The summer wasn’t meant to be like this. By April, Greene County, in southwestern Missouri, seemed to be past the worst of the pandemic. Intensive-care units that once overflowed had emptied. Vaccinations were rising. Health-care workers who had been fighting the coronavirus for months felt relieved—perhaps even hopeful. Then, in late May, cases started ticking up again. By July, the surge was so pronounced that “it took the wind out of everyone,” Erik Frederick, the chief administrative officer of Mercy Hospital Springfield, told me. “How did we end up back here again?”
The hospital is now busier than at any previous point during the pandemic. In just five weeks, it took in as many COVID-19 patients as it did over five months last year. Ten minutes away, another big hospital, Cox Medical Center South, has been inundated just as quickly. “We only get beds available when someone dies, which happens several times a day,” Terrence Coulter, the critical-care medical director at CoxHealth, told me.
Last week, Katie Towns, the acting director of the Springfield–Greene County Health Department, was concerned that the county’s daily cases were topping 250. On Wednesday, the daily count hit 405. This dramatic surge is the work of the super-contagious Delta variant, which now accounts for 95 percent of Greene County’s new cases, according to Towns. It is spreading easily because people have ditched their masks, crowded into indoor spaces, resumed travel, and resisted vaccinations. Just 40 percent of people in Greene County are fully vaccinated. In some nearby counties, less than 20 percent of people are.
Many experts have argued that, even with Delta, the United States is unlikely to revisit the horrors of last winter. Even now, the country’s hospitalizations are one-seventh as high as they were in mid-January. But national optimism glosses over local reality. For many communities, this year will be worse than last. Springfield’s health-care workers and public-health specialists are experiencing the same ordeals they thought they had left behind. “But it feels worse this time because we’ve seen it before,” Amelia Montgomery, a nurse at CoxHealth, told me. “Walking back into the COVID ICU was demoralizing.”
Those ICUs are also filling with younger patients, in their 20s, 30s, and 40s, including many with no underlying health problems. In part, that’s because elderly people have been more likely to get vaccinated, leaving Delta with a younger pool of vulnerable hosts. While experts are still uncertain if Delta is deadlier than the original coronavirus, every physician and nurse in Missouri whom I spoke with told me that the 30- and 40-something COVID-19 patients they’re now seeing are much sicker than those they saw last year. “That age group did get COVID before, but they didn’t usually end up in the ICU like they are now,” Jonathan Brown, a respiratory therapist at Mercy, told me. Nurses are watching families navigate end-of-life decisions for young people who have no advance directives or other legal documents in place.
Almost every COVID-19 patient in Springfield’s hospitals is unvaccinated, and the dozen or so exceptions are all either elderly or immunocompromised people. The vaccines are working as intended, but the number of people who have refused to get their shots is crushing morale. Vaccines were meant to be the end of the pandemic. If people don’t get them, the actual end will look more like Springfield’s present: a succession of COVID-19 waves that will break unevenly across the country until everyone has either been vaccinated or infected. “You hear post-pandemic a lot,” Frederick said. “We’re clearly not post-pandemic. New York threw a ticker-tape parade for its health-care heroes, and ours are knee-deep in COVID.”
That they are in this position despite the wide availability of vaccines turns difficult days into unbearable ones. As bad as the winter surge was, Springfield’s health-care workers shared a common purpose of serving their community, Steve Edwards, the president and CEO of CoxHealth, told me. But now they’re “putting themselves in harm’s way for people who’ve chosen not to protect themselves,” he said. While there were always ways of preventing COVID-19 infections, Missourians could have almost entirely prevented this surge through vaccination—but didn’t. “My sense of hope is dwindling,” Tracy Hill, a nurse at Mercy, told me. “I’m losing a little bit of faith in mankind. But you can’t just not go to work.”
