The EconomistNovember 28th 2020 United States 232
1whenhospitalsoverfill.Not only covid-19
patients suffer; disruptions also threaten
care for those afflicted by cancer, heart dis-
ease, car accidents and more. Rates of ex-
cess, non-virus deaths could surge. Across
Iowa, 80% of icu beds are now occupied. In
North Dakota it is over 90%.
Smaller hospitals suffer the greatest
strain—not least because 130 rural ones
closed across America in the past decade,
putting pressure on those that remain. Ben
Christians, an emergency-care doctor at
one in Sioux Falls, South Dakota, says it has
just experienced by far “the worst month”
of the entire pandemic, eclipsing the out-
break in the spring. For the past two
months “we’ve been functioning at over
100%” of icu beds, and adding other sorts,
he says. Finding enough trained staff is the
biggest constraint. He admits patients
from 80 sparsely populated but ever more
afflicted counties, sometimes over 150
miles away. The smallest rural clinics, with
just a handful of beds and a single doctor,
are easily overrun.
Across South Dakota, by November
25th, 43% of covid tests were coming back
positive—still terribly high, but a slight fall
on before. At the main emergency ward,
“some days almost every patient is covid-
positive”, he says. This is exhausting, be-
cause staff are constantly donning and re-
moving cumbersome protective gear.
Some fall ill, or endure what is sometimes
called “moral injury”. That means trauma,
such as when nurses care for otherwise iso-
lated, confused and slowly dying patients.
Holding iPads so that relatives can share
last words can upset health workers, too.
Doctors who need to get deteriorating
patients into bigger hospitals have also
struggled. Dr Runde helps to run patient
transfers in Iowa and says it can take hours
of calling hospitals, some in other states, tofind a bed. As bigger hospitals in cities fill,
less-sick patients are pushed back to small-
er rural ones. In Sioux Falls another 1,000
patients, including 100 on supplemental
oxygen, are monitored in their homes.
Shuttling patients around is not ideal.
Frontline staff have learned better ways
to treat patients, so mortality is not soaring
along with infections. Kurt Chamberlain,
an emergency doctor in eastern Iowa, says
his hospital, St Lukes near Cedar Rapids,
has 76 patients, far more than before: “We
couldn’t have handled that in May.” Every-
one knows, for example, that they must
avoid putting patients (except the most
desperate) on ventilators. Dr Christians es-
timates that only 5-10% of those who are in-
tubated survive it. Emma Nash, an icu fel-
low at a hospital in Omaha, Nebraska, says
emergency oxygen is delivered, instead,
via a high-powered nasal cannula.
At home, herself shivering from the vi-
rus, Dr Nash says hospital resources are
spread thin. “The rest of the country should
see what’s happening here and realise
they’re not out of the woods,” she says. (In-
fections are surging again in the South, es-
pecially.) In mid-November the Midwest
accounted for half of all new cases in nurs-
ing homes in America. Deaths are also tick-
ing up. On average covid-19 is now killing
over 1,550 Americans daily, with the dozen
midwestern states accounting for an out-
size share of that—560 deaths each day.
In North Dakota nearly one-in-ten peo-
ple is a confirmed covid case. Why is the re-
gion so afflicted? People in northern states
are probably meeting indoors, where coro-
navirus spreads most easily, more than
those in warmer spots. Those in rural
places, like north Wisconsin, who earlier
avoided outbreaks may be shunning pro-
tective measures. And policymakers are at
fault. Many Republican governors and leg-islators have long refused to shut bars or
restaurants, order statewide mask-wearing
or ban mass-gatherings—such as the Stur-
gis bike rally in South Dakota. All that
helped to spread the virus.
Since the election a few, belatedly, have
changed their tune. Kim Reynolds, Iowa’s
governor, at last issued a statewide mask
mandate, after months of scorning the
idea. North Dakota’s governor, Doug Bur-
gum, has done the same, also this month.
Some cities, such as Sioux Falls and Oma-
ha, do require masks, but in rural areas de-
nial of the virus and rejection of mitigation
efforts are both common.
Figures from recent days suggest infec-
tions may have fallen off from record highs
in some states. But no one is cheering in
the emergency wards. Health workers fear
that Thanksgiving gatherings will prove to
be superspreader moments. Ignoring pleas
from public-health officials to stay home,
many millions of Americans have flown
and driven to family celebrations in the
past few days. Meanwhile many college
students have just gone home for the year.
Dr Runde and the others all say that por-
tends predictably grim results to come. “It
is like slow-motion horror. We’re just
standing there and being run over.” 7Waving and drowningL
ess than24 hours after Donald Trump
concluded that he could block the tran-
sition to Joe Biden’s incoming administra-
tion no longer, the Democratic veteran
took the stage alongside his chosen nation-
al-security team. “America is back, ready to
lead the world, not retreat from it,” he said.
The happy gurgles of relief this elicited in
Washington, dc, London, Tokyo and be-
yond may be imagined.
Even more than expected, Mr Biden’s
choices reflected a stress on unflashy ex-
pertise, pragmatism and personal loyalty.
His secretary-of-state nominee and na-
tional security adviser, respectively An-
tony Blinken and Jake Sullivan, are well-re-
garded Obama administration veterans. Mr
Blinken, mild-mannered, impeccably coif-
fured and Francophone, served as the for-
mer vice-president’s national security ad-
viser and as a deputy secretary of state. Mr
Sullivan, possessed of a first-rate intellect
and slightly lesser coiffuring, was another
well-liked Biden nsa.
Being friends, they would not be at each
other’s throats as Mike Pompeo and JohnWASHINGTON, DC
Joe Biden unveils a reassuringly
familiar national-security teamTeam BidenIn transit