ANTICIPATING THE coronavirus pandemic that smashed into New York City would crash over his suburban New Jersey community, John Bonanni, a county administrator, believed he'd prepared for the worst. But in early spring, as infections surged and hospital bedspace and ventilators ran short, Bonanni worried the worst might have been an underestimate.
Half a continent away, as Wyoming's ski season wound down, Jodie Pond's plan to fight the oncoming contagion ramped up. The health director for a county that includes Jackson Hole, an international tourist destination, Pond and her colleagues decided the area must go on lockdown, even if resort and business owners didn't like it.
Meanwhile, in the Centennial State, Colorado communities were emerging as coronavirus hot zones, with Denver an epicenter. And as infections mounted, a patchwork of responses led to uneven results in fighting COVID-19.
While data has revealed the disproportionate toll of the pandemic on communities of color – a dangerous problem tied to the legacy of systemic discrimination and bias in the U.S. – the novel coronavirus in some ways has proved an equal-opportunity infection, afflicting urban and rural counties alike and tearing through communities that otherwise could be seen as healthy.
For example, counties that perform better in U.S. News' third-annual assessment of the country's Healthiest Communities tend to have seen lower rates of COVID-19 cases. Yet some that ranked among the highest in the analysis of overall community health and well-being still struggled to contain the novel coronavirus.
Ultimately, the impact of the novel coronavirus hinges not just on demographics and factors like access to health care, but on how community leaders prepare for and deal with the threat as well. Here's a snapshot of how some of the country's healthiest communities prepared for and have fared so far against the virus.
Morris County, New Jersey
In Morris County – a northern New Jersey enclave that landed in the top 25 of the Healthiest Communities rankings – more than 800 COVID-19 deaths had occurred as of early September, along with approximately 7,500 cases of the disease. Those numbers dwarfed data from its southwestern neighbor, Hunterdon County, which saw approximately 1,200 cases and 125 deaths, and also landed among the top 25 Healthiest Communities.
The two counties perform similarly in many Healthiest Communities metrics. But Morris County is the closer suburb to New York City, considered the national epicenter of the pandemic early on. Bonanni, Morris County administrator, saw the wave of infections in the Big Apple and knew it likely was headed his way.
"You could see geographically how it went from NYC to Bergen County and Essex County," he says. "It just flowed down the major highways."
In March, Bonanni met with the county's emergency services departments, set up a distribution plan for personal protective equipment and coordinated with Atlantic Health System, a major hospital operator in the county. When the surge of infections hit, dispatchers' switchboards lit up, and the case count steadily climbed.
By mid-April, hospitals were running short of intensive care beds and equipment. One evening – a Saturday at the end of April, Bonanni recalls – the emergency became a crisis.
"Our health care system was on divert because they had no ventilators left," Bonanni says, meaning hospitals were having to suspend at least some admissions. "I thought, 'Where the heck are all those people going to go?'"
In the end, Bonanni says, his county weathered that storm: He and his staff pressed New Jersey Gov. Phil Murphy for more ventilators, and used hotels and vacant houses as makeshift coronavirus wards. The situation eventually stabilized, and after working nearly three months without a day off, Bonanni allowed himself to breathe.
But his guard is still up.
"I'm going to assume that it's coming back," Bonanni says. "We have already stockpiled the PPE that will be needed. We already have the EMS units prepared. None of us have stopped preparing for the next wave."
Teton County, Wyoming
Teton County – ranked 16th in the 2020 Healthiest Communities analysis and a strong performer in the categories of infrastructure and population health – has escaped relatively unscathed from the virus compared with many other places around the U.S.: The county had recorded fewer than 500 cases of COVID-19 as of earlier this month, according to a Johns Hopkins University tracker, and just a single death from the disease.
Pond, director of health for the county – home to ski resorts and both Yellowstone and Grand Teton national parks – says it's all about shared sacrifice.
When the first coronavirus infection appeared, "we had a good month left" of skiing in Jackson Hole, the resort area that drives the county's economy, Pond says. During the season, the county's population swells, from around 25,000 residents to more than 60,000 people – a nightmare scenario for a small public health department tracking a highly contagious virus.
With a relative handful of hospital beds in the county and even fewer intensive care units, Pond and her colleagues quickly calculated that "old-fashioned public health" strategies were the best option. That included early orders limiting gatherings in the county to members of the same household and mandating that older adults and other high-risk people stay at home. The orders were issued by Teton District Health Officer Dr. Travis Riddell, who reportedly has sparred with state officials in efforts to enact stringent restrictions.
