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No stay-at-home order? Nebraska still rates well in coronavirus cases and deaths

No stay-at-home order? Nebraska still rates well in coronavirus cases and deaths

Critics see Nebraska’s lack of a stay-at-home order as a sign that it isn’t doing enough to combat coronavirus, but a World-Herald analysis finds that its results stack up well against other states.

The comparison of all 50 states shows that only two have fewer confirmed cases per capita of COVID-19, the disease caused by the virus.

While Nebraska ranks quite low in testing for the disease, it also has a low per-capita death rate from coronavirus — 40th in the nation. And Nebraska is doing better than nearly all of its neighbors in deaths and cases.

Gov. Pete Ricketts said he thinks the state-by-state data examined by The World-Herald shows that critics misunderstand the extent and effectiveness of what Nebraska state and local public health officials, employers and individual citizens have done to prevent the spread of COVID-19.

Many don’t realize, for example, that kids in Nebraska’s two largest school districts have been out of classes longer than those in New York City.

Or that Nebraska was one of the first states to adopt federal guidance limiting the size of gatherings.

Or that when you get down to the specifics, there really is not much difference between what Nebraska and many states with “stay-at-home” orders are doing to flatten the deadly coronavirus growth curve.

At the same time, Ricketts said, the favorable statistics don’t mean that the state should ease off. As he has on a near-daily basis for weeks, the governor continued to stress the need for Nebraskans to heed social distancing strictures and guidance in the critical weeks ahead.

“People need to stay home,” Ricketts said. “Even if the numbers appear to look good for us now, we do not want to take that for granted. Everyone really, really needs to stay home.”

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The early pandemic statistics also don’t change the view of those who think that Ricketts needs to do more.

State Sen. Megan Hunt of Omaha believes it would send a strong and meaningful message to Nebraskans if the governor handed down a formal, legal edict declaring that everyone should just stay at home. That could be what it takes for some Nebraskans to alter their risky, carefree behavior — and potentially save lives.

“If the governor says he is issuing a stay-at-home order, that’s something everyone in the country can understand,” Hunt said. “At this point, I think it’s both a psychological and practical need to emphasize how critical it is that we not fill up the stores and parks and go to each other’s houses.”

Ricketts and Iowa Gov. Kim Reynolds have faced local and national criticism for not enacting stay-at-home or “shelter-in-place” executive orders.

Even as 90% of the nation’s population has fallen under such orders, the two have been among a handful of Republican governors who have continued to resist.

Ricketts has insisted the unique approach Nebraska has taken to flatten the growth curve and keep hospitals from being overwhelmed is the right one for the state.

Following a plan drafted by pandemic experts, Ricketts moved early on to limit public gatherings to no more than 10 people. Since then, he has rolled out a series of county-by-county orders called directed health measures as the virus has spread across the state.

All of the state’s 93 counties are now under those measures. Bars and restaurants, for example, are limited to takeout only. Schools are closed. Anyone showing symptoms must quarantine at home. Some counties under such measures have offered additional restrictions of their own.

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Dr. Anthony Fauci, the federal government’s top infectious disease expert and key adviser to the White House on the pandemic, last weekend said he could not understand why all states have not issued stay-at-home orders.

But after a conversation with Ricketts and Reynolds on Monday, Fauci declared he was satisfied that what’s been adopted in Nebraska and Iowa is functionally equivalent to what’s happening in other states.

“I think there was a public response that they weren’t really doing anything at all, and they really are doing a very good job,” Fauci said during a White House briefing. “I want to make sure people understand that just because they don’t have a strict stay-at-home order, they have in place a lot of things that are totally compatible with what everyone else is doing.”

So is Fauci right? Has Nebraska’s response been just as strong as that of most other states?

A number of states certainly have taken more robust actions than Nebraska, particularly hard-hit states such as New York, where hospitals are under siege and ventilators in short supply.

But many of the stay-at-home orders around the country do not put residents in those places under some kind of state-imposed lockdown.

Many such orders include significant exemptions for a variety of activities and “critical” industries, and some include provisions that are looser than Nebraska’s. For example:

Churches

In Kansas, the stay-at-home order exempted church services and funerals. After at least three outbreak clusters were tied to churches in the state, Gov. Laura Kelly last week tried to extend the order to cover religious services. Then state legislators moved to block her and the issue wound up in the courts.

In Nebraska, nearly a month ago Ricketts, a devout Catholic, specified that his 10-person limit on gatherings applied to funerals and church services.

Businesses

Missouri Gov. Mike Parson received credit nationally for issuing a stay-at-home order this past week, but he made it clear that all businesses could remain open if they followed social distancing.