When Springfield’s hospitals saw the first pandemic wave hitting the coasts, they could steel themselves. This time, with Delta thrashing Missouri fast and first, they haven’t had time to summon sufficient reinforcements. Between them, Mercy and Cox South have recruited about 300 traveling nurses, respiratory therapists, and other specialists, which is still less than they need. The hospitals’ health-care workers have adequate PPE and most are vaccinated. But in the ICUs and in COVID-19 wards, respiratory therapists still must constantly adjust ventilators, entire teams must regularly flip patients onto their belly and back again, and nurses spend long shifts drenched in sweat as they repeatedly don and doff protective gear. In previous phases of the pandemic, both hospitals took in patients from other counties and states. “Now we’re blasting outward,” Coulter said. “We’re already saturating the surrounding hospitals.”
Meanwhile, the hospitals’ own staff members are exhausted beyond telling. After the winter surge, they spent months catching up on record numbers of postponed surgeries and other procedures. Now they’re facing their sharpest COVID-19 surge yet on top of those backlogged patients, many of whom are sicker than usual because their health care had to be deferred. Even with hundreds of new patients with lung cancer, asthma, and other respiratory diseases waiting for care in outpatient settings, Coulter still has to cancel his clinics because “I have to be in the hospital all the time,” he said.
Many health-care workers have had enough. Some who took on extra shifts during past surges can’t bring themselves to do so again. Some have moved to less stressful positions that don’t involve treating COVID-19. Others are holding the line, but only just. “You can’t pour from an empty cup, but with every shift it feels like my co-workers and I are empty,” Montgomery said. “We are still trying to fill each other up and keep going.”
The grueling slog is harder now because it feels so needless, and because many patients don’t realize their mistake until it’s too late. On Tuesday, Hill spoke with an elderly man who had just been admitted and was very sick. “He said, ‘I’m embarrassed that I’m here,’” she told me. “He wanted to talk about the vaccine, and in the back of my mind I’m thinking, You have a very high likelihood of not leaving the hospital.” Other patients remain defiant. “We had someone spit in a nurse’s eye because she told him he had COVID and he didn’t believe her,” Edwards said.
Some health-care workers are starting to resent their patients—an emotion that feels taboo. “You’re just angry,” Coulter said, “and you feel guilty for getting angry, because they’re sick and dying.” Others are indignant on behalf of loved ones who don’t already have access to the vaccines. “I’m a mom of a 1-year-old and a 4-year-old, and the daughter of family members in Zimbabwe and South Africa who can’t get vaccinated yet,” says Matifadza Hlatshwayo Davis, who works at a Veterans Affairs hospital in St. Louis. “I’m frustrated, angry, and sad.”
“I don’t think people get that once you become sick enough to be hospitalized with COVID, the medications and treatments that we have are, quite frankly, not very good,” says Howard Jarvis, the medical director of Cox South’s emergency department. Drugs such as dexamethasone offer only incremental benefits. Monoclonal antibodies are effective only during the disease’s earliest stages. Doctors can give every recommended medication, and patients still have a high chance of dying. The goal should be to stop people from getting sick in the first place.
But Missouri Governor Mike Parson never issued a statewide mask mandate, and the state’s biggest cities—Kansas City, St. Louis, Springfield, and Columbia—ended their local orders in May, after the CDC said that vaccinated people no longer needed to wear masks indoors. In June, Parson signed a law that limits local governments’ ability to enact public-health restrictions. And even before the pandemic, Missouri ranked 41st out of all the states in terms of public-health funding. “We started in a hole and we’re trying to catch up,” Towns, the director of the Springfield–Greene County Health Department, told me.
Her team flattened last year’s curve through testing, contact tracing, and quarantining, but “Delta has just decimated our ability to respond,” Kendra Findley, the department’s administrator for community health and epidemiology, told me. The variant is spreading too quickly for the department to keep up with every new case, and more people are refusing to cooperate with contact tracers than at this time last year. The CDC has sent a “surge team” to help, but it’s just two people: an epidemiologist, who is helping analyze data on Delta’s spread, and a communications person. And like Springfield’s hospitals, the health department was already overwhelmed with work that had been put off for a year. “Suddenly, I feel like there aren’t enough hours in the day,” Findley said.
