Haiti on the brink: The prospects and challenges of the Kenyan-led MSS initiative


Haiti on the brink: The prospects and challenges of the Kenyan-led MSS initiative


Across nine months, COVID-19 hit some US places worse than others. Now, it’s almost everywhere.

People walk past the entrance of PS 234 Independence School as elementary schools to reopen, New York, NY, December 7, 2020. New York City Mayor Bill de Blasio announced that public pre-K and elementary schools can return to in-person learning on Dec. 7., while middle and high schools remain closed; Schools were closed on Nov. 18 when the city surpassed the 3% infection rate threshold set by the Mayor de Blasio. (Photo by Anthony Behar/Sipa USA)No Use UK. No Use Germany.

The end of November marks the ninth month of the wider COVID-19 outbreak in the U.S. After winding its way through different parts of the country—from big Northeast cities in the spring to southern, then western, then Midwest areas of all sizes—November’s rates show large numbers of new cases almost everywhere. Last month, 47 states and Washington, D.C. registered at least 500 cases per 100,000 residents—with most substantially above that rate. The vast majority of U.S. counties have also crossed this threshold, affecting 93% of the nation’s population.

Particularly noteworthy is COVID-19’s continued rise in nonmetropolitan, Republican-leaning America. The pandemic was not a top issue for Trump voters in November’s presidential election, according to exit polls. This flies in the face of recent trends which show that—especially over the fall—counties that favored Trump experienced some of the highest COVID-19 rates. Racially diverse communities continue to exhibit high COVID-19 rates as well.

The below analysis tracks how COVID-19 has spread across states and counties from March to November, emphasizing where the pandemic’s newest surge has become most intense.

A nationwide spike that visits (and revisits) almost all states

The magnitude of the current COVID-19 surge can be seen by tracking new monthly COVID-19 cases per 100,000 residents nationally from March to November, as shown in Figure 1. (These reflect confirmed COVID-19 cases as reported by The New York Times.)


State map

March’s modest rate of 56 cases per 100,000 residents rose to beyond 200 in April to June, only to spike sharply to over 500 in July. The end of the summer saw a dip down to 366 in September. This was followed by a return to the 500-plus threshold in October, and a more than doubling of the national rate to 1,335 new cases per 100,000 residents in November.

The winding path of these cases across regions and states started in the Northeast, then moved to the South, then West in July with an unmistakable Midwest surge in the fall. This culminated in rising new COVID-19 rates in all states during November.

The maps above provide a more detailed picture, depicting which states exhibited new COVID-19 rates exceeding 500 cases per 100,000 residents on a month-to-month basis (see also downloadable Table A).

In March, not one state achieved a COVID-19 case rate exceeding 500, although New York—with a rate of 392—registered by far the highest. In April, New York and New Jersey zoomed to rates exceeding 1,000 cases per 100,000 residents, with the New England states of Massachusetts, Connecticut, and Rhode Island (as well as Washington, D.C.) achieving rates of 500 or greater.

By the month of May, COVID-19 rates in the greater New York metropolitan area slowed down, such that the new rates for New York, New Jersey, and Connecticut dropped below 500 cases, not to return to those levels until November. Still, Illinois (reflecting rises around Chicago) and Maryland (including Baltimore and suburban areas outside Washington, D.C.) as well as Nebraska joined the ranks of states with new COVID-19 cases exceeding 500 that month.

June was a transition month, in the sense that only Arizona exceeded rates of 500 cases per 100,000 residents. But just below the Grand Canyon State were rising rates in several southern states which entered that category in July.

In fact, the national July rise in new COVID-19 rates was largely due to southern states. Florida led, with a rate exceeding 1,400 new cases per 100,000 residents. Four other southern states—Louisiana, Mississippi, South Carolina, and Alabama—showed July rates exceeding 1,000 cases. Another six states—including Texas, Georgia, and North Carolina—showed rates exceeding 500 cases. Several western states, such as Nevada, Idaho, California, and Utah also exhibited high rates (Arizona led here, with a new monthly rate of 1,300 cases), raising this region’s profile in July.

