“Y’ALL…WE ARE NOT New York state.” Alabama’s governor, Kay Ivey, said that on March 26th, explaining why she was not locking her state down. At that time, she was right. The Empire State then had twice as many confirmed cases of coronavirus as all southern states combined (the 11 Confederate states, plus Kentucky). But the South is becoming more like New York.
The virus is spreading throughout the region with unnerving speed. Between the end of March and April 20th, the number of cases in the dozen southern states rose from 11,700 to 127,500, three times as fast as the national increase.
As elsewhere, the largest concentration of cases has been in cities. Greater Miami and New Orleans both have around 15,000, more than Los Angeles. In the ten days after the first confirmed case in the Big Easy, the number in Louisiana grew faster than anywhere else in the world, says Gary Wagner of the University of Louisiana at Lafayette. In mid-April, the New Orleans area had the highest per-person death rate from covid-19 of any American city, and Louisiana was second to New York state in deaths per person.
The South has also seen a rapid spread in suburbs and towns. Figures from the New York Times show how fast cases have been doubling in each county. On April 8th the South had 27 counties where they were doubling every two and a half days or more frequently. In the West, there are only three counties where cases were rising that quickly. Most of the areas affected have been suburbs or smaller cities such as Shreveport, Louisiana and Albany, Georgia. The growth rate has since slowed but infections contracted in early April will produce hospitalisations and deaths in early May. According to Mr Wagner, four southern states (Louisiana, Florida, Tennessee and Georgia) had faster growth rates during the first 36 days after their first confirmed cases than Spain or Italy.
As a result, the South is entering the most dangerous period in which numbers are large, growth is still high and health systems start to buckle. According to the Institute for Health Metrics and Evaluation at the University of Washington, New York and New Jersey have passed the peak of hospital demand but Georgia and Texas will not hit theirs until early May. “The worst is yet to come,” fears Peter Hotez, of Baylor University in Waco, Texas. That is worrying not just in itself but because three things make the South especially vulnerable to covid-19.
First, state policymakers were slow to respond to the virus and are being quick to loosen the lockdown. Four southern governors waited until early April before issuing stay-at-home orders; that was almost two weeks after California’s order. Barely three weeks later, seven states have either reopened, or plan to reopen, everything from beaches, gyms and tattoo parlours to shops, restaurants and (in the case of Tennessee) most businesses.
As a result, southerners are talking and acting differently. They are more likely than other Americans to say that they are not worried about the virus, according to YouGov, which does polling for The Economist. And they have been slow to adopt social distancing. Unacast, a company which analyses online tracking data, found they are limiting daily encounters with others less than most Americans. And four-fifths of counties where people were travelling the most in mid-April are in the south, according to Cuebiq, a measurement company. Infections caught then could turn into disease soon.
The second reason for the South’s vulnerability is demography. The region contains disproportionate numbers of old, black, Hispanic, uninsured, unhealthy and (a sometimes forgotten group) incarcerated Americans. That is an almost complete litany of susceptibilities to covid-19. In Florida’s Sumter county, home to one of the largest residential complexes for the old (and the fastest-growing metropolitan area in America), the median age is 67, care homes are suffering exponential growth in cases and the county’s death rate from covid-19 is a sky-high 10%. Florida’s governor is mobilising the national guard to boost coronavirus virus testing in care homes. His state is not unique. One in six deaths in Louisiana are in care homes.
Along with the vulnerable old, African-Americans have disproportionately high mortality rates. In Louisiana, blacks account for 32% of the state’s population but 70% of covid-19 deaths. In Mississippi, the figures are 37% and 72%. Blacks (and Hispanics) are more likely than whites to live in crowded conditions, more likely to have impaired underlying health and more likely to work in occupations (care workers, government clerks) that bring them into contact with others during quarantine. All these put them at greater risk. Fifty-eight per cent of African-Americans, or 24m people, live in the old confederacy.
The region also likes to lock people up and prisoners have much in common with other imperilled groups. A disproportionate number are black and, like care homes and cruise ships, prisons are incubators of the virus. Seven of the top ten states ranked by incarceration rates are in the South.
Put all this together and you find that southerners, on average, are sicker than others, more likely to contract the disease and more likely to die if infected. As Louisiana’s governor put it, we “have more than our fair share of people who have the co-morbidities that make them especially vulnerable,” meaning more obesity, high blood pressure, asthma and so on. The Gallup Health and Well Being index has worked out an index of covid-19 risk factors by state. Every southern state has above-average risk; four of the five most vulnerable are southern. “A toxic mix,” says Dr Hotez.
Perhaps this might not matter quite so much were it not for the third weakness: the medical system. As elsewhere in America, the South has plenty of large, modern hospitals. But it has more people without health insurance than any other region, with the lack of coverage worst in rural areas. Nineteen rural hospitals closed in 2019, mainly in the South; 170 have shut since 2005, says the Sheps Centre at the University of North Carolina. Some of the problems reflect national trends but southern states have added an extra dimension of their own: politically inspired restriction of health insurance. With fewer rural hospitals, patients must go to rural health clinics, which rely on federal funding. But eight of the 12 southern states have refused an offer to expand Medicaid, a federally funded programme to provide health insurance to the poorest, which was part of Obamacare. That has reduced the ability of clinics to deal with the coming flood of cases and left the very people who are most vulnerable anyway with less medical help.
“You could be looking at a perfect storm,” says Thomas LaVeist, the dean of public health at Tulane University in New Orleans. “When this is over, the South will be the region of the country that will be most severely impacted.”