Ali Mokdad’s job has become a particularly bleak one this year.
Forecasting illness and death, carefully considering the health policies that decide if people will live or die, is far from a happy way to spend working hours, but it's a necessary one.
The professor and chief strategy officer for population health at the University of Washington has become consumed by the projections program he leads at the school's Institute for Health Metrics and Evaluation.
The university has built one of the most well-recognized public COVID-19 projection tools in North America. It breaks down data from around the world, including at the provincial and state levels.
He slides the tab on an interactive map's timeline back and forth. As it moves from early to mid-September, North Dakota darkens substantially, indicating the state’s divergence from the pack, becoming the American hot spot for COVID-19 as the per capita number of daily deaths skyrocketed.
"In the smaller communities, they assume COVID-19 is not a problem, it’s the big cities," Mokdad tells the Free Press. "Rural communities didn’t see COVID-19 early on, they didn’t put the health measures and the brakes (in place)."
North Dakota reported its first case of COVID-19 on March 11. It took seven months for the state to reach 30,000. In the last four weeks, the cumulative number has doubled, to 70,016. Nearly 10,000 of those are currently active.
A map showing Canada through October shows a similar effect, as Manitoba darkens in contrast to the other provinces beside it.
North Dakota has a smaller population than Manitoba, but to date, 818 people there have died from COVID-19, this week crossing the threshold of one death for every 1,000 people. Mokdad and his team project that by March 1, the virus will have been responsible for ending more than 1,500 North Dakota lives.
Manitoba's circumstances haven't become quite as dire, reporting its 207th death Friday, but the province has become the hot spot in Canada. The IMHE projects that by March 1, based on current circumstances, lockdown measures and population adherence, 1,400 Manitobans will die from the virus.
The number is an improvement from the estimations given at the end of October, when the institute was projecting nearly twice as many deaths. The implementation of additional health safety measures improved the forecast.
It's a stunning picture of how bad things have become for these two Prairie populations. During the summer, it seemed as though Manitobans had escaped the worst of the pandemic, somehow managing to duck the devastation experienced elsewhere.
While the geographic proximity is obvious, there are other similarities that help explain why Manitoba and its American neighbour have fared so poorly in the battle against the second wave.
As North Dakota's outlook became darkest on the U.S. map and on the ground, White House coronavirus task force co-ordinator Dr. Deborah Birx paid a visit and lambasted residents for not following medical advice to wear masks.
"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," Birx said after having toured 40 states.
Both Manitoba and North Dakota have struggled with mask compliance; it didn't help that government leaders were hesitant to make it mandatory, In July, according to IHME research, roughly 15 per cent of Manitobans and 40 per cent of North Dakotans were wearing masks.
Gov. Doug Burgum advocated for face coverings, but shied away from a legal requirement even though doctors urged him to impose one. But on Nov. 13, as hospitals became overwhelmed and the state reported 10,397 active cases, he implemented a statewide mandate.
"He sets the example, he wears it in appropriate circumstances and has encouraged people to do it. He just didn’t use the mandate word," says Dr. Joshua Wynne, the dean of the University of North Dakota’s school of medicine, and the state's chief medical adviser.
On Aug. 7, Premier Brian Pallister dodged "the mandate word."
"There’s much debate about masks, it’s become the topic of choice. I would say the most important thing to remember… is to practise social distancing, to make sure you stay home when you’re sick, to make sure you wash your hands regularly, to make sure that you’re not touching your face, to make sure that you’re doing the right things fundamentally in the absence of a mask."
By the end of September, as the number of active cases neared 400, calls for a mandate had become louder and included the voice of Mayor Brian Bowman. Within days, chief public health officer Dr. Brent Roussin announced that masks would be mandatory in indoor public spaces in the Winnipeg region.
The delays have cost both Manitoba and North Dakota dearly, says Amir Attaran, a professor in both the faculty of law and school of medicine at the University of Ottawa.
"(Wearing a mask) is the single most potent thing you can do, short of marooning yourself on a desert island," says the expert in epidemiology and public health. "And if a government fails to implement a mask mandate, it is playing Russian roulette with the virus."
Mask adherence has risen only to about 50 per cent in North Dakota, but exceeds 80 per cent now in Manitoba.
The rationale for not mandating mask-wearing or imposing strict shutdown orders — at least the one made public — was the same from leaders on both sides of the border: we can count on our people to do the right thing.
"We’ve talked a lot about individual responsibility, but today we also have to talk about community responsibility and we do have some positive news because we have seen communities coming together, we’ve seen local leaders that are providing leadership in those communities, and we’re seeing some progress," Burgum said Oct. 29 as the number of active cases and deaths continued to climb.
"This virus, as we’ve said, can’t be fought on a global basis or international or a national basis, or even a state basis. It’s going to come down to building by building, school by school, church by church, business by business, family by family, interaction by interaction. Down to the transmissible moments, the choices that people make."
Although he implemented a state-wide mask mandate two weeks later, the governor has continued to preach about personal responsibility when it comes to questions about restricting people’s movements and closing portions of the economy. Thus far, he has only restricted capacity and opening hours at businesses.
