How North Dakota became a Covid cautionary tale

The rural state had every advantage in the fight against the virus, but complacency and conspiracy helped the spread, reports Richard Hall

A man prepares to receive a throat swab from a North Dakota National Guard soldier at a drive-thru testing site inside the Bismarck Event Centre, 26 October 2020 (Richard Hall/The Independent)

As summer turned to fall, Renae Moch watched with horror as the sick filled hospitals across her state. Unlike much of the country, North Dakota had refused to introduce strict measures to contain the coronavirus, and its citizens were paying the price.

Moch, the public health director for the state capital Bismarck, wanted more to be done. She worked with community leaders to push for local mask mandates.  

“It got to the point where our numbers were really increasing, and we decided we needed to do something more stringent,” she says. “That wasn’t something being done statewide at that point.”

For her efforts to save the lives of her fellow citizens and limit the spread of the coronavirus – for doing her job – Moch was called a Nazi, a tyrant and a liar. In the eyes of many North Dakotans, she was public enemy number one.

“It was emails, phone calls, social media. There was this characterisation of me trying to push an agenda and fearmongering. I was the face of the public health mitigation measures and all the people who opposed them directed their discontent and aggression at me,” she tells The Independent.

Over the last few months, North Dakota has become a hotbed of coronavirus conspiracy theories and scepticism over everything from public health measures to the severity of the virus. The result has been, unsurprisingly, more coronavirus. Today, three of the four worst-affected metro areas in America are located in the state. The capital Bismarck, where Moch pushed for stronger mitigation measures, is top of that list. 

Intensive care units have been stretched to their limits. Nurses have been flown into the state from across the country to meet the rising hospitalisations. Contract tracers became overwhelmed. Even the US air force was brought in to help out.  

It didn’t have to be this way. There were many reasons to think North Dakota could have escaped the worst ravages of the pandemic. It is a rural state, something which gave it an advantage in stopping community spread compared to states with numerous crowded cities. It had time, too. It survived its first wave relatively unscathed and was able to see how other states flattened the curve. It could have done the same if it followed the protocols public health experts had urged.

Instead, North Dakota has become something of a parable; a cautionary tale in which hubris and suspicion ultimately led to unnecessary suffering and death on a grand scale.    

The numbers tell the story: one in every 630 residents of North Dakota has died from the coronavirus – that is the fifth highest per capita death rate in the country, behind only New York, New Jersey, Massachusetts and Connecticut. The difference is that those states had their spikes early on in the pandemic, when public health experts were still learning about the virus.  

State leaders in North Dakota were reluctant to introduce mitigation measures like mask-wearing and banning public gatherings, instead leaving it up to people to decide for themselves. Republican governor Doug Burgum made repeated, often deeply emotional pleas to the public to mask up, but he eschewed state action in favour of encouraging “personal responsibility”. 

It didn’t work. When White House coronavirus response coordinator Dr Deborah Birx visited the state in late October, she described the public mask use as the worst she’d seen anywhere in the country.  

“Over the last 24 hours, as we were here and we were in your grocery stores and in your restaurants and frankly even in your hotels, this is the least use of masks that we have seen in retail establishments of any place we have been,” Dr Birx told reporters after meeting local officials.

“And we find that deeply unfortunate because you don’t know who’s infected and you don’t know if you’re infected yourself,” she added.

At this time, cases were already spiralling out of control. Moch wasn’t going out much due to the pandemic, but when she did she too was surprised at how few people were wearing masks.

“I definitely did not feel comfortable walking into a store wearing a mask. Those wearing masks were in the minority, when it should have been the norm,” she says. “You would get glares.”

Moch worked with community leaders to address the pandemic locally, but she was competing with a slew of conspiracy theories online. Facebook pages were awash with false information about the virus. An initiative to provide shelter for Covid-19 positive individuals who had no place to quarantine was branded as a “quarantine camp” and a “Covid camp” where people would be imprisoned against their will.

She frequently heard North Dakotans cite words like “freedom” and “liberty” in their reasoning for not abiding by public health measures.

“The attitude was that people are responsible for themselves and should be able to make their own choices and decisions. People don’t want to have that extra layer of government attached to all this.”

