In a nutshell:

• The coronavirus pandemic has hit Michigan, particularly Southeast Michigan, much harder than neighboring states.
• Detroit’s severe experience of COVID-19 is largely attributable to factors like income, education, transportation, housing, and other community characteristics collectively described as social determinants of health.
• While rural Michigan has so far remained somewhat unscathed, it shares many of the same social vulnerabilities that have caused Detroit to be hit so hard. 

Michigan has been one of the states hit hardest by the ongoing coronavirus pandemic. As a result, hospitals in Southeast Michigan have been inundated by patients suffering from COVID-19, the disease caused by the virus called SARS-CoV-2. The relatively high incidence and severity of the disease in Southeast Michigan—particularly Detroit—may be explained by various individual and community-level socioeconomic characteristics, commonly called social determinants of health. While strong social distancing policies appear to have spared rural Michigan so far, the demographic characteristics of these communities suggest that they could be hit even harder than Southeast Michigan without continued coordination and intervention from public policy, public health, and medical experts.  

Comparison with Neighboring States

The impact of COVID-19 in Michigan looks all the more stark when compared with four neighboring states: Ohio, Indiana, Illinois, and Wisconsin. 

COVID-19 Impact in Great Lakes States

Data Sources linked above (current as of April 20th, 2020 at 10:00 A.M. EST)

Michigan’s cases have been concentrated in and around Metropolitan Detroit, where the city of Detroit has been especially hard hit with 7,604 cases and 618 deaths. The greatest number of Ohio’s cases are in and around Cleveland and Columbus, with smaller outbreaks in Toledo, Cincinnati, and Youngstown. Cases in Illinois have been identified predominantly in and around Chicago, with a smaller cluster in southwest Illinois near St. Louis. Wisconsin’s cases have been concentrated in the population centers of Milwaukee, Madison, and Green Bay, though more than half of all deaths occurred in Milwaukee County.

Michigan’s death toll of 2,391 is nearly equal to the 2,543 deaths in Illinois, Indiana, Ohio, and Wisconsin combined. Although initial (and ongoing) capacity problems have resulted in less than optimal testing levels in each state, the problem of incomplete data and information doesn’t completely explain away this glaring disparity.

Why then has Michigan been hit so much harder than our neighbors?

Factors Affecting Michigan’s Vulnerability to COVID-19

The most plausible explanation for the pandemic first reaching major urban areas like Seattle, New York, and Detroit, is the international character of metropolitan economies. 

Metro Detroit has an international airport and strong industrial ties to China (where the virus was first identified), as well as other regions (e.g., Northern Italy) that may have facilitated its spread. Population density in urban areas also facilitates the spread of infection throughout communities, and Detroit’s unique brand of urban sprawl links commuters across several counties. Additionally, some say timing is everything: St. Patrick’s Day celebrations and a statewide election occurred just before the disease took off in Southeast Michigan.

And yet, Metro Detroit has experienced more cases (and deaths) than several other larger metro areas, indicating that the aforementioned business and population factors do not tell the entire story. Another possible way to understand Detroit’s experience is through the lens of social vulnerability.

The U.S. Centers for Disease Control and Prevention (CDC) calculates a Social Vulnerability Index that considers the socioeconomic factors (like poverty, education, transportation access, etc.) known to make some communities more vulnerable than others to disasters. At the most recent calculation in 2016, Wayne County was the most vulnerable in the state (with a score of 0.86 in a range of 0.0 to 1.0).

The U.S. has some of the largest class-based health disparities in the world—poor adults are five times as likely to report being in poor or fair health relative to wealthier adults—and these disparities are pervasive throughout Michigan. Here, individuals with the lowest income and least education are consistently the least healthy, and those with intermediate levels of income and education are in turn still less healthy than the wealthiest and most educated. Not only are economically disadvantaged people more likely to get sick, but disease severity and survival from various diseases (e.g., cancer) also varies by socioeconomic status. 

Socioeconomic status is predictive of a variety of factors that affect an individual’s overall health. A life spent in poverty can be frequently traumatic, causing poorer people to disproportionately experience chronic stress, eroding their health over time. Stress has long been understood to compromise a person’s immune system, but it also contributes to health-related behaviors like smoking and poor sleep quality. Stress, poor sleep quality, and lack of material resources all contribute to lower-income people consuming foods of poorer nutritional value, further undermining immune response and overall health status. Over time, this cascades into the higher rates of chronic disease and disability that occur among lower-income (and middle-income) adults. Health care access and paid sick time also vary across income and occupation, which affects the ability of poorer adults to respond to and recover from the illnesses and injuries that they inevitably experience.

