a statewide mask mandate on Friday, along with new requirements for gatherings and businesses.
McDonough and a chorus of doctors had heaped blame on Burgum for previously refusing to issue such a mandate. North Dakota had been one of 16 states with no mask requirement for residents, according to AARP , and state officials often said the lack of mask-wearing significantly contributed to the spread of the virus.
Plans to roll out a statewide mask mandate should have been made when active cases reached almost 1,000 on Aug. 19, McDonough said.
Active cases crept above 2,000 on Sept. 3, and about six weeks later, they doubled again, reaching 4,029 on Oct. 14.
“How many of those nearly 2,000 cases could have been prevented by a mask mandate?” the Bismarck doctor said. His answer: many.
Projections from early September by the University of Washington’s Institute for Health Metrics and Evaluation estimated that masks could prevent about half of the state’s estimated deaths by Dec. 1.
In the last month, North Dakota’s active cases have continued to balloon, surpassing 10,000 in the latest figures.
After allowing businesses to reopen in May, Burgum stuck to an approach that minimized government intervention and relied on residents to make responsible choices for themselves.
The state’s reliance on voluntary compliance came under sharp attack from labor leaders when a worker at the GPK Products plant in Fargo died after the company refused a request in May to shut down after an outbreak. However, the Republican governor was reelected in November by a landslide margin, and legislative leaders in his own party praised what was his “personal responsibility” policy on masks.
Before Friday, Burgum strongly encouraged mask-wearing, at times even pleading with residents to take up the practice, but he repeatedly denied that a statewide mandate would be effective. He even said without evidence that instituting a mask requirement could cause less mask-wearing.
A case study of Delaware’s pandemic response published by the Centers for Disease Control and Prevention earlier this month found mask mandates and state-ordered business closures coupled with contact tracing, contributed to massive reductions in COVID-19 cases, hospitalizations and deaths.
In recent weeks, Burgum voiced support for local mask requirements popping up in cities around the state, including Fargo, Grand Forks and Bismarck. Still, Burgum recently referred to discussions of mask mandates as an “obsession of the media.”
A survey in late September and early October by the state health department found that 55% of respondents supported a mask mandate and 68% said they wore masks. Surveys of mask usage show North Dakota lags behind most of the nation — but now has reached about 80% , according to Facebook surveys mapped by Carnegie Mellon University.
White House coronavirus coordinator Dr. Deborah Birx said during an October visit to Bismarck that residents of the capital city were the worst she had seen at mask-wearing and social distancing throughout her prolonged 38-state tour of the country.
Moch, the Bismarck public health director, said she agrees with Birx’s assessment, noting that “it’s unfortunate that the city of Bismarck was recognized in this way.” She said visitors have told her they feel “unsafe” because it appears that “people are just living their lives like there is no pandemic.”
McDonough argues the shortcomings of state leaders extend well beyond the failure to issue a mask mandate until so deep into the outbreak.
During the pandemic, the state’s leading health position has been a revolving door, with four different people serving in the role. Drs. Andrew Stahl and Paul Mariani each resigned as state health officer amid disagreements with the governor. Mariani stepped down in September after just 11 days on the job. Attempts to reach resigned state health officers Mariani and Mylynn Tufte were unsuccessful, and Stahl declined to comment for this story.
The position is now filled on an interim basis by Dirk Wilke, who does not have any medical training.
It’s “way beyond amateur hour at the state Capitol,” McDonough said.
Wilke has the benefit of ample medical advice, said Nicole Peske, a spokeswoman for the health department. “During the pandemic, there have been no shortage of physicians, epidemiologists, disease control experts and public health professionals working to provide the best recommendations in the fight against COVID, even when we did have physicians at the helm,” she said. “The health response is not carried by one person and Mr. Wilke has worked tirelessly to bring the right people together to ensure that the voice of public health is communicated and advocated for.”
'We North Dakotans are in crisis'
Jenn Kary drove to Fargo to pick up her husband after he was discharged from the hospital on Nov. 2.
A couple of days later, back at home in Mandan, Jason was well enough to do light desk work. His oxygen levels have stayed well above levels of concern. All three members of the Kary family are considered to have recovered from the virus, joining more than 49,000 other North Dakotans with that designation.
Still, Jenn Kary has lingering symptoms, including a persistent dull migraine, occasional coughing and an odd sensation that she’s exhaling smoke.
“I still feel very weak but my lungs feel fine,” Kary said. She’s grateful that doctors were able to intervene early when her husband showed signs his immune system could be overreacting to the virus.
But the health care system might not be there for the next Jason Kary if North Dakota’s rate of infection continues.
Dr. Jeffrey Sather, the chief of staff at Trinity Health in Minot, said his hospital reached its saturation point at least once in the last few weeks. Patients, some in urgent need of care, had to wait for beds to open up, and other hospitals denied Trinity’s requests to transfer patients, citing their own capacity concerns.
"We North Dakotans are in crisis," Sather said at a Nov. 3 news conference . “The general population doesn't realize the struggles that health systems are going through unless you or your family is one of those patients getting transferred across the state ... or laying on an ER gurney rather than a hospital bed for 24 hours or more."
If North Dakotans don’t dramatically change their behavior by wearing masks and social distancing, health department epidemiologist Grace Njau fears the state’s prognosis is “not a pretty picture.”
Echoing a worry floated by Birx, Njau said the cold weather will confine more residents to indoor spaces where the virus can spread more easily. And if North Dakotans don’t stop holding large gatherings, the outbreak will only get worse.
“I really do hope that people are more attentive because I think we’re at 500 (now 700) plus deaths currently, and I don’t see that improving in the near future,” Njau said. “I actually want to be wrong because if I’m wrong it means people are doing the right things.”
Forum News Service reporter Adam Willis contributed to this report. Contact Patrick Springer at firstname.lastname@example.org or Jeremy Turley at email@example.com.