But complacency was just as big of a problem as conspiracy. North Dakota has a large rural population and the fourth lowest population density in the country (behind only Alaska, Wyoming and Montana). Many residents here thought that would be enough to protect them against the worst of the virus.

The town of Rugby lies some 150 miles north of Bismarck. The road between them runs through the Great Plains into the Red River Valley, vast stretches of lowlands and farms and few people. Inside North Dakota’s cities and built-up areas, The Independent saw most people wearing masks. In rural gas stations and smaller towns along the way, most were not.

Linda Grossman, who works in healthcare with disabled people, lives on a farm near Rugby.

“Everybody thought Covid wasn’t going to hit here because in rural America it wasn’t bad. And it wasn’t – the first peak wasn’t bad, but nobody wore the masks, nobody took it seriously, or the second peak that came through,” she says.  

“There were always social gatherings. You had homemakers clubs. You have card games going on. Casinos were open.”

“You could tell the people who didn’t truly believe. A lot of them thought with the election it was going to go away. They thought it was just a political thing. And they didn’t care,” she adds.

Grossman couldn’t afford to take the virus lightly. As a healthcare worker, she didn’t have the option of staying home. When cases rose dramatically in the state, her family was not spared: her elderly father-in-law contracted the virus, and eventually recovered.  

She says it was only when people began to see the effects of Covid in their own community that people began to change their minds.

“Now it made people in this area realise. When they watch their friends die, when they watch their grandparents die, their aunts and uncles, people in their 20s are having lifelong health conditions. It’s changing everybody. It’s changing our outlook,” she says.  

By the middle of November, the situation had become catastrophic. Infections were rising at six times the national rate, reaching a high of 15 per cent positivity rate. Johns Hopkins University researchers said the state was witnessing the highest rate of new infections in the country. There were only 18 intensive care beds free across the state.

It was only then that Governor Burgum finally introduced a mask mandate and directed bars and restaurants to limit capacity to 50 per cent.

“Our situation has changed, and we must change with it,” he said on 13 November.

The damage had been done, and the state was forced to play catch-up. A building was leased in downtown Bismarck to add 20 ICU beds to its capacity. Some sixty US air force nurses were brought into the state from bases as far as Florida. The Department of Health sought to draft in dozens of travelling nurses, but coronavirus surges across the country had sparked a bidding war. One advert for a nursing job in Fargo offered $8,000 a week.

One of those nurses, who gave only his first name of Howie, travelled from California after working on the front lines of the Covid outbreak there. He says that scepticism over the virus and its effects had reached as far as the intensive care ward in which is now working in North Dakota.

“I have had people that were on their deathbeds, and I’m trying to help delay intubation and I’m trying to explain it to the patients, and at this point they’re still trying to process that Covid is real,” he says.

“It’s like first they’re shocked, and then they’re barraged by us explaining to them: ‘Do you want to have this tube down your throat? Do you want us to do CPR on you if you can’t breathe?’ So it’s hard for me to discern exactly how deep their disbelief goes.”

He says he had also got into disagreements with family members of sick patients over their reluctance to wear full protective gear when they are visiting.  

“I was like, I don’t have enough energy to discuss immunity. You know? We’re just still trying to focus on what's to do with the patients in front of us.”

Howie says that one of the biggest frustrations about his job is that few people see the true damage the coronavirus causes, something that he sees every day in the ICU.

“If you just go around North Dakota life is normal, it looks fine and you can’t see it. Nobody’s going to believe it unless they see it face to face, or have relatives that are actually suffering from actual Covid. It’s so frustrating,” he adds.  

In the past two weeks, North Dakota appears to have turned a corner. Hospitalisations are decreasing again, experts say, because of the mask mandate and limits on gathering in public places.

Moch has had little time to catch her breath since the pandemic began. But already she is wondering about the what-ifs.  

“We know what we could have done to prevent it, and we’ve been preaching that so hard since the very beginning and have had so much resistance. You look back and you think this could have all been prevented if people would have just listened to the public health professionals,” she says.

“There are protocols and plans in place, and it seemed like everything went every other direction but on the path it was supposed to go down. It was just, from the beginning, kind of wild.”