Minnesota’s March 26 “stay-at-home” executive order signed by Gov. Tim Walz lists nine pages of exemptions, including getting food or medical care, but also enjoying the outdoors and going out to buy liquor. The state’s labor commissioner estimated 78% of the state’s workers fall under the critical industries exempt from the order, such as construction and trades, food and agriculture, real estate, insurance, even a specific exemption for iron ore mining.

California and Colorado even issue exemptions for recreational marijuana shops.

Enforcement

Some states that have issued such orders have also provided no grounds to enforce them, governors saying they’re counting on citizens to voluntarily follow the directives.

In Nebraska, enforcement is generally a local decision, with law enforcement officers in Douglas County handing out tickets for violations. Omaha Mayor Jean Stothert has also been publicly calling out stores where too many people have been allowed to gather, and last week she shut down all city parks when too few people were heeding social distancing within them.

Functionally, what’s happening to stop coronavirus in Nebraska indeed appears to be generally not much different from what’s happening in many states across the country.

Both here and elsewhere, most public places like restaurants, bars, theaters, health clubs and salons are closed to the public. Stores are generally open. Takeout food is allowed. People can go outdoors. Most people can do their jobs but are encouraged to work from home. Almost everywhere, the message is that people should just stay home.

But analytics data taken from cellphones also suggest Nebraska’s success in reducing movement has lagged what’s happened nationally. Recent Google data show work-related travel is down 27% in Nebraska from its pre-pandemic baseline compared with a 40% reduction nationally.

A cellphone data analysis by the New York Times showed travel in Douglas County was not down as much as in most other counties of 500,000 or more population nationwide. Some rural Nebraska counties in the analysis showed no travel reductions at all.

That analysis also found a correlation between reduced travel and states with stay-at-home orders.

State Sen. Adam Morfeld of Lincoln said overall that he thinks Ricketts has been doing a good job of directing the state’s response to the pandemic.

But he said it would be valuable to have the governor issue a stay-at-home order. While many Nebraskans might not know what a “directed health measure” is, they do understand what it means when the governor orders them to stay put.

“Words matter,” Morfeld said. “I think when people hear ‘stay-at-home’ order, it’s more clear what our leaders want us to do, and they take it more seriously.”

Dr. Phil Boucher, a Lincoln pediatrician who has campaigned on Facebook to get Ricketts to issue a stay-at-home order, said he gets concerned when he sees the volume of people in Nebraska going about their business during the pandemic.

A stay-at-home order would address that, he said. In the public’s mind, he likened it to the difference between a tornado watch and a tornado warning.

“Right now, we are on coronavirus watch when we should be sounding the alarm,” he said. “(Ricketts) is making it seem like it’s less severe than it is.”

new sign

This sign at Gov. Pete Ricketts’ coronavirus press conference on Thursday lists guidelines for staying healthy and helping reduce spread of the virus.

Ricketts certainly would dispute that. He has preached for weeks during his daily press briefings that this is a significant public health emergency. April is going to be a tough and critical month, he has warned, and Nebraskans must follow directives and go out as little as possible.

Overall, the governor said, Nebraskans have shown “really good compliance.”

Just over one month after Nebraska’s first reported coronavirus case, statistics on the outbreak suggest most people here are taking heed.

“The data we can see looks encouraging,” said Dr. James Lawler, a pandemic disease expert at the University of Nebraska Medical Center who was asked to look at The World-Herald’s state-by-state analysis. “I think overall we’re in pretty good shape compared to other states and our neighbors.”

Among the 50 states, Nebraska ranks 48th in coronavirus cases per million residents, with only Minnesota and West Virginia posting lower figures.

Nebraska’s case numbers certainly are influenced by the fact that so few residents are being tested, Lawler cautioned. The state ranks only 43rd in its rate of coronavirus testing and has had difficulty obtaining supplies to do more, particularly chemical agents needed to conduct the tests.

“We don’t have perfect visibility into what’s going on,” said Lawler, a director in UNMC’s Global Center for Health Security who helped draft the pandemic plan that Ricketts has followed. He came to UNMC in 2018 after a Navy career in biodefense that included White House assignments dealing with biodefense, pandemic response and health preparedness.

But low testing isn’t the only reason why Nebraska’s numbers look good. Testing lags in many places across the country. While the national testing rate is 60% higher than Nebraska’s, the national rate of confirmed COVID-19 cases is 370% higher.

Nebraska’s low virus rate is also likely helped by its wide swaths of rural land, although those outside the state who see Nebraska as flyover country would be surprised to learn that two-thirds of the state’s population lives in metropolitan areas.

