Evidence-based explanations of the coronavirus crisis, from how it started to how it might end to how to protect yourself and others.

New York City is the current epicenter of the coronavirus crisis in the United States, in part, because of the nature of the city itself — an international hub tightly packed with people from all over the country and the world. What makes New York unique has also rendered it vulnerable to a pandemic.

The city has recorded more than 25,000 cases of coronavirus across its five boroughs as of March 27. This accounts for a large share of all confirmed cases — more than 90,000 — in the United States.

This is just the beginning. Though the state, including the city, has been under strict stay-at-home orders since Sunday, New York is not expected to reach its peak in coronavirus cases for at least another three weeks. On March 25, New York Mayor Bill de Blasio predicted that, in a city of 8 million, half the population should expect to get coronavirus before the pandemic ends.

There are still many unknowns about the coronavirus, but, based on current data, the current hospitalization rate is about 19 percent worldwide, with a fatality rate between 1 and 3.4 percent. Those numbers are evolving as more data becomes available.

What this means in reality is difficult to fathom. More than 4,500 people have been hospitalized in New York City since the start of the outbreak here. Hospitals and health care workers are already struggling to meet the surge of coronavirus patients in the city. “Mostly everything that’s coming in now is all a flavor of coronavirus,” Stefan Flores, a professor of emergency medicine at Columbia University, said of his emergency room in the city.

A doctor at Elmhurst Hospital Center in Queens — the borough that is the epicenter of the epicenter, with more than 8,000 confirmed cases — told BuzzFeed News that he estimates 60 people in the 545-bed facility have been intubated, which allows them to be hooked up to a ventilator. “Elmhurst is just getting destroyed. It’s very, very gruesome,” the doctor said. Outside the facility, lines of people stretch out, many in masks, waiting to be tested.

State and local officials are making urgent efforts to expand hospital capacity: adding more hospital beds, pleading for more ventilators. Gov. Andrew Cuomo said at a press conference on March 25 the entire state could need as many as 140,000 hospital beds. It has 53,000 right now.

Officials are frantically trying to find spaces to care for the New Yorkers they expect to become sick. The US Army Corps of Engineers is planning to build field hospitals at now-empty colleges on Long Island, and to remake the Jacob Javits Center, the convention center on the far west side of Manhattan, into a FEMA hospital. De Blasio said Thursday the city is trying to triple its capacity to 60,000 beds by May. That still may not be enough.

As the number of cases rise, so, too will the death toll. Right now, more than 365 have died in New York City from the coronavirus. On Wednesday, the city saw the largest in one 24-hour period so far, when 88 people died from coronavirus in a single day. Refrigerated trucks are being parked outside hospitals in case city morgues and hospitals are overwhelmed.

The city’s statistics are staggering, but New York City may also have a sharper grasp of the scale of the unfolding crisis. New York state has led the nation in testing, with more than 138,000 people tested, including nearly 58,000 in New York City alone. The total number of tests given in all 50 states is more than 519,000.

It is a warning, and a lesson, for the rest of the United States.

Is New York City unique — or just first?

New York’s first coronavirus case was detected on March 1, in Manhattan. Officials identified her as a woman in her 30s who had recently traveled to Iran. At that point, New York had tested all of 32 people for the coronavirus, all negative except for this one.

“There is no cause for surprise — this was expected,” Cuomo said in a statement at the time. “I said from the beginning it was a matter of when, not if, there would be a positive case of novel coronavirus in New York.”

A few days later, on March 3, the state said a second person had tested positive, a lawyer who lived in Westchester and worked in Midtown Manhattan. He hadn’t traveled or been exposed to anyone with the virus, which meant he was also the first instance of community spread in the state. Officials rushed to track his movements, but they were also direct: “This is a crisis that, it’s fair to say, will likely be with us for several months,” de Blasio said at the time.

Since then, the count of confirmed coronavirus cases in New York has surged. Museums, Broadway, and once-crowded bars and restaurants have shuttered. On March 15, the city shut down all public schools until at least April 20.

