ST. LOUIS _ On both sides of the state, very different coronavirus outbreaks have unfolded in Missouri's two largest metropolitan areas. The reasons are not perfectly clear to many experts.
The bulk of the state's approximately 9,500 cases to date have been found in the St. Louis region. Including the Metro East, St. Louis has recorded more than 7,600 confirmed cases since the outbreak began. That's more than twice the caseload of its cross-state neighbor, Kansas City, which has seen 3,700 cases of the virus across the metro area, including its Kansas counties.
Deaths from the virus have been even more disproportionate: 466 in the St. Louis area as of late this week, compared to 157 in greater Kansas City _ about three times as many here.
The St. Louis region is home to about 30% more people, which isn't enough to account for the lopsided totals. The discrepancy is all the more confusing, some experts say, because the timeline of each city's coronavirus outbreaks and response actions seemed to unfold _ at least initially _ in such similar fashion.
"The ingredients don't seem all that different, from what I can glean," said Chris Prener, a sociologist at St. Louis University who has closely tracked regional data on the virus. He has wondered about the imbalance between the two similarly sized cities. "It's a great question, and one I wish I had an answer to."
The St. Louis region saw its first known case of the virus emerge on March 7, after a college student returned home to the area from Italy, an early epicenter for the disease. Her case was the first to be confirmed in Missouri.
Meanwhile, the Kansas City area recorded its first case the same day, when a woman in Johnson County, Kansas _ just across the state line _ received a positive test result after reportedly traveling in the northeastern U.S. The patient also represented Kansas' first known case of the virus.
By March 14, a week after those initial cases were announced, the Kansas City region's caseload was up to six, while four people from the St. Louis area had tested positive, according to official data, tracked by Prener. A week after that, the Kansas City area was looking like more of a hotspot, with 68 cumulative cases as of March 21, compared to 43 in and around St. Louis.
But in the following week, the trend lines for each metro area diverged, even as stay-at-home orders went into place.
By March 28, St. Louis leapt to a total of 505 cases, versus 321 for Kansas City. One week later, on May 4, the widening difference was even more dramatic, with a total of 1,564 confirmed cases for St. Louis, and 790 cases _ half as many _ in Kansas City.
The timing of regional shutdowns was strikingly similar.
The city of St. Louis and St. Louis County rolled out stay-at-home orders that took effect on March 23, with St. Charles, Franklin, and Jefferson counties still considering additional restrictions of their own, at the time.
The following day, March 24, municipal governments across the Kansas City region worked in lockstep to enact coordinated stay-at-home orders. The synchronized rollout of uniform measures in the city and surrounding counties was described by the Kansas City Star as "an unusual public display of civic unity in a splintered and politically complicated metro area _ 2 million people who live in scores of cities, big and small, within a half dozen counties that's split down the middle by a state line."
More undetected cases'"There's more to the story than meets the eye, I guess," said Dr. Mary Anne Jackson, a dean and professor at the University of Missouri-Kansas City School of Medicine. "The difference in cases is striking."
Determining a cause for the difference is tricky, if not impossible, experts say, especially since state and county authorities aren't releasing victims' names, circumstances or even specific death locations.
But experts offer possible explanations: One theory is that the St. Louis community simply had more of the virus circulating undetected at the time shutdowns clicked into place. The local surge of cases in late March likely reflects many transmissions that occurred before stay-at-home orders took effect.
And St. Louis' proximity to Illinois _ hit early and hard by the disease _ may have seeded cases here, they said. Kansas City is better shielded from initial hotspots by a larger geographic buffer.
"I don't think I would've done anything differently than what they've done," Dr. Rex Archer, the director of Kansas City, Missouri's health department, said of the St. Louis metro response. "I think the difference was that there were more undetected cases in St. Louis than we had, when we put in our social-distancing, stay-at-home orders. At least in Kansas City, Missouri, we were very late in getting our first death. Our cases were extremely low when they were building in other places."
Some also pointed to population differences, with the St. Louis area packing in more residents per square mile than the Kansas City metro. Census data show about 350 residents per square mile in and around St. Louis, and 295 people per square mile throughout the Kansas City area.
"I think population density there has a significant effect," said Dr. Dana Hawkinson, an infectious disease physician and medical director of infection prevention and control for the University of Kansas Health System.
"That seems to be the distinct difference," agreed Jackson, noting that the cities are "just laid out a little differently."
But others cautioned that density, by itself, is not always a surefire culprit linked to virus prevalence or severity. While it is widely cited as fueling massive waves of transmission in places such as New York City, some cities with relatively high population densities, like Seattle, have been able to prevent the virus from getting runaway momentum, even after early spikes in cases. And internationally, several Asian cities with incredible density, like Singapore or Seoul, have been models for limiting the impact of the contagion _ achievements helped by aggressive testing and other public health measures.
Meanwhile, some experts credited the Kansas City region's blanket stay-at-home policies with helping to keep the virus' spread relatively controlled, for a major city.
{p class="p5"}"The coordination and the collaboration with the surrounding communities, I thought was pretty remarkable," said Jackson.
{h2 class="p1"}'Predicting more deaths'{/h2} Reopening may provide its own ways to compare and contrast the public health strategies employed in each metro region. The city of Kansas City, for instance, is rolling out a unique policy dubbed the "10-10-10" plan, which allows a maximum of 10 people in reopened spaces, or 10% of the typical occupancy limit that is permitted _ whichever is larger. And if it's a setting where anyone spends more than 10 minutes, the city asks that businesses get personal contact information for each visitor, for potential notification or contact tracing if cases of the virus are linked to their location.
"It's a very thoughtful way to approach it, and I'm not aware of other cities that have used this type of plan to open their communities," said Jackson.
But places everywhere, including Kansas City, are still in a vulnerable position, experts warn _ particularly as states like Missouri, Kansas and others begin to ease shutdowns.
"We're reopening way too soon," said Pam Walker, St. Louis' former city health director, who now acts as a consultant for entities including local governments.
"The earliest we should consider reopening is in June, and that's after we've seen a peak, a plateau and 14 days of decline," she said. "When you look at the trend line, (Missouri) never peaked."
Officials and experts around Kansas City worry that their early efforts and relative degree of success could come undone thanks to statewide openings.
Archer said the city has already faced troubling developments in recent days, even before impacts of any reopening could influence data on the virus. The city this week saw the largest number of new coronavirus cases since the outbreak began _ many of which he said were tied to workers who commute on a "crowded bus" to a St. Joseph meat plant that has become a hotspot for the disease.
"I'm predicting that we didn't really learn our lesson," said Archer, who expects multiple "waves" of the virus.
"I'm predicting more deaths in the Kansas City area from the second wave than we got from the first wave," he said. "I'm really afraid that we're going to catch up to St. Louis because we're loosening our restrictions at a time when we still have too much disease."
Indeed, by midweek, the rate of new cases in the Kansas City area had already pulled even with St. Louis.
