A record-high number of new COVID-19 cases were reported in the United States on Thursday, driven by spikes in Southern and Western states. The surges are steep and scary, and may be even harder to beat back than the first upswing.

The same problems that plagued New York City in March and April (limited access to testing, long turnaround times for results, and mixed messaging from officials) are cropping up in states like Arizona. They’re now canceling elective medical procedures and asking people to stay home. It’s a familiar pattern, one that played out in Italy and along the coasts of the US.

Those lessons didn’t sink in. Cases are rising in communities that, until now, had the virus under control. That made it harder for people to internalize the full risks of an outbreak, which are now emerging in those areas. Stay-at-home orders, phased shutdowns, and encouraging mask-wearing in public eventually helped places like New York reduce their caseloads. This time around, officials in new hotspots may not be able to deploy the same strategies.

Visible failures, invisible successes

In March and April, the virus hit New York City, Seattle, and San Francisco the hardest. New York City, in particular, was incapacitated by the pandemic: hospitals were overrun by patients, bodies piled up in trailers outside funeral homes, and people lived with the near-constant sounds of ambulance sirens.

Seeing the devastation, states that had relatively low numbers of confirmed cases also banned large gatherings, closed businesses, and ordered hospitals to free up bed space. Those measures were successful — they helped those case numbers and hospitalizations stay low, and states like Texas initially avoided the same fate as New York. “We really did flatten the curve,” Umair Shah, executive director of the health department in Harris County, which includes Houston, told The Daily Beast.

Triage tent set up in Long Island hospital during pandemic A COVID-19 triage tent built outside of Mount Sinai South Nassau Hospital in Oceanside, New York. Photo by Jeffrey Basinger/Newsday RM via Getty Images

The control was tenuous, though. Because those measures kept COVID-19 out of sight, it was harder for people to see why they were necessary in the first place, says Emily Toth Martin, an epidemiologist at the University of Michigan School of Public Health. “It’s the characteristic Catch-22 of public health. What you did worked if people say you overreacted,” she says. “You stopped that critical situation from happening, but it’s so hard to communicate that and for people to internalize it.”

Some critics seemed to willfully misunderstand how and why preventing a problem is a better option than responding to one — New York Times columnist Bret Stephens, for example, wrote in April that New York City’s stringent lockdown rules shouldn’t apply to the rest of the country. “The rest of America needs to get back to life,” Stephens wrote. Spikes over the past week clearly showed that getting “back to life” too early meant waves of infections.

The vast majority of people around the country supported shutdowns. But the economic challenges were real for millions, and without clear messaging on why continued prevention matters, it may have been easy for people to equate flattening the curve with an end to the threat. “You’re making those sacrifices for the benefit of a crisis you don’t see in front of you. I can see that’s a very emotional challenge,” Martin says.

Message (not) received

Not seeing a direct impact in their area may have also made some people less concerned about the virus, overall, and less likely to take actions — avoiding gatherings, wearing masks — that protect against the disease, Martin says. It’s understandable: it’s hard to make sacrifices when it doesn’t look like there’s anything wrong that would justify them.

“Your understanding of how serious a problem is, and how likely something is to affect you, is going to impact how likely you are to take up an intervention to prevent it,” Martin says.

She notes that Detroit, which was hit hard by COVID-19, has seen a steady, disciplined decline in caseload. Rural parts of Michigan, though, are seeing surges. Michigan had a statewide stay-at-home order, but only the Detroit area saw exponential case growth during that time.

“Within our own state, you have whole communities that don’t have that experience of seeing a field hospital being built up the street from you,” Martin says. “I think that that has a huge impact on people’s ability to be ready to receive the message.”

People living in early hotspots are more concerned about the virus than people living in places where case counts began ticking up later, according to a YouGov analysis published at the beginning of June. That follows familiar patterns from earlier in the pandemic. Even though people in New York watched as Italy teetered on the verge of collapse, the message didn’t sink in until it reached their doorstep.

Concerns may increase in those communities as case numbers climb, as they did in New York, which may inspire people to follow public health guidelines. It’ll be a harder sell this time, though. Those same guidelines that helped Detroit and New York recover have been heavily politicized, which makes them harder for public health officials to implement. President Trump pushed states to lift stay-at-home orders, and policy by governors in states like Florida curried favor with the president. Right-wing politicians pushed back on masks, and support for mask-wearing now breaks on party lines.

“We see this with vaccination, in certain communities. When something like this becomes connected to a sense of identity, we lose that as a public health tool,” Martin says.

US-HEALTH-VIRUS-TOURISM-ECONOMY-tourism-health-epidemic-pandemic A beach-goer wears a mask in the water at Miami Beach. Photo by EVA MARIE UZCATEGUI/AFP via Getty Images

Policy failures

The challenges that make this virus increasingly harder to contain were preventable. New York City had a chance to avoid the crush of cases, but the governor and mayor dragged their feet on implementing policies to stem the tide. The rest of the country had the chance to learn from New York. And for a while, many states had things under control.

Rather than keeping tight hold of those successes, though, local and national leaders let them slip away. They watched the steady nationwide case numbers through May and decided that the problem was over, even though region-specific trackers showed that certain areas of the country were ready to explode. Many states opened bars and restaurants before it was safe to do so, and before they had the testing and contact tracing to control any new spread.

Now, they’re left with the task of fighting new spikes without as much buy-in from communities around the strategies that could help. State leaders seem reluctant to reclose what they’ve already opened. Policy decisions and messaging failures made it less likely that individuals would stick to recommendations, and they weren’t prepared for the reality of a pandemic. Messaging stressed the critical importance of flattening the curve, but didn’t emphasize that it takes sustained effort to keep that curve flat. Claiming victory too early all but ensured a rebound.

If the messaging from officials at the beginning of the pandemic had stressed that the adjustments to daily life were going to be a marathon, not a sprint, it may have made a difference in how communities processed the risk from COVID-19, Martin says. “It hasn’t ever had that long-term view that really allowed people to mentally prepare that this is something that they’re gonna have to be dealing with for a long time,” she says. “So I think it’s understandable that the American public just got tired of it.”