While national new COVID-19 rates tamped down somewhat in August and September, states in the South and increasingly in the Midwest dominated those with new high case rates. Among the latter, North Dakota, South Dakota, Iowa, Missouri, and Kansas showed rates exceeding 500 cases per 100,000 residents in August. In September, North Dakota, South Dakota, Wisconsin, and Iowa showed highest new case rates of all states, followed by a mix of other states in the Midwest, South, and West.

It was in October and especially November that national new COVID-19 rates began to rise dramatically, with Midwest states in the top ranks. In both months, North Dakota and South Dakota led with new monthly COVID-19 rates, exceeding 2,600 cases per 100,000 residents in October and 3,800 in November. In October 10 states—all in the Midwest and West—showed new case rates exceeding 1,000 per 100,000 residents. In November, 17 states in those same regions exhibited rates exceeding 2,000 per 100,000 residents.

When using a benchmark of new monthly COVID-19 rates exceeding 500 cases per 100,000 residents, 31 states—representing all regions of the country—reached that level in October, and 47 (in addition to  Washington, D.C.) did so in November. In the latter month, several states that had dropped out of this category since May—including New York, New Jersey, Maryland, Washington, D.C., and most of New England —returned. The states of Pennsylvania, Delaware, Virginia, West Virginia, Oregon, and Washington reached this benchmark for the first time since the pandemic began. Only three states— Maine, Vermont, and Hawaii—did not register new case rates exceeding 500 per 100,000 residents in any of the first nine months of the pandemic, though each exhibited their highest rates in November.

County case rates rise, particularly in nonmetropolitan and racially diverse counties

Just as COVID-19 case rates broadened across states in the past two months, they also did for the nation’s 3,100-plus counties. Table 1 provides a month-by-month overview of the rise and fall in the number of counties that achieved monthly new case rates exceeding 500 per 100,000 residents between March and November.


In March, just 10 counties met the 500-plus new monthly COVID-19 case rate threshold. Because they included populous counties in the New York metropolitan area, they contained 11 million people, or 3.4% of the U.S. population. The number of counties that crossed this monthly COVID-19 threshold stayed below 300 (and no more than 15% of the U.S. population) until there was a broader spread across the South and other parts of the country in July. Then, more than 1,000 counties—representing 44% of the U.S. population—showed new monthly COVID-19 rates exceeding 500 cases per 100,000 residents.

While the number of such counties stayed similar in August and September, there was a switch from larger urban counties to smaller-sized metropolitan and nonmetropolitan areas. As a consequence, the overall affected population was reduced; in September, only 20% of the U.S. population lived in areas with new COVID-19 case rates exceeding 500 per 100,000 residents.

This changed in October and November, when 2,065 and 2,819 counties, respectively, reached a new monthly COVID-19 rate of over 500 cases per 100,000 residents. In November, these counties housed 93% of the population.

In addition to covering a broader stretch of the U.S. population, November’s nationwide rise in new COVID-19 cases meant more counties registered extremely high case rates. In November, the 200 counties with the highest new rates ranged from 4,003 new cases per 100,000 residents (in Johnson County, Neb.) to 18,858 per 100,000 residents (Crowley County, Colo.). Among these 200 counties, 174 are located outside of metropolitan areas, with large numbers in North Dakota (30), South Dakota (30), Kansas (30), Minnesota (19), and Iowa (18).

Fig 2

The rise of new COVID-19 rates in nonmetropolitan counties is illustrated in Figure 2, which shows trends in monthly new case rates from March to November using a classification of urban counties developed by the Brookings Institution.* While all categories of urban areas showed sharp rises in new monthly COVID-19 rates in November, the monthly rises for smaller metropolitan and especially nonmetropolitan counties are stunning. Since August, nonmetropolitan and small metropolitan counties displayed higher rates than their more urbanized counterparts, leading to November case rates of 1,485 and 1,760 per 100,000 residents, respectively.


Two other categories of counties that showed high monthly new COVID-19 case rates (especially in July) are those with large shares of residents identifying as people of color, and those where more than 25% of residents hold incomes below the federal poverty level.

