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Thursday, May 23, 2024

Iowa’s Covid Wave and the Limits of Personal Responsibility

On Monday night, Iowa governor Kim Reynolds came to her constituents with some surprising news. Along with a series of new restrictions on business operations and social gatherings, she was, for the first time, issuing a state-wide mask mandate. “No one wants to do this. I don’t want to do this,” Reynolds said during the live address. Yes, Iowans were well aware. That was not the surprising part.

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For much of the pandemic, Reynolds, a Republican, has insisted that the largely rural state could contain the coronavirus without resorting to measures widely adopted elsewhere in the US. In the spring, when the virus first began to spread nationwide, Reynolds closed down businesses, but declined to issue a statewide stay-at-home order. As Iowa reopened this summer, bars and gyms were allowed to operate at full capacity, provided people socially distanced themselves. And until this week, there was no limit on the size of social gatherings, either indoors or outdoors.

Reynolds also resisted calls to require mask-wearing in public. In July, she said such measures just make people “feel good,” since there’s no way to enforce them. (In fact, several studies have found that government policies supporting mask-wearing significantly slowed new infections. In Arizona, for example, a Centers for Disease Control and Prevention report found that the state’s hospital-buckling summer outbreak began to subside two weeks after mask mandates went into effect.) It wasn’t laws and fines that Iowa needed, said Reynolds, but for its citizens to “step up and take personal responsibility.” For months, she pushed this message of self-determination. And while the sun was shining, and people were spending time outdoors, it looked like it was working.

But the virus was still circulating. And as colder weather drove people indoors and students returned to schools and college campuses, case numbers began to explode across the Midwest. In Iowa, more than 4,100 people are testing positive for the virus every day, according to the Iowa Department of Public Health. To give you a sense of how steep the slope is, between November 3 and 17 the state recorded more new infections than it did during the first six months of the pandemic. The surge is already straining the state’s health care system. For the past week, Iowa hospitals have been admitting at least 200 Covid-19 patients a day. As of Thursday afternoon, 1,447 people are currently hospitalized with the coronavirus, making Iowa one of the worst states in the country for per capita hospitalizations. The governor’s reversal this week is tantamount to an admission that the policy of personal responsibility isn’t working.

“The strategy has just been to say: ‘We trust Iowans to do the right thing.’ But nobody was getting told what the right thing is,” says Eli Perencevich, an infectious disease doctor at the University of Iowa Hospital and Clinics. The absence of a mask mandate, the open bars, the public gatherings—they created the illusion of normalcy. And if things feel normal, people are going to act like they are.

Take one of Perencevich’s patients—a man in his seventies, who for months had been isolating at home with his wife. But a few weeks ago, Perencevich says, they decided to take a chance and go out to celebrate his birthday. They chose a bowling alley, because it seemed easier to stay 6 feet away from other people than in a bar or restaurant. A few days later, they were both admitted to the hospital with Covid-19. The couple believes they caught the virus at the bowling alley because it was the only time they’d been around a lot of other people. When Perencevich asked the man why they had risked it, he recalls, the man told him: “It was open, so I assumed it was safe.” In other words, the sign out front was advertising more than just the opportunity to hurl a ball at a phalanx of pins; it was also signaling a tacit endorsement of the safety of that activity by the very government that was telling Iowans they could make their own decisions about how to stay safe during a dangerous pandemic.

“That’s the major problem here,” says Perencenevich. “Clearly, so much of containing this virus comes down to personal responsibility, but there have to be guardrails.”

Without hard and fast rules, the people who run individual businesses and school districts have been on their own to decide whether or not to require masks and social distancing, and to set limitations on the number of people allowed inside stores, gyms, salons, bars, restaurants, and classrooms. Some counties did enforce mask mandates, including Johnson County, where the University of Iowa is located. And cases there were lower than counties without mask mandates, until students returned to campus in the early fall.

Matt Everson, the director of the Iowa Association of Small Businesses, says his members favor the flexibility to figure out which precautions they’re going to take, rather than a government mandate. Especially in a rural state, where delivery often isn’t an option and businesses might only have one or two employees, blanket restrictions could present an undue burden. “Compared to other states where we’re starting to see businesses closing and not coming back, Iowa’s approach has been a good one,” says Everson. (He says he and some of his family members contracted the coronavirus a few weeks ago and recovered with only minor symptoms.)

