Why I respectfully disagree with the course of action taken by the governor of Iowa to combat the novel virus.
Originally published Apr 3, 2020
Edited 4/14/2020: A CDC study concluded “Community mobility…decreas[ed] with each policy issued…This report suggests that public policy measures are an important tool to support social distancing and provides some very early indications that these measures might help slow the spread of COVID-19.”
Never be afraid to follow the evidence. No matter what you face or how loud the opposition may be, there is nothing so powerful as truth. — E. Rosalie
Edited 4/6/2020: I’m ecstatic to report that Iowa received measures closer to full distancing. The grading tool remains inadvisable as it requires data to indicate and we know the data to be unreliable at this time.
The current actions fail to reflect lessons learned from past pandemics, the number of high-risk Iowans, the evidence on presymptomatic transmission, flawed testing, and the incubation period. A lack of formal pronouncement will impact already-vulnerable Iowans most.
Lessons from History
In 1918, St Louis enacted strict measures within 2 days of the first case.
Philidelphia waited 17 days, and the delayed distancing measures were powerless to stop the exponential force of nature.
Iowa is already 26 days removed from the first recognized case. COVID-19 is more than twice as contagious as the seasonal flu and spreading in a 100% susceptible population.
High-risk Iowans include 525,000 older adults and 1,800,000 with chronic disease. Over 700,000 residents have two or more chronic diseases. Both factors increase the risk of serious illness and death.
Iowa maintains 635 critical care beds that serve its 3,100,000 people. The rate of severe disease with COVID-19 hovers around 18% meaning that Iowa could exceed critical care capacity in 1–2 weeks. See Iowa COVID-19 timeline.
COVID-19 patients can require lengthy hospital stays, but the rate of infection means new sick people appear before beds open again. Then doctors will face the decision that no one should ever have to make.
Presymptomatic spread, incubation, & testing
The long incubation period means cases we find today were infected a week ago. There are likely many more cases in Iowa than those currently recognized.
The virus spreads before people know they are sick, so asking people to self-isolate when they feel unwell won’t stop the virus. Issues with testing scarcity can give the appearance of low case counts.
If I have a room full of pregnant women and only one pregnancy test, my report could truthfully report only one positive pregnancy test. The testing only tells us about the people tested. Tests tell us nothing about where the virus is not. Even so, considering only confirmed cases portrays exponential growth.
Iowa COVID-19 Case Counts Exponentially Rising
Cases in Wuhan, China climbed for over a week after implementing strict measures. The longer we wait, the more Iowans we risk losing.
I fear even if we act today, the cases may continue to climb long enough to exceed capacity. It happens in a flash. Less than two months ago we had no confirmed COVID-19 cases. Now, the US has 300,000.
A Stay-at-home order by any other name
No suggestion equates to the preventative power of formal action. We are far from a vaccine with no powerful therapeutics. Containment is essential.
Senior policy fellow, Jeremy Konyndyk, a member of the WHO committee on health emergencies explained:
“If you don’t have that consistent approach, then you basically have a lowest-common-denominator approach, and whoever is making the weakest decisions puts everyone else at risk. You can see that with Florida.”
Managing an infectious agent like COVID-19 takes intentional, coordinated mitigation. Inaction will hurt us and it will hurt neighboring states. There are no good options anymore. The only proven tool requires “profound measures.” Even studying a variety of distancing styles, the data led them to their unchallenged conclusion.
“The effectiveness of any one intervention is likely to be limited, requiring multiple interventions to have a substantial impact on transmission.”
“Measures needed…will be profound. Even countries at an earlier stage…need to [act] imminently.”
Disadvantaged Iowans suffer without formal action
Analyses already show that wealthier Americans distanced themselves much sooner than their lower-income counterparts.
Lower-income New York neighborhoods suffered disproportionately high case numbers, likely related to the distancing delay. Vulnerable people cannot forgo work.
Without any clear, equally applied order, wealthier demographics enjoy benefits not available to disadvantaged parties, and relief funding may not arrive until September. Those who do not have the luxury of staying home, need the protection and advocacy of their leader.
One study already concluded that COVID-19 “affected vulnerable populations disproportionately across the world,” and “financial protection during an outbreak…ensured disease-control efforts reached…vulnerable people to contain the spread.”
Infectious diseases obey no borders nor societal status. The health of our community is inextricably linked by our shared environment. The President allowed states to discern the best course of action, but any benefit ceases without action.
We desperately need strict distancing measures and clear and equal protection for all Iowans. A comprehensive plan balancing health and economics prescribes strict distancing until states meet these benchmarks:
- the numbers of new cases decline for two weeks
- local hospitals can treat all residents in need of care and healthcare workers are protected — protected and not instructed to stay silent.
- the state has the ability to rapidly test all people with symptoms or exposure to COVID-19 at low or no cost to ensure people won’t avoid
- ability to contact trace and contain identified cases
I fear completely pausing life in our state, but we know aggressive social distancing positively impacts the economy in the end. Delaying costs lives and prosperity — the evidence is clear.
Locations that delay or cut distancing short struggled economically longterm. The scared mind is irrational, so we must root our choices in evidence.
What is right is rarely easy, but do it we must.
Please protect us.
With great respect from a fellow Iowan,
E. Rosalie Li Rodenborn | Graduate Student
Public Health Biology
Johns Hopkins Bloomberg School of Public Health
Disclaimer: The views expressed in this letter reflect only me and are not affiliated with any other persons or institution.