On Sunday, March 22, Cuomo ordered nonessential businesses to close and for people to stay at home, something the mayor had earlier proposed doing. The New York City subway and bus lines continue to operate, so they’re available to transport those essential workers. The city is even taking down basketball hoops to stop people from playing together. And yet, the number of cases in New York continues to grow, unabated.

“Why does New York have such a high number?” Cuomo said of coronavirus cases at a press conference on Wednesday, a recognition of the crisis that’s happening in the state.

He followed up by saying, in his opinion, there were two answers. The first was “because we welcome people from across the globe.” Cuomo said he expects the virus was in New York City much earlier than perhaps officials knew, because people came to New York from just about everywhere else.

“The second answer is because we are close,” Cuomo said. “We talk about the virus and how it transfers in a dense area, it is literally because we are close.”

“Our closeness makes us vulnerable,” Cuomo added.

Cuomo’s explanations — that New York is an international nexus, and an urban area where people live and commute packed together — likely does have something to do with the coronavirus’s rapid spread across the five boroughs. New York has 27,000 residents per square mile, beating second-place San Francisco with 18,000 residents per square mile, according to the New York Times. And if you’ve ever ridden a New York City subway at rush hour, imagine how a respiratory illness might fare in that environment.

“New York City is often ahead of the curve when it comes to trends. It has a huge number of travelers and is densely populated — both factors that likely accelerated spread of infections here,” Tom Frieden, former director of the US Centers for Disease Control and Prevention and former commissioner of the New York City Health Department, told Vox.

Public health officials still do not know when coronavirus arrived in New York, or why it hit here so hard and so fast. Officials do not yet have the data to get a complete picture, and probably won’t for quite some time — if at all.

The state of New York is testing more far people than the rest of the country right now, which contributes to the high number of cases (beyond the fact that it’s a populous city), but it’s not testing everyone. And there still isn’t blood testing to determine who has antibodies to decipher how much of the population has already been infected. Many companies and individual labs are working on developing such testing, and some antibody tests are being used in other countries but aren’t yet available in the US, said University of Washington virologist Keith Jerome in an email. “I expect we’ll start to see these in late April or May,” he said.

“One of the challenges everybody has is trying to explain something absent the data that would really be helpful,” said Andrew Goodman, a public health researcher at NYU.

New York might have these distinct factors that contributed to the rapidity and intensity of infections, but it also lacked the diagnostic testing capabilities to detect the coronavirus early on. This isn’t specific to New York; this is a problem the entire country has faced. Dr. Anthony Fauci, the federal government’s top infectious disease scientist, called this a “failing” at a congressional hearing earlier in March.

“The idea of anybody getting it easily the way people in other countries are doing it — we’re not set up for that. Do I think we should be? Yes. But we’re not,” Fauci said.

The United States as a whole struggled to get adequate testing ramped up, and New York was very much included in that. “We were seeing what was unfolding overseas,” said Syra Madad, a special pathogens expert at the NYC Health and Hospitals network. “So why would we not think that we would not see cases here in the United States? And so we were obviously ill-prepared as a nation. Not as a state, but as a nation, in ramping up our diagnostic capabilities.”

New York City officials were pleading with the federal government for more coronavirus tests and to expand the criteria on who could get tested, even before the first cases were confirmed in New York.

“We believe that if [the CDC] would empower local laboratories, we could work with them to do high-quality testing faster that would allow us to stay ahead of the situation,” de Blasio said on February 26.

On March 6, as New York already had 22 new coronavirus cases, city officials again begged the CDC for more tests, saying the lack of testing had “impeded our ability to beat back this epidemic.”

As the New York Times reported, the mix of competing federal, state, and local regulations compounded the problem and might have intensified delays. But it showed just how important testing was in trying to slow the spread of coronavirus.