Similarly, the PC government in Manitoba was hesitant to reinstate the strict health orders that were in place in the early days of the pandemic and lifted later in the spring. And while the province is under a stay-home advisory now, in late October, Pallister maintained his focus on individual responsibility to follow the basic principles.
"A government can't protect you from this virus, you have to protect each other, and that's our obligation as friends, as family members, as citizens of this beautiful province," Pallister said Oct. 26. "This is an obligation we share; thoughtful Manitobans are making sacrifices."
Wynne says this approach has proven ineffective in North Dakota.
"I think the issue was that (the governor) was counting on personal responsibility — which we value in each other in North Dakota — to carry the day. And I think the numbers show that not enough of us were following personal responsibility, regarding mask use and the other things. So, more stringent requirements were necessary," he told the Free Press.
The summer in both North Dakota and in Manitoba offered a reprieve. Harsh lockdowns in the spring had seemed like overkill, as case numbers remained low and there had been few deaths. Hospitals had treated few COVID patients and were a long way from being overwhelmed, lulling residents in both places into a false sense of security.
The first spikes in case numbers in North Dakota came after large gatherings on Independence Day in July, the annual August motorcycle rally in Sturgis, S.D., and students returning to college campuses in September. But as fall set in, people and their gatherings moved indoors, which is where the problem really took root.
"It won’t be as simple as closing public spaces, because public spaces, you can see, were very safe over the summer and probably remain safe," Birx said at the end of October, referring to the situation in North Dakota.
"This is really something that has happened in the last three to four weeks. And what’s happened in the last three to four weeks is it’s gotten cooler and people have moved their social gatherings indoors."
On Oct. 20, contact-tracing efforts were largely suspended in the state, with authorities having only the capacity at that point to focus on vulnerable populations in long-term care homes and other locations such as universities, where spread can occur quickly. Even with approximately 450 full- and part-time contact tracers, they just couldn't keep up.
"Initially it was just people getting together," says Kirby Kruger, director of the North Dakota Division of Disease Control.
Weddings, funerals, even just dinner parties became hotbeds for spread of the virus.
"As the fall went on, we had this transition of being able to identify these types of events, to people saying, 'I'm not really sure where I picked this up.' So we had this transition to community spread in the fall here," Kruger says.
The biggest concern is that people will disregard safety next weekend celebrating American Thanksgiving. There are fears that an already dire situation in the state could be worse in mid-December.
Manitoba's case numbers took a bit longer to pick up steam, but the fall weather delivered a harsh reality to both jurisdictions.
Dr. Michael Osterholm, director of the Center of Infectious Disease Research and Policy at the University of Minnesota, and a member of President-elect Joe Biden’s coronavirus advisory board, recently issued a frightening warning.
"The next three to four months are going to be, by far, the darkest of the pandemic," he said in an interview with CNBC.
The health-care systems in both Manitoba and North Dakota's are groaning under unprecedented demands on staff and resources.
"Our hospitals are under enormous pressure now," Burgum said on Nov. 9 in a shocking announcement ordering coronavirus-positive but asymptomatic health-care staff to continue working.
Similar measures had to be taken in Europe in the spring when hospitals with infected staff members couldn’t keep up with demand for services.
Evidence has shown clearly that infected but asymptomatic people are able to transmit the virus.
In Minot, one of the hardest hit cities in North Dakota, Mayor Shaun Sipma told ABC News that there is a stark juxtaposition in perspectives inside the local hospital compared to people on the other side of its doors.
"Within the community, there’s still a segment of the population that still isn’t taking this seriously, even though we do have a mask mandate," he said.
As has been the case in Manitoba, where the virus has rampaged through long-term care residences and taken dozens of lives, the situation is similar in North Dakota, where approximately 60 per cent of the deaths in the state have been linked to outbreaks in such facilities.
In Manitoba, according to Shared Health, 476 health-care workers and first responders have tested positive for COVID-19. Rapidly diminishing intensive-care unit capacity is an ongoing concern.
North Dakota reported 1,408 new cases of COVID-19 Friday. In the last week, there was an average of 177 cases daily per 100,000 people.
In Manitoba, Friday's number was 438 new cases. In the last week Manitoba had an average of 30 new cases per day per 100,000 people.
The province imposed tighter restrictions Thursday that prohibit gatherings that include anyone from outside a given household, as well as cracking down on in-store sales of non-essential goods.
"We're assuming (both jurisdictions) will hit the brakes now. Manitoba has, so I expect you to come down, North Dakota has not, except for the masks," Mokdad said. "They have to eventually hit the brakes and hit them hard."
Mokdad said action will force case numbers down in two weeks, but to return to caseload levels seen in early fall here in Manitoba, it will likely take until March. While both Manitoba and North Dakota were first to feel the effects of people heading inside, that phenomenon is likely to be replicated across Canada and across the Midwest in the United States as temperatures fall.
There is a long, cold winter ahead across North America.
Sarah Lawrynuik reports on climate change for the Winnipeg Free Press. Funding for the Free Press climate change reporter comes from the Government of Canada through the Local Journalism Initiative.