"We closed down all three of our resorts and asked people to go home," Pond says. "We lived in a bubble – nobody came in, and nobody left."
The gambit paid off: By mid-April, the county's infections had plunged. But Teton's businesses took a hit, and at least some tourists weren't happy. "The business community lost the end of ski season," Pond says. "And the tourists: 'I'm on vacation. I have to deal with COVID-19 when I'm home. I don't want to deal with it while I'm here.'"
Challenges remain: Data from July shows COVID-19 cases surged in the county well past their previous daily highs, before ticking down in August. Notably, Riddell was able to issue a since-extended mask mandate in late July; in its wake, Pond says the county hired as many contact tracers "as fast as we could get them onboard and trained."
Teton County also had the highest rate of confirmed cases in Wyoming as of mid-September. The county, among the richest in the nation and a below-average performer in the equity category of the Healthiest Communities analysis, hosts service employees who run the risk of catching the virus through work – a haves-vs.-have-nots dilemma the pandemic has laid bare in many communities.
"The cases were in our 20-something-year-olds" – college-age, seasonal resort and restaurant workers not taking the pandemic seriously, Pond says.
"It was all the things that were out of our hands," she says. "People coming here and not wanting to wear masks. People coming here wanting to have their 'Jackson Hole summer.' They were having backyard barbecues, hanging in bars, tubing down the river."
Pond gets it: She had summer jobs in the area at that age and did the same things.
"You want to have fun and don't remember that there's a pandemic," she says. "We were like, 'You guys have to change your behavior. This is really dire.'"
Attitudes did change when an outbreak forced one restaurant to shut down, Pond says. The staff had to quarantine, missing out on two weeks' worth of wages and tips.
Overall, Teton County has deployed a back-to-basics approach.
"This is what works, people," says Pond, who has worked in public health for three decades. "It's not rocket science."
"The whole country has to get on board with public health. It's not going to be this bad forever. We all have to make sacrifices," Pond says. Convincing young adults not to socialize and reminding frustrated tourists to wear masks is exhausting, she says, "but we still have faith. We hope the public does, too."
Seven Colorado counties landed in the top 25 of the Healthiest Communities rankings, but they varied when it came to how they handled the coronavirus pandemic and its effects.
Two of them, Douglas and Broomfield counties, are urbanized Denver suburbs – one to the north of the Mile High City, the other due south. Both have seen relatively high numbers of coronavirus infections and deaths, though they're also the two most populous counties of the seven and had lower overall rates of infection.
Meanwhile, Summit and Pitkin counties, locales home to famous ski towns Aspen and Breckenridge, had seen rates over 1,100 cases per 100,000 people as of early September, but lower total numbers. San Miguel County in the state's southwest, home to only about 8,000 people, recorded a similar case rate but was the only one of the group with zero COVID-19 deaths by early this month.
"We've seen quite a bit of variation across local communities, both in capacity to respond and capacity to implement recommendations" to keep the virus from spreading, says Glen Mays, chair of the Department of Health Systems, Management and Policy at the University of Colorado Anschutz Medical Campus and an expert on public health strategy and preparedness. "There have been variations in trajectory of infections across communities."
Douglas and Broomfield counties, for example, "are quite wealthy Denver suburbs," Mays says. "A couple of factors likely explain why they have struggled: These are places that are more likely to have experienced outbreaks in high-risk populations, particularly in long-term care settings" such as a nursing home or correctional institution.
At the same time, Mays notes that Douglas County is part of a regional public health department with Arapahoe and Adams counties. Although the department leaned into a mask requirement for the public in July, Douglas County officials opted out of the order, citing high voluntary compliance in the community with mask-wearing. The county seat of Castle Rock opted out as well, and county commissioners signaled an intent to withdraw from the department itself. Colorado Gov. Jared Polis issued a statewide mask mandate later that month.
"That to me signals Douglas County is probably a place that has struggled to get businesses and individual households" to wear face coverings, Mays says.
By contrast, Pitkin and Summit counties both implemented mask restrictions. Although they made it through the worst of the pandemic in early spring with relatively low case and death counts, it hasn't all been smooth sailing.
"When things started opening back up (in July) we did see some concerning trends," Mays says. Out-of-state tourists came in from hot-zone states like Texas and Arizona and brought the virus with them, he says.
"We were getting a lot of imported cases," Mays says.
While the virus is mostly in check, only time will tell if Colorado will see an increase in cases when winter comes around, Mays says.
"I think we've learned about the need to be agile as a society and as medical systems and public health systems," Mays says. "We have to be able to incorporate new information that we've learned."
But, he says, "we're definitely not done learning, either."