“If we had been more aggressive earlier with testing, identifying cases, doing contact tracing to identify the people who are exposed, we could have done a lot better,” said Goodman, the public health researcher at NYU. “But for public health, often the success is the absence of something happening.”

He compared it to watching a Category 5 hurricane approach. You can hope for the best, and if it doesn’t hit, it’s fine. But if it does make landfall, it’s much better to be prepared.

New York implemented its statewide stay-at-home orders on March 22, following lockdowns in San Francisco and the surrounding area, and California. New York City also closed schools a lot later than other states. In hindsight, experts said, maybe New York was slower to act than it should have been in implementing aggressive social distancing measures early on.

But shutting down an entire state or city without knowing the scale of the crisis — specifically the scale of infection in the city — is extraordinarily difficult. It takes adept planning and coordination, especially in a place like New York City, which also has commuters pouring out into the suburbs, including in states like New Jersey and Connecticut. It also requires the buy-in of residents, which is still not entirely happening, based on crowds at some parks. Would all of New York City, and all of its businesses, have bought into a citywide shutdown with two cases of coronavirus? Or even 100?

That, Madad said, is why testing — hard data — is so critical, and why the failures across the US to implement it are so striking. “It has a huge economic and social toll,” Madad said of these stay-at-home orders. “You don’t want to make these decisions without having some data. And unfortunately, that data didn’t exist because diagnostic capability was not ramped up. Everything goes hand-in-hand.”

And now, part of the reason New York City might look so bad is simply because it has a lot more information. “If you test a lot, you’re going to find a lot,” says Anna Muldoon, a former science policy adviser in the Office of the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services. “And New York’s Department of Health managed to get testing rolled out more effectively and efficiently than a lot of places, so they may just have found more cases.”

She added that here, too, New York City’s dense population might have helped — it might be much easier to access a testing site or to reach out to a population in a place like New York City. But the bottom line seems to be: Now that the city knows the scope of the problem, it may be too late.

What’s next for New York

The grim reality in New York right now is that the coronavirus situation is likely to get worse before it gets better. While state officials say social distancing measures may be working, the governor on March 25 warned that the outbreak is expected to peak in two to three weeks. And the next day, he noted the focus is currently not on a reduction of cases but instead on a reduction in the rate of increase in the number of cases. “That’s what comes first when you’re starting to make progress,” he said.

New York put out a statewide call for retired health care professionals to sign up to be part of a reserve staff for the coronavirus response. Judy Salerno, president of the New York City Academy of Medicine, who also volunteered in Louisiana after Hurricane Katrina, signed up and gained public attention when she responded to one of the governor’s tweets asking about when she would hear back. She and thousands of other medical professionals are now part of a reserve staff on hand.

“When they open up a place at the Javits Center, where are they going to get the doctors? They’re not going to pull them out of hospitals,” she said, noting that health care providers are also getting sick. “I’m ready, willing, and able to work, as are a lot of my friends.”

Salerno, who is in her 60s, is in a higher risk group for serious illness because of her age. “When it’s a matter of life and death, I’ve probably been exposed to a number of people going to Morton Williams to pick up groceries. If we all in a crisis do our part, we have to take our skills and figure out what’s the best and the highest use for our skills. And this is mine right now, and so as soon as they need me, I will be there,” she said. “Is there concern? Yeah. Fear? No.”

The city’s health care crisis will have ripple effects beyond what’s happening in hospitals and clinics.

“Obviously, the health care crisis is going to get worse in the next couple of weeks, I think that’s already being demonstrated today,” said Isaac Weisfuse, former deputy commissioner at the New York City Department of Health and Mental Hygiene. “I also think we’re going to face a social service crisis in that as more and more people get sick, some of the social service deliveries to vulnerable populations [are] going to suffer, and New York City is going to have to be very agile in figuring out how to deal with that.”