Figure 3 displays month-by-month rates for both groups in comparison with the U.S. population. There are 54 counties where more than four-fifths of residents identity as Black, Latino or Hispanic, Asian American, Native American, or other nonwhite races—altogether comprising 8.3 million people. These include counties on the Texas-Mexico border, Miami-Dade County, Fla., the Bronx, N.Y., as well as nonmetropolitan counties that span states from Mississippi to Alaska.

New monthly COVID-19 case rates for this group of counties rose above the national rate beginning in May and showed the greatest divergence in July, with a rate of 1,650 per 100,000 residents—almost triple the national rate. After dropping during the rest of the summer, it rose again in October and November. (It should be noted that these are county case rates, and that individuals identifying with racial groups often register higher rates.)

The group of counties with poverty levels exceeding 25% include 226 counties that house 6.6 million residents. The vast majority are nonmetropolitan counties, with heavy representation in southern states such as Kentucky, Mississippi, Louisiana, Georgia, and Texas. This group of counties also exhibited new monthly COVID-19 case rates that stayed above the national rate from May through October, and rose sharply after June. Still, it should be noted that the while the new COVID-19 case rates increased in November for this group as well as for the racially diverse counties discussed above, their gaps with the country as a whole were reduced due to the nationwide November rise in COVID-19 rates.

COVID-19 rates rose faster in Trump counties this fall

While much attention was paid to the COVID-19 pandemic across the 2020 presidential election, the picture painted last spring (and consistent with the data) was that that it was largely an urban, “blue state” phenomenon. This gradually changed over the summer, such that new COVID-19 rates tended to rise faster in Republican-leaning states and eventually counties within those states.

With the election now over, a comparison of new monthly COVID-19 case rates for counties that voted for Joe Biden with those that voted for Donald Trump shows a sharper rise in Trump county cases in October and November. As displayed in Figure 4, Biden counties registered higher monthly new case rates from March through July. This flipped modestly in August, when Trump counties exhibited higher new case rates. Yet, in September and especially in the months sandwiching the election, Trump counties exhibited noticeably higher new COVID-19 rates than Biden counties.


This should not be surprising, given that nonmetropolitan counties—a stronghold of Trump’s base—showed especially large gains in new COVID-19 cases. It is also noteworthy that the Trump-Biden county difference in new case rates was apparent in key swing states that Biden won, including Pennsylvania, Michigan, Wisconsin, Arizona, and Georgia (See downloadable Table B).

Among these, the new COVID-19 case rates in Trump counties began consistently exceeding those of Biden counties in August for Wisconsin and Georgia. In Pennsylvania, Michigan, and Arizona, Biden counties showed higher rates up through September, before reversing in October and November.

Higher COVID-19 case rates also occurred in recent months for Trump counties in two swing states that Trump won: North Carolina and Ohio. However, in Texas and Florida—states also won by Trump—counties taken by Biden showed higher new monthly COVID-19 case rates throughout the March-to-November period.

Whether these Biden-Trump county disparities affected the election is open to debate. Clearly, new COVID-19 cases rose in the month before election—especially in Trump counties. Perhaps this somewhat dampened Trump’s still strong support in some of the swing states that Biden won, particularly in suburban and small metropolitan counties where COVID-19 cases were also on the rise.

A truly nationwide pandemic

This analysis of the state and county COVID-19 spread over the nine months from March to November makes plain that the U.S. is experiencing a pandemic that is truly nationwide. As such, the early perception that COVID-19 was only impacting places “somewhere else”—and that adopting measures such as wearing masks, observing social distancing, and eschewing large gatherings need not be followed—is no longer credible.

The pandemic is impacting states and counties of nearly all types: urban, suburban, and rural, as well as areas with sharply different demographic attributes. It is revisiting parts of the country that many thought were no longer at risk. Thankfully, COVID-19 vaccines are now being tested and could soon be ready for deployment. But the recent sharp rise of new cases almost everywhere should make elected officials, policymakers, and the public at large aware that the adverse health and economic implications of the COVID-19 pandemic will be with us all for some time.

*This classification of U.S. counties, developed by the Brookings Metropolitan Policy Program, depicts urban cores and large suburbs within the 100 largest metropolitan areas, as well small metropolitan and nonmetropolitan counties.