Still, he says that business isn’t booming, even with the flexibility offered by a policy of personal responsibility. “A large portion of Iowa’s consumer economy just doesn’t feel comfortable going out,” he says. The answer isn’t more shutdowns to get the virus under control, he says, but the arrival of Covid-19 vaccines. As for the governor’s latest proclamation? He says he thinks it strikes a smart balance.

Christine Petersen, an epidemiologist and director of the Center for Emerging Infectious Diseases at the University of Iowa, disagrees, saying the new guidance doesn’t go far enough. The statewide mask mandate comes with a host of caveats. As of Tuesday, Iowans must wear a mask in indoor public places, but only if they will be within 6 feet of another person for more than 15 minutes. Schools are exempt—district officials can decide for themselves. Currently, about a third of the state’s districts don’t require masks. Petersen likens the new mandate to those drug commercials that spend 25 seconds singing the praises of a new medicine, followed by a 5-second rapid-fire litany of terrible side effects. “If the message is to wear masks, all the caveats undercut that message,” she says. “We need clear language about social distancing and masks. Not ‘Maybe, if you feel like it.’ Not that it ‘would be appreciated.’ But that every time you leave your house, you should be distancing and wearing a mask, no exceptions.”

Reynolds’ office did not respond to WIRED’s questions about the governor’s shift in policy. But according to The New York Times, rapidly rising hospitalization rates and increased pressure from the Iowa State Board of Health factored into the decision. In this regard, Reynolds is hardly alone. Republican governors in North Dakota and Utah also issued mask mandates in the past week, in response to an alarming shortage of hospital beds. Both those governors had also previously preached the gospel of personal responsibility.

Internationally, the country best known for leaving its coronavirus response up to the decisions of individual citizens is Sweden. While the rest of Europe locked down in the spring, Swedes remained remarkably free to shop, work, and eat out, provided they stayed 6 feet apart while indoors. Researchers at the University of Gothenberg analyzing the Swedish government’s lax response found that an overconfidence in personal responsibility contributed to death rates much higher than the country’s Scandinavian neighbors, and the fifth-highest in Europe overall. And after months of refusing to lock down or issue mask mandates, this week a second surge in coronavirus cases forced Sweden’s prime minister into tougher restrictions on business operations and social gatherings.

A policy of personal responsibility relies on the science of moral psychology—and the well-documented observation that, in general, people want to be responsible, and don’t want to look like norm-breaking jerks whose behavior endangers others. Across cultures and continents, this seems to hold true for most every human society, says Jillian Jordan, a psychology researcher at Harvard University, who studies how morality shapes the decisions people make. During a pandemic, when an individual’s choice to do something risky—like go out for a drink or to host a wedding—can lead to dozens, if not hundreds, of other people getting sick and even dying, there’s a lot there to tap into. But the effectiveness of that strategy comes down to giving people clear guidance.

“When there’s ambiguity around what it means to be responsible, and which behaviors are safe and which are risky, that limits our ability to leverage the fact that people don’t want to violate norms,” says Jordan. “Having official authority figures saying one thing is often not enough. If there isn’t a clear standard of what is appropriate, it’s harder to tap into people’s desire to be responsible in order to change their behaviors. And if enough people aren’t adhering to that message, it’s easy for it to get undermined.”

Iowa may not be alone in having attempted to rely solely on the voluntary cooperation of its citizens to stem the tide of a deadly pandemic. But it does have some unique policies that epidemiologists like Petersen say are unscientific and unsafe, and which contributed to the dire situation the state now finds itself in. The first is a rule the governor’s office issued for when students should be in school. Under this criterion, which Reynolds announced over the summer, schools should be open until a district’s home county experiences a 14-day coronavirus test positivity rate above 15 percent. At that point, district officials could apply for a two-week waiver from in-person instruction. This criterion is at odds with official guidance from the US Centers for Disease Control and Prevention, which recommends that schools close to in-person instruction when test positivity rates in a community exceed 5 percent. It’s also a more lax approach than any other state in the nation, an investigation by The Des Moines Register found this summer. “That number was just plucked from the air,” argues Petersen. “To say that threshold has any kind of public health benefit is just ludicrous. At that point, the epidemic has already happened.”