That translates, for example, to care for the elderly and others who depend on visiting nurses and home health aides to meet some of their basic needs. “If those nurses get sick and the elderly can’t be visited, or their home health aides can’t go to them, they’re going to have physical and mental problems that are just going to exacerbate the health care crisis,” Weisfuse said. The issue extends to services such as Meals on Wheels, food banks, protective services, mental health, and disability support.

At a press briefing on March 26, Cuomo described the crisis in New York as a “life moment.” But, he said, the state will persist. “We’re going to get through this,” he said. “The only question is how we get through it, and when we get through it.”

And, like the rest of the country, there are economic ramifications as well. All nonessential businesses across the state have been shut down, putting thousands of New Yorkers out of work and shuttering businesses big and small. It’s a “double whammy,” Cuomo said on Thursday, because the state has increased expenses to combat coronavirus and is also losing revenue because businesses are closed. “We’re spending more to take care of the Covid virus and we’re receiving less,” he said, estimating the state will lose $10 billion to $15 billion in revenue. “That’s a ton of money for the state of New York’s budget.”

Cuomo also has an antagonistic relationship with President Donald Trump, which could be detrimental to the state’s ability to respond. For example, the president has cast doubt on the state’s need for ventilators and suggested New York doesn’t need as many as state officials say.

Other cities and states may not be far behind New York

There’s almost a predictable cycle around coronavirus as it spreads across the globe: It’s somewhere else, you assume because of some shortcoming there, and it won’t be that bad where you are. But then it gets to where you are, and you think your city, state, or country will do better. But will it?

As long as New York City has existed, it has dealt with outbreaks and epidemics. From cholera in the 19th century to the 1918 flu pandemic to even the brief Ebola scare in the 2010s, the city has ended up on the front lines of global health crises. And because of certain aspects of the city — it’s an international hub and a populous and dense place — it has often been stereotyped by outsiders as a dirty place full of foreigners, including by much of America.

“It actually took a lot of work to get people to think of New York as a place that connected to the rest of the country,” Muldoon said, explaining that New York’s history with infectious diseases has a lot to do with that. “It’s not just New York ego that has set that up. That is a longstanding [view].”

That sense is not entirely absent from the coronavirus outbreak, either. The White House has ordered anyone who passed through New York City to self-quarantine for 14 days, and other states have made similar orders. The president’s home state is floundering as he insists the country will be back to normal by Easter.

But if New York was first, and was unprepared, other states should try not to repeat those mistakes. If city and state officials could have acted more quickly to put social distancing measures in place and prepare for the influx of cases, other states need to do that now, too.

“In New York City, we had an opportunity to act a little more aggressively sooner. Would that have helped? Possibly,” Goodman said.

New York is hardly the only place in the country where coronavirus is spreading, and it may be a signal of what’s to come elsewhere. Some states are taking proactive measures — shutting schools, ordering social distancing and stay-at-home measures. Others are not — and probably should be.

“New York is a warning for the rest of the country,” Muldoon said. “Places need to be preparing in case it gets that bad, and particularly places that as they’re testing are getting a high proportion of positives. Yes, they need to get ready.”

And, in many ways, New York City is better equipped than other places to deal with this onslaught. It has more doctors and health facilities than other places, which isn’t the case for other parts of the country, particularly in rural areas.

“The scale is so large here, the complexity, and the number of hospitals and people that we’re dealing with, if we can figure out how to respond to the crisis here, then there will be lots of other lessons learned that can be shared with other jurisdictions,” said Denis Nash, professor of epidemiology at the City University of New York’s School of Public Health.

And other parts of the country are already seeing spikes in cases, including Michigan and Louisiana, specifically New Orleans. Officials in those states and cities are replicating the warnings voiced by those in New York: They need more protective gear for hospital workers, more ventilators, more hospital beds to meet the coming surge.

“This doesn’t mean the rest of the country is spared,” said Nirav Shah, a former New York state health commissioner and adjunct professor at Stanford University. “Rather, we should work collectively to address the problem where it is. Today it is New York. Tomorrow it will be somewhere else, and only by coming together as a nation will we get this under control.”