“I think population density is a factor in spread of the epidemic,” Lawler said. “They just have more social mixing in Manhattan than you do in Ainsworth, Nebraska.”

Ricketts and Lawler said it’s possible Nebraska’s early actions helped flatten the state’s coronavirus curve.

After its first confirmed case on March 6, Nebraska for most of two weeks had more coronavirus cases per capita than the neighboring states of Iowa, Kansas, South Dakota and Missouri.

On March 16, Nebraska limited gatherings to 10 people — the same day it was recommended by the U.S. Centers for Disease Control and Prevention. The move overnight had the effect of shutting the doors to most bars and restaurants. Ricketts had actually three days earlier been among the nation’s first governors to set any kind of gathering limit, having declared a 250-person limit March 13.

Iowa’s Reynolds also acted quickly on the 10-person limit, endorsing the federal guidance the day after its issue.

Conversely, Missouri, Kansas and South Dakota all waited a week or more to implement it. Experts say such inaction can be critical early in outbreaks, allowing the virus to spread unchecked.

As the month continued, Nebraska’s trend line became less steep while those in Iowa, Missouri, Kansas and South Dakota began to spike up sharply. By late March, Nebraska’s per-capita caseload trailed all of its neighboring states and for a time became the lowest in the country.

Ricketts said it also helped that when Nebraska saw its first case, the state’s largest school districts were out on spring break, and their leaders never resumed classes. Students in the Omaha Public Schools and Lincoln Public Schools have actually been out of classes a week longer than students in New York City.

Despite the early success, Ricketts says he’s closely watching the daily count of new cases to see how the state is trending. Daily new cases hovered around 50 for most of the past week before hitting a new high of 71 on Friday.

“They are not going up at a geometric rate right now, and that’s really one of the keys,” he said.

Death rates also support the notion that Nebraska to date is faring relatively well.

Ricketts said anyone in a Nebraska hospital with pneumonia from an unknown source is being tested for coronavirus. If they test positive and subsequently die, they’re included in the count.

Nebraska’s death rate per million population is in the bottom fourth among the states. The national rate is six times as high. Among Nebraska’s six neighboring states, only Wyoming, which has yet to record a death, and South Dakota have lower rates.

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Still, Lawler noted that death is a lagging measure — people tend to die two to three weeks after initial infection. Looking only at deaths can hide the extent the disease is spreading in the community.

While Nebraska stood at 17 deaths as of Friday afternoon, a University of Washington model that’s being watched around the country was projecting the state to have 273 deaths by the time the pandemic peaks in late April and then runs its initial course by early June. That’s down from almost 450 deaths the model was projecting a week earlier.

Lawler said there’s no way to know at this point how accurate that projection is. Models are useful tools in a pandemic, he said, but they don’t have all the answers.

One state that particularly stands out in The World-Herald analysis is Minnesota.

That state about a week ago passed Nebraska as the state with the nation’s lowest rate of confirmed COVID-19 cases. And its rate has continued to level off to the point it’s now more than 25% below Nebraska and West Virginia, the next closest states. Minnesota’s death rate is slightly higher than Nebraska’s.

Ryan Demmer, an associate professor of public health at the University of Minnesota, said the numbers could support the notion that early efforts in Nebraska and Minnesota have made a difference in flattening the curve.

He was particularly interested that Nebraska’s largest school districts ceased classes before schools in New York City, saying that extra week “would be pretty powerful” in slowing infection spread.

Demmer also agreed with those who believe a stay-at-home order like the one issued in his own state could pack more punch than similar measures under another name.

“There is power in receiving a message like that,” he said. “I think there is a psychology to a state-level pronouncement.”

For his own part, Ricketts last week continued to reject issuing a stay-at-home order. But while he’s largely sticking to the state’s plan, he made some notable changes.

He expanded the requirements for counties under the state’s directed health measures. In doing so, he projected statewide some additional requirements that Douglas County and others had already adopted locally, among them closing any salons and tattoo parlors that had remained open and shutting down group sports.

His messaging also changed, as he formalized his stay-at-home message with a new promotional slogan to “Stay home, stay healthy, stay connected.” It’s one that is also being used by governors in other states.

And while he didn’t sign an executive order, he put his name to a ceremonial proclamation urging Nebraskans to buckle down in the coming weeks as the virus is projected to peak. He declared April 10 to 30 to be “21 Days to Stay Home and Stay Healthy.”

“This is not a shelter in place,” Ricketts made clear. “This is about asking Nebraskans to do what’s right.”