Additionally, the Iowa Department of Public Health redrew the boundaries around what constituted an outbreak. According to the Council of State and Territorial Epidemiologists, the definition of an outbreak for nonresident, non-health-care settings (like schools, businesses, and factories) is two or more laboratory-confirmed coronavirus cases within a two-week period among workers, students, or staff who do not share a household. As early as March, the state’s health department had redefined an outbreak as 10 percent absenteeism of either students or workers on a given day, due to coronavirus infections. That would mean that for a 1,000-person workplace, 100 people would need to call in sick with Covid-19 on the same day for the state to label it an outbreak.

In an email, Amy McCoy, a spokesperson for the Iowa Department of Public Health, told WIRED that the CSTE definition for an outbreak came out after Iowa had developed its own definition and was already reporting on outbreaks. In Iowa, she pointed out, if a small company of 10 employees had one person test positive, that would meet the 10 percent threshold, but not the two-case cluster definition. “As we always do, we offer public health support regardless of the number of cases and continue to adapt depending on what is needed in each situation,” McCoy wrote.

But Perencenevich thinks it’s another example of statewide policies that put companies ahead of public health. “It’s basically a threshold that can never be reached, even in the middle of a pandemic,” he says. “Everything was designed to keep things open.”

With coronavirus cases surging in almost every state in the US right now, Perencenevich sees Iowa’s predicament as a microcosm of a failed national response to the pandemic. American public health authorities were slow to recommend universal mask-wearing, providing mixed messages on their effectiveness early on. And the White House never modeled responsible risk-reducing behavior, even after it led to a large outbreak that sickened the president and dozens in his inner circle. “A lack of leadership, a lack of transparent communications, a lack of mask mandates,” Perencenevich says. “And now look where we are.”

Read all of our coronavirus coverage here.

Now, the US is not a monolith. The idea that rural states with low population density might take fewer precautions isn’t completely illogical—but in order for a more lax approach to work, case incidence rates have to also be low. What doesn’t make sense, says Jordan, is saying that mask mandates and other laws limiting opportunities for the virus to spread are pointless because there aren’t good mechanisms for enforcing them. “Just sending the signal that official authority figures think it’s bad not to wear a mask is meaningful information to people who are interested in complying with what society sees as appropriate behavior, even if there are no legal repercussions for not complying,” she says.

Take a state like Vermont, which is also rural and sparsely populated, but where precautions have been tougher and local government officials avoided turning the public health crisis into a partisan issue. In August, the governor, also a Republican, enacted a statewide mask mandate. Vermont state health officials also issued strict quarantine guidelines, requiring anyone traveling from out of state to self-isolate for 14 days. So far, the state has issued very few fines for lawbreakers. But yet, for the majority of the pandemic, Vermont has enjoyed the lowest infection rates of any state in the US.

Until November, the state was averaging newly reported daily cases in the single digits. In the past two weeks, cases there have begun to rise sharply, mirroring the surge seen across much of the rest of the country. Yet the raw numbers are striking. As of this week, Vermont has been averaging 89 new cases per day, compared to 4,154 in Iowa, according to data collected by The New York Times. It’s true that Iowa is much more populous than Vermont; it has about five times as many residents. But per capita, Iowa still has 10 times more coronavirus cases than Vermont.

It’s likely that the next few months are going to be difficult wherever you are; as colder weather drives people indoors and people gather for the holidays despite health authorities’ pleas not to do so, the virus will continue to spread, and hospitals will continue to be stretched to the brink. A November surge in infections means a deadly December is sure to follow. But what happens in these two states, which share similar demographics but differ on policy, should offer a useful comparison study. Will the policies that led to Vermont’s low rate of community spread, and helped its hospital systems stay relatively unburdened over the summer, now buffer the state against the winter wave of cases? And can Governor Reynold’s sudden reversal help pull Iowa back from the brink? Or is it too little too late?

The proclamation is only slated to last three weeks. And with all the caveats, it still leans heavily on hoping people will do the right thing. The governor said so herself. “If Iowans don’t buy into this, we lose,” Reynolds said during Monday’s address. If they don’t, she warned of coming closures to schools and businesses, and that the hospital system there could collapse: “The cost in human life will be high.”

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