These class-based differences have contributed to a long-term (and growing) gap in life expectancy between the poorest and richest people (and everyone on either side of the increasingly antiquated blue-collar/white-collar divide).

One shouldn’t talk about class differences without also discussing race, particularly vis-à-vis Metro Detroit’s COVID-19 experience. People who are black or African American comprise fourteen percent of Michigan’s population (and twenty-three percent of the population in Metro Detroit), yet thirty-three percent of COVID-19 cases and forty percent of the deaths attributable to the disease have occurred among black people.

Black Americans tend to have fewer economic and educational opportunities because of a long history of damaging circumstances, laws, and policies. Rates of poverty are disproportionately higher among black Americans and educational attainment tends to be lower. Since the social and physiological effects of historical trauma are still felt today, it should come as little surprise that black Americans tend to suffer poorer health on average than white Americans. While socioeconomic status explains much of this difference, even after controlling for factors like income and education black Michiganders (and black Americans in other states) still have worse health than their white counterparts with similar levels of income and education. The role that race (and racism) plays in these differing health outcomes, therefore, should not be discounted. 

The way we’ve watched the social determinants of health play out in real time as COVID-19 has ravaged Detroit has been tragic but unsurprising to public health experts: the impact of factors like socioeconomic status have long been recognized as the main drivers of divergent health outcomes. And yet, although Detroit has been hit hardest so far, this fact shouldn’t be construed to promote the belief that COVID-19 is a “Southeast Michigan problem.” It should only be understood as the place where the disease first surfaced in Michigan.

Rural Michigan at Risk

Most counties in West and Northern Michigan have a high degree of social vulnerability that exceeds the vulnerability measured in Oakland, Washtenaw, or Macomb counties. The social determinants of health are not unique concerns for Detroit: in terms of poverty, low levels of education, and high levels of chronic disease and disability, rural Michigan has more in common with Detroit than do many suburban communities. Add in rural Michigan’s older population, high rates of tobacco use, and limited health care access and infrastructure, and it’s a recipe for disaster.

While the number of cases has remained quite low in most of Michigan’s rural counties, cases are beginning to grow and several rural counties have experienced case fatality rates higher than even Detroit or Wayne County. Admittedly, due to various factors like testing limitations, localized population vulnerability, and small sample sizes in rural jurisdictions, interpreting these rates must be done with extreme caution and numerous caveats. At the same time, one can say with a fair amount of certainty that we would be seeing many more cases in rural Michigan today if not for policy interventions mandating social distancing.

While Southeast Michigan was hit first by the pandemic, it was also the social vulnerabilities in some communities that facilitated the pandemic’s outsized impact; it is all the more fortunate, then, that Metro Detroit has a strong healthcare sector to mitigate the resulting damage. It is important to recognize that rural parts of Michigan share many of Detroit’s vulnerabilities without having the countervailing benefit of its strengths. Just because rural Michigan hasn’t been hit yet, it doesn’t mean that it couldn’t get hit even harder without the protection of continued public health policies, activities, and interventions.

Health vs. Economy: A False Dichotomy

As Michiganders from all corners of the state yearn to return to “business as usual,” one artifact of the past that we should consider leaving behind is the idea that there is a zero-sum trade off between public health and the economy. We’ve seen this battle waged continuously over everything  from environmental regulations to food laws to the sale of alcohol and tobacco (and more recently, marijuana). At present, this notion has come to a boiling point over stay at home orders in states like Michigan.

It is essential that conversations move past the false idea that we must pick either health or the economy. Economic consequences ARE health consequences, and vice versa. Lost livelihoods and social isolation exert an immense toll on people’s health. Conversely, an economy cannot thrive unless it is made up of healthy individuals and communities. There are clear costs to Michigan’s ongoing stay at home order, but these costs cannot be debated without acknowledging the counterfactual costs we might have faced in the order’s absence.

Deciding how to equitably distribute the shared costs we face as a society is the core responsibility of politics. Let’s not let the politics of the day fool us into thinking we have to choose between health and the economy — this is a Sophie’s choice that we shouldn’t (and don’t actually have to) make.