Early last year, Findley stuck a note on her whiteboard with the number of people who died in the 1918 flu pandemic: 50 million worldwide and 675,000 in the U.S. “It was for perspective: We will not get here. You can manage this,” she told me. “I looked at it the other day and I think we’re going to get there. And I feel like a large segment of the population doesn’t care.”
The 1918 flu pandemic took Missouri by surprise too, says Carolyn Orbann, an anthropologist at the University of Missouri who studies that disaster. While much of the world felt the brunt of the pandemic in October 1918, Missouri had irregular waves with a bigger peak in February 1920. So when COVID-19 hit, Orbann predicted that the state might have a similarly drawn-out experience. Missouri has a widely dispersed population, divided starkly between urban and rural places, and few highways—a recipe for distinct and geographically disparate microcultures. That perhaps explains why new pathogens move erratically through the state, creating unpredictable surges and, in some pockets, a false sense of security. Last year, “many communities may have gone through their lockdown period without registering a single case and wondered, What did we do that for?” Orbann told me.
She also suspects that Missourians in 1918 might have had a “better overhead view of the course of the pandemic in their communities than the average citizen has now.” Back then, the state’s local papers published lists of people who were sick, so even those who didn’t know anyone with the flu could see that folks around them were dying. “It made the pandemic seem more local,” Orbann said. “Now, with fewer hometown newspapers and restrictions on sharing patient information, that kind of knowledge is restricted to people working in health care.”
Montgomery, the CoxHealth nurse, feels that disparity whenever she leaves the hospital. “I work in the ICU, where it’s like a war zone, and I go out in public and everything’s normal,” she said. “You see death and suffering, and then you walk into the grocery store and get resistance. It feels like we’re being ostracized by our community.”
If anything, people in the state have become more entrenched in their beliefs and disbeliefs than they were last year, Davis, the St. Louis–based doctor, told me. They might believe that COVID-19 has been overblown, that young people won’t be harmed, or that the vaccines were developed too quickly to be safe. But above all else, “what I predominantly get is ‘I don’t want to talk to you about that; let’s move on,’” Davis said.
People take the pandemic seriously when they can see it around them. During past surges in other parts of the U.S., curves flattened once people saw their loved ones falling ill, or once their community became the unwanted focus of national media coverage. The same feedback loop might be starting to occur in Missouri. The major Route 66 Festival has been canceled. More people are making vaccine appointments at both Cox South and Mercy.
In Springfield, the public-health professionals I talked with felt that they had made successful efforts to address barriers to vaccine access, and that vaccine hesitancy was the driving force of low vaccination rates. Improving those rates is now a matter of engendering trust as quickly as possible. Springfield’s firefighters are highly trusted, so the city set up vaccine clinics in local fire stations. Community-health advocates are going door-to-door to talk with their neighbors about vaccines. The Springfield News-Leader is set to publish a full page of photos of well-known Springfieldians who are advocating for vaccination. Several local pastors have agreed to preach about vaccines from their pulpits and set up vaccination events in their churches. One such event, held at James River Church on Monday, vaccinated 156 people. “Once we got down to the group of hesitant people, we’d be happy if we had 20 people show up to a clinic,” says Cora Scott, Springfield’s director of public information and civic engagement. “To have 156 people show up in one church in one day is phenomenal.”
But building trust is slow, and Delta is moving fast. Even if the still-unvaccinated 55 percent of Missourians all got their first shots tomorrow, it would still take a month to administer the second ones, and two weeks more for full immunity to develop. As current trends show, Delta can do a lot in six weeks. Still, “if we can get our vaccination levels to where some of the East Coast states have got to, I’ll feel a lot better going into the fall,” Frederick, Mercy’s chief administrative officer, said. “If we plateau again, my fear is that we will see the twindemic of flu and COVID.”
In the meantime, southwest Missouri is now a cautionary tale of what Delta can do to a largely unvaccinated community that has lowered its guard. None of Missouri’s 114 counties has vaccinated more than 50 percent of its population, and 75 haven’t yet managed more than 30 percent. Many such communities exist around the U.S. “There’s very few secrets about this disease, because the answer is always somewhere else,” Edwards said. “I think we’re a harbinger of what other states can expect.”