The Winter Surge Is Fracturing

A doctor holds a patient's hand in the Covid-19 alternative care site, built into a parking garage, at Renown Regional Medical Center, December 16, 2020 in Reno, Nevada.
PATRICK T. FALLON / AFP / Getty

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Updated at 11:14 p.m. ET on January 13, 2021.

Three weeks ago, the COVID-19 winter surge was well under way and terrifyingly broad. Since the beginning of November, the Northeast, South, and Midwest had seen more than 100 deaths per million people, and the West was just shy of that, at 94 per million, with deaths increasing.* The winter surge was the first time conditions had worsened nationwide; previously, the spring saw cases concentrated largely in the Northeast, followed by a summer surge across the South and West. But by early October, all four regions, as defined by the census, saw climbing hospitalizations.

Now, the pandemic’s geography is fracturing again. Hospitalizations in the Midwest peaked on December 1, and have maintained a precipitous decline ever since. Hospitalizations continue to rise in the Northeast, but they are still at about 60 percent of the spring’s awful totals.

The hardest-hit areas right now, as indicated by hospitalizations per million residents, are in the South and Southwest. The hotspots are primarily in the Sun Belt, including California, Nevada, Mississippi, Alabama, Tennessee, and Georgia. New York is also a cause for concern again. In other words, we’re returning to a patchwork pandemic.

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Nationwide, the most stable indicator—the number of hospitalizations—is still rising, though not as quickly as it was from November through mid-December, thanks to declines in the Midwest. Focusing on hospitalizations is particularly useful right now because holidays, like weekends, depress the reporting of cases and deaths across the country, while sick people continue to enter the hospital as they would on any other day. So even though cases are down compared to last week in most states, with a similar trend in the seven-day average of daily deaths nationwide, that’s likely a data lag that won’t clear up until the first week or two of the new year.

And hospitalizations tell a more complex story. Over the seven days ending December 29, the measure fell in 28 states and the District of Columbia and rose in 21 states (it was unchanged in New Mexico); it fell by 10 percent or more in 10 states, suggesting a substantial change in the state’s conditions, and rose by 10 percent or more in 12.

California is one of the five states—along with Arizona, Florida, Tennessee, and Texas—that account for 40 percent of new cases from December 17 to December 23, according to the COVID Tracking Project. Of the five, California has by far the highest number of hospitalizations, which beyond their general stress on the health-care system augur high death tolls to come. California had 21,240 people in hospitals on December 29, accounting for 17 percent of all hospitalizations nationwide. Twice as many Californians were hospitalized on December 29 as on December 6. Texas is also seeing a rise in hospitalizations—it had 11,775 on December 29—but its numbers are only up by about 2,800 since the first week of December.

Hospitalizations are also up in Arizona. Its hospitalization rate, at 615 people per million, is higher than California’s 538 per million. Arizona has now surpassed its devastating summer surge; while 3,517 people were hospitalized on July 14, that number was 4,475 on December 29. Nevada, whose population is centered in Las Vegas between the hotspots of Arizona and Southern California, has the highest hospitalization rate in the country, at 626 per million.

Just behind Nevada and Arizona in hospitalizations per million is Alabama. During its summer surge in early August, Alabama had about 1,500 hospitalized COVID-19 patients per day; it now has 2,804. The state’s seven-day average of deaths (which, because of the problems with holiday reporting, is quite volatile) has also recently been higher than in the summer. On December 23, the state reported 135 deaths, more than double the peak of 61 it suffered on July 27, and reported another 89 deaths on December 24. Hospitalizations are also up in neighboring Georgia, which reached a new record of 4,839 on December 29, one-third higher than its previous July peak.

In this patchwork, which includes clusters in the West and South, the country’s original epicenter is also back on the map. New York is nowhere near the dire conditions of the late winter and early spring, when the state had more than 18,000 people hospitalized and was recording more than 750 deaths per day, but there are worrisome signs. The seven-day average of hospitalizations more than doubled between December 1 and December 29, when it hit 7,184. Cases and deaths are also up. And unlike in the spring, the problem is statewide. According to New York State data, 2,717 people in New York City were hospitalized with COVID-19 on December 28, plus another 1,358 in Long Island. Those two regions are far below their spring peaks, as is the mid-Hudson region, which encompasses the area just north of the city, including its suburbs, while every other part of the state is at its highest level yet—there are more than 400 people hospitalized in the central New York area, for example, about five times higher than at any other point in the pandemic. There are 964 hospitalized in the Finger Lakes region, 4.4 times the previous peak.

Nationwide, the picture is certainly better than it was at the beginning of December, or even a week or two ago. Conditions in the Midwest have improved substantially. They’ve actually improved in most states in the West, even if California, Nevada, and Arizona are driving the top-line numbers up. The situation in the South and Northeast is mixed—some, but not all, states are struggling, and there’s a hint that the increase in hospitalizations in both regions could be slowing.

Still, the U.S. is far from out of the woods, and the murkiness of the data that will stretch into the first few days of 2021 makes it harder to see the path through it. The improvements in some places are real, especially in the Midwest, as hospitalizations indicate. In other places, falling case and death counts are just as likely to be the result of reporting lags. Even if the worst of the winter surge is, in fact, receding, the lack of clarity that could result from America’s new patchwork risks further confusion, complacency, and disjointed responses. With widespread vaccine access on the horizon, the end really is in sight, but a false dawn could lead to even more misery.


* This article previously misstated the number of deaths from COVID-19 in the United States in November and December.